Health Insurance Archives

Short-Term vs. Long-Term Care Coverage

By Ed Crowe | General Articles | 0 comment | 29 March, 2024 | 0

Short-term vs. long-term care coverage

In this post, we discuss short-term vs long-term care coverage. Most people have heard of long-term care insurance. This coverage pays the cost of care when a beneficiary has a chronic illness, disability, or injury. This coverage also helps individuals who require assistance due to the effects of aging. In general, long-term care insurance helps individuals pay the costs of custodial and personal care. Some people have never heard of short-term care which provides much of the same coverage for a shorter period of time.

Insurance agents, learn how to add ancillary products to your Medicare sales.

Long-term care insurance

Long-term care insurance provides help paying for custodial care for extended periods of time. The coverage this insurance provides is not provided by either Medicare or other health insurance policies.

Long-term care involves a variety of services designed to meet a person’s health or personal care needs when they can no longer perform everyday activities.

The companies that provide this benefit make money by investing the customer premiums they receive. Due to interest rates going down in recent years, these insurance carriers have lower stream of income. They are also losing revenue due to a rising number of beneficiary claims. This has caused a rise in cost and a lessening of benefits for those who wish to purchase a long-term care plan. Companies have also implemented a more difficult pre-qualification process for those who want to purchase coverage.

For most long-term care policy applications, the cutoff age is 79, while the cutoff age for short-term policies is 89. Long-term care policies have an elimination period, which is a specific number of days that the beneficiary pays for care until the policy starts to pay. A common elimination period for the plans to pay is 90 days.

Home-based care

Many individuals receive long-term care at home by either family members, friends, or neighbors. In most instances, home-based care involves help with “activities of daily living” which include bathing, dressing, eating, taking medications, and supervision for personal safety. This care is sometimes supplemented by paid formal caregivers. The professionals that provide these services include nurses, home health aides, and other professional care givers.

Does Medicare home health care.

Community and residential care

Individuals may receive some long-term care services in their community. There are adult day care services or senior center which may be equipped to provide some degree of care including meals, social activities, personal care, activities or transportation.

Residential facilities: assisted living or nursing homes also provide long -term care. Some facilities provide housing and housekeeping only. Others provide personal care, recreational activities, meals, and medical care.

Short-term care insurance

Short-term care insurance is very similar to long -term care in what it covers, Policies typically cover home care, assisted living, and nursing home care for those who cannot care for themselves. Recovery care is another name for short-term care, because it provides coverage for 12 months or less.

In some instances, short-term care insurance is used to cover gaps in Medicare coverage as a less expensive alternative to long-term care. Short-term care insurance is also a good choice to offset some long-term care expenses before long-term care kicks in.

Some benefits of short-term care insurance

Short-term care insurance does not usually have an elimination period; it generally pays benefits immediately. The cost for short-term insurance is less than log-term because it covers the beneficiary for much less time. Coverage options vary from days up to a year.

It’s easier for beneficiaries to qualify for short-term care insurance, there is no medical exam required. Some companies may ask a few yes-or-no questions. For those who are rejected or cannot afford a long-term care policy, short-term policies offer an alternative.

How to choose a coverage option

Make sure you get quotes from several different insurance companies before you choose one.
In this situation, it is a good idea to enlist the help of a licensed agent to be sure you get a plan that best meets your needs.
Have a budget and understand all the out-of-pocket expenses to be sure the plan is budget friendly.
Read the policy and be sure you understand what is covered and how it is covered.

Agents if you are looking for an FMO, see what Crowe has to offer.

Important: policy coverage differs by state and some coverage options are only available in specific states.

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Do you have any questions?

Questions and requests

Hospital Indemnity plans

By Ed Crowe | General Articles | 0 comment | 21 March, 2024 | 0

Hospital Indemnity plans

If you are a Medicare agent, it is a good idea to consider adding hospital indemnity plans to your product offerings. In the event someone becomes ill and is hospitalized, these plans provide clients an additional layer of coverage. Hospital Indemnity insurance provides policyholders a chance to protect their savings and lower their out-of-pocket costs.

It is important to note; when it comes to hospitalization, there are limits to what Medicare Advantage or Medicare supplement plans cover. When that happens, a hospital indemnity plan can provide an extra peace of mind for beneficiaries.

What is hospital indemnity insurance

Hospital indemnity insurance is additional health coverage that individuals can purchase and add an extra layer of protection. These plans have a monthly premium like other insurance coverage. If the beneficiary has to stay in the hospital, they receive a fixed payment amount they can use to cover any out-of-pocket costs members incur. Beneficiaries can use the payment to cover whatever they need such as, deductibles, co-pays, medication or for things like rehabilitation or home care expenses.

Unlike other insurance plans, hospital indemnity policies send payments directly to the policyholder. This gives beneficiaries more freedom to choose where their money goes. A good hospital indemnity plan should be easy to get, has no deductible or pre-certification and is not difficult to get payments from when you need them.

What hospital indemnity insurance covers

The coverage provided by a hospital indemnity plan depends on the plan chosen and the riders added. We have listed a few basic things these plans cover below.

When a beneficiary has a hospital stays weather or not surgery takes place.
If they are confined in an ICU (intensive care unit).
In the event they are confined in a CCU (critical care unit).

Additionally, there are plans that offer coverage of all or some of the items listed below.

If a beneficiary has medically necessary outpatient surgery , as opposed to an elective outpatient surgery.
If they require outpatient diagnostic imaging procedures, x-rays or lab procedures.
Some plans include payments for ambulance services.
There are plans that event pay for emergency room visits or specific doctors office visits (not routine annual checkups).

Waiting periods for benefits

In most cases, there is a 30 day waiting period for illnesses that result in a hospital stay. The waiting period varies by carrier and the plan chosen. However, some plans will not have a waiting period for hospitalization for an accidental injury. It is important that enrollees understand all benefits of their plan choice, including waiting periods, before they decide on a policy.

Hospital Indemnity plan cost

Hospital indemnity plans charge a monthly premium like any other health insurance. The cost depends on several factors including the plan & company choice, as well as age, gender and location.

It is important to consider if hospital indemnity insurance is worth getting or not. The beneficiary needs to consider what their current health plan covers, their out-of-pocket cost including deductibles and co-pays and co-insurance and the cost for an average hospital stay. They also have to take into account their personal financial situation and if they can better afford the coverage or payment for the out-of-pocket expenses.

Opportunity for cross sales

Hospital indemnity plans provide a great opportunity for Medicare agents to make a cross sale. Many of your current clients could benefit by purchasing one of these plans. Clients who enroll in a Medicare advantage plan without a premium ($0) may want to add an affordable hospital indemnity plan that adds that extra layer of protection. Their Medicare advantage plan may leave them paying high co-pays or deductible for a hospitalization. Be sure to go over their budget and possible value of adding the coverage.

Agents should go over the average cost of a hospital stay and the possible out-of-pocket cost as compared to the cost of adding a hospital indemnity plan. Do the Math for them. Make sure it is a viable option before they sign up.

Are you an agent who wants to offer these plan to your clients; click here for online contracting.

Rules for hospital indemnity insurance sales

It is important to remember, there are rules to follow when you offer a hospital indemnity plan to a client. Agents cannot mention this or any other product at a Medicare appointment if it is not included on the scope of appointment.

Watch a YouTube video on the scope of appointment rules.

Medicare enrollment dates

By Ed Crowe | General Articles | 0 comment | 20 March, 2024 | 0

Medicare enrollment dates

If you are either getting close to your 65th birthday or are in Medicare sales, you should understand the Medicare enrollment dates.

Enrolling in Medicare can be confusing for beneficiaries and understanding the enrollment process is crucial to access the benefits your clients need. From IEPs to SEPs, the Medicare system is designed to accommodate various life circumstances. In this post, we go over several of the Medicare enrollment periods and how beneficiaries can use them to get the healthcare coverage they need.

Initial Enrollment Period (IEP)

The Initial Enrollment Period (IEP) is the first opportunity for most individuals to enroll in Medicare. IEP is a 7 month time frame that starts 3 months before the month of your 65th birthday, includes your birthday month, and ends three months after the month you turn 65. During this period, individuals can sign up for Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) if they choose to.

Learn more about enrollment periods

Special Enrollment Periods (SEPs)

Special Enrollment Periods (SEPs) are designated times outside the initial enrollment period when individuals can sign up for Medicare due to specific qualifying events. Some of the most common qualifying events include:

Loss of Employer Coverage

If a beneficiary is covered under a group health plan through their own or their spouse’s current employment, they are eligible for an SEP when they lose the employer coverage.

Moving out of the plans service area

When a client moves out of their plan’s service area, they qualify for an SEP to enroll in a new Medicare plan.

Becoming Eligible for Extra Help

Individuals who become eligible for Extra Help with Medicare prescription drug costs qualify for an SEP to enroll in a Medicare Prescription Drug Plan (Part D) or Medicare Advantage Plan (Part C) that includes prescription drug coverage.

General Enrollment Period (GEP)

For individuals who miss their initial enrollment period, the General Enrollment Period (GEP) provides another chance to enroll in Medicare. The GEP runs each year from January 1st to March 31st. Coverage obtained during this period begins the first of the month after you enroll. it’s important to note, beneficiaries who wait until the GEP may have to pay a late enrollment penalty.

Click here to learn about late enrollment penalties LEPs

Annual Enrollment Period (AEP)

The Annual Enrollment Period (AEP), also known as the Medicare Open Enrollment Period, runs each year from October 15th until December 7th. During this time, Medicare beneficiaries can make changes to their Medicare coverage. This includes; switching from Original Medicare and Medicare Advantage plans, as well as joining, dropping, or switching prescription drug plans.

How to best use the Medicare enrollment dates

Stay Informed: Keep track of your eligibility and enrollment periods to ensure you don’t miss important deadlines.
Review Your Coverage Needs: Regularly assess your healthcare needs to determine if current coverage is still suitable or if changes are necessary. Agents make sure you contact your clients regularly, especially during AEP to go over coverage options for the following year and ensure they are happy.
Seek Assistance if Needed: If you have questions or need guidance regarding Medicare enrollment, it is best to reach out to a licensed insurance agent.

Medicare agents be sure to maintain your book of business, click here for some ideas.

Agents, are you ready to join a winning team, click here for Crowe contracting!

Understanding Medicare enrollment dates is essential for to ensure beneficiaries have access to the healthcare coverage they need. By familiarizing yourself with the various enrollment periods and their significance, you can navigate the Medicare system with confidence and peace of mind. Remember, staying informed and proactive is key to making the most of your Medicare enrollments.

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CT MSP income limits 2024

By Ed Crowe | General Articles | 0 comment | 18 March, 2024 | 0

CT MSP income limits 2024

It’s important for agents and Connecticut residents on Medicare to stay up to date on changes in healthcare programs that impact their lives. One such program is the Medicare Savings Program (MSP). This program provides assistance to beneficiaries with limited incomes cover their Medicare costs. Understanding the CT MSP income limits 2024 is vital for beneficiaries. Especially when they depend on financial assistance to get the healthcare they need.

What is the Medicare Savings Program

The Medicare Savings Program (MSP) is a state-administered program. It helps individuals with limited income and resources pay for Medicare premiums, deductibles, coinsurance, and copayments. The program is available to those eligible for Medicare Part A (hospital insurance) and meets specific income and asset criteria. In Connecticut, the MSP is administered by the Department of Social Services (DSS) and provides critical financial assistance to eligible beneficiaries.

Income Limits for the CT Medicare Savings Program 2024

Because the Medicare Savings Program in Connecticut consists of 4 levels of help, the income limits vary based on each separate program within MSP. The state also adjusts the income limits based on the size of each household. The income limits for each MSP programs, as of 2024, are listed below.

QMB (Qualified Medicare Beneficiary) Program

The QMB program provides the highest level of help. Those who qualify for this program, have an income level of up to 100% of the Federal Poverty Level (FPL). This program helps pay for Medicare premiums, deductibles, coinsurance, and copays.

SLMB (Specified Low-Income Medicare Beneficiary) Program

The SLMB program provides assistance with Medicare Part B premiums. To qualify for this program, individuals should have an income level of between 100% and 120% of the FPL.

ALMB (Additional Low-Income Medicare Beneficiary) Program

The ALMB program provides payment assistance with the Medicare Part B premium for those who have income between 120% and 135% of the FPL.

QDWI (Qualified Disabled and Working Individuals) Program

To qualify for the QDWI program, individuals must be under age 65, disabled, working, and not eligible for Medicaid. These individuals must have income of up to 200% of the FPL. This program provides assistance for individuals paying their Medicare Part A premiums.

Please note: the income limits are subject to change annually. There are other factors that affect MSP eligibility including: household size and financial resources.

How to Apply for Connecticut’s Medicare Savings Program

Beneficiaries who want to apply for CT’s MSP program, can do so through the DSS (Department of Social Services). The beneficiary must provide information such as: income, assets, Medicare enrollment, and other relevant information. DSS provides help completing the application for anyone who needs it.

Individuals apply for benefits by completing a CT state application form. There are several ways to complete and return the form, including; online, through the mail, or dropped off at a local DSS Regional Office. An authorized person can do the application for the beneficiary if they need them to.

For a list of local DSS offices, click this link.

To apply online, visit www.connect.ct.gov, you will see a tab to ‘Apply for Benefits.’

Beneficiaries who wish to apply for MSP program only, please download and complete application below:

Medicare Savings Program Application (W-1QMB)

Formulario de Renovación de programas de ahorro de Medicare (W-1QMBS)

To apply for the MSP program as well as additional programs such as: SNAP (food stamps), Medicaid for Employees with Disabilities (MED-Connect), Medicaid for the Aged/Blind/Disabled (HUSKY C), and/or cash assistance, download the application below.

Click here to apply for Husky C and or Cash assistance program benefits

Haga clic aqui para Husky o asistencia en efective CW-1ES Solicitud de Beneficios

MSP in Connecticut provides an essential service to many individuals. It provides financial assistance to cover Medicare costs. It is necessary to be aware of the income limits. eligible individuals can take advantage of this valuable program and access the healthcare they need without undue financial strain. As we navigate the complexities of healthcare, let’s ensure that everyone has the opportunity to receive quality care and support.

Agents, if you want to learn more about Medicare, subscribe to our YouTube channel

You have the right to a copy of the completed application. You can request a copy from DSS at any time in either in electronic or paper format.

For additional information on how to apply, please visit www.ct.gov/dss/apply.

Medicare annual wellness visits

By Ed Crowe | General Articles | 0 comment | 29 February, 2024 | 0

Medicare annual wellness visits

For Medicare beneficiaries, it is very important to stay vigilant with their health care. Medicare annual wellness visits (AWV) are an essential tool to maintain good health. Unfortunately, many beneficiaries are unaware of how significant this is and what it entails. In this post, we discuss the importance of wellness visits and their benefits.

Understanding Medicare Annual Wellness Visits

Medicare Annual Wellness Visits (AWVs) are preventive care appointments. These appointments help assess and maintain the overall health of Medicare beneficiaries. Unlike traditional annual physical exams, AWVs focus on preventive care planning, risk assessment, and health promotion. The purpose of these appointments in not to diagnose or treat existing conditions. Please note; anyone who has has Medicare Part B for over 12 months, is eligible for an annual wellness visit. It is important to understand; these visits are not a physical exam.

There is not cost for the visit as long as the provider accepts Medicare assignment and the Medicare Part B deductible does not apply. Although, if your provider preforms additional test, you may have to pay the Part B deductible as well as co-insurance. In the event these services are not cover under the preventative visit.

Why are annual wellness visits so important

Prevention Over Cure: When providers use this approach, they prioritize preventive care, to detect potential health risks early on. This helps prevent them from escalating into serious conditions. By identifying risk factors and developing personalized prevention plans, beneficiaries can take proactive steps towards better health outcomes.
Comprehensive Health Assessment: AWVs provide beneficiaries with a comprehensive overview of their current health status. By taking a holistic approach that includes screenings for cognitive impairment, depression, and functional ability, all aspects of health are addressed and monitored.
Establishing a Baseline: Regular AWVs enable healthcare providers to establish a baseline of a beneficiary‘s health status. This facilitates better care management and early detection of changes in health in subsequent visits.
Patient-Centered Care: ensures patient-provider communication is a priority. This fosters open dialogue about health concerns, lifestyle factors, and goals. This collaborative approach allows beneficiaries to actively participate in their healthcare decisions and take steps toward good health.
Cost-Effective Care: Preventive care, as emphasized in AWVs, is proven to be more cost-effective in the long run compared to treating advanced diseases. Medicare can reduce healthcare costs by investing in preventive measures to avoid chronic conditions.

Watch a YouTube video on the changes to Medicare Part D coverage

Components of an annual wellness visit

Health Risk Assessment: Beneficiaries undergo a thorough assessment of their medical history, current health status, and risk factors for chronic diseases.
Personalized Prevention Plan: Based on the health risk assessment, healthcare providers develop a personalized prevention plan that fits the individual’s needs and goals. This may include recommendations for screenings, vaccinations, lifestyle modifications, and community resources.
Health Education: AWVs offer an opportunity for beneficiaries to receive education on various health topics. This helps them make informed decisions about their well-being.
Review of Medications: Healthcare providers review the beneficiary’s current medications to verify they are safe, effective, and appropriate for their needs.
Referrals and follow-up visits: If necessary, healthcare providers refer beneficiaries to specialists or other healthcare services for further evaluation or treatment. Follow-up appointments are scheduled, when needed, to check progress and adjust the plan accordingly.

To sum it up

Medicare annual wellness visits are an important tool for the promotion of good health and well-being of Medicare beneficiaries. When we prioritize preventive care, health assessments, and patient-centered approaches, beneficiaries have the information they need to be proactive in their healthcare and wellbeing.

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Insurance sales training

By Ed Crowe | General Articles | 0 comment | 1 February, 2024 | 0

Insurance sales training

Anyone who wants to enter the field of Medicare sales, will need to have insurance agent training before they meet with any potential clients. Crowe and Associates offers Medicare agents access to several types of training tools. We provide free information on our website, YouTube channel as well as weekly informational webinars and zoom meetings geared for either beginners or experienced agents.

Think about joining an FMO

Getting started in insurance sales can be confusing, especially if you are trying to get it done on your own. An good FMO provides guidance and support not only to new agents but to experienced agents as well. Agents receive back office support as well as resources and tools that can make your business run effectively. it is important to choose an FMO that provides the support you need. Be sure to ask as many questions as you need to and contact as many as you need. Agents need to feel comfortable with their upline and secure knowing they will be there to answer your questions when they arise.

See what we offer Medicare agents

Decide what products to offer

We will focus on Medicare products, because that is the largest part of what we offer. If you are unsure which products you are going to offer clients, your FMO should assist you in choosing a reasonable number of Medicare and ancillary products to get started. It is best not to overwhelm yourself and get discouraged. A good FMO will run a quote in the area you plan to sell in and provide you with a few of the top carriers in each product type to et you started. This is easy to do with a good quote engine and takes only a few minutes.

Join the team at Crowe – click here for online contracting

Contracting and Certifications

After you choose the products and carriers you are going to offer, you must complete contracting. Your FMO should be able to help get this done. Once you receive your contracting links, you can complete them along with your carrier certifications(carrier specific training you do to gain knowledge about the products you are offering). When this is done, you will receive your RTS (ready to sell) and you can now offer that product.

websites and blogs focused on Medicare sales. Here you will be able to access information regarding all aspects of Medicare sales. Our recorded webinars will hit on just about every area of Medicare sales. For those, very new to Medicare sales, be sure to access our Medicare sales quick guide to lean the basics about contracting, certifying and selling.

Because Medicare is a federal program, there are a lot of rules and regulations agents must adhere to. These rules protect the clients as well as the agents and ensure everyone conducts business in a compliant and fair way. CMS mandates that agents take annual training courses to stay up to ate with all the regulations. That is why agents need to take and pas the AHIP annually with a score of 90% or higher.

Watch a quick YouTube video for 2024 AHIP test tips

Sales training

New agents often need more guidance to get an idea of how to get started. Comprehensive training programs provide an understanding of things like; eligibility, enrollment and coverage options. We provide newer agents weekly zoom training to help them feel confident and build their knowledge base. We are also available for a one on one meeting or phone call. In some cases agents may have an opportunity to pair up with a local agent and go on sales calls.

Product training

In the Medicare field, clients have soo many types of coverage offered by many carriers to consider. This means agents must be aware of new products and changes in plan products as well what their client is looking for. That is why agents complete specific product training, so they can ensure their client receives the coverage they need and can afford. We provide the opportunity for agents to join one of our weekly zoom meetings or webinars to get updated information and ask questions if they are unsure about anything.

Anyone can find information on our website or YouTube channel. We update our Events and information page so agents can easily find a webinar or event information on our website, just click on the link below.

Click here to view our updated Events and information post

Access the recorded webinars on various topics on our YouTube channel, just click on the link below:

Subscribe to our YouTube channel and view all our recorded training and informational videos

Learn to use our free quoting and enrollment tools

We provide our agents with a few ways to quote and enroll clients in a CMS complain way. Sunfire and Connecture are two of the tools we offer at no cost to our agents. Both of these tools provide a CRM as well as the ability to record sales calls and remain compliant.

Take a look at a Sunfire enrollment demonstration

Networking and Business Development Training

Agents require more training once they have a handle on the ins and outs of Medicare and the carrier plans. Some people require advice to help the design a business plan. They may need a strategy for networking opportunities, leads, and business development. These tools will establish their place in the community and build a book of business.

Generate Medicare referrals

Medicare lead program

Our agents have an opportunity to participate in our Medicare lead program to. We provide agents up $500 a month to offset lead and marketing costs. There are no minimums to start and absolutely no reduction in compensation.

More info on our Free Medicare Lead Program

What does a Medicare agent earn

Each year CMS sets the maximum amount for Medicare commissions. Click here to see the commission rates for 2024

Watch a YouTube video to see the CMS proposed changes to agent compensation

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Extra help Medicare

By Ed Crowe | General Articles | 0 comment | 17 January, 2024 | 0

Extra help Medicare

Medicare provides programs and benefits to many people. This includes the Extra Help Medicare program that provides qualified beneficiaries help paying their Medicare Part D monthly premium, annual deductible, coinsurance and copays for their prescription medications.
To qualify for this program, individuals must meet income requirements. Individuals who are accepted into this program do not have to pay any Part D late enrollment penalty they may have acquired.

How to apply for extra help

If you do not automatically qualify for Extra Help, you will need to apply. You must meet the following qualifications to be eligible for Extra Help.

Applicants must have Medicare Parts A and B.
They must reside in the U.S. or the District of Columbia.
They do not have more than $34,360 in assets that include savings, investments & real estate if they are married, or $17,220 if they are single or not living with a spouse. If your assets are more than that, you are not eligible for Extra Help. Important; this amount does not include your home, cars or personal possessions. It also does not include life insurance, irrevocable burial contracts or back payments from Social Security or SSI.

If you meet the qualifications specified above, you can apply for Extra Help online.

Click here to apply for Extra Help online

For help with the online application, call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

Please note: Some people do not need to apply for Extra help. If you have either Medicare and SSI (Supplemental Security Income) or Medicare and Medicaid, you do not need to apply for Extra Help. You will automatically be enrolled.

Extra Help isn’t available in Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa. But there are other programs available in those areas to help people with limited income and resources. Programs vary in these areas. Call your State Medical Assistance (Medicaid) office to learn more

Who can get Extra Help

If you think you meet the financial requirements and have Medicare A & B as well as are a resident of the U.S. or District of Columbia, just complete the online application. You will receive a letter notifying you if you are accepted into the program.

Important: residents of Guam, Puerto Rico, the US Virgin Islands, Northern Mariana Islands or American Samoa are not eligible for the Extra Help program. To find alternative programs in those areas, check your state’s Medicaid eligibility at Medicaid.gov to find resources.

Additional financial resources

Individual states also have financial resources available through Medicare Savings Programs for those who meet the income qualifications. Use this link to find additional information for financial help in your area.

Beneficiaries can also go to Medicare.gov or call 1-800-medicare (TTY 1-877-486-2048)to find information on financial assistance programs.

Please be aware: Extra Help is not a prescription drug plan. Beneficiaries must enroll in either an MAPD plan or a stand alone PDP plan to have coverage for prescription medications.

Agents, learn how to run a Medicare PDP or MAPD plan quote using Sunfire or Connecture. Watch our quick YouTube video

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Tricare and Medicare

By Ed Crowe | General Articles | 0 comment | 15 January, 2024 | 0

Tricare and Medicare

In this post, we explain how Tricare and Medicare work together to provide coverage for those who qualify.

What is Tricare

Tricare is a healthcare program available to active-duty service members, active-duty family members, National Guard and Reserve members and family members. It is also available to retired service members and their families, survivors, and some former spouses. This program combines military healthcare resources (military hospitals & clinics) with civilian healthcare professionals to provide services to its members.

It is helpful for anyone eligible for both Tricare and Medicare to know how these benefits work together. Tricare For Life (TFL) is provided free of charge to U.S. military retirees and their qualified beneficiaries. Medicare coverage is a separate program available to beneficiaries 65 or older as well as qualified disabled individuals.

TFL and original Medicare

Beneficiaries who are eligible for TFL, are automatically enrolled in TFL when they sign up for Medicare Part A and Part B. There is no need to fill out any enrollment forms. TFL beneficiaries must remain enrolled in Medicare Part B to maintain TFL enrollment. Medicare is the primary insurer for those enrolled in Medicare and TFL. In this case, TFL is the secondary insurer and covers costs the beneficiary would normally be left to pay. It covers the Part A deductible as well as Part B co-insurance costs.

Please note: Tricare does not provide insurance cards. Military members should register in DEERS (Defense Enrollment Eligibility Reporting System) database to receive Tricare. DEERS is a

access proof of their coverage through milConnect, a website that provides military members with benefit information for insurance, including help finding a provider, proof of coverage, GI benefits and much more.

TFL with Medicare supplements (Medigap)

TFL coverage is similar to a Medicare Supplement plan. Beneficiaries of TFL are eligible to enroll in a Medicare Supplement plan as long as they have both Medicare Part A & Part B. Enrollment in a Medicare supplement is not free and may not be necessary for members of TFL plans. It is best to consider all medical and financial needs before deciding on plan coverage choices. Beneficiaries who elect to enroll in Medicare, Medicare supplements and TFL have Medicare as the primary coverage, the Medicare supplement is secondary and the TFL pays after both the other options.

TFL and Medicare advantage

When TFL beneficiaries opt to enroll in Medicare Advantage (Medicare Part C) coverage, the Medicare advantage plan acts as the primary insurer. The TFL coverage is considered supplemental and will help cover costs for deductibles and co-pays as well as medically necessary out-of-network services.

It is always a good idea to be sure any providers the beneficiary uses are in-network with the MA/MAPD plan chosen. If the providers are in network, beneficiaries could end up not having to pay any out-of-pocket costs after TFL pays its share.

Learn about the pros & cons of Medicare advantage plans

Medicare Part D and TFL

Because TFL provides prescription drug coverage, beneficiaries do not need to enroll in Medicare Part D prescription drug coverage. TFL prescription coverage qualifies as creditable coverage. This means, if you decide to enroll in Part D later on, you will not receive a LEP (late enrollment penalty) from Medicare.

It is important to note, TFL members must fill maintenance drug prescriptions like, blood pressure or cholesterol, through Tricare’s mail order pharmacy. TFL members can fill other prescriptions at any pharmacy they choose. The beneficiary is responsible for any co-pays.

Tricare Prime and Medicare

Beneficiaries under age 65 who have Medicare and Tricare Prime, can remain on Tricare Prime for as long as they are eligible. Members receive a waiver for Prime enrollment fees or a refund for a prior enrollment fee.

Tricare Plus and Medicare

Tricare Plus provides beneficiaries a way to receive primary care in military hospitals or clinics. It is important to make sure the military facility accepts Tricare Plus before receiving care. To be part of this program, members must enroll.

The benefits provided by Tricare Plus are similar to Tricare Prime. They both work the same as regular Tricare in regard to Medicare because it is still primary coverage. It is important to confirm the military facility accepts Tricare Plus before scheduling care. Tricare Plus is for Tricare eligible individuals not enrolled in Tricare Prime.

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Medicare OEP rules

By Ed Crowe | General Articles | 0 comment | 8 January, 2024 | 0

Medicare OEP rules

Before we get into what the Medicare OEP rules are, we will discuss what the Medicare OEP is.

What is the Medicare OEP

The Medicare OEP is also called the Medicare Advantage OEP or (open enrollment period). This enrolment period is in addition to the Medicare annual enrollment period (AEP) that runs from October 15th through December 7th each year. The OEP is specifically enrollees of MA/MAPD plans. It begins January 1st and runs through March 31st each year. During this time, any MA/MAPD plan enrollee can switch to another MA/MAPD plan or Original Medicare and a PDP plan.

Find out more about the MA OEP

Clients who call you during the MAPD OEP and are unhappy with the coverage they chose, have one more opportunity to make a change. This can be helpful if they did not check their coverage options during the AEP. It is also useful when, your clients renew their coverage and find their plan has changed and no longer provides what they need for the new year.

To learn the differences between Medicare AEP vs. OEP

What agents can and can’t do during the MA/MAPD OEP

It is important to know; CMS has marketing guidelines in place for this enrollment period. Agents cannot knowingly target or send unsolicited marketing materials to members of MA/MAPD plans during this period.

Watch a quick YouTube video on the CMS AEP marketing rules

A few things you should not do:

Never send unsolicited marketing materials that mention the Medicare advantage OEP and the ability to change plans.
Do not target Medicare enrollees by using a list of clients or lead list of beneficiaries who enrolled in a plan during AEP.
Avoid using sales meetings that focus on the OEP to get beneficiaries to make plan changes.

Some things that are ok to do:

If a beneficiary asks for information, you should send it to them or meet them to provide the requested materials.
It is fine to continue marketing to anyone aging into Medicare who may need help going over their Medicare options.
You can always market a 5-star plan if there are any available in your sales area. Click here to watch a video on an 5-star ISNP MA plan.
Provide information to beneficiaries who qualify as either dual-eligible or LIS as they are able to make changes once during any of the first 3 quarters of the year.

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Medicare drug price negotiations

By Ed Crowe | General Articles | 0 comment | 4 January, 2024 | 0

Medicare drug price negotiations

Because of the high cost of some prescription drugs for Medicare beneficiaries, the CMS has announced the first 10 drugs that will be subject for Medicare drug price negotiations. The negotiations are part of the Inflation Reduction Act. Up until recently, Medicare has been able to negotiate prices for medical care beneficiaries receive but this did not include the costs of medications. This is about to change when the negotiated prices go into effect as of 2026.

Watch a quick video on the Medicare Part D changes

Medicare will negotiate with drugmakers over the cost for the some of the most expensive medications and does not apply to drugs that have a generic alternative. The first 10 medications chosen for negotiations are:

Eliquis (a blood thinner)
Enbrel (for rheumatoid arthritis)
Entresto (for heart failure)
Farxiga (for diabetes, heart failure & chronic kidney disease)
Fiasp & Novalog (for diabetes)
Imbruvica (for blood cancers)
Januvia (for diabetes)
Jardiance (for diabetes)
Stelara (for psoriasis & Chron’s disease)
Xarelto (a blood thinner)

According to the CMS, the 10 drugs above accounted for 20% of the Medicare Part D spending ($50.5 billion) during the period from June 2022 through the end of May 2023. Part D of Medicare covers prescriptions taken by beneficiaries at home. It does not cover medications administered by medical providers in medical facilities for treatment of things like cancer or other health conditions. In these situations, Medicare Part B covers the necessary drugs.

Click here to read the drug price negotiation fact sheet

Medicare beneficiaries spend billions of dollars for prescription drugs

Because of the high cost of some essential medications, beneficiaries sometimes have to either limit basic needs or go without the drugs that help maintain their quality of life. All the while, drug manufacturers rake in record setting profits.

These 10 drugs are just the beginning

This list of 10 drugs is just the starting point. In 2027 Medicare hopes to add 15 more drugs and even more in the years that follow. This list will grow each year as long as the drug manufacturers are unsuccessful in their attempts to stop the drug cost negotiations.

Find out about the Medicare prescription payment program.

What will drug manufacturers do

If the drug companies do not agree to the negotiations, they face possible tax penalties. Drug manufacturers can avoid the tax penalty if they remove their drug from the Medicare market. However, if they do that, they will take lifesaving drugs from Medicare beneficiaries as well as lose a large part of their market share.

Some large drug companies are seeking legal counsel to stop the drug price negotiations. They argue that the loss in income will affect their ability to fund necessary research and development and that in turn will reduce their ability to produce new medical treatments.

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