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When a client receives a denial for a Medicare claim, they may be frustrated. It is important to let them know they have options. If Medicare refuses to cover a service or item, or if there is a question about how much Medicare paid, clients need to understand the Medicare claim appeal process.

What Is a Medicare Appeal

A Medicare appeal is a formal request asking Medicare to review and reconsider a coverage or payment decision. You can appeal if:

• Medicare denies coverage for a service or item you think should be covered.
• You disagree with the amount Medicare paid for a service or item.
• Medicare decides to stop services you are currently receiving, like skilled nursing care or home health services.

Types of Medicare Appeals

The appeal process may differ depending on the type of Medicare you have. Here’s a breakdown:

1. Original Medicare (Part A and Part B) Appeals
2. Medicare Advantage (Part C) Appeals
3. Medicare Prescription Drug Plan (Part D) Appeals

Each type follows a specific set of rules, but the general steps remain similar across all parts.

Review the Medicare Summary Notice (MSN) or Explanation of Benefits (EOB)

Before beginning your appeal, review your Medicare Summary Notice (MSN) if you have Original Medicare or the Explanation of Benefits (EOB) if you have a Medicare Advantage or Part D plan. This document outlines what services Medicare paid for and what it denied. It will also tell you why the service was denied, which is critical information for your appeal.

Understand Your Appeal Rights

It’s important to understand your rights. Medicare guarantees that you can appeal their decisions, and there are five levels of appeals you can go through:

1. Redetermination by Medicare contractor
2. Reconsideration by a Qualified Independent Contractor (QIC)
3. Hearing before an Administrative Law Judge (ALJ)
4. Review by the Medicare Appeals Council
5. Judicial review in Federal District Court

You don’t have to go through all five levels, but it’s good to know that you have multiple opportunities to present your case if needed.

Filing a Level 1 Appeal

The first step in the appeal process is filing a request for redetermination. Here’s how to do it:

1. Fill Out the Medicare Redetermination Request Form (Form CMS-20027): You can download this form online, or you can write a letter that includes your name, Medicare number, the specific service or item you’re appealing, and the reason you disagree with the decision.
2. Attach Supporting Documents: Include any documents that support your claim. This might include doctor’s notes, medical records, or a letter from your provider explaining why the service is necessary.
3. Send Your Appeal: The address for sending your appeal is on your MSN or EOB. You must submit your request within 120 days of the date on your MSN or EOB.

Waiting for a Response

Medicare contractors are required to respond to your appeal within 60 days. If they approve your appeal, Medicare will cover the service or pay the amount you requested. If your appeal is denied, you can proceed to the next level.

Level 2 Appeal – Reconsideration by a Qualified Independent Contractor (QIC)

If your redetermination is denied, you can request a reconsideration from a Qualified Independent Contractor (QIC). This must be done within 180 days of receiving the redetermination notice.

1. File a Request for Reconsideration (Form CMS-20033): Similar to the first appeal, you can download this form or write a letter. Clearly state why you believe the initial decision was wrong and include any additional documentation to support your claim.
2. Send the Request to the QIC: The address is included in the denial notice from your redetermination.

The QIC must respond to your request within 60 days. If they uphold the denial, you can proceed to the next level.

Level 3 Appeal – Administrative Law Judge (ALJ) Hearing

If your reconsideration request is denied, you can appeal to an Administrative Law Judge (ALJ). This option is available if the amount in question meets a minimum threshold (in 2025, this amount is approximately $180).

1. Request a Hearing: You can request a hearing within 60 days of receiving the QIC decision. You can also request to participate in person, by video conference, or by phone.
2. Prepare for Your Hearing: This is your chance to present your case directly to an impartial judge. You may wish to have an attorney or advocate to help represent your interests.

The ALJ will issue a decision within 90 days of your hearing request.

Level 4 Appeal – Medicare Appeals Council Review

If the ALJ denies your appeal, you can request a review by the Medicare Appeals Council. This must be done within 60 days of receiving the ALJ’s decision. The Appeals Council can either make a decision or send your case back to the ALJ for another review.

Level 5 Appeal – Federal District Court

The final level of appeal is a judicial review in Federal District Court. This is typically reserved for cases where a significant amount of money is at stake (in 2025, the threshold is approximately $1,850). You must file your case within 60 days of the Appeals Council decision.

Tips for a Successful Appeal

1. File Your Appeal On Time: Always pay attention to deadlines to avoid missing your opportunity to appeal.
2. Provide Detailed Information: Include all relevant documents, medical records, and a clear explanation of why you disagree with the decision.
3. Get Help If You Need It: You have the right to get help from a Medicare advocate or attorney. You can also contact your State Health Insurance Assistance Program (SHIP) for free assistance.

Click here to join the team of licensed Medicare agents at Crowe and Associates

Filing a Medicare claim appeal may seem daunting, but understanding the steps can make the process more manageable. Whether you’re challenging a coverage denial or disputing the amount paid, following these guidelines can help you navigate the appeal process more effectively.

It is important to remember to always keep copies of all documents and correspondence, and don’t hesitate to seek assistance if you need it.

Medicare scope of appointment rules

The Medicare SOA rules 2025 are put in place by CMS.  The SOA (scope of appointment) is a form clients/potential clients as well as agents must complete before meeting to discuss Medicare plans. The SOA is mandatory when discussing either Medicare Advantage or PDP plans. It is always a good idea to collect a SOA before client meetings to protect both agents and clients.

Watch a quick video on the scope of appointment rules for 2024

Verbal scope of appointment

During the pandemic, agents did not host in-person meetings to discuss coverage options.  At that time, many appointments took place over the phone.  That led to the use of recorded, verbal SOAs. 

Watch a video on Connecture & Sunfire updates for 2025

Both Connecture and Sunfire offer easy ways to collect client intake forms and include SOAs.

View the RetireFlo intake demo for Connecture 

Take a look at the BlazeSync intake form on Sunfire

SOA information

• If the client calls the agent (inbound call), the 48-hour rule does not apply.
• The scope is good for 12 months from the date it is signed.  You must complete the appointment within that time or obtain a new scope. The scope is still good if the call drops and the same agent calls the client back.
• If additional benefits are added to the discussion, a new scope is necessary.

How long is an SOA good

A scope of appointment is good for 12 months from the signature date. During the appointment, it is important to discuss only products that were agreed to and included in the scope.  If additional products are added, the beneficiary needs to sign a new scope.

If the client needs to sign a new SOA,  this restarts the 48-hour waiting period and may move your meeting date further out.  This rule applies to any product regulated by CMS.

Click here for a generic SOA

CMS guidelines

In order to be complaint with CMS, agents need to have their clients complete a SOA form. The CMS final rule went into effect September 30. 2023 and added changes to how agents collect an SOA.

The SOA rules apply to agents and brokers who discuss Medicare coverage options and plans.  The 48-hour rule was put in place so beneficiaries could avoid the high-pressure sales tactics some agents use.  The 48-hour period provides beneficiaries time to consult friends, relatives or anyone they like to research their options. This time also provides agents time to prepare for the discussion.

Agents are able to contact the beneficiary once the SOA is completed for up to 12 months. It is essentially permission to contact until the meeting takes place.  The beneficiary has the option to opt out annually.

Please note, if the beneficiary does not select a coverage option on the SOA, Medicare requires the agent to avoid discussing that option without a new SOA where the option is clearly selected.

Exceptions to the 48-hour rule

If the beneficiary is in the last four days of a valid election period, agents may collect a same-day SOA.

When the beneficiary walks into your office and initiates a conversation about coverage options, agents can take a same-day SOA.  This same rule applies to inbound call initiated by the beneficiary to the agent requesting advice.

How long do you need to keep a SOA

Agents must be able to access the SOA form for ten years. Clients have the right to request a copy anytime within that time frame without any issues.  The SOA can provide help in the event that an issue or dispute occurs.  The Scope is in place to protect the consumer, but it can also protect the agent.

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

When it comes to Medicare Advantage plans, HMOs (Health Maintenance Organizations) are a popular option. Many Medicare carriers offer HMOs as a coverage option. They offer comprehensive healthcare coverage and focus on coordination and preventive care, however they come with advantages and limitations. Before suggesting enrollment in an HMO plan, it’s important for beneficiaries to understand Medicare HMOs Pros and cons. There are both benefits and drawbacks for those enrolling in a Medicare HMO plan.

What is an HMO

A Medicare HMO is a kind of Medicare Advantage plan (Part C). It provides coverage through a specific network of doctors, hospitals, and healthcare providers. Plan enrollees generally must receive care from in-network providers, except in emergency situations. Medicare HMOs typically include coverage for:

• Medicare Part A (hospital insurance)
• Medicare Part B (medical insurance)
• Medicare Part D (prescription drug coverage), if included in the plan
• Many plans include additional benefits such as dental, vision, hearing, fitness programs and OTC benefits.

Now let’s take a closer look at the pros and cons of Medicare HMOs.

Medicare HMO Pros

Lower Out-of-Pocket Costs

In some cases, Medicare HMOs have lower monthly premiums and out-of-pocket costs compared to Original Medicare (Parts A & B) or other types of Medicare Advantage plans, like PPOs.

Medicare HMO plans also set a maximum limit on out-of-pocket spending for covered services. Once you reach this limit, the plan covers 100% of the costs for covered services for the remainder of the year.

Comprehensive Coverage

Medicare HMOs often include benefits beyond what Original Medicare offers, such as dental, vision, hearing, fitness programs, and even OTC benefits and in some cases, rides to and from medical appointments. They also may include wellness services like acupuncture or chiropractic care.

Many Medicare HMO plans also include Part D prescription drug coverage. This makes it easier to manage all healthcare needs with one plan.

Coordinated Care

With Medicare HMOs, healthcare is often more coordinated. The enrollee’s PCP (primary care physician) acts as the point of contact for all healthcare needs. The PCP coordinates care and refers enrollees to in-network specialists as needed.

This coordinated approach may lead to better preventive care and management of chronic conditions, as all healthcare providers are working together and have access to your health records.

Focus on preventative care

Many Medicare HMO plans emphasize preventive care services, such as regular check-ups, screenings, and vaccinations. By encouraging preventive care, HMOs aim to keep enrollees healthier and reduce the need for more expensive treatments down the road.

Medicare HMO Cons

Limited Provider Network

The most significant downside to Medicare HMOs is the restricted provider network. In general enrollees must use doctors and specialists within the plan’s network, except in emergencies. HMO plans do not provide coverage for healthcare administered by out of network providers for non-emergency situations. If the potential enrollee has doctors that are not part of the HMO network, they will need to change providers.

Those who receive care outside the network without a referral or in a non-emergency situation, may be responsible for the entire cost of service. This can be a major inconvenience for those who prefer the freedom to see any doctor or specialist.

Referrals Required for Specialist Visits

If a specialist is needed, the enrollee must get a referral from their primary care physician. Although this can improve care coordination, it also adds an extra step that can delay receiving needed care. This may be true, especially if the beneficiary has multiple health concerns that require a specialist.

Some people opt not to join an HMO based on the need for referrals alone. The referral requirement may be too restrictive. Some Medicare beneficiaries may prefer PPO plans, that allow direct access to specialists without needing a PCP referral.

Not All Services Are Covered

Although Medicare HMOs often provide additional benefits, not all services are covered. For example, certain treatments, procedures, or medications may not be included in the plan’s formulary or service list, even if they are covered by other Medicare Advantage plans.

Regional Coverage Limitations

Medicare HMO networks are typically regional, in other words, the plan’s network of providers is centered around a specific area. Those who travel frequently or spend part of the year in a different location, may find it challenging to access in-network care outside the plan’s primary service area.

Some plans offer a limited network for non-emergency care while traveling, but it’s important to check the specifics of each HMO plan to understand how it handles out-of-area coverage.

Higher Costs If Out-of-Network

While Medicare HMOs generally have lower out-of-pocket costs, these savings only apply if enrollees stick to in-network providers. If they receive care outside the network (non-emergency and without a referral), the costs can add up quickly, and they will most likely be responsible for the entire cost of their care.

This can be a big disadvantage for those that require specialized care that isn’t available within the network or when traveling and need non-emergency medical attention.

Is an HMO the right coverage choice

Deciding whether a Medicare HMO is the best choice of coverage depends on healthcare needs, preferences, and budget. Here are a few things beneficiaries need to consider:

• Are they comfortable having a primary care physician coordinate their care?
• Do they mind getting referrals for specialist visits?
• Are all their doctors and healthcare providers part of the plan’s HMO network?
• Do they travel often and need flexibility in accessing care outside their local area?
• Are the costs and benefits offered in line with what you are looking for in a healthcare plan?

Medicare HMOs offer a range of benefits, including lower costs, comprehensive coverage, and coordinated care. However, the restricted network and referral requirements can be drawbacks for those who prefer more flexibility. Carefully reviewing the pros and cons can help determine if a Medicare HMO is the best choice for your client’s healthcare needs.

If you are interested in helping people find the best coverage options and are ready to join the team at Crowe and Associates, click here for online contracting

Many agents have asked this question year; What’s Different for AEP 2025. As we all know, Medicare AEP is a critical time for beneficiaries to review and adjust their health insurance coverage. The AEP takes place each year, from October 15th to December 7th. During this time, Medicare enrollees have the opportunity to make changes to their plans. This year’s AEP comes with some significant changes and updates that could impact coverage, costs, and benefits. Let’s go over some of the changes for Medicare AEP 2025.

Agents, click here to watch a quick YouTube video on strategies to manage this AEP

Medicare Part B Premiums and Deductibles

For 2025, the Medicare Part B premiums and deductibles will be adjusted as they have in previous years. The 2025 Part B premium is projected to increase about 5.9% to $185 per month. The deductible projection is approximately $257. This cost increase is largely due to inflation adjustments and increasing healthcare costs. Beneficiaries with higher incomes will also notice changes in their IRMAA (income-related monthly adjustment amounts). It is important for beneficiaries to review these updates and understand how they might impact their budget.

Changes to Part D drug plan benefits

The Medicare Prescription Drug (Part D) plans have made some significant changes. These changes will improve affordability for some beneficiaries:

• Removal of the Coverage Gap (Donut Hole) in 2025 there will be no coverage gap for PDP or MAPD plans.
• In 2025, catastrophic coverage begins once the beneficiary reaches the annual cap of $2,000 spent for prescriptions on their plan’s formulary.
• All plans that provide Medicare prescription drug coverage will be required to offer a payment plan option for beneficiaries. This will help enrollees spread out the cost of expensive prescriptions over the course of the plan year.
• The maximum deductible amount for PDP coverage will go up from $545 in 2024 to $590 in 2025.
• The $35 monthly insulin cost cap will continue in 2025. This ensures those with diabetes won’t pay more than $35 per month for insulin products covered under their Part D/MAPD plans.
• Necessary adult immunizations will be 100% covered by the plan providers. This includes flu shots, shingles shots and other adult immunizations.
• Some plan providers will no longer allow agents/brokers to sell their plans and plans will become non-commissionable.
• Some plan providers will leave the market all together while others will consolidate their product offerings.

Medicare Advantage Plans

• Many MA/MAPD plan providers will scale back benefits for 2025. This includes reductions in some dental and vision coverage amounts as well as a reduction in or removal of OTC benefits.
• Some MAPD plans will leave the market all together while others will reduce their market footprint. There are a few plans that will use this as an opportunity to expand their market area.
• The change in the number of available plans in certain areas may prove challenging for agents this year. It may be harder to find a plan that offers all the benefits your client wants as well as that their providers are in network with.

Expanded Coverage for Mental Health Services

There’s a growing recognition of the importance of mental health, and Medicare has responded by increasing its coverage for mental health services. More plans are now offering benefits like counseling, therapy sessions, and even virtual behavioral health services. This change addresses the rising mental health needs and to provides better access to care.

Medigap Policy Changes

While the main focus during AEP tends to be on Medicare Advantage and Part D plans, it’s important not to overlook Medigap (Medicare Supplement) policies. In some cases, AEP is a good time to see if clients are in the most cost-effective Medicare supplement available in their area. If another carrier offers the same plan at a lower cost, this is a great time to change plans.

Emphasis on Preventive Services

Medicare has increased focus on preventive care, encouraging beneficiaries to take advantage of annual wellness visits, vaccinations, and other screening services. Many preventive services are covered at no additional cost, depending on the plan. This makes it easier for enrollees to maintain their health without added expenses.

Key Takeaways for Beneficiaries:

• Review Current Coverage: Look at current Medicare Advantage, Medigap, and Part D plans, and see if the changes for 2025 affect coverage or costs.
• Compare Plan Options: This is the time to shop around. Use tools like the Medicare Plan Finder or a licensed Medicare agent to compare options and find the best plan for your needs and budget.
• Understand the New Benefits: Be sure to understand new benefits that may benefit you.

This year’s Medicare AEP brings many changes, as well as an attempt to make healthcare more affordable for some members.

It is always important to review your client’s plan options and provide assistance in navigating the changes. By staying informed, you can make the most of this year’s AEP and secure the healthcare coverage that best meets your client’s needs.

To join the team at Crowe and Associates, click here

Many people wonder how Medicare and ACA Marketplace insurance plans interact, whether they can keep their Marketplace coverage after enrolling in Medicare, and what happens to any premium tax credits they are receiving.

While Medicare and the ACA Marketplace both provide valuable health insurance options, they serve different populations and have distinct rules. Once you become eligible for Medicare, it’s generally best to transition from your ACA Marketplace plan to Medicare, as you will no longer be eligible for the premium tax credits that make ACA plans affordable.

What is Medicare and what it covers

Medicare is a federal health insurance program for people aged 65 and older as well as younger individuals with qualifying disabilities or end stage renal disease. Here is a quick look at some basic parts of Medicare:

• Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health care. There are 4 main parts of Medicare
• Part B (Medical Insurance): Covers outpatient services like doctor visits, preventive services, and durable medical equipment.
• Part C (Medicare Advantage): An alternative to Original Medicare that offers all Part A and B benefits through private insurance companies. Many Part C plans also include Part D coverage and additional benefits like vision, dental, and prescription drugs.
• Part D (Prescription Drug Coverage): Helps cover the cost of covered prescription medications.

What Is the ACA Marketplace

The Affordable Care Act (ACA) created the Health Insurance Marketplace (also known as the Exchange) to provide health coverage to individuals and families who do not have access to employer-sponsored insurance or other forms of coverage, like Medicare or Medicaid. Through the Marketplace, people can purchase private health plans that meet ACA requirements, such as covering essential health benefits and preventive care.

One of the key benefits of the ACA Marketplace is the availability of premium tax credits and cost-sharing reductions for eligible individuals, which help lower the cost of monthly premiums and out-of-pocket expenses based on income.

Agents -Watch a quick YouTube video on how to get contracted to sell ACA plans

Can You Have Medicare and an ACA Marketplace Plan at the Same Time

It is not legal for any agent/broker to enroll a Medicare beneficiary in an ACA plan. This is true even if the beneficiary has Mediare Part A or Part B only.

Medicare Eligibility Automatically Ends ACA Premium Tax Credits:

When an individual becomes eligible for Medicare, they are no longer eligible for the premium tax credits that reduce the cost of ACA Marketplace plans. Those who recieve these subsidies, will lose them once they are eligible for Medicare, even if thye have not enrolled in Medicare yet.

Therefore, the cost for a Marketpalce plan for those who choose not to enroll in Medicare will pay a much higher price once they lose the premium tax credits. In most cases, Medicare will offer better or comparable coverage at a lower cost than a Marketplace plan without subsidies.

What Happens If You Delay Medicare Enrollment

Some people may want to delay Medicare enrollment because they prefer their ACA Marketplace coverage or want to keep the premium tax credits. However, delaying Medicare enrollment can result in financial penalties down the road.

Late Enrollment Penalties

• Part A: If you are eligible for premium-free Medicare Part A (based on your or your spouse’s work history), you should enroll as soon as you’re eligible because there’s no cost and it can help cover certain hospital expenses. If you don’t qualify for premium-free Part A and delay enrolling, you could face a late enrollment penalty if you decide to sign up later.
• Part B: Medicare Part B comes with a standard monthly premium, and if you don’t sign up when you’re first eligible, you may face a 10% penalty for each 12-month period you delay enrollment unless you have other creditable coverage (like employer-sponsored insurance).

In most cases, enrolling in Medicare as soon as you’re eligible helps you avoid penalties and ensures that you have comprehensive coverage.

Medicare vs. ACA Marketplace Plans Comparison

Transitioning from an ACA Marketplace Plan to Medicare

Individuals approaching Medicare eligibility who currently have an ACA Marketplace plan, must plan for the transition to Medicare. Here are a few things to remember:

Enroll in Medicare on Time

Most people are automatically enrolled in Medicare Part A and Part B if they’re receiving Social Security benefits. those who have delayed recipt of Social Security benefits will need to sign up during their initial enrollment period (IEP). The IEP starts three months before your 65th birthday and ends three months after.

Drop Your ACA Marketplace Plan

Once Medicare coverage starts, individuals are no longer eligible for Marketplace premium tax credits, therefore it’s important to cancel the ACA plan to avoid paying for unnecessary coverage.

Consider Additional Coverage

Depending on individual healthcare needs, enrollees may want to consider a Medicare Advantage plan (Part C) or a Medicare Supplement (Medigap) plan and a Part D plan for prescription drug coverage. These plans can provide coverage for out-of-pocket costs like deductibles, copays and coinsurance.

Are you thinking about becoming a Medicare agent,

Watch a video and learn why you should partner with Crowe.

Click here for online contract

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The recent changes to Medicare SEPs for full, partial and LIS only members has caused some people to ask questions about Full vs Partial Dual Eligibility.

Watch a quick YouTube video on the Dual eligible SEP changes

Full Dual Eligibility

Individuals who are eligible for both Medicaid and Medicare are dual eligible. In other words, To have full dual eligibility, it means you qualify for full Medicaid benefits from your state as well as Medicare. Medicare covers most healthcare benefits, although Medicaid pays some out-of-pocket costs such as premiums, copays, coinsurance and deductibles as well as long-term care.

Those who are dual eligible may qualify for a DSNP plan. A DSNP plan is a kind of Medicare Advantage plan that provides additional benefits not provided by Medicare or Medicaid.

Partial Dual Eligibility

If an individual is Partial dual eligible, it means their income level qualifies them for an MSP (Medicare Savings Program). Each state manages the MSPs using their Medicaid program. MSPs cover some Medicare costs, such as Part A & Part B premiums. It is important to note; partial dual eligibility doesn’t provide the same medical benefit coverage as full Medicaid.

Some individuals who qualify as partial dual may also qualify for a DSNP (Dual Special Needs) plan. Although Medicare pays most of the health care benefits, partial duals are responsible for out-of-pocket costs.

How a MSP helps partial duals

When Medicare enrollees receive medical care, Medicare doesn’t cover the entire cost of the services. There is usually an amount that’s left over. This amount is the beneficiaries’ responsibility and is called cost share or out-of-pocket cost and includes copays, coinsurance premiums and deductibles. This amount is the responsibility of the member. This who are enrolled in an MSP may receive help from Medicaid in paying for some of those costs. The amount of help (or cost sharing) received from Medicaid depends on income level and assets (such as real estate).

The 4 types of partial dual eligibles

QMB – Qualified Medicare Beneficiary

Members who receive help at the QMB level receive helps paying for premiums for Medicare Parts A & B as well as some cost shares for deductibles, copays and coinsurance.

SLMB – Specified Low Income Medicare Beneficiary

The SLMB program provides help with Part B premiums only.

QI – Qualified Individual

Those at the QI level receive help with Part B premium payments, these individuals may have a higher income than SLMB recipients.

QDWI – Qualified Disabled and Working Individuals

Individuals on QDWI program receive helps paying Medicare Part A premiums (hospital insurance) . This level of help applies to disabled individuals who have returned to work and lost their premium-free Medicare Part A coverage.

The new SEPs for DNPs and LIS 2025 change when a dual eligible can leave or switch Medicare Advantage Plans. The Final Rule changed existing SEPs and put a new SEP for D-SNPs in place. Starting in 2025, dual eligible and LIS (Low-Income Subsidy) recipients can change their Medicare Advantage plan enrollment once per month. The rules vary according to the beneficiary’s level of help and include full-benefit dual eligibles, partial-benefit dual eligibles, and individuals enrolled in the LIS program but are not also enrolled in Medicaid (LIS-only).

Watch our recorded webinar on the changes to SEPs for DSNPS

SEP changes starting Jan 1, 2025:

1. The current SEP for Dual eligibles and LIS only individuals is available once per quarter. It lets individuals switch or disenroll from a Medicare Advantage plan. This SEP will be end as of Jan 1, 2025.
2. A new monthly SEP for all dual eligibles and LIS only individuals to disenroll from a MAPD plan and go back to Original Medicare and a stand-alone PDP plan.
3. There will be a new SEP for all Dual eligibles and LIS only individuals to switch PDP plan enrollment.
4. A new monthly SEP for full duals to enroll in an integrated and aligned D-SNP plan.

Monthly SEP for Dual Eligibles and LIS recipients

As of 2018, CMS put a quarterly SEP in place. This SEP allowed duals & LIS recipients to either enroll or disenroll in a MAPD or PDP plan. The enrollment or disenrollment goes into effect the first day of the following month after the enrollee makes a plan change during the first three quarters. If the change is made in the last quarter AEP from Oct 15 – Dec 7, the plan goes into effect as of January 1st of the following year.

CMS created a new SEP to replace the quarterly SEP. In 2025, dual eligible individuals and LIS-only individuals can change their MAPD and PDP enrollment one a month.  Those who qualify can switch to another standalone PDP plan or disenroll from a Medicare Advantage plan and go back to Original Medicare and a standalone PDP plan. Individuals cannot use this SEP to enroll in another Medicare Advantage plan.

Integrated SEP

The CMS Final Rule created an SEP that will help facilitate enrollment for Dual eligibles into integrated Medicare Advantage plans. Each month, Full-benefit dual eligibles have the option to enroll in, or switch between, integrated D-SNPs. This SEP is only available to full-benefit dual eligible individuals who wish to enroll in integrated plans. Doing this will align enrollment between their Medicare and Medicaid coverage.

Those eligible can use this SEP to enroll in either a FIDE SNP (Fully Integrated Dual Eligible Special Needs Plan); or a HIDE SNP (Highly Integrated Dually Eligible Special Needs Plan); or a D-SNP that is an AIP (Applicable Integrated Plan).

What you can’t do with the SEP

Individuals cannot use the SEP to enroll in a Coordination only D SNP that is not an AIP, or a standard Medicare Advantage plan. The goal CMS has with this AEP is to have dual eligible individuals enroll in aligned plans if they are available in their home state.

Who can use this SEP

This SEP is only available to full-benefit dual eligible individuals who have access to an integrated, aligned plan. The following individuals cannot use this SEP: partial-benefit dual eligible individuals, and Medicare-only individuals cannot use this SEP. Presently, partial-benefit dual eligible individuals and LIS-only individuals have a quarterly SEP they can use to switch Medicare Advantage Plans. Keep in mind, this SEP will end as of Jan 1. 2025.

What happens if a person uses both the monthly and integrated SEP in the same month?

If an individual attempts to use the monthly SEP and the integrated SEP the same month, the SEP used last in will be effective. For example, Ms. Smith uses the monthly SEP to go back to Original Medicare on March 10th and on March 16th, she uses the integrated SEP to enroll in an Integrated Plan A, the integrated SEP is last used, and Ms. Smith will be enrolled into Integrated Plan A on April 1st.

SEP Changes for DSNPS & LIS 2025

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When it comes to helping clients choose a Medicare plan, there are many types of plans to consider. Those clients leaning towards a Medicare Advantage plan need to understand Medicare PPO vs. Medicare HMO plans. Although both plan types provide comprehensive coverage, they differ in many ways including how the enrollee’s healthcare is managed, costs for care flexibility of providers used. In this blog, we’ll go over some benefits of PPO and HMO plans to help determine which option may suit your client’s needs best.

Medicare PPO Plans

Provider choice flexibility

Although Medicare PPO plans have a network of preferred providers, plan enrollees may opt to receive care from an out of network provider for a higher fee. PPOs give the enrollee the freedom to see any doctor or specialist they choose, without the need for a referral.

Costs

In general, PPO plans may have similar cost share amounts compared to HMO plans. These amounts vary by plan type, carrier and service area. However, PPO plans offer lower out-of-pocket costs if enrollees stay within the network. The flexibility to see out-of-network providers comes with the potential to pay higher out-of-pocket amounts for those services.

PCP (Primary Care Physician) requirement

Unlike HMO plans, PPO plan enrollees are not usually required to choose a primary care physician (PCP). They do not need to get a referral from a PCP before seeing a specialists or other healthcare provider.

Medicare HMO Plans

Restrictions

In general, the choice of providers in a Medicare HMO plan is more restrictive. Enrollees are required to use healthcare providers and facilities within the plan’s network, unless it is emergency situation. Those who opt to receive care from an out-of-network provider, may have to pay out-of-pocket for the full cost of services.

Lower Costs

HMO plans often have lower out-of-pocket costs compared to PPO plans. Although, the network of providers is limited, and enrollees must stay within the network to keep low costs.

PCP (Primary Care Physician) Requirement

HMO plans require enrollees to choose a primary care physician. Their PCP will manage their healthcare needs. If the enrollee wants to see a specialist, they must first obtain a referral from their PCP. This helps manage and coordinate care effectively but may be inconvenient for some people.

Agents watch a quick YouTube video on strategies to manage the 2025 AEP

How to choose

The best choice differs from one person to the next and is based on individual healthcare needs and preferences. Both plan types have advantages and disadvantages.

Consider a PPO Plan if:

1. The enrollee wants the flexibility to see any doctor or specialist without a referral.
2. Higher costs are less important than the ability to choose any provider
3. There may be a desire for out of network services, even at a higher rate.

Consider an HMO Plan if:

1. Enrollees are willing to use a specific network of providers.
2. They like the idea of a PCP managing and coordinating their healthcare needs.
3. The enrollee does not see the need to use out-of-network providers and does not mind network restrictions.

Agents must consider the clients’ needs, budget and service area in order to find the best fit for their client.

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When it comes to Medicare, most people have an understanding of the traditional options like Original Medicare and Medicare Advantage plans. However, individuals with certain chronic conditions, may want a specialized Medicare Advantage plan called a what is a Chronic Secial needs plan, or C-SNP. In this post, we answer the questions; what are Medicare C-SNP plans, who is eligible to enroll in them, and what they provide.an medicare

What Are Medicare C-SNP Plans

Medicare C-SNPs are a type of Medicare Advantage plan that serves individuals with specific chronic health conditions. Unlike typical Medicare Advantage plans, C-SNPs provide tailored coverage and care coordination to address the unique needs of individuals with specific health conditions. Just like regular Medicare Advantage plans, these plans are offered by private insurance companies and include all the benefits of Original Medicare. In addition, they cover the necessary services to managing chronic conditions.

Who Qualifies for a C-SNP

To enroll in a Medicare C-SNP, you must meet specific eligibility criteria:

Chronic Condition Diagnosis

You must have one or more chronic conditions that the C-SNP is designed to manage. Common conditions that C-SNPs cover include diabetes, chronic heart failure, cardiovascular disorders, chronic lung disorders (like COPD), and end-stage renal disease (ESRD).

Medicare Eligibility

You must be eligible for Medicare Part A and enrolled in Part B.

Living in the Service Area

Enrollees must reside in the service area of the C-SNP plan in order to join. Not all plans are available in every location.

Key Features of Medicare C-SNP Plans

Targeted Care Coordination

One of the primary benefits of C-SNPs is the focused care coordination tailored to the chronic condition. These plans offer a network of healthcare providers who specialize in managing specific illnesses. Additionally, C-SNPs may offer case managers who help navigate healthcare needs, ensure enrollees follow treatment plans, and connect with resources and support.

Customized Benefits

C-SNPs may offer additional benefits beyond what is covered by Original Medicare. These could include: specialized treatment plans, rides to appointments, a care coordinato, nutrition plans and much more.

Specialized drug formularies

C-SNPs often include a list of covered prescription drugs specifically tailored to manage your chronic condition.

Access to specialists

Enrollees have access to specialists and healthcare providers who have expertise in treating a specific condition.

Wellness programs

In some cases, these plans offer services designed to help manage the condition, such as nutrition counseling, exercise programs, or disease management education.

Lower Out-of-Pocket Costs

Because C-SNPs manage chronic conditions more effectively, they may offer lower out-of-pocket costs for common services and medications associated with treatments. This can be a significant financial benefit for those managing costly, ongoing medical care.

Why choose a Medicare C-SNP Plan

Personalized Care: The primary advantage of a C-SNP is the personalized care that aligns with your specific health needs. This targeted approach ensures that treatment is optimized for your condition and can lead to better health outcomes.

Comprehensive Coverage: C-SNPs provide all the benefits of Original Medicare and often include Part D prescription drug coverage, along with additional services tailored to your condition.

C-SNPs emphasize care coordination. This ensurs that all aspects of your healthcare are managed effectively. This can reduce the likelihood of hospitalizations and improve your overall quality of life.

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what to consider before choosing a C-SNP

While C-SNPs offer significant advantages for those with chronic conditions, there are some considerations to keep in mind:

Network Restrictions: Like other Medicare Advantage plans, C-SNPs typically require you to use a network of providers. Ensure that your preferred doctors and specialists are within the plan’s network.

Plan Availability: Not all C-SNPs are available in every area, and the specific chronic conditions covered can vary by plan. Be sure to check if a C-SNP that fits your needs is available in your region.

Eligibility Requirements: You must have a qualifying chronic condition to enroll in a C-SNP. If your health needs change, you may need to switch plans, which could affect coverage.

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How to Enroll in a Medicare C-SNP Plan

If you think a C-SNP might be the right choice for you, follow these steps:

1. Find a licensed Medicare agent to help show you plan options and explain differences in coverage. This will help you make a well-informed decision.
2. See what’s available in our area. Consider the specific chronic conditions covered, the provider network, and the additional benefits offered.
3. Look at the costs including; premiums, deductibles, and out-of-pocket costs associated with each plan.
4. Ensure you meet the eligibility criteria for the C-SNP, including the diagnosis of a qualifying chronic condition.
5. You can enroll in a C-SNP during your Initial Enrollment Period, the Annual Election Period (October 15 to December 7), or a Special Enrollment Period if you qualify.

Learn about enrollment periods for Dual and Partial Dual & LIS enrollees

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Medicare C-SNP plans offer a valuable option for individuals with chronic health conditions who need specialized care. By providing tailored coverage, enhanced care coordination, and access to specialized providers, C-SNPs help better manage some chronic conditions and improve overall quality of life.

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