Due to the CMS’ Medicare Final Rule, changes have been made to both Part C and Part D Medicare Advantage commissions 2025. The CMS has tried to discourage plan providers from financially incentivizing agents to offer one plan over another using the following compensation rules:
- Prohibiting enrollment incentives that could cause potential agent bias
- Implementing fixed commission amounts for MA and PDP sales.
- Placing a cap on any non-salary agent compensation
- The elimination of separate admin fee payments by carriers
Medicare Advantage Commissions 2025: Notes
The increases listed below include the additional $100 payment for initial MA commissions and $50 payment for MA renewal commissions.
ADDITIONAL NOTE: A federal court in Texas stayed the provision of the CMS Final Rule that would add the additional $100 and $50 to the CMS max allowable compenstation due to two pending lawsuits. Depending on carrier interpretation, the changes created by the Final Rule may not be applied for the 2025 plan year. If they are not, the commissions listed below would be reduced by $100 initial and $50 renewal for all states and all products (MAPD and PDP)
In addition to the extra payment listed above, there was a commission increase due to an increase in the Fair Market Value (FMV) of MA and PDP plans. The maximum broker compensation below reflects the increase.
We assume carriers will add the additional $50 payment to current MA cases but that is not confirmed.
We also assume a number of PDP plans will not be paying commission in 2025. This is due to the additional $100 and $50 increase that will be applied to PDP plans. If carriers make a PDP plan “non-commissionable” they do not pay commission and do not pay the additional $100 and $50 payments.
Maximum commissions for Medicare advantage plans 2025
It is important to note: all commission rates are not the same. They vary by state they are available in.
In the sates of both CA and NJ, the initial commission rates have increased from $762 per member for the year to $880 per member for the year. This is an increase of 15.49% YOY. The renewal commissions for CA and NJ have gone up from $381 per member for the year to $440 per member for the year. This also adds up to an increase of 15.49%.
The states of CT, DC and PA have had an increase in initial MA commissions from $689 per member for the first year to $805 per member for the first year. This adds up to an increase of 16.84% YOY. Renewal commissions for CT, DC and PA have increased 16.81%. Renewal commissions will go up from $345 per member per year to $403 per member per year.
Both Puerto Rico and the U.S. Virgin Islands initial MA commissions have gone up from $418 per member for the year to $528 per member for the year, this amounts to an increase of 26.32% YOY. The renewal commissions have increased from $209 a member for the year to $264 per member for the year, this is equivalent to an increase of 26.32%.
In all other states not listed above, the initial MA commission amounts have increased 18.82% YOY from $611 per member for the year up to $726 per member for the year. Renewal commissions have increased at a rate of 18.63% from $306 per member for the year to $363 per member for the year.
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Maximum commissions for PDP plans 2024:
The commission rates for PDP plans are the same in all states.
Initial commission rates for PDP plans have gone up by 109% YOY. This means commissions have gone from $100 per member for the year to $209 per member for the year. Commissions for PDP plan renewals have also increased by 110% YOY. Commissions have now gone from $50 per member each year to $105 per member each year.
Medicare Advantage Commissions 2025: Side by side comparison
**See “ADDITIONAL NOTE” above regarding CMS max commission amounts
| Product | Region | 2024 | 2025 | % Increase | 2024 | 2025 | % Increase |
| MAPD | National | $611 | $726 | 18.82% | $306 | $363 | 18.63% |
| CT, PA, DC | $689 | $805 | 16.84% | $345 | $403 | 16.81% | |
| CA, NJ | $762 | $880 | 15.49% | $381 | $440 | 15.49% | |
| Puerto Rico, U.S. Virgin Islands | $418 | $528 | 26.32% | $209 | $264 | 26.32% | |
| PDP | National | $100 | $209 | 109% | $50 | $105 | 110% |
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Understanding ACA enrollment periods is crucial for agents offering the plans as well as for potential enrollees. We will go over the opportunities both individuals and families have to enroll in health coverage.
Open Enrollment Period
The Open Enrollment Period (OEP) is the primary time each year individuals and families can sign up for health insurance through the ACA marketplace. Each year, the OEP begins November 1st and ends on January 15th. In some cases, the enrollment deadline is extended for a specific reason.
Important dates:
November 1st – Open enrollment begins. Coverage starts January 1st.
December 15th – This s the last day to enroll in or change plans for coverage to start January 1st.
January 1st – Coverage begins for anyone who enrolled in a plan by December 15th nd paid their premium.
January 15th – Open enrollment ends; this is the last day of the year individuals/families can either enroll in or change healthcare plans without a Special Enrollment period.
February 1st – Coverage begins for those who enrolled between December 16th and January 15th and paid their first premium.
During this enrollment period, individuals/families can:
- Enroll in a new health insurance plan.
- Renew their current plan.
- Make changes to an existing plan.
Please note: Plans for those who use the OEP for enrollment begin on January 1st of the following year. Those who miss the OEP may not be able to enroll in or change their current plan until the next year’s OEP, unless they qualify for a Special Election Period.
Special Enrollment Period
The Special Enrollment Period (SEP) allows individuals/families to either enroll in or change health insurance plans outside the OEP. The SEP is available to those who experience specific life events.
These life events include:
Loss of health coverage: What qualifies as loss of health coverage; loss of either job-based coverage, Medicaid, or CHIP.
Changes in household: Here are examples of changes in a household; getting married or divorced, either having a baby or adopting a child, or a death in the family.
Changes in residence: This includes; moving to a different zip code or county, another state, or when you move to or from the place where you attend school.
Other qualifying events: Changes in your income (gains or losses) that affect the coverage you qualify for, gaining membership in a federally recognized tribe, becoming a U.S. citizen, leaving incarceration, or AmeriCorps members who are either starting or ending their service.
In most cases, the individual/family has 60 days from the date of the qualifying event to enroll in a plan through the SEP.
Medicaid and CHIP Enrollment
Medicaid and the Children’s Health Insurance Program (CHIP) offer free or low-cost coverage to millions of Americans, including qualifying low-income people, families and children, pregnant women, the elderly, and people with disabilities. Unlike marketplace plans, you can apply for and enroll in Medicaid and CHIP any time of the year. Remember; enrollment in either Medicaid or CHIP gives the enrollee an SEP for a marketplace plan.
If you are an insurance agent, here are some helpful links:
Click here to watch a video on Crowe ACA offerings for agents & agencies
Watch a demo of our ACA agent portal
Click here to add ACA to your Crowe contracts
Enrollment tips
- Mark Your Calendar: Keep track of important dates for the OEP and plan ahead to gather necessary documents and information.
- Check for SEP Eligibility: Those who miss the OEP, should check if they qualify for an SEP.
- Explore Medicaid and CHIP: If your income is low, you may qualify for Medicaid or CHIP, which have year-round enrollment.
- Compare Plans: Compare different plans available in the marketplace to find one that best suits your needs and budget.
- Seek Assistance: Navigating health insurance can be complex. Don’t hesitate to seek help from certified navigators, agents, or brokers.
Understanding and taking advantage of the ACA enrollment periods is essential to ensure you have the health coverage you need.
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Since the start of the introduction of the Affordable Care Act (ACA), there’s been a growing demand for professionals with the knowledge and skills to provide assistance to enrollees. ACA certification and training are one of the ways agents can stay up-to date on plan options and proper enrollment practices. This allows agents to help individuals make informed decisions and get access to healthcare.
Learn about our ACA sales contracting
Certifications agents need to offer ACA plans
Agents who want to offer ACA plans through the federal exchange site (healthcare.gov), must complete the FFM (Federally Facilitated Marketplace) certification. Although the ACA plans operate differently than Medicare does, the CMS also oversees ACA training. Agents complete this certification through CMS’ MLMS (Marketplace Learning Management System). One important thing to note; the FFM certification doesn’t cover insurance products sold through any of the state-based marketplaces.
FFM certification does not cover products sold in states that have their own state-based marketplace, The following states have state-based marketplaces that require agents to take their specific certifications:
CA – the state’s marketplace is Covered California
CO – the state’s marketplace is Connect for Health Colorado
CT – the state’s marketplace is Access Health CT
Please note: Access Health CT certification for 2024 for both Brokers and CACs is closing on July 31. Certification for Open Enrollment and for 2025 will start in September (Date TBA). Those who certify before 7/31 will need to certify again in September for 2025.
DC – the state’s marketplace is DC Health Link
ID – the state’s marketplace is Your Health Idaho
KY – the state’s marketplace is Kynect
ME – the state’s marketplace is CoverME
MD – the state’s marketplace is Maryland Health Connection
MA – the state’s marketplace is Health Connector
MN – the state’s marketplace is Mnsure
NV – the state’s marketplace is Nevada Health Link
NJ – the state’s marketplace is Get Covered NJ
NM – the state’s marketplace is beWellnm
NY – the state’s marketplace is New York State of Health
PA – the state’s marketplace is Pennie
RI – the state’s marketplace is HealthSource RI
VT – the state’s marketplace is Vermont Health Connect
VA – the state’s marketplace is Virginia’s Insurance Marketplace
WA – the state’s marketplace is Washington Healthplanfinder
When do agents need to complete certifications
Certifications for states on the Federal Exchange as well as many state-based marketplaces must be completed annually. However, although some state-based training, such as NY, is required every 2 years. When there are changes to the ACA, CMS provides updated training modules.
Find out why you should offer ACA plans through Crowe:
Watch a Youtube video on ACA contracting with Crowe and Associates
Click here to view a demo of our ACA portal for agents and agencies
FFM certification
Agents who need to complete FFM (Federally Facilitated Marketplace) can access CMS’s Enterprise Portal to complete their FFM certs. If you don’t already have an account, you can create one. Once you are in the portal, go to choose “Add Application” and click on the FFM/Request for MLMS Training Access and follow the instructions.
The states that require FFM training: AL, AK, AZ, AR, DE, FL, GA, HI, IL, IN, IA, KS, KY, LA, ME, MI, MS, MO, MT, NE, NH, NM, NC, ND, OH, OK, OR, SC, SD, TN, TX, UT, VA, WV, WI and WY.
New ACA agents vs. returning agents
Agents who are new to the ACA market must take the entire training course while returning agents can take a shortened version of the course.
New agents: click here for the CMS Marketplace training guide for 2024
Returning Agents: click here for CMS’ Marketplace training guide for 2024
The entire FFM certification consists of 10 training modules and four test; this takes a few hours to finish. A score of 70% or higher is required to pass the tests although agents who do not pass them can retake them. The refresher training only takes about an hour and a half to finish. There is no cost to the agent to take either course.
To check that CMS has updated your FFM cert status, use your NPN on the Agent and Broker FFM Registration Completion List (RCL), just enter your NPN to check. Please note, it may take a few days for CMS to update the system.
FFM certification assistance
CMS provides technical assistance for agent who experience issues while completing the FFM course. Call the Marketplace service desk at 1-855-267-1515 for portal password resets and issues as well as registration and training questions. Agents can also contact the help desk via email at: FFMProducer-AssisterHelpDesk@cms.hhs.gov
Offering ACA plans is a great way to grow your business and assist more members of your community.
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Each year, Medicare agents have to take several tests and certifications before they can offer products to their clients. This year, our AHIP 2025 test tips will help get you up and running for a successful 2025.
Most MA/MAPD and PDP carriers require agents to pass the AHIP although, UHC does not require it, they have their own certification. The 2025 exam is available starting June 24th, 2024. The 2025 AHIP covers any business you write for the rest of 2024 as well as through 2025.
Watch our YouTube video ” AHIP Test Tips 2025″
The AHIP is a CMS compliant course that is updated each year. This ensures the training is accurate as well as relevant to current CMS regulations. For this reason, the AHIP 2025 test tips is a great tool for agents to use and complete the AHIP successfully.
Please note: In order to pass the exam, you must receive a grade of 90% to pass the exam. Agents have 2 hours to complete the exam and have 3 attempts to pass. The exam consists of 50 multiple choice questions. Those who do not pass after the third attempt, must pay for and retake the course.
Important; if you do not pass in the first 3 attempts, some carriers will not allow you to market their products for the year.
New agents who want to join the team at Crowe; click here for online contracting
If you are a Crowe agent who wants to add a carrier to your existing contract; click here
The cost for AHIP:
AHIP course and exam has a cost of $175. Agents can get a $50 discount by taking it through one of the major carrier’s sites (UHC, Aetna, Humana, etc.). Any agent who is part of the Pinnacle financial team can also receive are a $50 discount as well. All you need to do is go to pfsinsurance.com sign in, click on certifications tab and then the AEP Toolkit; from there you scroll down and see a link for the:
Click here for the Pinnacle AHIP discount
Please note; the 2025 AHIP is very similar to the 2024 AHIP
There are some new concepts and rules you need to be aware of. Click on the link below to watch our video and learn more:
Here is what the AHIP covers:
The first part consists of 5 modules
- Medicare basics; fee-for-service and eligibility as well as benefits
- The different types of Medicare Advantage & prescription drug plans (Part D)
- Who is eligible and what is covered
- Nondiscrimination training
- Requirements for marketing and enrollment of Medicare Advantage as well as Part D/PDP plans
It is important to download each module once you are in it. This is suggested to help you complete the test later. If you took the 2024 AHIP, you only need to click through the slides on modules 4 & 5. We recommend clicking on modules 1-3 so you can download the content. It is also not a bad idea to complete the practice tests at the end of ALL modules; many of those questions will be on the test.
Each module has a 20 question practice test at the end. Pay attention to the practice questions; most of the test questions come from there.
Once you finish all modules and the exam, do not forget to take the second part of the AHIP.
The second part covers fraud, waste, and abuse
- Learn how to spot fraud, waste, and abuse (FWA)
- Find out what the Medicare industry is doing to detect fraud
- What are the legal tools that combat FWA
- Understand the human as well as the financial cost of fraud waste and abuse
- Review general compliance requirements for Medicare Parts C and D fraud, waste, and abuse.
- Find out who commits fraud, waste, and abuse
- What are loophole and obligations to reporting fraud, waste and abuse
Once you successfully complete everything, remember to download your AHIP certificate. In some cases, carriers allow you to transmit your score directly from the AHIP site, but some require you to upload it into their dashboards yourself.
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If you are in Medicare sales, I am sure you have heard many uplines are adding ACA contracts. We will go over some reasons to add ACA health insurance sales to your business.
The Affordable Care Act (ACA) provides healthcare options for millions of Americans. Additionally, healthcare agents have an opportunity to make a difference in the lives of many individuals who need healthcare.
ACA Health Plans
The ACA introduced reforms to improve access to healthcare and enhance the quality of coverage. Health Insurance Marketplace and ACA-compliant health plans must adhere to standards, such as covering essential health care services and prohibiting discrimination based on pre-existing conditions. Subsidies and tax credits provided by the ACA, make health coverage more affordable for eligible individuals and families. To learn more about the ACA, visit healthcare.gov.
Reasons to add ACA health insurance sales
Providing access to necessary healthcare services
ACA health plans are crucial to many underserved individuals who otherwise do not receive the care they need. This is especially true in many low income communities. Agents helping individuals find affordable coverage options and the expansion of Medicaid eligibility, are both ways to ensure more people have access to medical care.
Protecting enrollees
Plans that comply with ACA regulations protect enrollees from the high cost of medical treatment and coverage denials. Selling these plans allows agents to advocate for their clients’ interests and guide them towards the best options for their coverage needs and budget.
Financial benefit
Agents who offer ACA health plans have the ability to earn commissions as well as various sales incentives. Because there are thousands of people who need coverage and the demand continues to grow, there is a real need for qualified professionals who can navigate the complexities of the insurance enrollment process.
If you are an agent who wants to get set up to offer ACA plans, click here to learn more
Certifications and Training:
Selling ACA health plans requires a solid understanding of healthcare regulations, insurance products, and customer needs. Although there are not as many certifications with the ACA as in the Medicare world, there are trainings and credentials required that vary by market and carrier. A few things agents need to have before they offer ACA plans:
- Health Insurance License: Obtaining a state-issued health insurance license is a prerequisite for selling ACA health plans. This license demonstrates your understanding of insurance laws and regulations, as well as your commitment to ethical sales practices.
- E&O Insurance: Agents need to have a valid certificate of E&O insurance to cover themselves for any mistakes they make that could prompt legal action by the client.
- ACA Marketplace Training: The Centers for Medicare & Medicaid Services (CMS) offer training courses for agents and brokers seeking to assist consumers with Marketplace enrollment. These courses cover topics such as eligibility determination, plan selection, and enrollment assistance.
Watch a few YouTube videos on the ACA:
Find out what Crowe has to offer ACA agents and agencies
Learn more about ACA contracting
Watch a demo of what our ACA portal has to offer
Why offer ACA plans
For those agents looking to make a positive impact on people’s lives while building their business, selling ACA health plans could be the perfect fit for you. Medicare agents can use this opportunity to build a long-lasting relationship with your client. This will lead to a greater trust and knowledge of the client’s needs and wants for coverage and can lead to more Medicare leads in the long run.
By demonstrating competency and commitment to providing good service, agents can become a trusted resource in the community for various types of healthcare coverage.
Find Out More
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Crowe and Associates offers ACA agent sales contracting with a number of carriers. In addition, we have the ability to pay overrides to accommodate agencies with sub agents. All commissions are paid at full street level or above and the agent/agency owns the book of business. Our agent and agency partners can access a number of benefits including an agent specific admin portal, contracting support, enrollment portals and commission overrides.
Watch a 5 minute video review all our ACA program benefits for agents and agencies
ACA carriers available to contract
Agents have access to 20+ ACA carriers in all 50 states. Carriers include Anthem, Oscar, Ambetter, Aetna, Cigna, Molina, Medico, UHC, multiple BCBS organizations and a number of other carriers. We are adding additional carriers on an ongoing basis and are always open to inquiring with suggested carriers our partners need.
ACA Agent sales contracting
CLICK HERE FOR CONTRACTING
ACA Agent commissions
All agents are contracted to receive full street commission offered by each company. We do not reduce or keep any portion of an agents compensation. Agents will also receive 100% of any agent level bonus payments that may be available. (Not all carriers pay a bonus and some only do in certain states)
Agents will receive compensation directly from the carrier. Some carriers do not pay commissions directly to agents. When that is the case, we will pay the commissions and any applicable bonus payments to the agent.
Agents own the book of business and will continue to receive all commissions even if they go to another upline or move direct to a carrier
Carrier bonuses and bonuses specific to our agents
Agents will receive 100% of any carrier specific bonus programs. We also have bonus programs specific to agents with our agency. For example, we have an exclusive Anthem bonus that is available exlusively to our agents for 2024
Tier 1- 20 – 49 new members – $100 per member
Tier 2- 50+ new members – $150 per member
Agent and agency portal
All agents and agencies will have access to a personalized admin portal. The portal will provide acces to a number of features including: Applications, current book of business, commissions, contracting status, street commission amounts by carrier and state and training information and videos.
Agencies will have access to an admin version of the portal which will show production, contracting and commissions for all sub agents and agencies
Override payments for agents and agencies
We have the ability to pay agencies overrides above the street level commission. Overrides are paid on the same schedule as commission on a PMPM basis. Agencies looking for current override amounts should contact us to discuss what is available
Are you a Medicare agent? Learn about our programs and benefits for Medicare agents
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In general, Medicare is an affordable way for qualified individuals to receive healthcare coverage. However, there are some Medicare costs both agents and beneficiaries need to understand.
Plan Premiums
Premiums are a monthly fee the beneficiary pays for Medicare coverage.
Part A premiums
Although most beneficiaries do not pay a premium for Part A as long as they have worked for a Medicare-taxed job for a period of at least 10 years (40 quarters). In 2024, the premium for those who do not qualify for free Part A are between $278 to $505 monthly. The amount is based on the number of quarters the beneficiary or their spouse worked and paid Medicare taxes.
Part B premiums
Unlike Part A, almost everyone pays a Part B premium with the exception of those who meet certain income and asset levels and qualify for extra help. In general, most beneficiaries pay a standard amount for Part B. In 2024, the Part B premium amount is $174.70, although this amount may be adjusted according to each beneficiary’s income level. Those who earn over a specific thresh hold will pay an additional amount (IRMAA).
Part C (Medicare Advantage)premiums
Part C plans offer a variety of premiums, although many provide coverage for $0. The premium amount is based on the beneficiary’s location and plan availability. Please note; an IRMAA can also apply to a Medicare advantage plan if it includes Part D coverage.
Part D premiums
Similar to Part C premiums, the cost for Part D coverage varies by plan and coverage area. The national base beneficiary premium for 2024 is $34.70 per month. This is just a general premium amount CMS uses to calculate LEP penalties and not an actual premium amount. Premiums actually vary from $0 up to over $100 per month. Similar to Part B, individuals may pay a higher rate if they qualify for an IRMAA.
Find out how ancillary health insurance can cover some of the gaps in coverage.
IRMAA (Income Related Monthly Adjustment Amount)
An IRMAA is an additional amount CMS adds to the beneficiary’s monthly premium amount for Part B and Part D if their income exceeds the threshold amounts set by Medicare each year. The IRMAA is based on the individuals tax return from 2 years prior.
Click here to learn more about the income brackets for IRMAA 2024
LEP (Late enrollment penalty)
There are specific times beneficiaries must enroll in Medicare coverage. These are enrollment periods. If the beneficiary misses their enrollment period, they may pay an LEP. Medicare will add the penalty to their monthly premium.
Watch a YouTube video on OEPs, SEPs and Late Enrollments
Part A LEP
The LEP only applies to those who do not qualify for premium free Part A. Those who do not enroll on time have to pay a 10% higher Part A premium. Medicare applies the penalty for twice the number of years the beneficiary was eligible but didn’t enroll in Medicare. This means, if the beneficiary was eligible for Medicare but didn’t sign up for 3 years, they would pay an additional 10% for their Part A premium for 6 years.
Part B LEP
This penalty adds 10% times the number of years the beneficiary did not enroll in Medicare to the monthly premium and applies as long as the beneficiary has Medicare. In other words, if the beneficiary signs up for Medicare 3 years late, they pay 30% more for their premium. However, if they are actively working or have coverage through a spouse who is working, they can delay Part B enrollment without an LEP. Once they stop working, they qualify for an SEP and are eligible to enroll in Part B.
Part D and Part C plans that include drug coverage LEP
The LEP for Part D or Part C plans that include prescription drug coverage is 1% of the national base premium (this premium changes annually), multiplied by the number of months the beneficiary was eligible and did not enroll. This penalty is similar to the Part B penalty, because it lasts as long as the individual is enrolled in Medicare Part D. The federal government uses the standard rate (national base premium) to calculate Part D penalties not the individual’s actual plan premium. If the beneficiary delays Part D enrollment because they have another creditable drug plan, the penalty doesn’t apply to them.
Deductibles
Enrollees pay a deductible each year before their plan pays it’s portion of covered medical expenses.
While other Medicare plans have annual deductible, the deductible for Medicare Part A is $1,632 for each inpatient hospital stay. An individual could pay this deductible more than once a year depending on how many times they are admitted to the hospital. Each hospital admission counts as a new benefit period, unless the beneficiary is readmitted before the end of the benefit period. Each benefit period ends 60 days after the enrollee is discharged.
Both Part B and Part D plans have one annual deductible. The Part B deductible is $240 in 2024. Although Part D deductibles vary according to plan, Medicare puts an annual limit on the maximum deductible allowed; in 2024 the maximum deductible is $545.
Copays and coinsurance
Both copays and coinsurance are fixed amounts the beneficiary pays for covered services or medications. These amounts apply after the beneficiary pays the deductible.
Part A coinsurance and copays
Once the beneficiary is in the hospital for over 60 days, they pay a coinsurance amount of $408 per day in 2024 for days 61 to 90. If the beneficiary is in the hospital for over 90 days, they can use some or all of their 60 lifetime reserve days. In 2024, each of these days cost $816. Each beneficiary qualifies for 60 reserve days for their lifetime. Once the beneficiary uses them all, they pay the entire remaining cost of their hospital stay.
Part A pays the first 20 days in a skilled nursing facility, once the beneficiary goes over the 20 days, they pay $204 per day for days 21-100. After day 100, the beneficiary is responsible for all costs. Many beneficiaries apply for Medicaid if they qualify, once they exhaust the Medicare coverage.
Part B coinsurance and copays
Part B normally provides coverage for 80% of approved Medicare expenses. That leaves the beneficiary with the remaining 20%. However, Medicare fully covers most preventative visits. Beneficiaries pay a higher co-insurance amount if their provider does not accept Medicare assignment.
Supplemental insurance can cover the 20% co-insurance cost and some of the copays with original Medicare. Click here to learn more.
Part C coinsurance and copays
Because Medicare Advantage plans work differently than Original Medicare, the coinsurance and copays work in a very different way. Medicare advantage plans use a specific network of providers who agree to accept the terms of payment. Each plan has it’s own co-pay amounts for doctor and specialist visits. Some plans provide coverage for visit to out of network providers at a higher cost share amount.
Each plan also has an out of pocket maximum. Once the beneficiary reaches this amount, the plan pays 100% of their approved medical costs.
Part D coinsurance and copays
Part D copays and coinsurance can vary quite a bit from one plan to another. That is why it is important to check all medications and cost sharing amounts before choosing a plan. In general, the cost for a prescription is higher for brand-name medications especially if they are on a higher tier in the plans formulary. If the beneficiary uses medications that are not on the formulary, they may have to pay the full costs of the medication.
There are other factors that decide the cost of medications such as the deductible, tier, the coverage gap and the catastrophic phase of coverage. Although there are changes coming in 2025 that will alter some of those cost shares. Plan enrollees should check their plan every year to ensure they are on the best plan to meet their coverage and budgetary needs.
Click here to learn about the Part D changes for 2025
Providers who don’t participate in Medicare
It is important to note: Not all doctors participate with Medicare. In some instances (rarely, but some), a provider has opted out of Medicare and does not accept Medicare as payment. This means the patient is responsible for paying any fees for service out of pocket.
Find out what Medicare Advantage plans don’t cover
As you can see, there are many potential costs associated with Medicare plans. We have not listed all of them. It is important to check the summary of benefits or evidence of coverage each year to ensure enrollment in the best plan option for each individual situation. A licensed Medicare agent can provide invaluable insights into plan choices and coverage options.
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There are a few different terms people use for supplemental Medicare insurance such as; Medigap, Medicare Supplement or Med Supp. Private insurance companies offer these health insurance policies to individuals who are eligible for Medicare coverage. In general, Medicare covers about 80 % of approved medical charges. Medicare supplement plans are designed to cover the 20% of approved medical charges not covered by Original Medicare. Essentially, Medicare supplement policies help reduce out-of-pocket costs. This ensures healthcare costs are predictable and manageable.
Why choose a Medicare Supplement
Although Original Medicare provides substantial coverage, it doesn’t cover everything. Here are some reasons to consider a Medicare Supplement:
Out-of-Pocket Costs: Original Medicare requires beneficiaries to pay for a percentage of their approved medical expenses. Because these can add up quickly, especially if you have frequent medical needs, a Medicare supplement pays these costs and saves enrollees money.
Find out more about Medicare costs
Foreign Travel: In general, Original Medicare doesn’t cover healthcare services outside the U.S.. Although some Medicare supplement plans provide coverage for emergency medical care during foreign travel.
Predictable Expenses: With a Medicare supplement plan, enrollees have predictable medical expenses, making it easier to manage their healthcare budget.
No Network Restrictions: Medicare supplement plans do not have network restrictions, this allows individuals to see any doctor or specialist that accepts Medicare.
Supplemental Medicare insurance plans
There are ten standard Medicare supplement plans, labeled A through N. Each plan provides a different level of coverage. The plan benefits of each plan letter are standardized, meaning Plan A from one insurance carrier offers the same benefits as Plan A from any other insurance carrier. These benefits are universal and don’t change by location. Although, plan availability varies by location. Insurance carriers do not offer all plans in every state.
Here is a basic over view of plan benefits:
- Plan A: This plan provides basic benefits, covers coinsurance and hospital costs (up to 365 additional days after Medicare benefit is used).
- Plan B: Benefits Include all the Plan A benefits plus it covers the Medicare Part A deductible.
- Plan C: Covers all of Plan B as well as skilled nursing facility care coinsurance and foreign travel emergency and also covers the Part B deductible.
- Plan D: This plan is similar to Plan C , although it does not cover the Part B deductible.
- Plan F: Provides comprehensive coverage, including the Part B deductible. Please note; this plan is no longer available to anyone who is eligible for Medicare after January 1, 2020.
- Plan G: These plans provide coverage very similar to Plan F although, they do not cover the Part B deductible.
- Plan K and L: Both these plans offer lower premiums but higher out-of-pocket costs, with coverage limits.
- Plan M and N: Plans provide a good cost-sharing option for specific benefits and lower plan premiums.
Click here to view a comparison chart of Medigap plans
Choosing the Right Plan
Selecting the right Medicare supplement plan requires careful consideration of both health needs and finances. Things to consider when choosing a plan. Please consider using the services of a licensed Medicare agent when making important health coverage decisions. This will ensure you have all the information you need to make an informed choice.
Assess Your Health Needs: Consider your current health status and any anticipated medical needs. If you require frequent medical services, a plan with more comprehensive coverage might be beneficial.
Budget Considerations: Evaluate your budget for monthly premiums versus out-of-pocket costs. Higher premiums generally mean lower out-of-pocket expenses.
Compare Plans: It is a good idea to use the services of a licensed Medicare agent when making important health coverage decisions. In most cases, they can access tools that can provide a comparison of the plans available in your area. This ensures you have all the information you need to make an informed choice.
Watch a YouTube video comparison of our quoting tools Sunfire vs Connecture
Check for Special Benefits: Some plans offer additional benefits, such as foreign travel emergency coverage or even a fitness benefit.
If you want to learn some of the differences between a Medicare Supplement and an Advantage plan, click here.
Enrollment Periods
The best time to buy a Medicare supplement policy is during your Open Enrollment Period, which starts the first month you have Medicare Part B and are 65 or older. During this period, you have a guaranteed issue right, meaning insurers cannot deny you coverage or charge higher premiums due to pre-existing conditions.
Always remember to meet with your agent each year to review your options and adjust your plan as your healthcare needs change.
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Because many people on Medicare require additional help at some point it is important to understand Medicare and home healthcare coverage. The main goal of home healthcare is help individuals recover from an illness or injury and regain independence.
Eligibility
In order for a beneficiary to qualify for home healthcare services under Medicare, the following criteria must be met:
- A doctor or another licensed healthcare provider must have a face-to-face meeting with the beneficiary and certify that they require home health services.
- The beneficiary must require part-time/intermittent skilled nursing care, physical therapy, occupational therapy or speech-language pathology services.
- Patients must be homebound. In other words, it is difficult for them to leave the house without help due to their condition.
- A Medicare certified home healthcare agency must provide the care.
Services Medicare covers
Once the eligibility criteria are met, Medicare covers many home health care services, including:
- Skilled Nursing Care: Provided on a part-time or intermittent basis.
- Therapy Services: Physical, occupational, and speech-language therapy to aid in recovery and rehabilitation.
- Home Health Aide Services: Assistance with personal care on a part-time basis if the patient is also receiving skilled care.
- Medical Social Services: Counseling and help finding community resources.
- Medical Supplies: Certain medical supplies like wound dressings.
- Durable Medical Equipment (DME): This includes equipment such as walkers or wheelchairs.
Services Medicare does not cover
- Full-time care: 24-hour-a-day care at home.
- Meals: Meals delivered to the home.
- Homemaker services: Medicare dose not cover services such as; shopping, cooking or cleaning if they are the only services needed.
- Personal care: If this is the only care required, Medicare will not pay a home health aide to provide basic personal care services such as bathing, dressing or using the bathroom (activities of daily living).
How to set up home healthcare services under Medicare
- Make an appointment with your doctor or healthcare provider to go over your health needs and establish if home health care is a good choice.
- Be sure you see your doctor face-to-face as required by Medicare.
- Ask your doctor or insurance provider to help you find a Select a home health agency that is certified by Medicare.
- Work with your doctor and the home health agency to develop a plan of care to fit your specific needs.
How Original Medicare covers home healthcare costs
In most cases, individuals enrolled in original Medicare pay nothing for covered home healthcare services. Although, there is a cost for DME durable medical equipment. In general, Medicare covers 80% of the approved amount while the individual is responsible for the remaining 20%.
Part A: Typically covers home health care services after the beneficiary has been in the hospital for a period of 3 days or more.
Part B: Covers home health services without the requirement of a prior hospital stay.
Watch a YouTube video the difference between Medicare Supplements and Medicare Advantage
Medicare Advantage Plans and Home Health Care
Medicare Advantage plans (Medicare Part C), are an alternative to Original Medicare. Private insurance companies that are approved by Medicare offer these plans. They must provide the same benefits as Medicare Part A and Part B. Many Medicare advantage plans also offer additional benefits that original Medicare does not cover, such as vision, dental, wellness programs, OTC as well as rides to medical appointments.
How Medicare Advantage plans cover home healthcare costs
Although Medicare Advantage plans must cover at least the same level of home health care services as Original Medicare, there are a few things you should know:
- Network Restrictions: Unlike Original Medicare, Medicare Advantage plans often have network restrictions. Beneficiaries of most plans need to use home health agencies that are in the plan’s network.
- Prior Authorization: Some Medicare Advantage plans require prior authorization for home health services. In other words, beneficiaries need approval from the plan before they receive certain services.
- Additional Benefits: Many MA plans offer extra benefits beyond what Original Medicare provides. These could include additional support services, like caregiver support, home modifications, or wellness programs.
- Cost Structure: Although Medicare Advantage plans must cover home health care at least as well as Original Medicare, the cost structure (copays, coinsurance, and deductibles) may be different. It’s important to understand your plan’s specific costs.
Find out how to cover the gaps left by Medicare advantage plans
Medicare’s home health care coverage can significantly benefit those who need medical care in the comfort of their own home. Understanding the eligibility criteria, the types of services covered, and how to initiate these services ensures that beneficiaries receive the appropriate care while minimizing out-of-pocket expenses.
Please note: before choosing a Medicare plan, it is best to consult a licensed healthcare agent to get accurate, personalized plan information.
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Agents and beneficiaries need to understand the actual cost of any healthcare plan they are considering. That being said; we will explain deductibles vs out of pocket maximums and how they apply to your clients’ coverage.
Many health insurance plans have both a deductible as well as an out of pocket maximum. Both terms refer to a specific amount the beneficariy must pay each year before their insurance provides a specific level of coverage. Once the enrollee meets the dedcutible, the insurance plan pays the specified portion of eligible cost. On the other hand, once the enrollee meets the the out of pocket maximum, the insurance plan pays the entire cost for all covered services.
Deductibles
The amount an enrollee pays out of pocket for eligible services before the insurance plan covers their portion of the costs is a deductible. The amount of the deductible varies by plan and is specified in the summary of benefits or evidence of coverage for each plan.
Keep in mind, each type of coverage has it’s own deductible, for example; Medicare Part B, has one specific annual deductible for all enrollees. Medicare Part A has a hosptial deductible that the enrollee must meet each time they are admitted into the hospital (except in specific situations). Many Part D (prescrption drug plans) have an annual deductible that varies depending on the plan.
Find out about Medicare costs for 2024
Out of pocket maximums
An out-of-pocket maximum is the most a beneficiary pays out of pocket annually for covered healthcare expenses. Once the beneficiary reaches this limit, their insurance plan covers 100% of the costs of covered benefits. Deductibles, copays, and coinsurance are all included in this amount. It does not include expems premiums, balance-billed charges, or services that Medicare does not cover.
Learn more about out of pocket maximums
Additionally, several types of payments count towards the out of pocket maximum including; deductibles, copays and coinsurance. The plan’s monthly premium does not count toward the out of pocket maximum.
Please note; Original Medicare and supplements do not have an out of pocket maximum.
Additional information
Each year the deductible amount is subject to change. The deductible does not apply to many preventative services, such as annual check-ups, immunizations and vaccines. Most insurance plans cover these serices at 100%.
For those enrolled in a healthplan with a deductible and an out of pocket maximum, the amount paid toward the deductible applies to the maximum out of pocket cost. They continue to pay copays and coinsurance costs until they reach the out of pocket maximum.
Consider all costs before choosing a plan
There are many plans available with different deductibles and out of pocket maximums. That is why it is important for individuals to be aware of all costs associated with the plan they choose. A licensed insrance agent can help provide a comparison of plans that offer the coverage and costs each beneficiary is looking for. Each year during AEP, Medicare beneficiaries have an opportunity to meet with their agent to review their plan cost and coverage and make any changes necessary.