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Home Posts tagged "medicare coverage"
What is Original Medicare

What is Original Medicare

By Ed Crowe | General Articles | 0 comment | 7 May, 2025 | 0

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.

Medigap Standardized Benefits

Medigap Standardized Benefits

By Ed Crowe | General Articles | 0 comment | 6 May, 2025 | 0

Navigating the world of Medicare can be overwhelming, especially when it comes to choosing the right supplemental coverage. That’s why it is important to understand what Medigap standardized benefits are and how they work.

Medigap is a type of private insurance that helps beneficiaries cover the “gaps” in Original Medicare (Parts A and B). Medigap plans cover things like; deductibles, coinsurance, and copays. What many people don’t realize is that Medigap policies are standardized, meaning the benefits for each plan type are the same, no matter which insurer you choose.

What “Standardized” Means

Starting in 1992, federal law requires all Medigap policies to adhere to standardized benefit structures, designated by letters: Plans A through N. The only real difference in plans is the premium each carrier charges for the plan. Although insurance companies charge different premiums, the benefits for each plan letter must be identical no matter who the provider is. In other words, every Plan N has to provide the exact same coverage for medical expenses no matter what company offers it.

Standardization makes it easy for beneficiaries to compare plans without worrying about differences in coverage. They can simply compare cost and company ratings to find the best options.

Examples of Medigap Plan options

  • Plan A: This is the most basic plan option. It provides coverage for Medicare Part A coinsurance and hospital costs, Part B coinsurance, and the first three pints of blood.
  • Plan G: The most comprehensive plan available to those who turned 65 after 1-1-2020. It covers all Medicare approved expsnes with the exception of the Part B deductible.
  • Plan N: Offers lower premiums than Plan G and covers a portion of the copays for doctor visits and hospital visits. The enrollee will still have a small copay for Medical services. This plan does not cover the Part B deductible or excess charges.

Some States Have Different Medigsp Standards

Although most states follow the federal standardization model, Massachusetts, Minnesota, and Wisconsin have their own versions of standardized Medigap plans. These states use their own benefit structures however, they still follow the principle of offering consistent benefits across insurers within their states.

Please Note

  • Plan C and Plan F are no longer available to beneficiaries who became eligible for Medicare on or after January 1, 2020. These plans provided coverage for the Medicare Part B deductible, which new legislation phased out to cut back on the overuse of services.
  • Beneficiaries must have both Medicare Part A and Part B to enroll in a Medigap plan. There is a premium for Medigap plans in addition ot the Part B premium.
  • Medigap works with Original Medicare, beneficiaires cannot use a Medigpa plan with a Medicare Advantage (Part C) plan.

Why Standardization is Important

Standardization simplifies decision-making for Medicare beneficiaries. It eleiminates the need to decipher insurnace benefits accross multiple insurance companies; instead, the focus is on price, company reputation, and rate increase history.

Watch a quick YouTube video on Medicare Supplement Underwriting

This helps foster competition between companies based on cost and service quality instead of confusing plan designs.

Choosing a Medigap plan doesn’t have to be a guessing game. With standardized benefits, benficiaries can make apples-to-apples comparisons between insurers and choose the coverage that meets both healthcare and financial needs.

Agents, are you ready to join the team at Crowe; click here

Differences Between Copays and Coinsurance

Differences Between Copays and Coinsurance

By Ed Crowe | General Articles | 0 comment | 12 February, 2025 | 0

When navigating health insurance, you come across terms like coinsurance and copays both of which determine how much you pay for medical services. While some people use these terms interchangeably, they have distinct meanings and impact out-of-pocket healthcare costs differently. Understanding the differences between copays and coinsurance can help beneficiaries have a better understanding of how their coverage works.

What is a Copay

A Copay (copayment) is a fixed amount plan enrollees pay for a specific healthcare service. Copays are typically required at the time of service and apply to things like primary care or specialist visits, urgent care visits, and prescription medications.

How Copays Work

  • If a health plan has a $30 copay for primary care visits, plan enrollees pay $30 each time they see their doctor, regardless of the total cost of the visit.
  • When a plan specifies a $50 copay for a specialist visit, enrollees pay that amount, while the insurance covers the rest of the cost for the visit itself. Please keep in mind; some medical services include additional charges.
  • Copays for prescriptions vary based on tiers (generic vs. brand-name drugs). Copays for prescriptions may vary greatly based on the drug.

What is Coinsurance

Coinsurance is a percentage of the cost for medical services, equipment or prescriptions that enrollees are responsible for after they meet the deductible. Unlike copays, which are fixed amounts, coinsurance is a percentage of the total bill.

How Coinsurance Works

  • If the plan enrollee has a coinsurance of 20% and receives medical services that cost $1,000, their cost is $200. Their insurance covers the remaining $800, once they meet their annual deductible amount.

Differences Between Copays and Coinsurance

FeatureCopayCoinsurance
Payment TypeFixed amountPercentage of total cost
When It AppliesAt the time of serviceAfter meeting the deductible
PredictabilityPredictableCan vary depending on service cost
Common ExamplesDoctor’s visits, prescriptions, ER visitsHospital stays, surgeries, specialized procedures

Which is Better: Copay or Coinsurance

Neither is inherently better. Each affects overall healthcare costs in different ways. Plans with higher copays may have lower monthly premiums, making them ideal for those who prefer predictable costs. In contrast, plans with coinsurance may have lower copays. This can result in higher out-of-pocket costs for major medical procedures.

Choosing a Plan

Those who visit doctors frequently may prefer a plan with lower copays to help save some money. It is important to consider any known major medical expenses and focus on a plan that provides a lower coinsurance amount and a manageable deductible. It is also important to be aware of the maximum out-of-pocket limit, which caps the amount enrollees pay each year before approved medical expenses are covered at 100%.

Online quoting and enrollment tools help show plan costs side by side to make choosing a plan easier. Medicare agents; click the links below to see how to run a quote on Sunfire and Connecture, our free agent quoting sites.

Agents see how easy it is to use Sunfire for a quote and an enrollment

Take a look at how to use Connecture for quoting and enrollments

Understanding how copays and coinsurance work helps individuals estimate medical expenses and choose a plan that aligns with their healthcare needs and budget. Carefully comparing these costs can help avoid unexpected bills and make the best health coverage choice for each individual

Medicare Wellness visits vs checkups

Medicare Wellness Visits vs Checkups

By Ed Crowe | General Articles | 0 comment | 5 February, 2025 | 0

If you’re a Medicare agent, you may receive calls from clients asking if Medicare covers their annual checkup. Most likely, your answer will confuse them. Many do not understand the difference between Medicare wellness visits vs checkups. Some people use these terms interchangeably. However, these are actually two different types of appointments. Understanding the distinction can help beneficiaries make the most of their Medicare benefits.

What is an annual wellness visit

An annual wellness visit is a preventive service that Medicare Part B covers. This visit helps beneficiaries and their providers create or update a personalized prevention plan based on current health and risk factors.

During this visit, the doctor reviews the beneficiary’s medical history, medications, height, weight, and blood pressure. They also assess cognitive function and risk factors for conditions like dementia. The beneficiary receives personalized health advice and screenings. The doctor and beneficiary may use this visit to discuss advance care planning and develop or update a prevention plan.

Medicare covers 100% of the cost for an annual wellness visit. In other words, there is no copay or deductible if your provider accepts Medicare assignment.

What is an annual checkup

An Annual Checkup (Routine Physical Exam) is a comprehensive medical evaluation that goes beyond the preventive focus of an annual wellness visit. Unlike the annual wellness visit, Medicare does not cover routine physicals. Those who request an annual checkup, may pay out of pocket unless they have insurance that covers it. During an annual checkup, the doctor may perform a physical exam, listen to the heart and lungs as well as order lab tests such as blood work. The provider assess overall organ function and diagnose medical issues.

Because an annual checkup involves diagnostic and treatment-related services, Medicare does not cover this visit unless it is used to address health concerns under medical necessity.

Why this matters for Medicare beneficiaries

Many Medicare beneficiaries schedule an “annual physical” expecting it to be fully covered, only to find out later that Medicare does not pay for it.

In order to avoid unexpected costs; beneficiaries who want a preventive visit covered by Medicare should ask for an “annual wellness visit.”

Click here to learn more about Medicare annual wellness visits


Anyone who needs a full physical exam including diagnostic tests, or lab work should check on the potential costs.

Understanding the difference between these visits ensures beneficiaries receive needed care and helps them avoid unexpected medical bills.

Medicare Part D Enrollment Periods

Medicare Part D Enrollment Periods

By Ed Crowe | General Articles | 0 comment | 13 December, 2024 | 0

Medicare Part D (prescription drug coverage) is essential for anyone enrolled in Medicare. Additionally, it is equally important that both agents and enrollees understand the Medicare Part D enrollment periods.

IEP (Initial Enrollment Period)

The IEP ( Initial Enrollment Period) is the beneficiaries first opportunity to enroll in Medicare coverage, this includes Part D. IEP is a 7 month window that begins three months before the month the beneficiary turns 65. It includes their birthday month and ends three months after their 65 birthday month.

Individuals who are eligible for Medicare due to disability have an IEP that starts three months before their eligibility date and ends three months after their 25th month of disability benefits.

During this period, beneficiaries can either enroll in a standalone Part D plan or an MAPD (Medicare Advantage plan that includes drug coverage).

AEP (Annual Enrollment Period)

The AEP (Annual Enrollment Period), sometimes referred to as Open Enrollment, takes place annually from October 15 to December 7. During this time, beneficiaries can enroll in a Part D (PDP) plan if they miss their IEP. They can also switch from one Part D plan to another or enroll in an MAPD plan. As long as they have Part D coverage.

Please note: any changes in coverage made during AEP take effect on January 1st of the following year.

MA OEP (Medicare Advantage Open Enrollment Period)

This enrollment period runs from Jan 1 through March 31 each year and is only available to those already enrolled in a Medicare Advantage plan. This provides enrollees an additional opportunity to make changes to their current MA/MAPD plan.

During the MA OEP beneficiaries can change from one Medicare Advantage plan to another Medicare Advantage plan either with or without Part D coverage. They can also disenroll from a Medicare Advantage plan and go back to Original Medicare with the option to enroll in a stand alone Part D plan and a Medicare Supplement. Please note the beneficiary must have a guaranteed issue election or pass underwriting to enroll in a Medicare Supplement plan.

Watch a quick YouTube video on OEP best practices

SEPs (Special Enrollment Periods)

SEPs (Special Enrollment Periods) allow beneficiaries to make changes to Part D coverage outside the standard enrollment windows under specific circumstances, such as:

Losing other creditable drug coverage: If the enrollee loses employer sponsored coverage or their plan is discontinued in their service area, they have 63 days to enroll in a Part D plan after losing coverage.

Moving to a new service area: If the current plan isn’t available in their new location, the enrollee is eligible for an SEP.

Qualifying for Extra Help: Individuals eligible for Medicare’s Extra Help program can change their Part D plan once per calendar quarter during the first three quarters of the year.

LEP (Late Enrollment Penalty)

It’s important for beneficiaries to enroll in Part D coverage when first eligible to avoid the late enrollment penalty. The penalty applies if they go without creditable prescription drug coverage for a period of 63 consecutive days or more once their IEP is over.

The penalty is calculated based on how the beneficiary went without coverage and is added to their monthly premium amount for life.

How to choose the right plan

  1. It is imperative to check all medications to see which plan provides the best coverage for them. All plans have their own formulary.
  2. Compare the plans that cover the drugs best. Consider all costs for each plan. The cost includes the premium as well as deductibles, copays and coinsurance.
  3. Make sure the plan is in network the preferred pharmacy to ensure you get the best price.
  4. Because plan costs and coverage changes each year, it is important to review coverage options each year during the AEP.
  5. Ask for assistance from a licensed Medicare agent who is appointed with several area carriers to provide the best options for coverage. The medicare.gov tool is a good way to check prices but it cannot answer your specific questions.

Understanding Medicare Part D enrollment periods and rules can save money and ensure you have the coverage you need.

Medicare Insurance Agents

Medicare Insurance Agents

By Ed Crowe | General Articles | 0 comment | 26 November, 2024 | 0

Why use a Medicare agent

If anyone asks why people use Medicare insurance agents, we have a few good reasons below.

To start; Medicare agents complete hours of training on both compliance regulations.  They also complete hours of study and testing on the Medicare products available in their area.  They must be well versed on the plans and provide detailed information to clients. A good agent can provide comparisons of several plans and help find the Medicare plan to best fit their needs.

learn the difference between Medicare Advantage and Medicare Supplements,

Compare plan choices

Because health insurance coverage is such an important decision, it is important for clients to understand all their choices. Choosing the wrong plan can be a very costly mistake.  For this as well as many other reasons, the help of a licensed Medicare agent is essential. A Medicare agent can go over the client’s list of wants/needs for coverage and find plan options that are right for them. Agents help clients weigh the benefit of each plan. Medicare plan benefits, rules, and exceptions may be overwhelming to sort out without a trained professional.

Medicare agents can easily narrow down the options and provide a comparison of potential plans.  They can provide clients an understanding of each plan to help them make an informed decision as well as enroll the client in the plan of their choice.

To find out about our quoting tools, Connecture and Sunfire, click here

Many Medicare agents have quoting and enrolling tools that can show you plan options side by side within minutes.  This can save clients countless hours of research.

Consider the client’s current coverage

It is important to consider the client’s current Medicare coverage and find out what about the plan works or does not work for them.  With this information in mind, it is easier to find help them decide whether they should stay in their current plan or if there are better options available to them.

Agents do not charge for their service

As a Medicare agent, you cannot take money from the client for the advice you provide.  This means clients receive expert advice at no cost.  This service is provided for free.  That is one deal you cannot beat!

Medicare agents receive payment through a couple different ways depending on the type of agent they are.  Agents who are employed by and insurance company receive payment based on their agreement with their employer.  Many other agents who are not captive with a carrier, receive payments through the commissions they earn.  They may receive this payment directly from the carrier or if they are LOA, they receive payment from their up-line.  Either way, the amount they make is based on their total number of sales made.

Please note: commission amounts vary based on the plan type and carrier as well as the level each individual agent is contracted at.

Find out about commission levels for 2025

How clients choose a Medicare agent

Here are some things clients may consider when they choose a Medicare agent.

  1.  The first way clients choose an agent is usually word of mouth.  If you have done a great job helping their friends, relatives or co-workers, believe me they will hear about it.  People love to tell their friends about an agent who really did a good job for them.  That is why all your clients need to know that you are there to answer any questions or concerns they have.
  2. Clients feel better knowing they are working with an experienced agent someone who understands the plan benefits and how they work.  Be sure you are up to date on all the plans in the areas you sell in as well as what the rules for enrollment are.
  3. Offer many different carries and plan types for each area you sell in.  Clients want to work with an agent who has access to all the best plans in their area.  Each client is an individual and one plan type may not be the best choice for every client. Do not offer only Medicare Advantage plans as some clients are better off with a Supplement and PDP plan.

Click here for a scope of appointment

    A knowledgeable and caring Medicare agent is a very valuable resource for the community. If you make sure you are well informed and truly enjoy helping those who need advice on Medicare coverage, you can become a successful agent with the right amount of time, effort & training.

    What qualifies as preventative under Medicare

    What qualifies as preventative under Medicare

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

    What qualifies as preventative under Medicare and how do you ensure you take full advantage of these benefits? Because preventive care is an essential part of staying healthy and managing potential health risks before they become serious, Medicare recognizes the importance of preventive care and offers a range of services to help beneficiaries maintain their health.

    What Is Preventive Care

    Preventive care refers to medical services that aim to prevent illness, detect conditions early, or promote overall good health. These services can include screenings, vaccines, counseling, and much more. By focusing on prevention, Medicare helps beneficiaries proactively manage their health and reduce the need for more costly treatments in the future.

    Click here to download a copy of a comprehensive list or covered preventative services

    Medicare Coverage for Preventive Services

    Medicare provides a wide array of preventive services under Part B (Medical Insurance). Many of these services are available to beneficiaries at no cost. These services may help detect health problems early when treatment is sometimes more effective and less expensive.

    Some common types of preventive care Medicare covers:

    Wellness Visits

    Within the first 12 months a beneficiary enrolls in Medicare Part B, they are entitled to a “Welcome to Medicare” preventive visit. This one-time visit includes a review of your medical and family history, as well as basic measurements like height, weight, and blood pressure.

    After your initial visit, Medicare covers an annual wellness visit each year. This can help create or update a personalized prevention plan. This plan can help beneficiaries stay on top of their health by identifying risk factors and setting health goals.

    Vaccinations and Immunizations

    Medicare covers vaccines that help prevent serious illnesses, including:

    1. Flu Shot (Influenza): Covered once per flu season, typically every fall or winter.

      2. Pneumococcal Vaccines: Medicare covers two different pneumococcal shots. The initial shot as well as a second shot a year later if appropriate.

      3. Hepatitis B Vaccine: Available to those at medium or high risk for Hepatitis B.

      4. COVID-19 Vaccines and Boosters: Medicare covers COVID-19 vaccines and booster shots as recommended by health authorities.

      5. The Shingles Vaccine: This vaccine is administered in two doses. The second dose is given two to six months after the first. Medicare covers the cost of both doses.

      Read more about Medicare coverage of vaccines

      Screenings and Tests

      Medicare offers a variety of preventive screenings and tests to help detect health issues early, including:

      1. Mammograms: Medicare covers mammograms for the purpose of screening once every 12 months for women aged 40 and older. Medicare may also cover diagnostic mammograms if medically necessary.

        2. Colon Cancer Screenings: Medicare covers multiple types of colon cancer screenings, including fecal occult blood tests, multi-target stool DNA tests (like Cologuard), flexible sigmoidoscopy, and colonoscopy. The frequency of these tests depends on the specific test and risk factors.

        3. Bone Density Tests: Covered once every two years (or more often if medically necessary) for individuals at risk for osteoporosis.

        4. Diabetes Screenings: Medicare covers up to two diabetes screenings per year for individuals at risk. This includes those with a history of high blood pressure, high cholesterol, obesity, or a family history of diabetes.

        5. Cardiovascular Screenings: Medicare covers a screening blood test every five years to check for conditions like high cholesterol and triglyceride levels.

        Cancer Screenings

        Because early detection of cancer can lead to better treatment outcomes. Medicare covers:

        1. Cervical and Vaginal Cancer Screenings: Medicare covers pap tests and pelvic exams are once every two years, or every year for women at high risk

        2. Prostate Cancer Screenings: Annual prostate-specific antigen (PSA) tests and digital rectal exams for men aged 50 and older.

        3. Lung Cancer Screenings: Low-dose CT scans are covered annually for individuals at high risk, particularly heavy smokers or those who have quit smoking within the past 15 years.

        Cardiovascular Health

        Medicare covers several services to help maintain cardiovascular health, including:

        1.Cardiovascular Behavioral Therapy: This includes counseling on diet and exercise to help reduce the risk of heart disease.

        2. Blood Pressure Screenings: These are typically part of your annual wellness visit.

        Diabetes Prevention Program

        The Medicare Diabetes Prevention Program offers lifestyle coaching and resources to help beneficiaries at risk for diabetes prevent the onset of the disease. The program is designed to encourage weight loss, healthy eating, and regular physical activity.

        Mental Health and Wellness

        Medicare also covers preventive services aimed at mental health, including:

        1. Depression Screenings: Medicare includes an annual screening for depression as part of the yearly wellness visit.

        2. Alcohol Misuse Counseling: Medicare covers counseling for beneficiaries who are screened and found to have alcohol misuse issues.

        3. Smoking Cessation Programs: Medicare covers up to eight counseling sessions per year to help beneficiaries quit smoking.

        Obesity Screening and Counseling

        For individuals with a body mass index (BMI) of 30 or higher, Medicare covers counseling sessions to help promote weight loss and healthy living. This coverage includes regular face-to-face meetings with a healthcare provider.

        Screenings for Infectious Diseases

        Medicare also offers coverage for screenings to detect infectious diseases, including:

        1. HIV Screenings: Covered once every 12 months, or more frequently for individuals at higher risk.

        2. Hepatitis C Screenings: Covered once if born between 1945 and 1965, or annually for those at high risk.

        3. Sexually Transmitted Infections (STIs): Medicare covers both screenings and counseling sessions annually for individuals at risk.

        Make the Most of Medicare Preventive Services

        1. Schedule an annual wellness visit: This visit is a great opportunity to discuss overall health and get a personalized prevention plan. It’s also a good time to make sure you’re up to date on all the preventive services you’re eligible for.
        2. Know What Medicare Covers: Familiarize yourself with the list of preventive services Medicare covers and discuss these options with your healthcare provider. They can help determine which screenings and vaccines are appropriate for you.
        3. Keep Track of When You’re Eligible: Medicare covers some services once a year or every few years. Make a note of when you’re eligible for your next screening or vaccination.

        Preventive care is an important part of Medicare coverage and can help you stay healthier, detect potential problems early, and avoid costly treatments. Whether it’s a simple flu shot, a cancer screening, or an annual wellness visit, Medicare makes it easy for beneficiaries to access a wide range of preventive services. Understanding what’s covered and taking advantage of these benefits can play a key role in maintaining health and well-being.

        If you need help choosing a Medicare plan, click here to learn why you should use a licensed Medicare agent

        Medicare income limits 2024

        Medicare income limits 2024

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

        Medicare income limits 2024

        The Medicare income limits 2024 effect about 7% of Medicare beneficiaries.  Each year, the Social Security Administration determines the income limit that the IRMAA is based on.  It’s crucial to stay up to date on the annual income limits weather you are an agent or a beneficiary. In this post, we go over Medicare income limits for 2024 and how they can impact beneficiaries.

        Why Medicare income limits matter

        The income limits come into play with both Medicare Part B & Part D. The limits are used to determine if an individual pays either the standard premium amounts or a higher income-based premium for Part B & Part D.

        Beneficiaries who earn more than the Medicare income limit have to pay an IRMAA for their Part B & Part D coverage.  In 2024, the income limit is $103,000 for an individual.  The income limit is $206,000 per couple.

        Which Medicare coverage is income based

        Medicare Part A is free to most beneficiaries and no IRMAA applies.

        Part B of Medicare is income based as most beneficiaries have to pay for it, with the exception of those who qualify for “Extra Help“.

        Learn more about help for Medicare beneficiaries with limited resources.

        Beneficiaries of Medicare Part C (Medicare Advantage Plans) only have to pay the IRMAA when the plan they choose includes prescription drug coverage.  Few plans called MA only do not include prescription drug coverage and therefore, the IRMAA does not apply to those plans.

        The IRMAA does apply to Medicare Part D (PDP) plans.

        How is individual income determined

        For 2024, the income limit is based on the beneficiaries’ 2022 tax return.  In other words, each year the IRMAA is based on the tax return from 2 years prior.  Medicare uses the MAGI (modified adjusted gross income) to determine who pays the IRMAA.

        Although beneficiaries don’t see this amount on their tax return, they can find it by adding their income after deductions to any tax-free interest they earned.

        Agents: Learn more about IRMAAs; watch our  YouTube video.

        More about income limits in 2024

        For 2024, there is more than one income threshold used to determine the IRMAA amount each individual pays for their Part B and Part D coverage.  Here are the Part B & Part D IRMAA amounts:

        Single
        Married Filing Jointly
        Married Filing Separately
        Part B Premium
        Part D IRMAA
        $103,000 or less
        $206,000 or less
        $103,000 or less
        $174.70
        $0 + plan premium
        $103,000 up to $129,000
        $206,000 up to $258,000
        N/A
        $244.60
        $12.90 + plan premium
        $129,000 up to $161,000
        $258,000 up to $322,000
        N/A
        $349.40
        $33.30 + plan premium
        $161,000 up to $193,000
        $322,000 up to $386,000
        N/A
        $454.20
        $53.80 + plan premium
        $193,000 less than $500,000
        $386,000 less than $750,000
        $103,000 less than $397,000
        $559.00
        $74.20 + plan premium
        $500,000 or above
        $750,000 or more
        $397,000 or more
        $594.00
        $81.00 + plan premium

        Most people pay the standard Medicare Part B premium rate.  The premium rate for Part D varies according to the plan selected. Beneficiaries with higher incomes pay extra for both Part B and Part D.

        IRMAAs for Part B and Part D are automatically taken from their Social Security or Railroad Retirement Board benefits. Beneficiaries who do not receive monthly benefit payments receive a bill from Medicare.

        How to handle an IRMAA

        For beneficiaries subject to an IRMAA for Medicare Part B & Part D, there are ways to potentially lower your MAGI and reduce premiums.  Beneficiaries can consult their accountant and or financial advisor to help lower taxable income amounts.

        How to request an IRMAA redetermination

        Because the Social Security Administration bases their IRMAA determination on income reported on tax returns from 2 years prior, beneficiaries may have had a reduction in income.   There are some life events that can cause a reduction in income, these include:

        1. Death of a spouse, a divorce or annulment or a marriage
        2. When either spouse stops or reduces the number of hours they work
        3. If either spouse loses a pension
        4. Loss of income due to income producing property loss because of a natural disaster, fraud or similar circumstances

        When beneficiaries receive notice of an IRMAA, they also receive information that explains how to request a new initial determination.

        If Social Security receives a new initial determination, they may revise the amount of the IRMAA or dismiss it all together.  Beneficiaries can request a redetermination by either scheduling an appointment with their local Social Security office or by submitting the following form:

        Medicare IRMAA Life-Changing Event form

        beneficiaries must provide documentation of correct income or life-changing event that affected their income level in a negative way.

        Beneficiaries can also call the representatives at SSA +1 800-772-1213 and request help lowering their IRMAA.  Explain that Social Security used outdated or incorrect information when calculating the IRMAA.

        To view more images by this artist, click here

        Medicare agents, subscribe to our YouTube channel for free training videos!

        Extra help income limits 2024

        Extra Help income limits 2024

        By Ed Crowe | General Articles | 0 comment | 24 March, 2024 | 0

        Extra Help income limits 2024

        Medicare Extra Help is a federal program put in place to help individuals whose income and financial resources are limited.  It provides help for those who qualify to pay the costs of their Medicare prescription drugs. The subsidies provided by this program cover premiums, deductibles, as well as co-pays for the costs of Medicare prescription drug plans (Part D).  To qualify for this program, individuals must meet the income criteria set by the federal government each year.  In this post, we will go over the Extra Help income limits 2024.

        How to Qualify for Extra Help

        1.  Be a U.S. citizen or legal resident

        To enroll in Original Medicare, individuals must either be a United States citizen or a legal resident for at least 5 years. In turn, to enroll in Medicare’s Extra Help program, an individual must qualify for Medicare.

        2. Enroll in Medicare Part A and/or Part B

        Beneficiaries must be enrolled in at least one part of original Medicare. They do not need to enroll in Part D before applying for Extra help.  If the beneficiary does not currently have Part D coverage, they are automatically enrolled in one once the Extra Help is approved.

        3.  Meet resource and income limits

        Individuals cannot exceed the asset and income limits to qualify for Extra Help.  If an individual is eligible for Medicaid or any of the Medicare Savings Programs, they automatically qualify for Extra Help. Individuals do not have to apply for Extra Help if they automatically qualify.  They will be enrolled in the Extra Help program as well as a Medicare drug plan.

        Extra Help Income and Resource Limits 2024

        Important: the Extra Help income limits are based on the adjusted gross income reported on the individual’s tax return.  Governmental assistance such as food stamps, housing or home energy assistance do not negatively impact your acceptance.

        Marital Rights Resource Limit 2024 Resource Limit with Burial Expenses 2024 Extra Help Income Limit 2024
        Single $17,220 an additional $1,500 $22,590
        Married $34,360 an additional $3,000 $34,360

         

        In some instances, individuals with income that exceeds the limit may still qualify for Extra Help.  The following circumstances may allow for special consideration of Extra Help acceptance:

        1. If the individual provides financial support for other family members who reside with them.
        2. When the beneficiary earns money by working.
        3. Anyone who lives in either Alaska or Hawaii.

        Because resource limits also count towards determining eligibility, we listed a few examples of what does and does not count below.

        These are some things that count as resources:

        1.Money in Checking or savings accounts

        2.Real estate that does not include a primary residence.

        3. Stocks, Bonds & Mutual funds, IRAs or cash

        These are some things that DO NOT count as resources:

        1. An individual’s primary residence

        2. Any vehicles owned by the individual

        3. Expense set aside for the individual’s burial; this includes interest on money set aside for burial

        4. Personal belongings

        For a comprehensive list of what does and does not qualify, contact the local Social Security office.

        Drug costs with Extra Help

        Individuals who receive Extra Help pay reduced out-of-pocket costs for prescription drugs. In 2024, those who qualify for full Extra Help pay up to $4.50 for generic drugs and up to $11.20 for brand-name drugs. If total drug costs reach $8,000 (this includes what beneficiaries pay and what their plan pays) they pay $0 for covered drugs.

        Additionally, those who did not enroll in Medicare Part D when first eligible, don’t pay the late enrollment penalty if accepted in the program.

        How to apply for Extra Help

        • Apply online at www.ssa.gov/medicare/part-d-extra-help.
        • Beneficiaries can call Social Security at 1-800-772-1213 (TTY 1-800-325-0778) to either apply over the phone or request an application.
        • Visit your local Social Security office to apply.  Click here to locate a local office.

        After the application is submitted, Social Security sends a letter to let the beneficiary know if they qualify and what level of Extra Help they will receive.

        Extra Help is crucial for individuals who require assistance with the costs of prescription drugs. Understanding the requirements is the first step to finding the necessary help to ensure the needed coverage is received.

        If you like the image in this post and want to view more from this artist, click here

         

         

        Medicare leads

        Medicare Leads

        By Ed Crowe | General Articles | 0 comment | 22 March, 2024 | 0

        Medicare leads

        If you are a Medicare agent, one thing that you are always looking for is Medicare leads.  There are many places you can find leads. The most valuable leads are T-65 leads.  These leads are the best to get because insurance carriers pay the highest commissions for new to Medicare enrollments.

        Watch a YouTube video on Medicare commission payments

        Individuals turning 65 are also a great lead to get because an agent that does their job well, now has a new client on his books for quite a long time to come.  As long as the agent provides useful guidance to the beneficiary and ensures they are happy with their plan choice, they can develop a mutually beneficial relationship.

        Before you contact anyone, it is very important to understand the CMS rules of how to do it.  Click here for details.

        Click here to find out about our Medicare lead program.

        In reality, many leads sources like online leads, inbound calls and pre-set leads do not produce many T-65 prospects. What they do provide is the contact information for current Medicare beneficiaries.  In reality, many of the people already have an agent and are not seeking guidance, although agents may find individuals who are unhappy with their current plan and/or their agent.  If you find a valid enrollment period, you can provide the assistance and coverage that the beneficiary is looking for.

        If the potential client decides to enlist your assistance as an agent, you may need them to list you as their AOR.  Some Insurnace carriers allow clients to designate an agent as AOR even if they do not write a plan at that time.  When this happens, you have a client added to your book and can help them change their plan at a later date if it is appropriate. Learn how to make AOR changes.

        T-65 Seminars

        A great way to meet several individuals turning 65 is by hosting an educational event.  Our seminar selling program is an effective tool to provide needed information to the people who need it. This is truly a turn-key program that guarantees agents get in front of T-65 leads. Find out more about the seminar program.

        Watch a video on the T-65 seminar program

        If you decide to host an educational event, it is important to follow CMS guidelines for hosting an educational event.  If you decide to do a sales event, there are specific guidelines to follow as well.

        Additionally, Crowe agents can access to a preset lead program.  This program provides leads at a very good close ratio.

        Watch a video on our preset lead program.

        Free leads

        Agents who put in the effort to ensure their clients are happy with their coverage choices can easily earn referrals.  In order to ensure clients are happy, agents must be in contact with their clients and go over new plan options each year during the AEP.  As well as other times during the year to maintain the relationship and ensure clients are happy and do not seek answers to Medicare questions elsewhere.

        Read more about how to get Medicare referrals

        Establish relationships with other local professionals

        It is a great idea to introduce yourself to healthcare professionals, doctors and clinics in your area as well as other professionals who work with clients that may need your advice.  Once they know you and are aware of the services you provide, it is easy to build a partnership and open doors to new lead prospects.  This will help establish you as a knowledgeable resource for anyone who needs advice.

        Take a look at a few more Medicare marketing ideas

        If you like the image on this post and want to view more, click here

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