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As a Medicare agent, you’re not just helping clients find the right plan, they depend on your advice to help them navigate through all the complexities of Medicare. One important thing agents do is explaining Medicare penalties, this ensures clients avoid costly surprises.

Educating clients early using understandable terms on how to avoid these charges helps build trust and reinforces your value as a trusted advisor. Here’s a breakdown of the most important penalties clients need to understand and how to help them stay ahead of the game.

Start with the Enrollment Timeline

Some clients are unaware of the IEP (Initial Enrollment Period) and how crucial timing is. As you know, the IEP is a seven-month window:

• Three months before the month of their 65th birthday,
• The birthday month,
• And three months after their birthday month.

If they don’t enroll in Medicare Part B or Part D during this period, and they don’t qualify for an SEP (Special Enrollment Period), they could face lifelong penalties.

Encourage clients to begin planning their Medicare enrollment early; at least 3 to 6 months before turning 65. Use this time to review their current coverage and explain how Medicare will coordinate (or replace) it.

Clarify Each Type of Penalty

Clients rarely understand the specific consequences of delaying enrollment. Be sure to cover these key penalties in your consultations:

Medicare Part B Late Enrollment Penalty

• What It Is: A 10% increase in the monthly premium for every full 12-month period the client delayed enrollment without other creditable coverage.
• How Long It Lasts: For life, and CMS will add it to their Part B premium.
• Common Misunderstanding: Clients often believe they can just delay Part B if they’re healthy or not using care without knowing there is a penalty and it keeps growing.

Watch a YouTube video on OEP, SEPs an Late Part B Enrollment

Part D Late Enrollment Penalty

• What It Is: 1% of the national base premium (currently $36.78 in 2025) multiplied by the number of full uncovered months they went without creditable prescription drug coverage.
• How Long It Lasts: For life, and it’s added to their monthly Part D premium.
• Common Misunderstanding: Clients are often unaware of this penalty and if they don’t need drug coverage now, they do not have to enroll in a plan. Although, not having creditable coverage triggers the penalty anyway.

Medicare Part A Penalty

Penalty: 10% increase in the premium for twice the number of years they delayed enrollment.

Applies only to clients who do not qualify for premium-free Part A (usually those with less than 10 years of Medicare-covered work history).

Explain Employer Coverage and SEPs

This is where your expertise can be very useful.

Many clients working past 65 assume they can delay Medicare without issue. However, eligibility for an SEP (Special Enrollment Period) depends on their employment and the type of coverage they have.

Key Points:

• Employer coverage must be from active employment (not COBRA or retiree plans).
• The employer must have 20 or more employees for the coverage to delay Medicare enrollment without penalty.
• They must enroll in Medicare within 8 months of losing employer coverage to avoid penalties.

Review your client’s group health plan documents or provide them with specific questions to ask their HR department. It’s critical they confirm whether their plan is considered creditable coverage for both Part B and Part D.

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Conduct Annual Reviews

Clients’ needs, income levels, and coverage can change year to year. Use the AEP (Annual Enrollment Period) that runs Oct 15–Dec 7 to:

• Verify their current coverage.
• Check for plan changes that could increase costs.
• Remind them of potential penalties if they drop coverage without a replacement.

Document Everything and Communicate Clearly

Because it is easy for some clients to misunderstand Medicare rules, it’s essential to:

• Take notes that summarize the appointment after each consultation, some clients may want a copy for their own records.
• Track enrollment deadlines and follow up as key dates approach.
• Encourage clients to keep copies of any employer or plan letters that state their coverage is creditable.

Medicare penalties are preventable; only if your clients have the right information at the right time. As an agent, your ability to explain these rules in simple terms and guide clients through timely enrollment is a key part of your value.

By proactively addressing fees and penalties in your process, you not only protect clients financially you also strengthen your reputation as a knowledgeable and trustworthy advisor in a competitive marketplace.

Stay up-to-date on the latest events and information for agents

Medicare beneficiaries who have a limited income may be eligible for help paying for some healthcare costs. That’s where a Medicare agent can provide some insight into understanding the Medicare savings program. This can be a great resource for individuals who qualify. The Medicare Savings Programs (MSPs) are state-run programs that help pay Medicare premiums, deductibles, copays, and coinsurance, depending on the individual’s financial situation.

There are four main MSP categories, each with slightly different income and resource limits; each provides a different level of help. We will break them down to provide a better understanding of each level.

QMB (Qualified Medicare Beneficiary)

QMB provides the most comprehensive benefits. It helps pay for:

• Medicare Part A premiums (if applicable)
• Medicare Part B premiums
• Medicare deductibles
• Medicare coinsurance and copays
• Help paying for prescription drugs (beneficiaries pay no more than $12.15 for each prescription covered by their Medicare drug plan).

If an individual qualifies at the QMB level, doctors and medical providers do not bill them for services covered by Medicare; except in very limited situations.

2025 QMB income and resource limits:

• Individual: monthly income limit $1,325; resource limit $9,660
• Married couple: monthly income limit $1,783; resource limit $14,470
  (Limits vary by state)

What counts in resource limits: Money in checking, savings and retirement accounts, stocks and bonds. States do not count: Your home, furnishings, household and personal items, one car, burial plots, up to $1,500 for burial expenses if that money is put aside.

SLMB (Specified Low-Income Medicare Beneficiary)

The SLMB Program is more limited than the QMB Program but still provides assistance. The only premium it helps pay for is the Medicare Part B premium (beneficiaries must have both Part A & Part B to qualify for the program).

The program also provides help paying for prescription drugs. Individuals pay no more than $12.15 for any drug covered by their Medicare drug plan.

This program is useful for people with limited income slightly above the QMB threshold.

2025 Income and resource limits:

• Individual: monthly income of $1,585 with a resource limit of $9,660.
• Married couple: monthly income of $2,135 with a resource limit of $14,470.

QI (Qualifying Individual)

The QI Program also helps pay the Medicare Part B premium, just like the SLMB program, but with slightly higher income limits. QI beneficiaries also receive extra help paying for their prescription drugs and pay no more than $12.15 in 2025 for any drug covered on their Medicare plan. The QI benefit is provided on a first come, first served basis, and individuals must apply every year to continue receiving benefits.

Important: Individuals who are eligible for Medicaid do not qualify for QI program.

2025 Income and resource limits:

• Individual: monthly income limit of $1,781 with resource limits of $9,660 (the same as QMB & SLMB).
• Married couple: monthly income limit of $2,400 with resource limits of $14,470 (the same as QMB & SLMB).

QDWI (Qualified Disabled and Working Individuals)

The QDWI Program is specifically for individuals under age 65 who are disabled but have returned to work and lost their Social Security disability benefits and premium-free Medicare Part A.

QDWI helps pay the Medicare Part A premium for these individuals.

2025 Income and resource limits:

• Individual: monthly income limit of $5,302 with resource limits of $4,000.
• Married couple: monthly income limit of $7,135 with resource limits of $6,000.

Please note: Income limits vary by states. The amounts listed in this post are federal limits. Individuals with slightly higher incomes may still qualify in their states.  Check your state to find out.

Apply for MSP (Medicare Savings Program)

Because MSPs are administered by each state’s Medicaid office; the application process varies by state. In general, individuals will need to provide:

• Proof of income (such as Social Security or pension statements)
• Information about assets (like savings, investments, etc.)
• Medicare card and ID

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Medicare Savings Programs can make a huge difference in the lives of people within the income limits. They provide assistance for important medical services that are essential for quality of life. It is free to apply, and the potential savings can be substantial.

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If you’re a Medicare agent, you know leads are an essential part of your business. But purchasing leads can be expensive as well as frustrating, with low contact rates and high competition. The good news? There are effective, low-cost Medicare lead sources to generate quality Medicare leads that build lasting client relationships.

Here are four strategies to help find leads that actually convert without emptying your wallet:

Grassroots Marketing Still Works

Even in the digital age, nothing beats local visibility and personal interaction. Although grassroots marketing may take some time, it’s cost-effective and builds genuine relationships.

• Community bulletin boards: Post flyers offering your services at grocery stores, libraries, pharmacies, and senior centers. Remember; use only general information and do not mention specific benefits or carriers on flyers.
• Local events: Set up a booth at farmers markets, church fairs, or health expos. Offer free Medicare information and assistance to attract interest. Free items of nominal value like pens or candy sometimes helps attract people and start the conversation.
• Business cards everywhere: Leave them at coffee shops, laundromats, grocery stores or anywhere seniors gather.

This method takes consistency, however, over time, it helps establish you as a valuable, local Medicare resource.

Click here for a Scope of Appointment Form

Host Medicare Educational Seminars

Educational events are a great way to build credibility as a knowledgeable community member and generate leads in a non-salesy setting. Many seniors are overwhelmed by Medicare choices and appreciate trustworthy advise.

• Partner with libraries, senior centers, or churches to host free events.
• Offer a clear, simple presentation explaining Medicare basics and common questions.
• Use voluntary sign-in sheets and follow-up cards to capture contact information for attendees.
• Bring printed materials like basic plan comparison charts or a “Medicare 101” guide they can take home.

Watch a Medicare Educational Event Best Practices Video

You don’t need a big crowd; even a small gathering can yield solid, qualified leads when people trust you from the start.

Leverage Professional Community Relationships

Think beyond individual clients; build relationships with people who serve your target audience every day.

• Pharmacists and independent pharmacies: Ask if you can leave materials or host a “Medicare Check-Up Day.”
• Financial advisors and tax preparers: Many of their clients are Medicare-aged. Offer to co-host an event or provide educational resources.
• Home health agencies and caregivers: These professionals regularly interact with people who need help with healthcare coverage.
• Faith leaders and community organizers: Trusted voices in the community can refer their members to you when Medicare questions arise.

These referral partners don’t have to sell for you; they just need to know you’re a trusted resource.

Referrals from Current Clients

Once your business is established, happy clients are often your best lead source. In most cases, all you have to do is ask; they are happy to recommend your services to friends and family.

• Ask at the right time: After helping a client enroll or during an annual review, simply ask, “Do you know anyone else who could use help with Medicare?”
• Send follow-up emails with referral reminders: Include a link to a referral form or offer a small incentive (where compliant).
• Provide extra business cards they can hand to friends or family.
• Stay top-of-mind with birthday cards, newsletters, or check-in calls. The more visible you are, the more likely they are to refer others.

Remember, a referred lead is already partially sold; they trust you because someone they know trusts you.

A few more strategies for Medicare agents

You don’t need a massive marketing budget to grow your Medicare business. With the right combination of grassroots outreach, community connections, educational events, and referrals, you can build a steady stream of qualified leads that cost very little and convert into sales.

Are you ready to join the team at Crowe; click here for online contract

It is important to be visible, approachable and a valuable resource for your community. If you do these things, the leads will follow.

To find upcoming agent events and webinar; click here

As America’s population ages, the demand for healthcare and those who can help people navigate it continues to grow. One very important and often misunderstood area of healthcare is Medicare. For those looking for a rewarding and potentially lucrative career, you might want to consider a Medicare sales career.

Why Consider a Medicare Sales Career

Growing Market

Every day, thousands of Americans turn 65 and become eligible for Medicare. That trend is not expected to slow down anytime soon. As baby boomers age into the program, the need for knowledgeable, trustworthy agents to guide them through their options has never been greater. This isn’t a short-term trend; it’s a long-term opportunity based on demographics.

Make a Meaningful Impact

Choosing a Medicare plan can be overwhelming. All the options can cause confusion for beneficiaries. Between Original Medicare, Medicare Advantage, Medigap, Part D, this is difficult for many to sort out. That is why they often need help to find the best fit for their unique medical and financial needs. As a Medicare sales professional, you’re not just selling a product; you’re offering clarity, confidence, and peace of mind at a critical point in life.

Quick Start Up with Great Earning Potential

For a determined individual, becoming a licensed Medicare agent can be accomplished in a relatively short amount of time when compared to many careers. Once certified (through licensing and passing the required exam), agents can complete the AHIP and add in carrier contracts and purchase E &O insurance. Once contracted and compliant, they can put together a plan to build their book of business. Top agents enjoy competitive commissions, including renewals, which creates an opportunity for recurring income over time.

Watch a quick YouTube of what Crowe has to offer agents

Flexible Career Options

Medicare sales can fit a wide range of career goals and lifestyles. Those who want to work independently and set their own schedule can do that. If you enjoy working as part of a larger agency or brokerage with support and resources?; that’s also an option. Whether you’re looking for a full-time career or a side hustle, the flexibility of Medicare sales is hard to beat.

Continuous Learning Keeps the Work Interesting

Because Medicare is constantly evolving, new plans, changing regulations, updates to benefits, there’s always something new to learn. For professionals who enjoy staying sharp and growing their expertise, Medicare sales offers a dynamic and intellectually stimulating environment.

Digital Tools Make It Easier

Medicare agents have access to powerful online quoting and enrollment platforms, including telephonically with voice recording systems, CRMs, and so much more. Agents no longer need to visit a prospect’s home unless they want to. Many successful agents run their business entirely online, serving clients across multiple states. Although some prefer the grass roots approach. There are options for many different types of agents.

Watch a quick video of Connecture & Sunfire quoting and enrollment tools

Click here for online contracting and join the team at Crowe!

A career in Medicare sales is about more than just earning commissions; it’s about becoming a trusted advisor for people facing important health coverage decisions. If you enjoy helping others, are driven to succeed, and want to be part of a growing industry with real impact, Medicare sales could be the opportunity you’ve been looking for.

For a look at upcoming agent events and to view our webinar schedule, click here

When it comes to navigating the maze of Medicare, choosing the right supplemental coverage can make a significant difference in both healthcare coverage and out-of-pocket costs. One option that remains popular is Medigap Plan N. We will outline the benefits of Medigap Plan N and highlight it’s balance of coverage and affordability. This post includes both the benefits and downsides of Medigap Plan N.

Medigap Plan N

Medigap (Medicare Supplement Insurance) helps pay for healthcare costs that Original Medicare (Part A and Part B) doesn’t cover, such as copays, coinsurance, and deductibles. Plan N is one of 10 standardized Medigap plans available in most states. It offers a good blend of coverage and cost savings, making it appealing to Medicare enrollees who want solid protection without having to pay the highest premiums.

Benefits of Medigap Plan N

Lower Monthly Premiums

In general, Plan N has lower premiums than more comprehensive plans like Plan F or Plan G. This makes it a good option for individuals who are relatively healthy and want to save on fixed monthly costs.

Plan N Covers Cost Gaps

• 100% of Part A coinsurance and hospital costs
• 100% of Part B coinsurance (with a few exceptions)
• Skilled nursing facility care coinsurance
• Part A deductible
• Emergency care during foreign travel (up to plan limits)

Nationwide Access

Like all Medigap plans, any provider that participates with Medicare will accept Plan N. Enrollees do not have to worry about provider networks or referrals. Enrollees can see any doctor or specialist who accepts Medicare.

Predictable Inpatient Costs

Because inpatient services are well covered by Plan N, beneficiaries can feel confident with their choice, if they are hospitalized or require skilled nursing care. Their costs should generally be predictable.

Downsides of Medigap Plan N

Copays for Doctor and ER Visits

While most Part B coinsurance is covered by Plan N, beneficiaries must still make some copays:

• Up to $20 for office visits
• Up to $50 for emergency room visits (waived if the patient is admitted)

These copays can add up for anyone who frequently requires the care of a doctor.

Doesn’t Cover Part B Deductible

Like all Medigap plans issued to new enrollees after January 1, 2020, Plan N does not cover the Medicare Part B deductible, which is $257 in 2025.

Excess Charges Not Covered

Plan N does not cover Part B excess charges. These are extra charges from providers who don’t accept Medicare assignment. These providers are allowed to bill up to 15% over the Medicare-approved amount. While this isn’t common, it can be a concern for those who live in or travel to areas where non-participating providers are prevalent.

Not Ideal for High Users of Care

Beneficiaries who require frequent doctor visits, lab work, or outpatient treatments may cause the recurring copays and potential for excess charges to outweigh the savings of the lower premiums. When that is the case, Plan G could be a better value despite higher monthly premiums.

Plan N can be an excellent choice for

• People in relatively good health
• Those who prefer lower monthly premiums
• Individuals who rarely see non-participating Medicare providers
• Enrollees who are comfortable paying small copays in exchange for premium savings

Plan N may not be ideal for

• People who visit the doctor frequently
• Those who live in areas where excess charges are more common
• Individuals who want the most comprehensive coverage available

Watch a video on Physicians Mutual Innovative Plan G

Medigap Plan N is a well-balanced choice for Medicare beneficiaries who want solid protection without paying top-dollar premiums. Its design provides comprehensive healthcare at an affordable rate. As always, choosing the right Medigap plan depends on health needs, budget, and lifestyle. Comparing Plan N with other options like Plan G can help beneficiaries make the most informed decision. A licensed Medicare agent can help compare plans and weigh all the options.

As the population ages, many individuals are seeking care while in the comfort of their own homes. One of the most common questions people ask is: how Medicare covers home healthcare? In some cases Medicare provides some coverage; although there are some important limitations and conditions Medicare enrollees and their families need to be aware of.

In-Home Health Care

In-home health care refers to a range of medical services patients may receive at home. This can include skilled nursing, physical therapy, occupational therapy, speech-language pathology, and certain types of personal care.

What Medicare Covers

Medicare Part A and/or Part B may cover in-home health services if the beneficiary meets specific conditions. These include:

1. They Must Be Homebound

Medicare defines “homebound” as being unable to leave your home without considerable effort or assistance due to illness or injury. The beneficiary may leave for things like medical appointments or religious services, however they must not be able to leave home on regular outings.

2. Care Must Be Medically Necessary

Any Medicare services received must be (medically necessary) a doctor or a qualified healthcare provider must order the care. They must also create and regularly review a care plan for the beneficiary.

3. Individuals Must Require Skilled Services

Medicare provides coverage for home health services such as; intermittent skilled nursing care, physical therapy, speech-language pathology, or continued occupational therapy. If a beneficiary requires services for personal care alone (dressing or bathing), Medicare will not cover them unless it’s part of a broader medical plan involving skilled care.

4. Only Medicare-Certified Home Health Agencies Can Provide Care

To receive coverage, services must be provided by an agency that is certified by Medicare.

What’s Covered

• Skilled nursing care (part-time or intermittent only)
• Physical, occupational, or speech therapy
• Medical social services
• Home health aide services (if you’re also receiving skilled care)
• Durable medical equipment (DME) like walkers, oxygen tanks, or wheelchairs (covered under Medicare Part B)

Please Note: Medicare does not cover; 24-hour home care, meals delivered to your home, or homemaker services if they are the only care you need.

Out-of-Pocket Costs

For most eligible home health services:

• Beneficiaries pay $0 for covered home health care services.
• Typically, the out-of-pocket amount for Medicare-approved durable medical equipment is 20% of the cost.

No copay or deductible is required for the care itself, assuming the beneficiary meets the qualifying criteria.

Examples of How Medicare Covers In-Home Health Services

Let’s say Jack, age 78, recently had hip surgery and his doctor prescribes in-home physical therapy for recovery. This is prescribed in-home because; he is temporarily unable to travel to outpatient therapy due to mobility issues. Because he meets the homebound requirement and the care is medically necessary and ordered by a doctor, Medicare will likely cover the services.

In contrast, if Leo needs help cooking, cleaning, and taking medications but does not need skilled nursing or therapy, Medicare would not cover a home health aide for him.

How to Initiate In-Home Healthcare Through Medicare

1. Beneficiaries must talk to their doctor. A doctor’s order is required before any service is authorized for payment.
2. Choose a Medicare-certified home health agency. Beneficiaries can request suggestions from their doctor’s office or their Medicare insurance carrier or the Home Compare Tool Link below.
3. The beneficiary’s provider and the agency will work together to develop a care plan.

The Medicare’s Home Health Compare tool to find certified agencies in the local area.

Medicare can be an important source of support for those recovering at home or managing chronic health conditions. However, its coverage of in-home health care comes with specific conditions that must be met. Understanding these rules helps beneficiaries and caregivers plan effectively and avoid unexpected expenses.

As a Medicare agent, mastering all the different enrollment periods is crucial to ensure smooth enrollment for your clients. It also helps you stay compliant and that is also very important. Understanding IEP vs ICEP is essential to anyone in Medicare sales. Although these two sound similar, they serve distinct purposes and apply to different parts of Medicare.

IEP (Initial Enrollment Period)

First we will go over The IEP. Most agents know that this is the first window of time when someone is eligible to enroll in Original Medicare; specifically Parts A and B.

• Who is eligible to apply: Individuals turning 65 who worked and paid Medicare taxes for a period of at least 10 years (40 quarters) or their spouse or ex-spouse. Those who are under 65 with a qualifying disability, ESRD or ALS are also eligible to enroll.
• Timing: For those who are turning 65; The IEP spans 7 months: it begins 3 months before their 65th birthday, includes their birth month and ends 3 months after the month they turn 65.
• Timing: Individuals who are under 65 and qualify due to a disability; the IEP begins 3 months before the 25th month of their disability benefit entitlement.

Example: If a client turns 65 in May, their IEP runs from February 1st to August 31st.

What beneficiaries can do during IEP

1. Enroll in Medicare Part A and/or Part B
2. Enroll in a Medicare Part D plan (if they have Part A and/or Part B)
3. If they enroll in both Part A & Part B, they may also opt for either a Medicare Advantage (Part C) plan or a Medicare Supplement (Medigap) plan.

ICEP (Initial Coverage Election Period)

When an individual is first eligible for Medicare, the ICEP can specifically be used to enroll in a Medicare Advantage (Part C) plan.

• Who can use the ICEP: Individuals who are first enrolling in both Medicare Part A and B, and want to join a Medicare Advantage plan.
• Timing: Usually, the ICEP coincides with the IEP. However if an individual delays Part B enrollment (e.g., due to employer coverage), the ICEP does not start until they have both Part A and Part B and ends the last day of the month before their Part B coverage begins.

Example 1 (standard case): Client enrolls in A & B to begin July 1. Their ICEP runs from April 1 to June 30.

Example 2 (delayed Part B): Client took Part A at 65; delayed Part B until they retired at 67. Their ICEP begins when they enroll in Part B and ends the last day of the month before Part B becomes effective.

What beneficiaries can do during ICEP

1. Enroll in a Medicare Advantage (Part C) plan, with or without drug coverage (MAPD or MA-only).

Differences at a Glance

Feature	IEP	ICEP
Purpose	Enroll in Parts A, B, and D	Enroll in a Medicare Advantage (Part C) plan
Who It’s For	All newly Medicare-eligible individuals	Those first enrolling in both Part A & B and considering MA
Timing	7-month window around Medicare eligibility	Coincides with IEP, unless Part B is delayed
Applies to	Original Medicare + Drug Plans	Medicare Advantage Plans

Why Understanding IEP vs ICEP Matters to Agents

Confusing IEP and ICEP could lead to enrollment mistakes, missed opportunities, and compliance issues. Knowing when each applies ensures:

• You recommend the right plans at the right time.
• You help clients avoid penalties for delayed Part D enrollment.
• You position yourself as a knowledgeable and trusted resource.

Watch a YouTube video on Medicare enrollment periods

Important: Always ask clients if they’ve enrolled in both Part A and B before discussing Medicare Advantage options. This small question helps determine whether they’re in their ICEP.

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As a Medicare agent, you’re always looking for ways to support your clients; especially those who have difficulty affording their medications. One of the most overlooked tools in your toolkit is the State Pharmaceutical Assistance Program (SPAP) and the Special Enrollment Period (SEP) it can trigger. This SEP can be a great opportunity for individuals with lower income levels. This post answers the question: what is an SPAP SEP and how you can use it effectively to provide clients the benefits they need and remain complaint.

What Is an SPAP

State Pharmaceutical Assistance Programs (SPAPs) are state-specific programs. Each state designs them to provide assistance to qualified residents; usually low-income seniors or people with disabilities, to pay for prescription drugs. Benefits may include help with:

• Part D premiums
• Deductibles
• Copays and coinsurance
• Coverage gaps (including the “donut hole”) Please keep in mind; the coverage gap was eliminated in 2025.

Important: Not all states offer SPAPs, and those that do have varying eligibility criteria. For example, Connecticut’s PACE, New York’s EPIC or New Jersey’s PAAD and Senior Gold, are a few of the better-known programs.

The SPAP SEP

Once a client becomes eligible for or enrolls in an SPAP, they qualify for an SEP (Special Enrollment Period). Eligible individuals can use the SEP to:

• Enroll in a Medicare Part D plan (if they haven’t yet)
• Switch from one Part D plan to another

The SPAP SEP is useful for:

• Individuals who miss their Initial Enrollment Period (IEP)
• Clients in unsuitable plans with high out-of-pocket costs
• Individuals who are newly eligible for financial help anytime during the year

Timing Rules For SPAP SEPs

• Trigger: The SEP is triggered by eligibility for or enrollment in an SPAP.
• Usage: Individuals can use this SEP only once per calendar year.
• Window: Clients have two full months after the month of SPAP enrollment/eligibility to make a change.

Example: If an individual is approved for their state’s SPAP in April, they can enroll in or switch Part D plans through June 30.

Why This SEP is Important to Agents

Some agents are unsure of how SPAPs work with Medicare timelines. Using the SPAP SEP can:

• Help your clients access more affordable drug coverage outside of AEP (the Annual Enrollment Period)
• Allows agents to proactively help clients who receive an SPAP approval notice
• Position an agent as a knowledgeable advisor who ensures clients receive the best coverage for their budget

Understanding SPAPs also gives you a competitive edge; especially when working in states that offer generous or well-known assistance programs.

Best Practices for Agents

1. Know Your State’s SPAP: Research the program(s) available in each state you are licensed in. Make sure you are aware of income limits and how the program coordinates with Part D.
2. Know the application process. Be sure you can provide assistance to clients to access the SPAP application and what they need to complete it.
3. Educate Your Clients: Many beneficiaries don’t know these programs exist. Include SPAP information in your annual reviews, especially when you have clients with low-income or high drug-costs.
4. Be aware of SEP Opportunities: If a client is approved for SPAP mid-year, this is an opportunity to review their current drug coverage and potentially move them to a plan that better suits their needs.
5. Coordinate with SHIPs: Partnering with your local State Health Insurance Assistance Program (SHIP) can help your clients apply for SPAPs and get extra help if needed.
6. Stay Compliant: Always document the SEP reason when submitting applications or plan changes, and be sure the client’s enrollment in the SPAP can be verified.

The SPAP SEP is an important but underutilized option for helping Medicare clients reduce prescription drug costs and access more suitable coverage. By understanding and using the guidelines correctly, you can serve clients better and potentially improve your retention and referral rate in the process.

Watch a YouTube video on 2025 SEP Changes for DSNP

Note: It is a good idea to bookmark your state’s SPAP website and use it as a resource when appropriate. Being the agent who knows the programs that can make a real difference in people’s lives builds long-term relationships and trust.

Individuals enrolled in Original Medicare probably have a pretty good understanding of Medicare Part B and what it covers. Many Medicare beneficiaries are surprised when they receive an unexpected bill; these unexpected costs may come from excess charges. Some of you may not have heard of excess charges. We will answer the question; What are Part B excess charges and hopefully help some of you avoid them.

Medicare Part B Excess Charges

Medicare Part B excess charges occur when a doctor or healthcare provider does not accept Medicare assignment and charges more than the Medicare-approved amount for a covered service.

Here’s how it works:

• Medicare sets an “approved amount” for every Part B service.
• Doctors who accept Medicare assignment agree to accept this amount as payment-in-full.
• Providers who don’t accept assignment can charge up to 15% over the Medicare-approved rate.
• The extra 15% is called an excess charge; the beneficiary must pay that amount out of pocket, unless they have supplemental coverage that pays it.

Example of a Part B Excess Charge

Let’s say a beneficiary has met his annual deductible and receives a procedure from his doctor; the Medicare-approved amount for the procedure is $200.

• If the doctor accepts assignment, they’ll charge $200. Medicare pays 80% of the cost ($160). The beneficiary pays the remaining 20% ($40).
• If the doctor does not accept assignment, they can charge up to 15% more: $200 + $30 = $230. Medicare will still pay 80% of the approved $200 ($160), but the beneficiary owes not only their 20% ($40) they also have to pay the excess charge of $30, therefore their total out-of-pocket cost is $70.

When Do Excess Charges Apply

Excess charges only apply to Medicare Part B services and only when:

1. It is a service that Part B covers.
2. The provider does not accept Medicare assignment.
3. The provider charges more than the Medicare-approved amount.

Important: Not all states allow excess charges. For example, Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont have laws that prohibit excess charges for Medicare beneficiaries.

How to Avoid Excess Charges

1. Use Participating Medicare Providers
   Always ask the provider if they accept Medicare assignment before receiving care. This ensures the beneficiary does not pay more than the Medicare-approved amount.
2. Consider a Medicare Supplement Plan (Medigap)
   Individuals who are worried about excess charges, consider a Medigap Plan. The Plan G or Plan F (if you were eligible before 2020) both cover 100% of Medicare Part B excess charges. This provides protection from surprise bills.
3. Check State Rules
   Those who live in states that bans excess charges don’t need to worry about them; providers in those states can’t legally charge more than the Medicare-approved rate.

Unfortunately, some agents or beneficiaries overlook Medicare Part B excess charges when discussing Medicare coverage. That cost can surprise even savvy Medicare beneficiaries. However, with the right knowledge and the right plan, beneficiaries can avoid them altogether.

Click here to watch a quick YouTube video on Medicare Enrollment Periods

Please note; It is important to verify the provider accepts Medicare assignment and beneficiaries may want to consider supplemental coverage for full protection.

Success Strategies for Medicare Agents: How to Grow, Compete, and Thrive

The Medicare market continues to expand, with millions of Americans enrolled and thousands more becoming eligible every day. Although, with opportunity comes competition. Whether you’re new to the field or a seasoned agent looking to stay ahead, success in Medicare sales requires planning and effort. We will go over a few success strategies for Medicare agents that we hope will help your business reach it’s full potential.

Five Essential Success Strategies For Medicare Agents

1. Build a Strong Online Presence

Today’s consumers do their homework before making decisions; especially when it comes to healthcare. A professional, credible online presence isn’t optional; it’s essential.

• Website: Create an easy to use website that clearly explains your services, displays your contact info, and includes a few helpful blog posts or answers to FAQs. watch a video Improve Your Website Traffic With Blogs.
• Google Business Profile: It is important to claim and optimize your business listing so you show up in local searches. When possible have satisfied clients leave a review of your services.
• Social Media: Focus on platforms where your audience is active; in many cases, Facebook is a great place to connect with seniors who are looking for information. Post educational content, reminders about enrollment periods, and success stories.
• Email Marketing: Build and maintain a list of clients and potential clients who opt in to stay top-of-mind throughout the year with helpful updates and tips.

An active digital footprint helps establish your brand, help establish you as a trusted resource and expands your reach far beyond your immediate network.

2. Stay Educated – Commit to Continued Learning

Medicare is constantly changing. New plans, rule changes, and compliance updates roll out constantly. The most successful agents stay current and compliant by:

• Renewing AHIP certification annually
• Attending carrier training webinars
• Joining industry associations or local networking groups
• Subscribing to Medicare and healthcare newsletters
• Complete compliant sales and communication training courses

The more you know, the more confident and credible you become. Clients appreciate the guidance of a knowledgeable agent.

3. Use Up-To-Date Tools

Time is your most valuable asset. The right tools help you stay organized, work efficiently, and grow your business without burning out.

• CRM systems such as; AgencyBloc, BOSS for agents, or other systems help track leads, manage follow-ups, and retain client information securely.
• Quote and enrollment platforms like SunFire or Connecture, simplify side-by-side comparisons and digital applications.
• Automated email sequences can educate leads and onboard new clients with minimal manual effort.
• Calendar tools allow clients to book appointments online, reducing back-and-forth communication.

Automating routine tasks frees up your time and allows you to focus on what really matters: serving your clients and growing your book.

4. Invest in Marketing and Branding

In a crowded field, your personal brand sets you apart. What do people think of when they hear your name? Trustworthy? Knowledgeable? Accessible?

• Logo and branding adds professionalism, consistency and recognition across all communications channels.
• Clear messaging that speaks directly to your ideal client (e.g., veterans, low-income seniors, new-to-Medicare enrollees).
• Lead generation strategies like paid search, Facebook ads, community events, or referral partnerships.

Marketing is not a one-time effort; it’s an ongoing investment. If you’re not actively expanding your visibility, you’re losing ground.

5. Focus On Client Retention

Acquiring a client is just the beginning. Retaining them is where long-term income and reputation are built.

• Annual policy reviews help ensure clients are enrolled in the plan that best fits their current needs. Every year you have an opportunity to prove your value and build your client relationships.
• Birthday cards, holiday greetings, or “thank you” notes add a personal touch and help maintain contact.
• Client newsletters keep them informed and engaged throughout the year.
• Referral requests: A happy client is often your best source of new business, do not hesitate to tactfully ask for them.

Long term clients provide renewal income, referrals, and stability to your business.

Are you ready to work with a partner who supports you; click here for Crowe contracting

Success as a Medicare agent isn’t just about selling policies; it’s about building relationships, staying visible, and continuously learning your craft. By embracing digital tools, strengthening your brand, staying informed, and nurturing client loyalty, you can create a sustainable and thriving Medicare business that continues to grow.

For many people trying to navigate Medicare, understanding how and when out-of-pocket costs apply can be overwhelming. The terminology “first dollar Medicare services” may cause confusion for some individuals. We will explain what it actually means and how they work in the context of Medicare services.

First Dollar Coverage

First dollar coverage refers to insurance benefits that begin immediately. The enrollee is not required to, pay a deductible, copay, or coinsurance before the carrier provides coverage for a medical service. This coverage literally begins from the “first dollar” of a medical bill providing the highest level of financial protection.

With Original Medicare (Parts A and B), this kind of coverage is not included by default, although it may be accessed through either supplemental plans or Medicare Advantage plans in some circumstances.

Original Medicare: No First Dollar Coverage

Medicare is divided into Part A (hospital insurance) and Part B (medical/outpatient insurance).

Original Medicare enrollees are responsible for the following out-of-pocket costs:

• Deductibles: Part A ($1,632 per benefit period in 2025); Part B ($240 annual)
• Coinsurance: 20% for most Part B services after the deductible
• Copays: Varies depending on the service or provider

Please note; although Medicare covers a significant portion of approved healthcare costs, it does not offer first dollar coverage when used on its own. Beneficiaries are responsible for cost-sharing amounts unless they purchase supplemental coverage.

First Dollar Coverage for Medicare Services

In general, there are two ways Medicare beneficiaries receive first dollar coverage:

1. Medicare Supplement (Medigap) Plans

The Medigap plans listed below cover most or all out-of-pocket costs after Original Medicare pays its share.

• Plan F: Offers true first dollar coverage. This plan covers both Part A and Part B deductibles as well as all coinsurance and copays for approved medical expenses as well as excess charges.
• Plan C: Similar to Plan F but doesn’t cover excess charges. Important: Plans F and C are not available to individuals who were eligible for Medicare after January 1, 2020.
• Plan G: Covers all approved Medicare expenses; except the Part B deductible, making this plan very close to first dollar coverage.

Beneficiaries enrolled in a Plan F shouldn’t have to pay anything out-of-pocket for Medicare covered services.

2. Some Medicare Advantage (Part C) Plans

Medicare Advantage plans are an alternative to Original Medicare. Some Medicare Advantage plans offer enrollees:

• $0 monthly premiums
• $0 copays for primary care, lab work, preventive services, or telehealth
• Reduced out-of-pocket costs through annual limits

Although technically they are not considered “first dollar” coverage, some plan benefits can effectively eliminate upfront costs for specific services, depending the plan design.

Keep in mind: Medicare Advantage plans may include networks, referrals, and prior authorization requirements.

Watch a quick YouTube video on Medicare enrollment periods

Examples of First Dollar Medicare Service

• Example 1: A Medigap Plan F enrollee visits the emergency room. The bill is fully covered; no deductible, no copay, no coinsurance. This is real first dollar coverage.
• Example 2: A Medicare Advantage plan enrollee has a $0 copay for a primary care visit. Although the plan may have a deductible for other services, this specific visit is a first dollar service.
• Example 3: A individual with Original Medicare and no supplemental coverage uses the services of a specialist. This individual must meet the Part B deductible and then pay 20% for all approved charges. In other words, this is not first dollar coverage.

Why First Dollar Coverage Matters

• Predictable healthcare costs
• Easier budgeting for individuals on fixed incomes
• Reduces the risk of surprise bills
• Encourages timely medical visits and screenings

Possible Downside

• Higher monthly premiums (especially with Medicare Supplement Plans)
• Less flexibility (if beneficiaries opt for a Medicare Advantage Plan) they must use specific provider networks.
• Limited plan availability for more recent enrollees (Medicare Supplement Plan F and Plan C enrollment restrictions).

First dollar Medicare services are about financial peace of mind. While Original Medicare doesn’t provide this level of coverage on its own, many beneficiaries learn that Medicare Supplements or Medicare Advantage plans reduce or eliminate the high price of medical care.

Beneficiaries who like predictable expenses and minimal out-of-pocket costs, may opt for a plan that offers first dollar coverage. As a licensed Medicare agent, it is important to understand your clients healthcare needs and budget to offer plan choices that provided the best benefit options.

Although there are millions of people on Medicare, many find it a confusing subject especially since there are so many different parts to it. For individuals approaching 65 or anyone who or just wants to understand more about how this insurance works, here’s a brief answer to the question; what is Original Medicare and what does it cover.

What Is Original Medicare

The federal government established Original Medicare, a federal health insurance program, in 1965. The following individuals may qualify for Medicare benefits:

• People age 65 or older
• Certain younger people with qualifying disabilities
• People with End-Stage Renal Disease (ESRD) or ALS (Lou Gehrig’s disease)

There are 2 parts of Original Medicare: Part A and Part B.

Medicare Part A

Medicare Part A is sometimes referred to as hospital insurance. It provides coverage for:

• Inpatient hospital care (once the enrollee is formally admitted)
• Skilled nursing facility care (following a qualifying hospital stay)
• Home health care (limited and medically necessary services)
• Hospice care for individuals with a terminal illness

For most people, Part A is free,there is no premium payment as long as eiither the beneficiary or thier spouse worked and paid Medicare taxes for a minimum of 10 years.

Please note: Although Part A covers hospital stays, it doesn’t cover long-term care such as; nursing homes, custodial care or unlimited days in a hospital or facility. There are limits to what it pays; beneficiaires must pay a portion of their expenses (cost-sharing), such as deductibles and coinsurance and copays.

Medicare Part B

Medicare Part B is also known as medical insurance. It provides coverage for the following:

• Doctor visits and outpatient medical care
• Preventive services such as; wellness visits, flu shots and cancer screenings
• Durable medical equipment (DME) this include things like; walkers, wheelchairs, oxygen as well as some diabetes supplies and more
• Lab tests and diagnostic imaging
• Mental health services
• Some home health care

Unlike Part A, beneficiaries do pay a monthly Part B premium. Fo rmost people, this is a standard amount although higher-income beneficiaries may pay an additional cost.

Click here to learn more about Part B eligibility

Part B coverage includes an annual deductible (this amount is adjusted annually). Typically beneficiaries pay 20% coinsurance for most covered services; in other words, Medicare pays about 80% of the cost leaving enrollees responsible for the remaining 20%.

What Original Medicare Doesn’t Cover

Original Medicare provides coverage for many medical expenses; although, they do not cover everything. Some important things to know about what Medicare does not cover:

• Prescription drugs (beneficiaries must enroll in separate Part D plan)
• Routine dental, vision, and hearing care
• Long-term custodial care
• Most care received outside the U.S.

In order to fill some of these coverae gaps, many people purchase additional insurance. Some of the plans people choose are; Medicare Supplement (Medigap) plans, Stand-alone PDP (prescprion Drug) plans, Medicare Advantage (Part C) plans. Beneficiaries also may opt for ancillary coverage like dental, vision and hearing or cancer heart attack and stroke plans.

Medicare agents; learn how to sell ancillary products with Medicare – watch a quick video.

Original Medicare provides valuable health coverage for millions of Americans, but it’s important to understand what it cover and what it doesn’t. Knowing the basics helps beneficiaries make informed decisions and avoid unexpected costs.