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Medicare OEP Open Enrollment Period

The Medicare Open Enrollment Period (OEP) runs annually from January 1 to March 31. It is specifically for individuals already enrolled in a Medicare Advantage (Part C) plan as of January 1.

This period does not apply to those with Original Medicare (Part A and B) only; it’s strictly for Medicare Advantage plan members who may want to make a one-time change.

What Changes Can You Make During OEP

Those enrolled in a Medicare Advantage plan, can make one change during the OEP. The options include:

• Switching to a different Medicare Advantage plan, with or without drug coverage
• Dropping your Medicare Advantage plan and returning to Original Medicare, with the option to add a Part D prescription drug plan

Changes You Cannot Make:

• Switch from Original Medicare to a Medicare Advantage plan
• Enroll in Part D drug coverage if you’re on Original Medicare and missed your IEP or AEP
• Make multiple changes; OEP only allows one switch

Watch a video on Medicare enrollment periods

Why Use the OEP

Here are a few common reasons beneficiaries take advantage of the Medicare OEP:

• Their current Medicare Advantage plan doesn’t cover a needed medication or provider
• They discovered higher costs or restrictions after using the plan in January
• They had a change in health and want a different plan with better specialist coverage
• They were unaware of better plan options during the Annual Enrollment Period (AEP), which runs from October 15 to December 7

How Is OEP Different from AEP

Important Considerations

• If you switch to Original Medicare during OEP, you may not be guaranteed Medigap (Medicare Supplement) coverage; unless you’re in a trial right or qualify for a Special Enrollment Period.
• Any changes made during the OEP become effective the first day of the month after the change is made (e.g., a change in February takes effect March 1).
• It’s important to review coverage early in the year to determine if your current plan still meets your needs.

Work with a Licensed Agent

The Medicare OEP is a valuable but limited opportunity to make corrections or improvements to your coverage. If you’re unsure whether your plan fits your health needs or budget, speak with a licensed Medicare agent. They can help you compare options, check provider networks and drug formularies, and make confident decisions about your healthcare.

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Medicare TrOOP Costs: What Beneficiaries and Agents Need to Know

When it comes to Medicare Part D prescription drug coverage, there’s one term that often causes confusion but plays a big role in how much a beneficiary pays: TrOOP. In this post, we explain Medicare Part D TrOOP Costs and their effect on the client’s costs for prescription medication.

Whether you’re a Medicare beneficiary trying to understand your coverage or a Medicare agent helping clients navigate their plans, understanding TrOOP is essential.

What Is TrOOP

TrOOP (True Out-of-Pocket) costs refers to the amount a Medicare beneficiary pays for covered prescription drugs before reaching catastrophic coverage under a Part D plan. These costs include deductibles, copays, and coinsurance for medications covered by the plan.

TrOOP is used to track a beneficiary’s spending so that Medicare knows when to move them through the different Part D coverage phases.

What Counts Toward Medicare Part D TrOOP Costs

Not everything a beneficiary pays will count toward TrOOP. Only qualified out-of-pocket spending applies. Here’s what counts:

• Annual deductible (if applicable)
• Copays and coinsurance for formulary drugs (covered by your plan)
• Payments made by:
  • The beneficiary
  • A family member
  • State Pharmaceutical Assistance Programs (SPAPs) or the Federal Government’s Extra Help Program.

What Doesn’t Count Toward Medicare Part D TrOOP Costs

Some expenses don’t count toward your TrOOP total, including:

• Monthly premiums for the Part D plan
• Drugs not covered by the plan (not on the plan’s formulary). Although, if the drug is approved via exception or appeal, it does count towards the TrOOP
• Over-the-counter (OTC) drugs
• Drugs purchased outside of the U.S.
• Payments by other insurance (e.g., employer group plans or TRICARE)

TrOOP and the 3 Phases of Part D

To understand how TrOOP affects drug costs, it helps to review the stages of Medicare Part D:

1. Deductible Phase
   • The beneficiary pays 100% of their drug costs until they meet the deductible.
2. Initial Coverage Phase
   • Beneficiaries pay about 25% of the cost for formulary drugs in the form of copays or coinsurance until they reach $2,000 out of pocket (the initial coverage limit).
3. Catastrophic Coverage Phase
   • After TrOOP reaches a set amount ($2,000 in 2025, increasing in 2026), the beneficiary pays $0 for covered drugs once they have hit the TrOOP under the new 2025 rules.

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Key Takeaways for Beneficiaries and Agents

• TrOOP helps Medicare track spending to determine when beneficiaries qualify for better cost-sharing.
• Only qualified out-of-pocket costs count.
• In 2025, TrOOP maxes out at $2,000; a major win for Medicare enrollees.
• Medicare agents should explain TrOOP carefully when helping clients compare drug plans or estimate yearly costs.

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Understanding Medicaid Spend Downs: What It Is and How It Works

For many individuals, especially older adults and those with disabilities, affording healthcare and long-term care can be a significant financial challenge. Medicaid offers crucial support, but not everyone qualifies based on income or asset limits. That’s where understanding Medicaid Spend Downs is important. It is a pathway to eligibility for those who exceed Medicaid’s financial thresholds but still have high medical costs.

What Is Medicaid Spend Down

Medicaid Spend Down is a process that allows individuals with income or assets above Medicaid eligibility limits to “spend down” their excess resources on medical expenses to qualify for Medicaid coverage. It’s similar to an insurance deductible; once you’ve paid out a specific amount in medical bills, you become eligible for Medicaid assistance for the rest of the period.

There are two common types of spend down:

• Income Spend Down: For people whose monthly income is too high but who have recurring medical expenses.
• Asset Spend Down: For those whose savings or property exceed Medicaid’s asset limits.

Who Needs a Spend Down

Spend down is often needed by:

• Seniors over age 65
• Individuals with disabilities
• People in need of long-term care
• Those receiving home and community-based services

For example, someone with a small pension or Social Security income that slightly exceeds their state’s Medicaid income limit might still qualify if they have regular out-of-pocket medical costs like prescription drugs, doctor visits, or even insurance premiums.

How Does It Work

Each state administers Medicaid differently, so spend down rules and procedures vary. However, the basic process looks like this:

1. Determine Excess Income/Assets: Compare income or resources to the state’s Medicaid limits.
2. Calculate the Spend Down Amount: This is the amount you must use for medical expenses to qualify.
3. Submit Proof: Provide receipts or bills to your state Medicaid office as evidence of your medical expenses.
4. Become Eligible: Once you meet your spend down requirement, Medicaid covers your additional medical costs for a certain period; often between one and six months.

Agents, watch a quick video on the quarterly SEP for dual and drug help elimination 2025

What Counts Toward a Spend Down

Expenses that may count include:

• Unpaid medical bills
• Prescription drugs
• Health insurance premiums
• Doctor and hospital visits
• In-home care services
• Medical equipment

Important Considerations

• Timing Matters: Medicaid coverage through spend down is usually limited to specific timeframes (e.g., a one- or six-month period). Beneficiaries will need to re-qualify at the end of each spend down period. The length of each spend down varies by state.
• Asset Rules Are Strict: Some assets are exempt (like your home or one vehicle), but others may need to be spent down or placed in a trust.
• Documentation Is Key: Keep all receipts and records of medical expenses as proof.

Medicaid Spend Down can be a lifeline for those who need healthcare but don’t meet traditional financial eligibility criteria. It requires careful planning and documentation, but it opens the door to critical services like long-term care and in-home support.

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If you or a client may benefit from Medicaid but don’t meet the income or asset limits, a CMP (Certified Medicaid Planner) or elder law attorney can provide spend down options and help beneficiaries make informed decisions.

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

Medigap Plan N

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

Benefits of Medigap Plan N

Lower Monthly Premiums

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

Plan N Covers Cost Gaps

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

Nationwide Access

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

Predictable Inpatient Costs

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

Downsides of Medigap Plan N

Copays for Doctor and ER Visits

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

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

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

Doesn’t Cover Part B Deductible

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

Excess Charges Not Covered

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

Not Ideal for High Users of Care

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

Plan N can be an excellent choice for

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

Plan N may not be ideal for

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

Watch a video on Physicians Mutual Innovative Plan G

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

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

In-Home Health Care

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

What Medicare Covers

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

1. They Must Be Homebound

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

2. Care Must Be Medically Necessary

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

3. Individuals Must Require Skilled Services

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

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

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

What’s Covered

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

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

Out-of-Pocket Costs

For most eligible home health services:

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

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

Examples of How Medicare Covers In-Home Health Services

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

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

How to Initiate In-Home Healthcare Through Medicare

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

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

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

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

IEP (Initial Enrollment Period)

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

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

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

What beneficiaries can do during IEP

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

ICEP (Initial Coverage Election Period)

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

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

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

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

What beneficiaries can do during ICEP

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

Differences at a Glance

Why Understanding IEP vs ICEP Matters to Agents

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

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

Watch a YouTube video on Medicare enrollment periods

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

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

Medicare Part B Excess Charges

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

Here’s how it works:

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

Example of a Part B Excess Charge

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

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

When Do Excess Charges Apply

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

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

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

How to Avoid Excess Charges

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

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

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

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

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

What Is Original Medicare

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

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

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

Medicare Part A

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

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

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

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

Medicare Part B

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

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

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

Click here to learn more about Part B eligibility

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

What Original Medicare Doesn’t Cover

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

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

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

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

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

When helping clients plan for their healthcare coverage needs, it’s important to discuss not just what Medicare does cover, but also what it doesn’t. Understanding these gaps can help clients avoid unexpected expenses and make informed decisions about supplemental insurance options. Let’s take a closer look at some of what Medicare won’t cover.

Long-Term Care

One of the biggest misconceptions about Medicare is that it covers long-term care, like nursing home stays or in-home care for chronic conditions. In reality, Medicare only covers short-term skilled nursing care under specific conditions. Clients may need separate long-term care insurance or other financial strategies to cover these considerable costs. Learn about short-term care vs long-term care plans.

Most Dental Care

Routine dental services such as cleanings, fillings, tooth extractions, dentures, and dental implants are generally not covered by Medicare. If dental care is important to your client, you should explore standalone dental insurance or Medicare Advantage plans that offer dental benefits.

Learn about stand-alone dental coverage available in all 50 states

Vision Care

Medicare does not cover routine eye exams for glasses or contacts. It will, however, cover eye exams related to medical conditions like glaucoma or cataracts. Clients needing regular vision care might consider standalone vision insurance or a Medicare Advantage plan with vision coverage.

Hearing Aids and Exams

Original Medicare doesn’t cover hearing aids or exams for fitting them, which can be a significant expense. Some Medicare Advantage plans offer hearing benefits, so this is worth exploring based on client needs.

Routine Foot Care

Routine foot care, such as treatment for corns, calluses, or nail trimming, is not covered unless it’s deemed medically necessary due to a condition like diabetes.

Overseas Health Care

Most care received outside the United States is not covered by Medicare. For clients who plan to travel internationally, consider recommending a Medigap plan that includes foreign travel emergency coverage or a separate travel insurance policy.

Elective Surgery

Medicare won’t cover elective cosmetic surgeries, such as facelifts or liposuction. It will however, cover surgeries that deemed medically necessary, such as reconstructive surgery after an accident or some forms of cancer.

Key Takeaways for Agents

This is just an idea of what is not covered by Medicare, for a complete lists click here.

• Discuss Supplement Options: Educate clients on the benefits of Medigap (Medicare Supplement) plans, Medicare Advantage plans, or standalone insurance options for things like dental, vison & hearing or other ancillary products to fill the coverage gaps.
• Tailor Recommendations: Understand each client’s lifestyle and health priorities to recommend the right supplemental coverage.
• Plan for the Unexpected: Help clients build a financial plan that anticipates out-of-pocket healthcare expenses.

Being proactive about Medicare’s limitations helps clients better prepare for retirement. As agents, we can offer tremendous value by guiding clients through their options to ensure they have the comprehensive healthcare coverage they need.

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In this post, we discuss the basics of Medicare enrollment for those approaching 65 and for agents getting started in Medicare sales. Trying to navigate all the ins and outs of Medicare may be a bit confusing, but it does not have to be. Understanding when and how to enroll in Medicare is key to ensuring beneficiaries receive the best coverage for their needs.

Original Medicare

Original Medicare consists of Part A & Part B. It is a federal health insurance program put in place for individuals aged 65 and older or younger individuals with a qualifying disability or those with End-Stage Renal Disease (ESRD). Medicare provides coverage for many healthcare services, including hospital stays (Part A), and doctor visits (Part B).

It is important to note; Medicare covers approved expenses at about 80% after beneficiaries meet the Part B deductible.

The Parts of Medicare

Before diving into enrollment, it’s helpful to understand the different parts of Medicare:

• Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care.
• Part B (Medical Insurance): Covers outpatient care, doctor visits, preventive services, and some home health care services.
• Part C (Medicare Advantage): An alternative to Original Medicare (Parts A and B) offered by private insurers. Often includes additional benefits like vision, dental, and prescription drug coverage.
• Part D (Prescription Drug Coverage): Helps cover the cost of prescription medications. Beneficiaries may receive coverage through a Medicare Advantage plan or a stand-alone PDP plan.

Medicare Enrollment Periods

There are several enrollment periods to be aware of:

Initial Enrollment Period (IEP)

This is the first opportunity to sign up for Medicare. It lasts seven months:

• Begins three months before the month individuals turn 65
• Includes their birth month
• Ends three months after the month they turn 65

In most cases, those already receiving Social Security benefits are auto-enrolled in Original Medicare (Parts A and B). If they are not, they must enroll via the Social Security Administration.

General Enrollment Period (GEP)

Individuals who miss their Initial Enrollment Period can use the GEP to enroll between January 1 and March 31 each year. Coverage starts the first day of the month following enrollment. Please note; those who miss their initial enrollment period and don’t have other creditable coverage (usually through an employer) may face late enrollment pentalties.

Special Enrollment Period (SEP)

In some cases, individuals qualify for a Special Enrollment Period if they delayed Medicare because they had coverage through an employer or union. This SEP allows them to enroll without penalty when their other coverage ends.

Annual Enrollment Period (AEP)

AEP Each year from October 15 to December 7, beneficiaries can:

• Switch between Original Medicare and Medicare Advantage
• Switch from a Medicare Advantage plan back to Origianl Medicar
• Change from one Medicare Advnatage plan to another
• Join, switch, or drop a Part D plan

Medicare agents watch a YouTube video on marketing rules for AEP

How to Enroll in Medicare

There are a few ways to enroll in Medicare:

• Online at ssa.gov/medicare
• By phone by calling Social Security at 1-800-772-1213
• In person at your local Social Security office (call ahead for an appointment)

A Few Tips

• Beneficiaries should mark their calendar so they do not miss their enrollment window. Delaying enrollment can lead to gaps in coverage and penalties.
• Ask questions! Medicare can be complex, and there are plenty of free resources available to help. This is where it is important to have a reputable , licensed Medicare agent to provide guidance.
• Because Medicare does ot cover 100% of medical expenses, beneficiaries need to consider additional coverage options; Medicare Advantage or Medicare Supplement and Prescrption Drug plans.

Learn how to appeal a Medicare LEP

Understanding the basics of Medicare enrollment is a vital first step in managing healthcare needs. With a little preparation and the right information, beneficiaries can make good decisions that provide peace of mind and the coverage that best suits their needs.

Agents:

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