Medicare’s 2026 Drug Price Negotiations: A New Era of Affordability
Starting January 1, 2026, Medicare will implement its first-ever negotiated prescription drug prices; a historic change that could lower costs for millions of beneficiaries. In this post, we discuss Medicare’s 2026 Drug Price Negotiations. This is a direct result of the Inflation Reduction Act of 2022, which for the first time gave Medicare the authority to negotiate the prices of certain high-cost medications.
Why This Matters
For decades, Medicare was prohibited from negotiating directly with drug manufacturers. Instead, it relied on private Part D plan sponsors to manage drug costs. The 2026 negotiations mark a turning point. Medicare will now establish a Maximum Fair Price (MFP) for select drugs, reducing both what the government pays and what beneficiaries spend at the pharmacy counter.
- Projected Medicare savings: About $6 billion in 2026
- Projected out-of-pocket savings for beneficiaries: About $1.5 billion
The First 10 Drugs Negotiated for 2026
CMS chose these drugs because; they are some of the highest-cost Part D medications. In addition; there are no generic or biosimilar medications available, and are widely prescribed.
- Eliquis – blood thinner for preventing stroke and blood clots
- Xarelto – blood thinner for reducing risk of clotting
- Januvia – diabetes medication (DPP-4 inhibitor)
- Jardiance – diabetes, heart failure treatment (SGLT2 inhibitor)
- Farxiga – diabetes, heart failure, kidney disease treatment (SGLT2 inhibitor)
- Entresto – heart failure medication
- Enbrel – rheumatoid arthritis and autoimmune conditions
- Stelara – psoriasis, Crohn’s disease, ulcerative colitis
- Imbruvica – blood cancers (leukemias and lymphomas)
- NovoLog / Fiasp – fast-acting insulin for diabetes
How Beneficiaries Will Benefit
- Lower copays and coinsurance: Out-of-pocket costs will drop for patients taking these medications.
- Broader affordability: Even if you don’t take one of these drugs, Medicare’s overall savings help stabilize Part D premiums.
- Expanded impact in future years: In 2027 and beyond, CMS has scheduled more drugs for negotiation.
Watch a YouTube video on the Inflation Reduction Act and Changes to Medicare
What Comes Next
- 2027: Fifteen more high-spend drugs are already set to be negotiated, with prices effective January 1, 2027.
- 2028 and beyond: CMS will continue expanding the program, selecting additional drugs each year.
- Rulemaking: Starting in 2026, the program shifts to a formal rulemaking process, adding more transparency.
Challenges and Legal Pushback
The pharmaceutical industry has filed multiple lawsuits challenging Medicare’s new authority, arguing that price negotiations are unconstitutional. At the same time, new legislation has delayed or exempted certain blockbuster drugs, such as Keytruda, from early negotiation. While these challenges could affect the program’s scope, the 2026 savings are locked in and moving forward.
What You Should Do
- Review your Medicare Part D plan during open enrollment to ensure it covers your prescriptions at the lowest cost.
- Talk to your agent if you take any of the drugs on the 2026 negotiation list, you could see meaningful savings.
- Stay informed about future negotiation cycles, as more medications are added each year.
Agents:
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Medicare’s 2026 drug price negotiations represent a historic shift in prescription drug policy. For the first time, Medicare is actively reducing the cost of some of the most expensive and widely used medications in the program. While legal and political challenges remain, the immediate savings for beneficiaries and taxpayers are significant—and this is only the beginning.
Levels of D-SNP Eligibility Explained for Medicare Clients
Dual Eligible Special Needs Plans (D-SNPs) are Medicare Advantage plans designed for people who qualify for both Medicare and Medicaid. These plans can be a tremendous help to clients who have limited income and resources, but understanding the levels of DSNP eligibility and plan types can sometimes be confusing.
As of 2025, understanding the levels of D-SNP eligibility and how they connect to different plan structures is more important than ever for agents. Here’s a simplified breakdown.
Full vs. Partial Dual Eligibility
Full Dual Eligible Members
- Who qualifies
Clients in categories such as Qualified Medicare Beneficiary Plus (QMB+), Specified Low-Income Beneficiary Plus (SLMB+), or Full Benefit Dual Eligible (FBDE). - What does this mean
These are individuals with the highest financial or health-related needs. States decide who qualifies, often based on strict income, asset, or disability requirements. - Why it matters in 2025:
Only full dual members can use the monthly D-SNP Special Enrollment Period (SEP) if there’s a HIDE or FIDE plan in their area.
Partial Dual Eligible Members
- Who qualifies
Categories include Qualified Medicare Beneficiary (QMB), Specified Low-Income Beneficiary (SLMB), Qualified Individual (QI), and Qualified Disabled Working Individual (QDWI). - What does this mean?
These members get some help with Medicare costs, such as Part B premiums, but they do not qualify for full Medicaid benefits. - Why it matters:
Partial duals can join certain D-SNPs, but they don’t have access to the monthly SEP; only the regular Medicare enrollment windows (AEP, OEP).
Watch a YouTube video on DSNP Changes for 2025
Types of D-SNPs
D-SNPs are also categorized by how much Medicare and Medicaid benefits are integrated. Here’s what agents should know:
- Highly Integrated D-SNP (HIDE):
- Covers Medicaid services such as behavioral health or long-term services and supports (LTSS).
- As of 2025, the Medicaid contract must cover the D-SNP’s entire service area.
- Fully Integrated D-SNP (FIDE):
- Combines both Medicare and Medicaid under one entity.
- Must include primary and acute Medicaid services, plus LTSS (at least 180 days of nursing facility coverage).
- Offers the highest level of integration and coordination between Medicare and Medicaid benefits.
- Applicable Integrated Plan (AIP):
- A FIDE or HIDE plan with exclusively aligned enrollment.
- Works directly with Medicaid managed care organizations tied to the D-SNP’s parent company.
- Coordination-Only D-SNP (CO):
- Meets CMS minimum requirements but doesn’t integrate as fully as HIDE or FIDE plans.
- Still required to coordinate Medicare and Medicaid services and share information between programs.
- Exclusively Aligned Enrollment (EAE):
- Limits enrollment to full duals whose Medicaid is through the same company that operates the D-SNP.
- Allows for better integration (single ID card, unified appeals and grievances, simplified materials).
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Why This Matters for Agents
- Enrollment rules are changing. As of 2025, only full duals with HIDE or FIDE plans in their service area can use the monthly SEP.
- Integration levels affect care. The more integrated the plan (like FIDE or HIDE), the easier it is for clients to navigate benefits and reduce confusion.
- Educating clients builds trust. Explaining eligibility clearly helps clients understand why they qualify (or don’t) for certain plans and enrollment periods.
The levels of D-SNP eligibility; full vs. partial, determine not just what benefits clients receive but also when they can enroll. On top of that, the type of D-SNP (HIDE, FIDE, CO, AIP) affects how well Medicare and Medicaid benefits work together.
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For agents, simplifying these distinctions is key. By guiding clients through their eligibility level and helping them choose the right type of D-SNP, you can ensure they get the maximum financial protection and coordinated care available.
United American HDG Plan Sales – Why Consider Them This AEP
Why Add UA Now
The Annual Election Period (AEP) for Medicare runs each year from October 15 through December 7. It’s the window when beneficiaries can enroll in, switch, or drop Medicare plans. With all the changes to Medicare plans this year, agents might want to consider United American HDG Plan Sales.
What is a High-Deductible Plan G (HDG)
United American’s HDG plan offers the same benefits as a standard Plan G after enrollees meet the deductible ($2,870 in 2025). That means once the deductible is met, the plan pays 100% of Medicare-approved services, including:
- Hospital costs and Part A coinsurance
- Skilled nursing facility coverage
- Part A deductible
- Part B coinsurance and excess charges
- 80% of foreign travel emergencies
Because of the higher deductible, monthly premiums are significantly lower, making HDG an attractive choice for cost-conscious beneficiaries.
Watch a quick YouTube video on High Deductible Plan G
Why choose United American’s HDG plan this AEP
Fewer Medicare Advantage options, especially PPOs
Carriers are withdrawing some Medicare Advantage plans from the market, particularly PPOs, and many agents are reporting fewer plan choices this AEP. In some areas, commissions on Medicare Advantage plans are also being reduced or eliminated. For beneficiaries who want stability, freedom of provider choice, and nationwide access, an HDG plan offers an excellent alternative.
Great value for cost-conscious consumers
HDG balances affordability and coverage; lower monthly premiums without sacrificing comprehensive protection once the enrollee meets the deductible.
Nationwide flexibility
Unlike Medicare Advantage, which often restricts members to networks, United American’s HDG allows you to visit any provider that accepts Original Medicare, with coverage that travels across state lines.
Financial strength and trust
United American has been selling Medicare Supplements since 1966 and maintains strong financial ratings, including an A (Excellent) from A.M. Best. Their history of stability reassures clients looking for long-term reliability.
Consumer-friendly features
Guaranteed renewable: You can’t be canceled as long as premiums are paid.
30-day free-look period: Cancel within 30 days if not satisfied.
Switching flexibility: Start with HDG and, at your second anniversary, move to a standard Plan G without underwriting if you decide you want richer coverage.
Why HDG makes sense in today’s market
With Medicare Advantage options shrinking, especially PPOs, and rising uncertainty in benefits and provider access, many beneficiaries are reconsidering Medigap. HDG is a way to:
- Keep premiums affordable
- Retain freedom to choose providers nationwide
- Have peace of mind that coverage won’t change annually the way MA plans often do
Sample Comparison: Is HDG Worth It
- High Deductible Plan G: Lower monthly premium, pay the $2,870 deductible first, then full coverage.
- Standard Plan G: Higher premiums, but no deductible. Total yearly cost could be higher even with no deductible, depending on your health needs and provider use.
If saving on monthly cost is a priority—and you’re able to manage the deductible if needed—HDG offers strong value, especially during this AEP when you have the flexibility to enroll.
GET CONTRACTED
Contracting for UA is easy; just email lisa@croweandassociates.com, she will request the contract for you. Those looking for a GA level contract will need to have a minimum of 5 sub agents and 100 Medicare supplement cases on the books. Call our office at 203-796-5403 with any additional questions.
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This AEP presents a unique opportunity. With fewer Medicare Advantage choices and increasing restrictions, United American’s High-Deductible Plan G stands out as a cost-effective, flexible, and stable solution. For beneficiaries who value freedom of choice, reliable coverage, and the ability to control their long-term costs, HDG is a smart move this enrollment season.
Medicare Prescription Drug Coverage: Why Agents Should Guide Their Clients
When it comes to Medicare, prescription drug coverage (Part D) is one of the most important decisions beneficiaries will make. Prescription costs can have a major impact on a person’s budget and quality of life, and the right plan can save thousands of dollars each year.
For Medicare agents, helping clients navigate their Part D options isn’t always about commissions, it’s about building long-term trust, maintaining strong relationships, and positioning yourself as a valuable resource.
Why Agents Should Assist With Part D Decisions
Client Trust and Retention
Even if you aren’t earning a commission on every Medicare Prescription Drug Plan, guiding your clients through their choices shows that you care about their overall well-being. Beneficiaries notice when an agent takes the time to help without a financial incentive. That trust builds loyalty, which translates to long-term client retention.
The Importance of Enrolling on Time
Many beneficiaries don’t realize that failing to enroll in Medicare prescription drug coverage when first eligible or going without creditable drug coverage for more than 63 continuous days can lead to a lifetime late enrollment penalty (LEP). This penalty is added to the monthly Part D premium and grows the longer someone goes without coverage.
As an agent, explaining this to clients ensures they understand the financial consequences of delaying enrollment. Helping them avoid unnecessary penalties is another way to build trust and showcase your expertise.
Strengthening Relationships
By reviewing drug coverage options, you’re demonstrating your commitment to helping clients find the most cost-effective and comprehensive plan. This not only makes clients more likely to refer friends and family, but it also establishes you as their go-to resource for future Medicare needs.
Positioning Yourself for Additional Sales Opportunities
Helping with prescription drug coverage is often the first step toward uncovering other gaps in coverage. Once trust is built, clients may be more open to discussing:
- Medicare Supplement plans (Medigap): To help with out-of-pocket costs not covered by Original Medicare.
- Ancillary products: Such as dental, vision, hearing, short-term care, or critical illness coverage. These plans can provide extra protection and peace of mind for expenses Medicare doesn’t cover.
Watch a quick YouTube video on how to deal with non-commissionable PDP plans
Showing That You Put Clients First
Beneficiaries can feel overwhelmed by the number of plan choices. When you guide them, without focusing on commissions, you prove that your priority is their best interest. This approach differentiates you from competitors and builds long-term credibility.
Stay updated on agent events and information
The Bottom Line
Helping clients choose the right Medicare Prescription Drug Plan isn’t just about filling out enrollment forms; it’s about demonstrating integrity, earning trust, and protecting clients from costly mistakes like lifetime penalties.
Even when commissions aren’t involved, the time you invest in helping clients with their Part D decisions will pay off in other ways: stronger retention, new sales opportunities, and a reputation for truly putting clients first. With the client’s permission, agents can run the comparison and send the recommendation through a quick email. If the best option is a non-commissionable plan, clients can easily self-enroll through medicare.gov or a phone call to the carrier.
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Please keep in mind, it is always important to follow all CMS enrollment rules.
By taking a holistic approach, you not only help clients get the coverage they need, you also ensure your business continues to grow through loyalty, referrals, and expanded product offerings.
Why Choose an HMO
When selecting a Medicare Advantage plan, one of the most common choices is a Medicare HMO (Health Maintenance Organization) plan. While Medicare Advantage plans come in different forms; such as PPOs, PFFS, and SNPs, HMO plans continue to be a popular option for many beneficiaries. But what makes them attractive, and why choose an HMO plan over other types of Medicare Advantage coverage?
Lower Monthly Premiums
HMO plans often come with lower monthly premiums compared to PPOs and some Medigap options. In fact, many HMO Medicare Advantage plans are available with a $0 monthly premium (though you must still pay your Part B premium). This makes them a budget-friendly choice, especially for retirees on fixed incomes.
Predictable Costs
With set copays for doctor visits, hospital stays, and prescriptions, Medicare HMO plans can make it easier to budget healthcare expenses. Instead of worrying about large unexpected bills, members often have a clearer idea of what their out-of-pocket costs will be.
Coordinated Care
The HMO plan designed encourages coordinated care. Beneficiaries select a primary care physician (PCP) who manages their overall health and provides referrals to specialists when needed. This system helps reduce unnecessary testing and ensures care is streamlined across providers.
Watch a YouTube video on how Advanced Diabetes Supply can help get needed diabetes supplies
Extra Benefits Beyond Original Medicare
Original Medicare (Parts A and B) does not cover certain benefits like dental, vision, hearing, or fitness programs. Many HMO Medicare Advantage plans include these extras, along with prescription drug coverage (Part D). This makes HMO plans a convenient “all-in-one” package for many beneficiaries.
Lower Out-of-Pocket Maximums
Unlike Original Medicare, which does not cap spending, Medicare HMO Advantage plans include an annual out-of-pocket maximum. Once this limit is reached, the plan pays 100% of covered costs for the rest of the year, offering an important layer of financial protection.
Local Network Focus
Because HMO plans require members to use a network of doctors and hospitals, they often negotiate better rates, helping keep costs down. For beneficiaries who primarily receive care close to home, an HMO network may be more than sufficient.
Is an HMO Right for You
While HMO plans offer many advantages, everyone is different and has their own coverage needs. The main limitation is that you must use providers within the plan’s network (except in emergencies). If you prefer flexibility to see specialists without referrals or want coverage that extends more broadly outside your area, a PPO or Medigap plan may be a better choice.
However, for Medicare beneficiaries looking for affordable, coordinated, and benefit-rich coverage, a Medicare HMO is often an excellent option.
Medicare agents:
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Why Offer Medicare HDG Plans
The question; why offer Medicare HDG Plans, because the Medicare market is changing rapidly. Agents must stay ahead of the curve to remain successful. Many major carriers are scaling back their Medicare Advantage (MA) offerings and even cutting commissions on some plans. This leaves agents with fewer options to present to clients. This is where HDG Plans can make all the difference.
The Current Landscape of Medicare Advantage
In recent years, Medicare Advantage has been one of the most popular plan options among seniors. However, for the last couple years, carriers are:
- Pulling plans from the market – especially PPOs, which have traditionally been popular for their provider flexibility.
- Reducing commissions – some carriers are paying no commission on certain MA products, leaving agents with fewer options to offer.
- Tightening supplemental benefits – carriers are scaling back some of the extra benefits that once attracted clients, making MA plans less competitive.
For agents, this creates a challenge: how do you provide value to your clients while maintaining a sustainable business model?
Click here to join the team at Crowe and Associates- online contract.
Why HDG Health Plans Stand Out
HDG Health Plans provide a strong alternative that agents should be offering. Here’s why:
1. Plan Stability
Unlike some Medicare Advantage carriers that are exiting markets or restructuring benefits, HDG Health Plans are built for long-term stability. This ensures agents can confidently enroll clients without worrying about sudden disruptions.
2. Expanded Client Options
As carriers discontinue PPOs and other MA plans, seniors need reliable choices that meet their healthcare and financial needs. HDG offers products that can help fill the gaps left by Original Medicare. This gives agents a competitive edge in retaining and growing their book of business.
3. Consistent Compensation
With some carriers cutting or eliminating commissions on MA plans, agents need products that continue to provide fair, reliable compensation. HDG Health Plans recognize the value of the agent’s role and support them with commission structures that make sense.
4. Strong Value Proposition for Clients
Carriers design HDG Plans with seniors in mind, balancing affordability, access to care, and flexibility. This makes them attractive alternatives for clients who may be frustrated with shrinking MA networks or reduced plan options.
5. Ability to seek care from most providers
Unlike MA plans, Medicare supplements allow the enrollee to seek care form any provider that accepts Medicare. This can be a huge advantage to any enrollee.
Agents learn why and how to sell ancillary products – watch a quick YouTube video
The Opportunity for Agents
As the Medicare market shifts, agents who adapt quickly will come out ahead. By offering HDG Health Plans, agents can:
- Differentiate themselves from competitors still relying heavily on shrinking MA offerings.
- Provide solutions to clients facing plan cancellations or limited coverage options.
- Build a more stable book of business with products that pay fairly and retain members long-term.
Stay up-to-date on agent events and information
The Medicare Advantage space is in transition, and relying solely on it may leave both agents and clients at a disadvantage. By incorporating HDG Health Plans into your portfolio, you can protect your business, serve your clients more effectively, and position yourself as a trusted advisor during a time of change.
Now is the time to diversify your offerings, and HDG Health Plans should be at the top of your list.
When is a Referral Required – Which Medical Services Require a Referral
Navigating the healthcare system can sometimes feel overwhelming, especially when it comes to understanding when you need a referral to see a specialist. A referral is essentially a written order from your primary care provider (PCP) that allows you to receive care from another doctor, specialist, or healthcare service. But referrals aren’t always required, when is a referral required; that depends on the health insurance plan and the type of care needed.
Why Referrals Exist
Referrals are designed to coordinate care, avoid unnecessary tests, and ensure your treatment is medically appropriate. They also help insurance companies manage costs by making sure patients start with a PCP who oversees their overall health.
When a Referral is Required
Here are common situations where you’ll likely need a referral:
- HMO (Health Maintenance Organization) Plans
- Most HMO plans require you to have a referral before seeing a specialist.
- Without a referral, the plan may not cover the service, leaving you responsible for the full cost.
- Specialty Care
- Services like dermatology, cardiology, orthopedics, and other specialist visits often need a referral under certain insurance plans.
- Imaging and Diagnostics
- Advanced tests such as MRIs, CT scans, or certain lab work may require a referral or prior authorization.
- Out-of-Network Care
- If your plan allows out-of-network services, you may need a referral and pre-approval for coverage.
- Medicare Advantage (Part C) Plans
- Many Medicare Advantage HMOs require referrals to see specialists.
- PPO-style Medicare Advantage plans usually allow you to see specialists without referrals, though costs may be higher if you go out-of-network.
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When a Referral May Not Be Required
Not every plan or situation requires a referral. Examples include:
- PPO (Preferred Provider Organization) Plans – Generally, you can see specialists without a referral, but in-network providers will be more cost-effective.
- Emergency Care – True emergencies do not require a referral.
- Preventive Services – Annual wellness exams, certain screenings, and vaccinations are usually covered without a referral.
- Original Medicare – If you have Medicare Part A and Part B (without a Medicare Advantage plan), you typically do not need referrals to see specialists.
Watch a YouTube video on Medicare enrollment periods
How to Know if You Need a Referral
- Check Your Plan Documents – Your insurance card or plan booklet will outline referral requirements.
- Ask Your PCP – If you’re unsure, your primary doctor can confirm whether you need a referral for the service you’re seeking.
- Call Your Insurance Provider – The member services number on your card can clarify referral rules for your coverage.
Stay up-to-date on agent events and information – click here
Why This Matters
Getting care without the proper referral could result in unexpected bills or denied claims. Knowing when referrals are required can save you time, money, and stress—and ensure your care stays coordinated across providers.
Using HSAs with Medicare: What Beneficiaries and Agents Need to Know
Health Savings Accounts (HSAs) are a valuable tool for people with high-deductible health plans (HDHPs), allowing them to set aside pre-tax dollars for qualified medical expenses. However, once Medicare enters the picture, the rules change. For Medicare beneficiaries and the agents who guide them, it’s important to understand how using HSAs with Medicare works. There are important changes when Medicare begins, so educating your clients help them use those funds wisely.
Can You Contribute to an HSA While on Medicare
The short answer: no.
Once someone enrolls in any part of Medicare (Part A, Part B, or both), they are no longer eligible to make contributions to an HSA. Because Medicare is not considered a high deductible health plan, The IRS prohibits contributions after Medicare enrollment.
Key timing note:
- Many people are automatically enrolled in Medicare Part A at age 65 if they are already taking Social Security benefits. This means their HSA contribution eligibility ends immediately.
- If a person delays Medicare enrollment (and Social Security benefits) while still working and covered by an employer-sponsored HDHP, they can continue contributing to their HSA until Medicare coverage begins.
Watch a YouTube video about Medicare and employer coverage
Using HSA Funds After Enrolling in Medicare
While contributions must stop, the good news is that HSA funds remain available for future use. Beneficiaries can use those dollars tax-free on a wide range of expenses, including many costs associated with Medicare.
Eligible Medicare-related expenses include:
- Medicare Part A, Part B, and Part D premiums
- Medicare Advantage (Part C) plan premiums
- Out-of-pocket costs like deductibles, copays, and coinsurance
- Dental, vision, and hearing expenses not covered by Medicare
- Prescription drugs (both covered and not covered by Medicare)
Important restriction: Beneficiaries cannot use HSA funds to pay for Medigap (Medicare Supplement) plan premiums.
Tax Benefits of Using an HSA with Medicare
- Tax-free withdrawals: As long as beneficiaries use funds for qualified medical expenses, withdrawals are tax-free.
- Penalty-free withdrawals after age 65: Even if funds are used for non-medical expenses, the 20% penalty is waived after age 65. However, the IRS taxes those withdrawals as regular income.
This flexibility makes HSAs a powerful retirement planning tool—especially for covering health costs, which typically rise with age.
Guidance for Medicare Agents
For agents advising clients, it’s helpful to remember:
- Ask about employer coverage: If clients are still working past 65 and covered under an HDHP, delaying Medicare could allow them to continue building HSA savings.
- Review timing carefully: Enrolling in Medicare Part A retroactively (up to 6 months) can affect HSA contribution eligibility and may trigger penalties if excess contributions are made.
- Highlight the benefits of saved funds: Even if contributions stop, those HSA balances can play a big role in covering Medicare premiums and out-of-pocket costs.
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Agents; stay updated on events and information.
HSAs and Medicare don’t work together in the traditional sense; contributions must stop once Medicare begins. But the funds already in the account can provide significant financial relief for medical costs in retirement. For Medicare beneficiaries, understanding the rules ensures they maximize both their HSA and Medicare benefits. For agents, this knowledge is another way to bring clarity and value to client conversations.
Final Rule CY 2026
On April 4, 2025, CMS released the final rule CY 2026, covering Medicare Advantage (MA), Part D (Prescription Drug Plans), Medicare cost plans, and Programs of All-Inclusive Care for the Elderly (PACE). In this post, we go over some key points of the CMS final rule 2026 to keep agents up dated.
Key Provisions
- Prescriber and Prior Authorization Adjustments: MA plans can only reverse inpatient admission approvals if there’s clear evidence of fraud or error, preventing sudden post-approval denial
- Appeals Expansion: Decisions affecting appeals now apply if made during, after, or before services begin
- Insulin & Vaccine Cost-Sharing Protections: No deductible and capped cost-sharing (either less than or equal to $35 or 25% of price) for insulin; rules go live in CY 2026. Adult ACIP recommended vaccines under Part D do not charge cost-sharing or a deductible.
- Medicare Prescription Payment Plan: Monthly OOP drug payment options become standard. Automatic renewals apply unless beneficiaries opt out.
- Medicare Drug Price Negotiation Program: Pharmacies must enroll in CMS’ data Module. PDE submission timeline for selected drugs is shortened to 7 days (was originally 30).
- Medical Loss Ratio (MLR) Changes: Certain federal subsidies (selected drug subsidy, IRASA, etc.) are excluded from MA/Part D calculations
- Payment Updates: MA plan payments increased by 5.06% on average. This raises carrier reimbursement by over $25 billion. Because of late year FFS data inclusion, the effective growth rate grew to 9.04%.
- Full phase-in of medical-education cost adjustments in MA risk model
What Didn’t Make it Into the Final Rule
- Anti-obesity medication coverage remains excluded.
- No finalized rule on AI guardrails or formal health equity assessments
Implications for Medicare Agents
Plan Design and Marketing Impact
The improved payment rates and stronger benefits (e.g., capped insulin costs, free vaccines) make MA/Part D plans more attractive to beneficiaries—enhancing your ability to recommend compelling, cost-effective options.
Client Conversations and Value Messaging
You can emphasize zero cost-sharing for critical needs like adult vaccines and insulin, and promote payment flexibility via monthly prescription cost installment plans—boosting engagement with clients, especially those on tight budgets.
Administrative & Compliance Updates
- Prepare for stricter documentation requirements, especially for prescription payment plans and MLR-related tracking.
- Expect increased scrutiny on marketing practices, including proof that compensation adheres to CMS limits.
Watch a YouTube video on CMS Medicare Final Rule Proposal 2026
Compensation Boosts (Broker Commissions)
Although not part of the CMS final rule, standard compensation data from CMS shows a significant increase in 2026:
- MA Plans:
- National initial commissions rise 10.9% (e.g., from $626 to $694).
- Renewal commissions up 10.9% (e.g., $313 to $347).
- In CT, PA, DC: initial rises to $781, renewal to $391
- View a more detailed commission explanation – click here
- Part D Plans:
- Initial commissions up 4.6% ($114).
- Renewal commissions up 3.6% ($57)
- Sponsoring organizations must submit these updated commission rates to CMS and maintain payment records.
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Summary Final Rule CY 2026
Capped insulin costs, vaccine cost-sharing elimination, and flexible payment options empower agents to provide more affordable, client-focused solutions.
Higher broker commissions reward agents, but with greater compliance expectations.
Marketing oversight and fiduciary responsibility pressures are rising; agents must prioritize ethics and accuracy in representation. Agents should stay vigilant; future enforcement or reform may impact compensation and operational protocols.
Stay updated on agent events and information
As an agent, your role is stronger than ever. Stay informed, compliant, and focused on client outcomes. Although 2026 promises to be a challenge, agents who put together a good strategy and work with integrity, can thrive while supporting clients’ health and financial well-being.
Part D Late Enrollment Penalties (LEP) Appeals: What Beneficiaries Need to Know
Missing the Medicare Part D Initial Enrollment Period (IEP) can lead to costly consequences. Medicare charges those who go more than 63 consecutive days without creditable prescription drug coverage Part D Late Enrollment Penalties. CMS will add the (LEP) to the Part D plan premium.
Fortunately, those who are assessed this penalty, have the right to appeal through the Part D LEP Reconsideration process. Here’s what beneficiaries and agents should know.
When Does the LEP Apply
A Late Enrollment Penalty is typically added when:
A beneficiary delays enrolling in a Part D plan during their Initial Enrollment Period, and they didn’t have other creditable coverage for 63 consecutive days.
If a Part D plan determines there is a lapse in creditable coverage, they must send a written notice explaining the penalty. This notice will include the LEP Reconsideration Request Form, which gives you the option to appeal.
Your Right to Appeal
When you receive a reconsideration notice, it will outline your right to request an LEP review. Either you or an authorized representative can file the appeal. The reconsideration form also lists examples of situations that may qualify for review.
Important: If a beneficiary receives Extra Help (Low-Income Subsidy), they do not have to pay the Late Enrollment Penalty at all.
Watch a YouTube video on the drug cap, please note; CMS adjusts the drug cap amount annually.
How to File an LEP Appeal
To request a reconsideration, you must complete the Part D LEP Reconsideration Request Form (C2C) and submit it through one of the following methods:
By mail:
- Standard mail – C2C Innovative Solutions, Inc.
Part D LEP Reconsiderations
P.O. Box 44165
Jacksonville, FL 32231-4165 - Courier/tracked mail – C2C Innovative Solutions, Inc.
Part D LEP Reconsiderations
301 W. Bay St., Suite 600
Jacksonville, FL 32202
By fax:
- 833-946-1912
Online submission (fastest option):
- Visit C2C Innovative Solutions to create an account and securely upload the completed form.
If someone such as a family member, doctor, or agent files the request on your behalf, they must be designated as your representative by completing the final section of the reconsideration form.
The Appeal Review Process
- LEP appeals are reviewed by an Independent Review Entity (IRE) contracted by Medicare.
- The IRE will notify you of their decision within 90 days of receiving your request.
- The outcome may include upholding the penalty, overturning it, or dismissing the request.
If you are a Medicare agent who is ready to join the team at Crowe, click here for online contract.
Key Takeaways
- Missing Part D enrollment without creditable coverage for more than 63 days can lead to an LEP.
- Beneficiaries have the right to appeal the penalty through a reconsideration request.
- Appeals can be filed by mail, fax, or online with C2C Innovative Solutions.
- Those who qualify for Extra Help never have to pay the LEP.
Understanding the appeals process helps beneficiaries avoid unnecessary costs and ensures fair review of their coverage history.
Agents: Educating clients about timely Part D enrollment and LEP appeals is an important way to protect them from unexpected penalties—and to strengthen your role as a trusted Medicare advisor.
Agents, stay up-to-date on events and information; click here to learn more.
SEPs for Medicare Part B Enrollment
For Medicare beneficiaries, the timing of enrollment is very important. While most people enroll in Medicare Part B during their Initial Enrollment Period (IEP) when they first become eligible, life circumstances don’t always fit neatly into those timelines. That’s where SEPs for Medicare Part B enrollment come in.
SEPs provide and opportunity for beneficiaries to sign up for Part B outside of their IEP or the GEP(General Enrollment Period), without facing late enrollment penalties, provided they meet certain conditions.
What is Medicare Part B
Medicare Part B helps cover outpatient care, doctor visits, preventive services, lab work, durable medical equipment, and more. Since it comes with a monthly premium, some people delay enrolling—especially if they’re still working and covered under an employer health plan.
When Can You Qualify for a Part B SEP
SEPs are designed to protect people who already had other coverage or experienced specific life events. Some of the most common situations include:
1. Employer or Union Coverage
- If you (or your spouse) are still working past 65 and covered by a group health plan, you can delay enrolling in Part B.
- Once that employment ends, or the employer coverage ends; you qualify for an 8-month SEP to sign up for Part B without penalty.
2. Coverage Through a Spouse
- If you’re covered under your spouse’s employer plan, the same SEP protections apply.
- This is important for individuals who retire before their spouse does, or vice versa.
3. Losing Other Creditable Coverage
- If you lose health insurance that’s considered “creditable” by Medicare standards (meaning coverage that’s at least as good as Medicare), you’ll likely qualify for an SEP.
Watch a YouTube video on Medicare enrollment periods
4. Special Circumstances (New Rules Starting in 2023)
CMS expanded SEPs to include situations such as:
- Emergency or disaster situations (declared by FEMA or other agencies).
- Employer or plan error where you were misinformed about enrollment.
- Medicaid coverage ending.
- Other exceptional conditions as determined by Medicare.
Forms you’ll need for a PArt B SEP enrollment
When enrolling in Medicare Part B during a Special Enrollment Period, most beneficiaries will need to complete two key forms:
- CMS-40B — Application for Enrollment in Medicare Part B (Medical Insurance); this is the standard enrollment form used to request Part B coverage. The beneficiary must complete this form.
- CMS-L564 — Request for Employment Information; this is the standard enrollment form beneficiaries use to request Part B coverage. It is completed by the beneficiary and their employer to verify that you had group coverage based on employment. Medicare uses it to confirm penalty free eligibility.
Please note: If your employer cannot fill out the CMS-L564, you can still submit it along with other proof of creditable coverage, such as pay stubs showing insurance deductions or health plan ID cards.
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Why SEPs Matter
Missing your enrollment period for Part B can lead to late enrollment penalties that increase your premium by 10% for each 12-month period you could have had Part B but didn’t enroll. These penalties usually last for as long as you have Medicare.
SEPs help people avoid those lifelong penalties if they had valid reasons for delaying enrollment.
Key Takeaways for Beneficiaries and Agents
- Always confirm whether an employer plan is considered creditable coverage before delaying Part B.
- Keep records of your health coverage and employment dates; Medicare often requires documentation.
- Complete both CMS-40B and CMS-L564 when applying for a Part B SEP.
- Educate clients that timing is everything. Even with an SEP, strict deadlines apply.
Agents stay up-to-date on events and information, click here.
Special Enrollment Periods give Medicare beneficiaries flexibility and protection when life events affect their coverage. Knowing the rules and having the right forms ready can save money, prevent penalties, and ensure continuous access to healthcare.
What Value Based Care Means
Healthcare has been shifting away from the “fee-for-service” model, and Medicare is at the center of that transformation. Traditionally, doctors and hospitals were paid based on the number of tests, procedures, or visits they provided, regardless of whether patients got healthier. What Value Based Care means is a little different. VBC rewards providers for improving patient health and keeping costs down.
The Basics of Value Based Care
Value Based Care is about quality over quantity. Instead of simply paying for services rendered, Medicare ties payments to outcomes such as:
- Better health results – like reduced hospital readmissions or better management of chronic diseases.
- Improved patient experience – including communication, accessibility, and overall satisfaction.
- Lower overall costs – through preventive care, care coordination, and reduced unnecessary treatments.
How Medicare Uses Value-Based Care
Medicare has introduced several programs and models to encourage providers to embrace VBC. Some of the key examples include:
- Accountable Care Organizations (ACOs): Groups of doctors, hospitals, and other providers who work together to give coordinated, high-quality care to Medicare patients. If they save money while meeting quality goals, they share in those savings.
- Bundled Payments for Care Improvement (BPCI): Instead of billing separately for every service, providers receive a single payment for an entire episode of care, like a hip replacement or heart surgery.
- Hospital Readmissions Reduction Program (HRRP): Hospitals receive rewards for keeping patients healthier after discharge and avoiding costly readmissions.
- Medicare Advantage Plans (MA): Many MA plans already use value-based arrangements with providers to improve preventive care and manage chronic conditions.
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Why Value-Based Care Matters
For Medicare beneficiaries, Value-Based Care means:
- More preventive services: Encouragement to get screenings, vaccines, and wellness visits.
- Better coordinated care: Doctors and specialists share information to avoid duplication and gaps.
- Healthier outcomes: The focus is on managing conditions and preventing complications, not just treating problems when they arise.
For the healthcare system overall, VBC helps reduce wasteful spending and ensures taxpayer dollars are used more effectively.
Watch a YouTube video on SEP changes for Dual, Partial Dual & LIS members
The Future of Value-Based Care
Medicare’s long-term goal is to have most of its payments tied to value instead of volume. This means more providers will be incentivized to deliver patient-centered care that is proactive, efficient, and focused on health rather than procedures.
Value-Based Care is Medicare’s way of rewarding healthcare providers for keeping patients healthier, not just for doing more. As this model continues to grow, beneficiaries can expect better care coordination, more preventive services, and a stronger focus on long-term health.