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Preparing for AEP 2026: Boost Your Sales, Retain Clients, and Grow Your Book

The 2026 Annual Enrollment Period (AEP) isn’t just another enrollment season; it’s a golden opportunity to build stronger client relationships and grow your business. With more non–commissionable Prescription Drug Plans (PDPs) and Medicare Advantage (MA) plans in the market, preparing for AEP 2026 is more difficult than ever.

Here’s how you can maximize earnings, protect your clients, and position yourself as the go-to Medicare resource this AEP.

Turn Non-Commissionable Plans Into Revenue Opportunities

Yes, some PDPs and MA plans won’t pay you. But don’t let that stop you from helping your clients:

• Be the expert they trust. Walk them through all available options; even the ones you don’t get paid for. This honesty builds loyalty and keeps them coming back every year.
• Leverage the conversation. Once you’ve solved their drug plan or MA needs, introduce other solutions that can better protect them and generate income for you.
• Think lifetime value, not one commission. The client you help today (even for free) could be the one who buys a Medigap plan, final expense policy, or ancillary product tomorrow.

Promote Medicare Supplements

Medicare Supplements are a powerful tool for agents looking to grow their book with long-term, commissionable business.

• High Deductible Plan G (HDG): Sell the benefits of lower premiums, network freedom, and great cost protection once the deductible is met. Perfect for healthy, budget-conscious clients.
• Plan G or Plan N: Offer predictable out-of-pocket costs and peace of mind. Great for clients leaving MA plans or worried about networks shrinking.
• Target switching opportunities: Use the Medigap Open Enrollment period, guaranteed issue rights, and birthday rules where available to win new clients.

Cross-Sell Ancillary Products to Increase Income

Every client interaction is a chance to protect more of their health and finances. Cross-selling not only grows your revenue; it keeps competitors out of your book.

Products to focus on this AEP:

• Hospital Indemnity Plans – Cover MA plan hospital copays and reduce client financial stress.
• Cancer, Heart & Stroke Policies – Offer lump-sum protection for serious illness expenses.
• Dental, Vision & Hearing Plans – Fill in coverage gaps Original Medicare doesn’t touch.
• Final Expense Life Insurance – Help clients plan for end-of-life costs and leave a legacy.

Watch a YouTube video – Why and how to sell ancillary with Medicare in 5 minutes

Strengthen Client Retention with Education

AEP isn’t just about selling — it’s about proving you’re the trusted Medicare expert year-round.

• Send an AEP prep email or postcard to let clients know you’ll review their coverage.
• Host a quick webinar or local seminar on “What’s New for 2026.”
• Offer annual policy reviews to make sure they’re always in the best plan for their situation.

Education keeps your name top of mind and positions you as the advisor they call before making a move.

The agents who win this AEP will be those who combine client-first service with smart product recommendations. Help with the non-commissionable PDPs and MA plans, but don’t stop there; present Medigap, HDG, and ancillary products that protect your clients’ health and finances while boosting your bottom line.

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Your clients get better coverage, you get stronger renewals, and your book of business grows. That’s a win-win AEP strategy.

The Medigap Birthday Rule: A Unique Opportunity for Medicare Beneficiaries

If you or your clients have a Medicare Supplement plan (Medigap), there’s a little-known rule that can save money and improve coverage and it’s called the Medigap Birthday Rule. This rule is an excellent opportunity for beneficiaries to switch Medigap plans without going through medical underwriting, but it only applies in certain states and during a very specific timeframe. Here’s what you need to know.

What Is the Medigap Birthday Rule

The Medigap Birthday Rule is a state-level regulation that allows Medicare beneficiaries to switch to another Medigap plan with equal or lesser benefits each year around their birthday, without answering health questions or going through medical underwriting.

Normally, after the initial Medigap open enrollment period (which happens when someone first signs up for Medicare Part B), switching Medigap plans could require underwriting; meaning the insurance company can deny coverage or charge more based on health history. The Birthday Rule removes that barrier, making it easier for people to shop for a better premium or a different carrier’s plan.

How the Rule Works

The details of the rule depend on the state you live in, but generally:

• Eligibility: You must already have a Medigap plan in place.
• When You Can Switch: You have a short window each year, usually starting on your birthday (some states give you up to 60 days, others 30).
• What You Can Switch To: You can move to a Medigap plan with the same or lesser benefits; for example, switching from Plan G with one company to Plan G with another, or from Plan F to Plan N.
• No Underwriting: You don’t have to answer health questions, so pre-existing conditions won’t prevent you from switching.

Watch our YouTube video on Medicare Supplement underwriting

States That Offer the Birthday Rule

As of 2025, the Medigap Birthday Rule is available in several states, including:

• California
• Oregon
• Illinois
• Nevada
• Idaho
• Louisiana
• Kentucky (newer version of the rule)

Each state’s version is slightly different, so it’s essential to check the exact length of the switching window and eligibility criteria.

Why the Birthday Rule Matters

For beneficiaries, this rule can mean:

• Lower Premiums: Shop for the same coverage at a better price.
• More Carrier Choices: If you’re unhappy with your current insurer, you can switch without worrying about being declined.
• Guaranteed Access: People with health issues who might otherwise be denied coverage can still change plans.

Tips for Agents

If you’re a Medicare agent, the Medigap Birthday Rule is a perfect client retention opportunity:

• Reach out proactively before a client’s birthday to review their coverage.
• Shop carriers and rates to see if they can save money without losing benefits.
• Build trust by showing clients you’re looking out for their financial well-being.

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This annual touchpoint can strengthen your book of business and help you stay top-of-mind with clients.

The Medigap Birthday Rule is a valuable consumer protection that gives beneficiaries a yearly chance to make their coverage more affordable; no health questions asked. If you or your clients live in a state that offers it, don’t miss this opportunity. Mark those birthdays on the calendar and be ready to take advantage of this unique enrollment period.

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Why Sell Critical Illness Insurance

When it comes to protecting clients from financial hardship, health coverage alone isn’t always enough. The big question is; why sell critical illness insurance. The answer is: as an insurance agent, you already know the cost of a serious illness can go far beyond hospital bills. That’s where this insurance comes in. Offering this valuable coverage to your clients not only strengthens their financial safety net, but also helps your business grow.

What Is Critical Illness Insurance

Critical illness insurance is a supplemental policy that provides a lump-sum cash benefit if the policyholder is diagnosed with a covered illness such as:

• Heart attack
• Stroke
• Cancer
• Organ failure
• Major surgery

Unlike health insurance, which pays doctors and hospitals, critical illness insurance puts money directly in your client’s hands to spend however they need.

Why Agents Should Offer It

Fill a Major Coverage Gap

Even clients with excellent health insurance can face substantial out-of-pocket costs; deductibles, co-pays, non-covered treatments, travel expenses for care, and lost income during recovery. Critical illness benefits can bridge that gap, giving clients peace of mind.

Protect Clients’ Financial Well-Being

A major diagnosis can derail a family’s finances. This coverage can help with:

• Mortgage or rent payments
• Childcare
• Utility bills
• Transportation to treatment
• Alternative or experimental treatments not covered by insurance

Helping your clients plan for these “hidden” costs builds trust and shows you care about their full financial picture.

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Create a New Revenue Stream

Critical illness policies are generally affordable and easy to quote. Adding them to your portfolio can boost your sales without requiring significant additional effort. Many carriers offer simplified underwriting and electronic applications, making the process smooth for both you and your clients.

Cross-Sell Opportunities

Critical illness coverage is a natural add-on for clients purchasing:

• Health insurance
• Medicare Advantage or Supplement plans
• Life insurance
• Disability income insurance

By bundling solutions, you create a comprehensive protection plan and increase client retention.

Watch a quick YouTube video on why sell ancillary products with Medicare

Stand Out from Competitors

Many agents overlook supplemental health products. Offering critical illness insurance shows that you go beyond the basics and are committed to providing complete risk protection for your clients.

Positioning Critical Illness Insurance with Clients

When discussing this coverage, focus on real-life scenarios and emphasize flexibility:

• “If you were diagnosed with cancer tomorrow, would you have enough savings to cover your expenses while you focus on getting better?”
• “This policy gives you cash you can use however you want – not just on medical bills.”

Simple, empathetic conversations often lead to meaningful sales.

Selling critical illness insurance is more than an opportunity to increase commissions – it’s a way to help clients face one of life’s biggest challenges with confidence. By offering this coverage, you can:

• Strengthen your client relationships
• Provide real financial security
• Build a more resilient, profitable business

Stay up-to-date on Medicare agent events and information

Helping clients prepare for the unexpected is what great agents do. Critical illness insurance is an essential piece of that puzzle.

Compliant Medicare Sales Events: A Guide for Agents

Hosting Medicare sales events is a powerful way to educate beneficiaries, build trust, and grow your Medicare business; but compliance must always come first. The Centers for Medicare & Medicaid Services (CMS) has strict rules about how these events are marketed, set up, and conducted. We go over how to conduct compliant Medicare sales events, Staying compliant protects you from regulatory issues, safeguards beneficiaries, and helps maintain carrier confidence in working with you.

Step 1: Choose the Right Type of Event

Start by deciding what kind of event best serves your audience:

• Formal Sales Events – Structured, scheduled presentations where you review plan-specific information with an invited audience.
• Informal Sales Events – More casual setups, like a table, booth, kiosk, or RV, where you only share plan information if a beneficiary asks for it.

Your choice will determine how you promote the event and the materials you’ll need.

Step 2: Select the Time and Location

After choosing the event type, decide when and where to host it. CMS requires that all sales events:

• Be registered with the carriers you are representing before adverting for it.
• Be held in a public setting where beneficiaries are not actively receiving health care services.

Approved locations include:

• Common entryways and vestibules
• Waiting rooms
• Hospital or nursing home cafeterias
• Community, recreational, or conference rooms

These locations are considered neutral spaces that allow beneficiaries to attend without disrupting care.

Step 3: Market Your Event the Right Way

How you advertise is just as important as what you present. CMS has specific rules for marketing Medicare sales events:

• No mandatory RSVPs – You cannot require attendees to provide personal contact information just to attend.
• Use accurate language – Don’t label the event “educational,” since educational events have different compliance rules. Instead, disclose which products or plans you’ll discuss.
• Include all required disclaimers – Every flyer, invitation, ad, or mailer must include:
  • “Not affiliated with or endorsed by the government or federal Medicare program.”
  • The accommodation statement: “For accommodation of persons with special needs at sales meetings call [insert phone and TTY number].”

If your event involves marketing Medicare Advantage or Part D plans, you must also include the appropriate TPMO (Third-Party Marketing Organization) disclaimer on all event materials:

• If you market fewer than all plans in the area: “We do not offer every plan available in your area. Currently we represent [insert number of organizations] organizations which offer [insert number of plans] products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.”
• If you market all plans in the area: “Currently we represent [insert number of organizations] organizations which offer [insert number of plans] products in your area. You can always contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) for help with plan choices.”

You can promote your event online, through direct mail, social media, or other media channels, just ensure all ads are carrier-approved and compliant.

Step 4: Handling Cancellations

Life happens. You may need to cancel an event due to a family emergency, weather conditions, or other business priorities.

While CMS does not require sales event cancellations to be submitted through HPMS, you should follow these best practices (and your carrier’s policies):

• Notify the carrier or FMO as soon as possible.
• Post a cancellation notice at the event location if feasible.
• If attendees preregistered, notify them promptly through phone, email, or mail.
• Reschedule when appropriate and advertise the new date clearly.

Clear communication helps maintain your professionalism and demonstrates respect for beneficiaries’ time.

Step 5: Run a Compliant Event

Once your event begins, compliance remains front and center:

• Use only CMS-approved materials – Benefit highlights, plan comparisons, and enrollment forms must be pre-approved.
• Stay unbiased and low-pressure – Present information clearly and allow attendees to make their own decisions.
• Provide optional sign-in sheets – Attendees must never be required to share personal information.
• Read required disclaimers at the start – Identify the plans you represent, note that other plans may be available, and clarify that attendance does not obligate enrollment.
• Document everything – Keep a record of your event details, materials used, and sign-in sheets (if any) in case of a CMS audit.

Visit our YouTube channel and review the Medicare AEP marketing rules

Why Compliance Matters

Compliance ensures beneficiaries receive accurate information without feeling pressured. It also protects you from regulatory violations and maintains your reputation as a professional, trustworthy agent.

Tips for a Successful Event

• Prepare and rehearse – A smooth, professional delivery builds credibility.
• Know your material – Be ready to answer common Medicare questions with confidence.
• Engage attendees – Allow time for Q&A and use simple examples to explain benefits.
• Follow up responsibly – Only contact beneficiaries who gave permission to be called.

Stay up-to-date on Medicare agent events and information

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Compliant Medicare sales events not only meet regulatory standards — they build trust, improve client relationships, and set you apart as a professional. By marketing correctly, including the right disclaimers, handling cancellations professionally, and following CMS rules during the event, you’ll grow your business while staying protected.

Medicare and Dental Coverage: What You Need to Know

When people think of Medicare, they often assume it covers all their healthcare need; including dental. Unfortunately, that’s not the case. Original Medicare (Parts A and B) does not cover most routine dental care. This can come as a surprise to new Medicare beneficiaries, and as an agent, it’s important to help clients understand Medicare and dental coverage.

What Original Medicare Covers

Original Medicare only covers dental care in very limited situations; usually when it is part of a hospital stay or a medically necessary procedure. For example:

• Jaw reconstruction after an accident.
• Tooth extractions needed before certain surgeries, such as heart valve replacement.
• Oral exams done in the hospital before a covered procedure.

Routine services like cleanings, fillings, dentures, or root canals are not covered.

Why Dental Coverage Matters

Oral health is closely tied to overall health. Poor dental health can contribute to heart disease, diabetes complications, and infections; all of which are major concerns for Medicare-aged clients. Helping your clients plan for dental costs can protect both their health and their wallets.

Options for Dental Coverage

Here are the most common ways beneficiaries can get dental coverage:

1. Medicare Advantage Plans (Part C)
   Many Medicare Advantage plans include dental benefits. Coverage can range from basic preventive care (cleanings, x-rays) to more comprehensive services like crowns, root canals, and dentures. Make sure to compare networks, coverage limits, and annual maximums.
2. Stand-Alone Dental Insurance Plans
   These plans are separate from Medicare and can offer flexible options. Beneficiaries can choose plans based on coverage needs and budget.
3. Discount Dental Plans
   Not insurance, but these plans provide negotiated discounts with participating dentists. They can be a low-cost option for those who only need occasional care.
4. Paying Out-of-Pocket
   Some clients may choose to budget for routine care rather than purchase coverage. This may work for those with minimal dental needs, but it carries financial risk if major dental work is required.

Watch a YouTube video on Individual Dental Plan Sales

Tips for Agents

• Ask about oral health needs during your fact-finding process. This helps you recommend plans that fit your clients’ situation.
• Compare annual maximums carefully — dental coverage is often capped between $1,000–$2,000 per year.
• Educate clients about timing — enrolling in dental coverage early can help them avoid waiting periods for major services.

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Medicare beneficiaries need to know that Original Medicare will not take care of their routine dental needs. By helping them understand their options Medicare Advantage plans, stand-alone dental insurance, or discount plans; you position yourself as a trusted advisor and help them maintain both their oral and overall health.

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Medicare Advantage Unused Benefit Rules – What Agents Need to Know

Medicare Advantage (MA) plans can be a great choice for clients; especially because of their extra perks like dental, vision, hearing, OTC allowances, and fitness memberships. But these benefits often go unused, which can lead to client dissatisfaction and plan switching. Recently, CMS has put some Medicare Advantage unused benefit rules in place.

Here’s what you need to know to guide your clients.

Key Points About Unused Benefits

• Most benefits expire monthly, quarterly, or annually; no rollovers.
• OTC allowances are among the most commonly missed benefits.
• Dental/vision/hearing dollars disappear at year-end if not used.
• Provider networks matter — clients must follow plan rules or they risk missing out on some benefits.

CMS’ Mid-Year Notification Rule

CMS recently finalized a rule requiring MA plans to send personalized mid-year notices (June 30–July 31) showing members which supplemental benefits they haven’t used and how to access them.

However, enforcement is paused for 2026, so most plans will not send these reminders. Some may do so voluntarily, but agents should not assume clients will get them.

Watch a YouTube video: Why agents should include ancillary products with MA sales

Why This Matters for Agents

• Client Retention: Clients often switch plans because they feel they aren’t getting value; even when benefits were available.
• Education Opportunity: Helping clients understand and use their benefits builds trust and keeps them engaged.
• Competitive Edge: Agents who proactively remind clients about OTC orders, dental visits, and other benefits stand out.

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Agents

• Review each client’s benefits during mid-year check-ins.
• Send reminders about quarterly OTC allowances and annual dental/vision appointments.
• Explain provider network requirements to avoid frustration.
• Track CMS updates; when they enforce the rule, you can align your outreach with plan notices.

Stay updated on agent events and information

Even with CMS’ rule delayed, agents can fill the gap by educating clients and helping them use the benefits they signed up for. Proactive communication strengthens client relationships, improves satisfaction, and keeps your book of business stable.

Medicare Coverage of DME (Durable Medical Equipment)

When it comes to staying healthy and independent, many Medicare beneficiaries rely on durable medical equipment (DME). Whether it’s a walker, a hospital bed, or a CPAP machine, understanding Medicare coverage of DME is essential for many.

In this post, we’ll break down what DME is, how Medicare covers it, and what clients should know to avoid costly surprises.

What Is Durable Medical Equipment (DME)

Durable Medical Equipment is defined as reusable medical equipment that is:

• Medically necessary for the patient’s health condition
• Able to withstand repeated use
• Primarily used for a medical purpose
• Appropriate for use in the home

Examples of common DME include:

• Wheelchairs and scooters
• Walkers and canes
• Hospital beds
• Oxygen equipment
• Blood sugar monitors and test strips
• CPAP machines and supplies

How Medicare Covers DME

Medicare Part B

Most DME is covered under Medicare Part B (Medical Insurance). Here’s how it works:

• Doctor’s Order Required: A physician or other Medicare-approved provider must prescribe the equipment.
• Approved Supplier: The equipment must be purchased or rented from a Medicare-approved supplier that accepts assignment.
• Cost-Sharing: The beneficiary pays 20% of the Medicare-approved amount after meeting the Part B deductible.

Those who have a Medicare Supplement plan may pay as little as $0 depending on the plan they have.

Some equipment is available for purchase, while other items are only available for rental. For rentals, Medicare usually pays the supplier monthly for up to 13 months, after which the beneficiary typically owns the equipment.

Watch a YouTube Video on Advanced Diabetes Supply – Help clients get the supplies they need.

Prior Authorization and Competitive Bidding

In some cases, Medicare requires prior authorization for certain high-cost or frequently abused items (like power wheelchairs). Additionally, in certain areas, Medicare runs a competitive bidding program for DME, meaning beneficiaries must use specific contracted suppliers to get full coverage.

Medicare Advantage and DME

Medicare Advantage (Part C) plans also cover DME, but:

• Networks and suppliers may be different from Original Medicare.
• Some plans require prior authorization for more types of equipment.
• Cost-sharing may vary (some plans may have lower copays or coinsurance).

Agents should always remind clients to check their plan’s provider directory and approval process before ordering DME.

Tips for Agents and Beneficiaries

• Verify Coverage First: Always confirm that the prescribing provider and supplier are Medicare-approved.
• Check the Need: Make sure there’s documentation showing the equipment is medically necessary.
• Understand Costs: Explain that clients will still owe 20% coinsurance under Part B unless they have Medigap or other supplemental coverage.
• Watch for Scams: DME fraud is common – warn clients not to accept unsolicited equipment or offers.

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Durable Medical Equipment can be life-changing for Medicare beneficiaries, but coverage rules can be tricky. By helping your clients understand what Medicare covers, where to get equipment, and how to keep costs low, you can build trust and ensure they get the care they need without unexpected bills.

2026 Medicare Part D Costs & Drug Price Negotiations

Medicare Part D (the prescription drug benefit) has seen some major changes recently. For 2026, several provisions are coming into play that affect what enrollees pay, how much Medicare pays, and how drug prices are negotiated. Below are the key updates to the 2026 Medicare Part D costs.

Key Changes in Medicare Part D for 2026

Here are some of the most important cost‐related changes that beneficiaries should know:

What Is the Drug Price Negotiation Program

Under the Inflation Reduction Act of 2022, Medicare now has the power to directly negotiate prices for certain high-cost drugs covered under Part D (and later also Part B). Previously, Medicare was more restricted in its ability to force manufacturers to lower prices for prescription drugs.

Here’s how the negotiation program works in broad strokes:

• Each year, a certain number of “single-source” brand drugs (i.e. those without generics or biosimilars) that have been on the market for a set minimum time become eligible for negotiation.
• Medicare (through CMS) makes an initial offer (“maximum fair price” or MFP) based on drug spending, clinical benefit, manufacturer costs, price in comparable drugs, etc. Manufacturers can counter. There are meetings and data sharing to arrive at a negotiated price.
• If agreement is reached, the negotiated price becomes effective as of a certain date. For the first set of drugs, prices begin for 2026

Watch a quick YouTube video on the Medicare Prescription Payment Plan

Which Drugs & Savings with Negotiation in 2026

• The first round of negotiation selects 10 Part D drugs.
• For 2026, these negotiated prices go into effect starting January 1, 2026.
• The discounts negotiated are substantial: for those 10 drugs, reductions range from 38% to 79% off list price.
• Estimated savings: If those new prices had been in effect earlier (e.g. in 2023), Medicare would have saved about $6 billion in overall drug spending on those drugs. For beneficiaries, out-of-pocket savings for those 10 drugs in 2026 are projected to be about $1.5 billion.

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How Negotiations & Costs Interact: What This Means for Beneficiaries

• Lower list/transaction prices for selected drugs should directly reduce what beneficiaries pay (especially in the initial and gap phases), because coinsurance or cost sharing is often a percentage of drug cost.
• The out-of-pocket cap ($2,100 in 2026) limits how high total costs for drugs can go in a year, making unexpected high drug bills somewhat more predictable.
• The negotiation program may also influence which drugs are placed on formularies or on preferred tiers, as plans respond to the new negotiated prices.
• However, the savings from negotiated drugs apply only to those drugs selected for negotiation; many other drugs will still be under traditional pricing structures.

Some Caveats & Things to Watch

• The negotiated max fair price is not always simply a percentage cut—there are statutory minimum discounts, comparisons with existing net prices, evaluation of alternatives, etc. Some drugs may see smaller reductions depending on existing rebates or other discounts.
• The program phases in over years: more drugs will be subject to negotiation in 2027, 2028, etc. So the full effects take time.
• Courts and industry challenges may affect implementation or enforcement.

Stay up-to-date on agent events and information

For 2026, people with Medicare should expect higher costs including; premiums, deductibles and out‐of‐pocket thresholds compared to previous years. Although there will be relief for certain high‐cost drugs thanks to the new Medicare drug price negotiation program. If you’re taking one of the drugs selected for negotiation, the discounts will reduce what you pay. Over time, broader negotiation and other reforms aim to make more drugs more affordable for all Part D enrollees.

Medicare Costs for 2026 – What Beneficiaries Need to Know

Each year, Medicare updates the premiums, deductibles, and coinsurance amounts for Parts A and B. These changes can have a significant effect on your budget; especially if you are living on a fixed income. Below we go over the projected Medicare costs for 2026. We have included a brief look at Part D and the high-deductible Medigap option.

Medicare Part A Costs for 2026

Medicare Part A covers inpatient hospital care, skilled nursing facility care, hospice, and some home health services. Most people do not pay a Part A premium, but you are still responsible for deductibles and coinsurance amounts.

• Part A deductible (per benefit period): Projected to rise from $1,676 in 2025 to about $1,716 in 2026.
• Hospital coinsurance (days 61–90): Expected to increase from $419/day to around $429/day.
• Lifetime reserve days (beyond day 90): Rising from $838/day to about $858/day.
• Skilled Nursing Facility coinsurance (days 21–100): Expected to increase to about $214.50/day.

Since the Part A deductible applies per benefit period, you could pay it more than once in a year if you have multiple hospital stays separated by 60+ days.

Medicare Part B Costs for 2026

Part B covers outpatient services, doctor visits, preventive care, and durable medical equipment.

• Standard Part B premium: Expected to increase from $185/month in 2025 to around $206.50/month in 2026.
• Part B annual deductible: Projected to rise from $257 to about $288 in 2026.

After you meet your Part B deductible, Medicare generally covers 80% of approved charges, leaving you responsible for the remaining 20% unless you have supplemental coverage.

Part D Prescription Drug Costs (Quick Note)

Even though Part D is separate from Parts A & B, it’s worth noting that the maximum Part D deductible is expected to increase from $590 in 2025 to $615 in 2026. There will also be a new out-of-pocket cap of $2,100 for covered drugs (it was $2,00 in 2025), which helps those with high prescription costs.

High-Deductible Medigap (HDG) Plans – A Quick Overview

For those who purchase a high-deductible Medigap plan (Plan G or F), the annual deductible must be met before the plan starts paying for costs that Original Medicare doesn’t cover.

• The 2025 high-deductible amount is $2,870.
• The 2026 amount has not yet been finalized but is expected to rise slightly in line with medical inflation.

These plans often have lower monthly premiums, making them attractive for healthier beneficiaries who expect lower healthcare usage, but you’ll need to budget for that large deductible in case of an unexpected illness or hospitalization.

Watch a YouTube video on High Deductible G Plans

Why This Matters

The projected increases in Part B premiums and deductibles could take a big bite out of Social Security cost-of-living adjustments. Planning ahead helps you avoid surprises.

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Here’s what clients should do:

• Budget for higher premiums and deductibles.
• Review supplemental coverage to ensure it still meets your needs and budget.
• Compare Part D plans during the Annual Enrollment Period (AEP) to find one that best covers medications at the lowest cost.
• Stay informed—CMS will finalize these numbers in Fall 2025, so check back for updates.

Understanding Medicare Deductibles

Medicare deductibles are one of the most important; and sometimes confusing, parts of how Medicare works. Whether your clients are on Original Medicare or a Medicare Advantage plan, understanding Medicare deductibles is an important part of healthcare decisions. Knowing what they are, when they apply, and what services count toward them can help avoid costly surprises.

As an agent, being able to break this down simply is a great way to build trust and guide clients to the right coverage.

What Is a Medicare Deductible

A deductible is the amount a beneficiary must pay out of pocket for covered services before Medicare or their Medicare plan starts sharing the cost.

There are several types of Medicare deductibles:

• Medicare Part A Deductible – applies to each benefit period for inpatient hospital care.
• Medicare Part B Deductible – applies once per calendar year for medical services like doctor visits and outpatient care.
• Medicare Advantage (Part C) Deductible – set by the private plan and may apply to medical, drug coverage, or both.
• Medicare Part D Drug Deductible – applies to certain prescription drugs (usually higher-tier medications).

Watch a quick YouTube video on Medicare Advantage vs. Medicare Supplements

Services That Use Deductibles

Here’s what typically applies to each deductible:

• Part A (Hospital) Deductible:
  • Inpatient hospital stays
  • Skilled nursing facility care (after meeting Part A requirements)
  • Some home health care and hospice services
• Part B (Medical) Deductible:
  • Physician visits
  • Outpatient surgery
  • Diagnostic tests (labs, X-rays, imaging)
  • Durable Medical Equipment (DME)
  • Preventive care is usually exempt — covered at 100%
• Medicare Advantage Deductible:
  • Inpatient hospital care (if plan requires it)
  • Outpatient hospital/surgical care
  • Advanced diagnostic imaging (MRI, CT scans)
  • Durable Medical Equipment (DME)
  • Emergency/urgent care (sometimes)
• Part D Deductible:
  • Applies to most Tier 3 and higher brand-name drugs
  • Generic drugs on lower tiers may bypass the deductible

Services That Skip the Deductible

To keep care accessible, Medicare and Medicare Advantage plans often waive the deductible for:

• Preventive screenings (wellness visit, mammogram, colonoscopy)
• Routine lab work
• Many primary care visits
• Many Tier 1 and Tier 2 generic prescriptions

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Deductibles Are Just One Piece of the Puzzle

When reviewing coverage options with clients, don’t just look at the deductible amount. Also compare:

• Coinsurance and copays – what clients pay after meeting the deductible
• Maximum Out-of-Pocket (MOOP) on Medicare Advantage plans
• Medigap coverage – many Medigap plans cover some or all deductibles, reducing out-of-pocket costs

Stay updated on agent events and information; click here.

By helping clients understand when and how deductibles apply, you make it easier for them to budget for healthcare and choose the plan that fits their needs.