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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.

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.

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

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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.

Medicare’s 2026 Drug Price Negotiations: A New Era of Affordability

Starting January 1, 2026, Medicare will implement its first-ever negotiated prescription drug prices; a historic change that could lower costs for millions of beneficiaries. In this post, we discuss Medicare’s 2026 Drug Price Negotiations. This is a direct result of the Inflation Reduction Act of 2022, which for the first time gave Medicare the authority to negotiate the prices of certain high-cost medications.

Why This Matters

For decades, Medicare was prohibited from negotiating directly with drug manufacturers. Instead, it relied on private Part D plan sponsors to manage drug costs. The 2026 negotiations mark a turning point. Medicare will now establish a Maximum Fair Price (MFP) for select drugs, reducing both what the government pays and what beneficiaries spend at the pharmacy counter.

• Projected Medicare savings: About $6 billion in 2026
• Projected out-of-pocket savings for beneficiaries: About $1.5 billion

The First 10 Drugs Negotiated for 2026

CMS chose these drugs because; they are some of the highest-cost Part D medications. In addition; there are no generic or biosimilar medications available, and are widely prescribed.

1. Eliquis – blood thinner for preventing stroke and blood clots
2. Xarelto – blood thinner for reducing risk of clotting
3. Januvia – diabetes medication (DPP-4 inhibitor)
4. Jardiance – diabetes, heart failure treatment (SGLT2 inhibitor)
5. Farxiga – diabetes, heart failure, kidney disease treatment (SGLT2 inhibitor)
6. Entresto – heart failure medication
7. Enbrel – rheumatoid arthritis and autoimmune conditions
8. Stelara – psoriasis, Crohn’s disease, ulcerative colitis
9. Imbruvica – blood cancers (leukemias and lymphomas)
10. NovoLog / Fiasp – fast-acting insulin for diabetes

How Beneficiaries Will Benefit

• Lower copays and coinsurance: Out-of-pocket costs will drop for patients taking these medications.
• Broader affordability: Even if you don’t take one of these drugs, Medicare’s overall savings help stabilize Part D premiums.
• Expanded impact in future years: In 2027 and beyond, CMS has scheduled more drugs for negotiation.

Watch a YouTube video on the Inflation Reduction Act and Changes to Medicare

What Comes Next

• 2027: Fifteen more high-spend drugs are already set to be negotiated, with prices effective January 1, 2027.
• 2028 and beyond: CMS will continue expanding the program, selecting additional drugs each year.
• Rulemaking: Starting in 2026, the program shifts to a formal rulemaking process, adding more transparency.

Challenges and Legal Pushback

The pharmaceutical industry has filed multiple lawsuits challenging Medicare’s new authority, arguing that price negotiations are unconstitutional. At the same time, new legislation has delayed or exempted certain blockbuster drugs, such as Keytruda, from early negotiation. While these challenges could affect the program’s scope, the 2026 savings are locked in and moving forward.

What You Should Do

• Review your Medicare Part D plan during open enrollment to ensure it covers your prescriptions at the lowest cost.
• Talk to your agent if you take any of the drugs on the 2026 negotiation list, you could see meaningful savings.
• Stay informed about future negotiation cycles, as more medications are added each year.

Agents:

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Medicare’s 2026 drug price negotiations represent a historic shift in prescription drug policy. For the first time, Medicare is actively reducing the cost of some of the most expensive and widely used medications in the program. While legal and political challenges remain, the immediate savings for beneficiaries and taxpayers are significant—and this is only the beginning.

Levels of D-SNP Eligibility Explained for Medicare Clients

Dual Eligible Special Needs Plans (D-SNPs) are Medicare Advantage plans designed for people who qualify for both Medicare and Medicaid. These plans can be a tremendous help to clients who have limited income and resources, but understanding the levels of DSNP eligibility and plan types can sometimes be confusing.

As of 2025, understanding the levels of D-SNP eligibility and how they connect to different plan structures is more important than ever for agents. Here’s a simplified breakdown.

Full vs. Partial Dual Eligibility

Full Dual Eligible Members

• Who qualifies
  Clients in categories such as Qualified Medicare Beneficiary Plus (QMB+), Specified Low-Income Beneficiary Plus (SLMB+), or Full Benefit Dual Eligible (FBDE).
• What does this mean
  These are individuals with the highest financial or health-related needs. States decide who qualifies, often based on strict income, asset, or disability requirements.
• Why it matters in 2025:
  Only full dual members can use the monthly D-SNP Special Enrollment Period (SEP) if there’s a HIDE or FIDE plan in their area.

Partial Dual Eligible Members

• Who qualifies
  Categories include Qualified Medicare Beneficiary (QMB), Specified Low-Income Beneficiary (SLMB), Qualified Individual (QI), and Qualified Disabled Working Individual (QDWI).
• What does this mean?
  These members get some help with Medicare costs, such as Part B premiums, but they do not qualify for full Medicaid benefits.
• Why it matters:
  Partial duals can join certain D-SNPs, but they don’t have access to the monthly SEP; only the regular Medicare enrollment windows (AEP, OEP).

Watch a YouTube video on DSNP Changes for 2025

Types of D-SNPs

D-SNPs are also categorized by how much Medicare and Medicaid benefits are integrated. Here’s what agents should know:

• Highly Integrated D-SNP (HIDE):
  • Covers Medicaid services such as behavioral health or long-term services and supports (LTSS).
  • As of 2025, the Medicaid contract must cover the D-SNP’s entire service area.
• Fully Integrated D-SNP (FIDE):
  • Combines both Medicare and Medicaid under one entity.
  • Must include primary and acute Medicaid services, plus LTSS (at least 180 days of nursing facility coverage).
  • Offers the highest level of integration and coordination between Medicare and Medicaid benefits.
• Applicable Integrated Plan (AIP):
  • A FIDE or HIDE plan with exclusively aligned enrollment.
  • Works directly with Medicaid managed care organizations tied to the D-SNP’s parent company.
• Coordination-Only D-SNP (CO):
  • Meets CMS minimum requirements but doesn’t integrate as fully as HIDE or FIDE plans.
  • Still required to coordinate Medicare and Medicaid services and share information between programs.
• Exclusively Aligned Enrollment (EAE):
  • Limits enrollment to full duals whose Medicaid is through the same company that operates the D-SNP.
  • Allows for better integration (single ID card, unified appeals and grievances, simplified materials).

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Why This Matters for Agents

• Enrollment rules are changing. As of 2025, only full duals with HIDE or FIDE plans in their service area can use the monthly SEP.
• Integration levels affect care. The more integrated the plan (like FIDE or HIDE), the easier it is for clients to navigate benefits and reduce confusion.
• Educating clients builds trust. Explaining eligibility clearly helps clients understand why they qualify (or don’t) for certain plans and enrollment periods.

The levels of D-SNP eligibility; full vs. partial, determine not just what benefits clients receive but also when they can enroll. On top of that, the type of D-SNP (HIDE, FIDE, CO, AIP) affects how well Medicare and Medicaid benefits work together.

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For agents, simplifying these distinctions is key. By guiding clients through their eligibility level and helping them choose the right type of D-SNP, you can ensure they get the maximum financial protection and coordinated care available.

Why Choose an HMO

When selecting a Medicare Advantage plan, one of the most common choices is a Medicare HMO (Health Maintenance Organization) plan. While Medicare Advantage plans come in different forms; such as PPOs, PFFS, and SNPs, HMO plans continue to be a popular option for many beneficiaries. But what makes them attractive, and why choose an HMO plan over other types of Medicare Advantage coverage?

Lower Monthly Premiums

HMO plans often come with lower monthly premiums compared to PPOs and some Medigap options. In fact, many HMO Medicare Advantage plans are available with a $0 monthly premium (though you must still pay your Part B premium). This makes them a budget-friendly choice, especially for retirees on fixed incomes.

Predictable Costs

With set copays for doctor visits, hospital stays, and prescriptions, Medicare HMO plans can make it easier to budget healthcare expenses. Instead of worrying about large unexpected bills, members often have a clearer idea of what their out-of-pocket costs will be.

Coordinated Care

The HMO plan designed encourages coordinated care. Beneficiaries select a primary care physician (PCP) who manages their overall health and provides referrals to specialists when needed. This system helps reduce unnecessary testing and ensures care is streamlined across providers.

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Extra Benefits Beyond Original Medicare

Original Medicare (Parts A and B) does not cover certain benefits like dental, vision, hearing, or fitness programs. Many HMO Medicare Advantage plans include these extras, along with prescription drug coverage (Part D). This makes HMO plans a convenient “all-in-one” package for many beneficiaries.

Lower Out-of-Pocket Maximums

Unlike Original Medicare, which does not cap spending, Medicare HMO Advantage plans include an annual out-of-pocket maximum. Once this limit is reached, the plan pays 100% of covered costs for the rest of the year, offering an important layer of financial protection.

Local Network Focus

Because HMO plans require members to use a network of doctors and hospitals, they often negotiate better rates, helping keep costs down. For beneficiaries who primarily receive care close to home, an HMO network may be more than sufficient.

Is an HMO Right for You

While HMO plans offer many advantages, everyone is different and has their own coverage needs. The main limitation is that you must use providers within the plan’s network (except in emergencies). If you prefer flexibility to see specialists without referrals or want coverage that extends more broadly outside your area, a PPO or Medigap plan may be a better choice.

However, for Medicare beneficiaries looking for affordable, coordinated, and benefit-rich coverage, a Medicare HMO is often an excellent option.

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What Value Based Care Means

Healthcare has been shifting away from the “fee-for-service” model, and Medicare is at the center of that transformation. Traditionally, doctors and hospitals were paid based on the number of tests, procedures, or visits they provided, regardless of whether patients got healthier. What Value Based Care means is a little different. VBC rewards providers for improving patient health and keeping costs down.

The Basics of Value Based Care

Value Based Care is about quality over quantity. Instead of simply paying for services rendered, Medicare ties payments to outcomes such as:

• Better health results – like reduced hospital readmissions or better management of chronic diseases.
• Improved patient experience – including communication, accessibility, and overall satisfaction.
• Lower overall costs – through preventive care, care coordination, and reduced unnecessary treatments.

How Medicare Uses Value-Based Care

Medicare has introduced several programs and models to encourage providers to embrace VBC. Some of the key examples include:

• Accountable Care Organizations (ACOs): Groups of doctors, hospitals, and other providers who work together to give coordinated, high-quality care to Medicare patients. If they save money while meeting quality goals, they share in those savings.
• Bundled Payments for Care Improvement (BPCI): Instead of billing separately for every service, providers receive a single payment for an entire episode of care, like a hip replacement or heart surgery.
• Hospital Readmissions Reduction Program (HRRP): Hospitals receive rewards for keeping patients healthier after discharge and avoiding costly readmissions.
• Medicare Advantage Plans (MA): Many MA plans already use value-based arrangements with providers to improve preventive care and manage chronic conditions.

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Why Value-Based Care Matters

For Medicare beneficiaries, Value-Based Care means:

• More preventive services: Encouragement to get screenings, vaccines, and wellness visits.
• Better coordinated care: Doctors and specialists share information to avoid duplication and gaps.
• Healthier outcomes: The focus is on managing conditions and preventing complications, not just treating problems when they arise.

For the healthcare system overall, VBC helps reduce wasteful spending and ensures taxpayer dollars are used more effectively.

Watch a YouTube video on SEP changes for Dual, Partial Dual & LIS members

The Future of Value-Based Care

Medicare’s long-term goal is to have most of its payments tied to value instead of volume. This means more providers will be incentivized to deliver patient-centered care that is proactive, efficient, and focused on health rather than procedures.

Value-Based Care is Medicare’s way of rewarding healthcare providers for keeping patients healthier, not just for doing more. As this model continues to grow, beneficiaries can expect better care coordination, more preventive services, and a stronger focus on long-term health.

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Understanding Medicare’s SSBCI Benefits: What They Are and Who They Help

If you’re a Medicare beneficiary or a Medicare agent working with clients you may have come across the term SSBCI. It stands for Special Supplemental Benefits for the Chronically Ill; it’s part of Medicare Advantage plans (not Original Medicare). Understanding Medicare SSBCI benefits is important. These benefits are designed to help people with certain chronic health conditions live healthier, more independent lives by addressing needs that traditional Medicare doesn’t usually cover.

Let’s break down what SSBCI is, how it works, and why it’s so important.

What Are SSBCI Benefits

SSBCIs allow Medicare Advantage plans to offer non-medical supportive benefits to enrollees with serious chronic illnesses. These can include things like:

• Preloaded grocery or utility cards
• Home modifications (e.g., grab bars, ramps)
• Air purifiers or pest control
• Meal delivery
• Social or physical activity programs

The benefits come with an important rule: each benefit must show a reasonable expectation of improving, or at least maintaining, the enrollees’ health or functional status. These targeted benefits can help prevent hospital visits and keep members healthier at home.

Who Qualifies for SSBCI Benefits

To be eligible, an enrollee must meet a three-part definition of “chronically ill,” including:

1. Having one or more complex or serious chronic conditions
2. Being at high risk of hospitalization or adverse outcomes
3. Needing intensive care coordination

Eligibility standards align with what qualifies for Chronic Condition Special Needs Plans (C-SNPs), though not all plans offer SSBCIs.

How SSBCI Differs From “Regular” Medicare Advantage Benefits

Most Medicare Advantage benefits are “primarily health-related.” SSBCI benefits expand that definition to include supports that aren’t strictly medical, as long as they address a specific health condition and can reasonably be expected to improve or maintain health.

Although regular supplemental benefits might include gym memberships or dental coverage for everyone in the plan, SSBCI benefits are customized to the needs of individuals who meet specific health criteria.

Why SSBCI Benefits Matter

Holistic Support: SSBCIs target real-life challenges; nutrition, safety, social connection, that can worsen health.

Flexibility: They can be customized to meet local needs and conditions.

Preventive Benefit: Reducing real-world barriers may lower healthcare costs down the line.

Personalized Care: Plans determine how SSBCIs are structured, shaping the benefits based on member needs.

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What’s New in 2026

Stricter Rules on What Plans Can’t Offer

Starting in 2026, Medicare Advantage plans will face a tightened definition of SSBCI. CMS has codified a list of non-allowable benefits, meaning some popular extras are now prohibited under SSBCI, including:

• Junk food, unhealthy groceries
• Alcohol, tobacco, or cannabis-related items
• Life insurance or funeral benefits
• Cosmetic procedures not covered by Original Medicare
• Insurance discounts unrelated to health care
• Hospital indemnity or unrelated insurance products

Mandatory Mid-Year Notifications

Also beginning in 2026, MAOs (Medicare Advantage Organizations) must send personalized mid-year notices (between June 30 and July 31) to members who have unused supplemental benefit allowances. These notices must include:

• Which benefits the enrollee hasn’t used (from Jan 1–Jun 30)
• Eligibility criteria and limitations
• Instructions on how to access the benefits and provider networks

This ensures beneficiaries don’t miss out on benefits they’re entitled to because they weren’t aware of them.

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Other Medicare-Wide 2026 Changes (Broader Context)

While not SSBCI-specific, here are some broader 2026 updates that complement the Medicare Advantage landscape:

• Automatic Renewal of the Medicare Prescription Payment Plan (MPPP); opt-outs must be processed within three days
• Part D Out-of-Pocket Cap increasing to $2,100 (up $100 from 2025)
• Part D Deductible capped at $615 (up by $25)
• Insulin Cost Cap: Still $35 or less, whichever is lower of negotiated or maximum fair price—now effectively enforced annually
• Adult Vaccines under Part D remain free with no cost-sharing as a permanent policy

Bottom Line

SSBCIs remain a powerful innovation within Medicare Advantage pushing beyond clinical coverage to tackle the lived experiences of chronically ill beneficiaries. But in 2026, plans must tighten the focus and communicate more clearly, including:

• No more non-health-related extras under SSBCI
• Required mid-year check-ins to help enrollees use their benefits effectively

Those who rely on SSBCIs, should:

Always review your 2026 ANOC for SSBCI benefit changes. Pay close attention to mid-year notices and unused benefits. Contact a licensed Medicare agent if you have questions about your current coverage or to look at your options during AEP or other available enrollment periods.

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