Blog

SEPs are important for both agents and beneficiaries to understand. Missing an SEP can cause a beneficiary to pay more for their medical care then necessary. We will discuss the disaster/emergency SEP requirements to make sure your plan is approved without delays.

It is important to note; disasters or emergency SEPs that are declared by a government entity are only applicable to beneficiaries who were unable to complete an enrollment during a valid election period that took place during the emergency or disaster. CMS has clear guidelines when beneficiaries can use this SEP.

How to qualify for this SEP

The beneficiary has to have missed a valid election period when the declared disaster or emergency occurred. They have to have been unable to make the desired plan change during the specified time period. SEPs for disasters or emergencies are only applicable to those who live in the affected area during the emergency.

CMS also states; beneficiaries who rely on the help of individuals who reside in an area where the disaster or emergency occurs for health care decisions, may also be eligible for the SEP

Some reasons for not using this SEP

This SEP is not valid in cases when the beneficiary has already used another valid election period during the time the SEP begins. This is the case when the disaster SEP occurs during another valid election period. For instance, if the disaster SEP begins at some point during the AEP and the beneficiary uses the AEP election period, they are not eligible to use the SEP. This is because they have already used an election period. Thye are now ineligible to switch plans again.

Watch a quick YouTube video on SEP Changes for Dual, Partial Dual and LIS members in 2025

Learn more about SEPs – click here to watch a video

How long does the SEP last 

SEPs last for either at least 2 months after the end of the emergency or disaster or when the end of the incident is stated, the rules follow whatever date is later.

Here’s an example:

On August 8th through August 15th there is a wildfire that causes FEMA to declare a disaster/emergency in two counties. FEMA declares the SEP on August 20th; this means the start of the SEP is August 8th. This SEP would end two full months after the SEP is announced on August 20th. In other words, the end of the SEP would be October 20th because this is the later date.

If you like the image in this post, click here to view more by this artist

Managing healthcare online is not only easy but in some cases, a necessity. In this post we answer the question: why create an online Medicare account. We discuss some of the ways this makes accessing information easier.

The online Medicare account is tailored to each individual and provides personal information about benefits and coverage. This ensures beneficiaries receive updates and reminders in a timely manner.

Create an Online Medicare Account

It is not difficult to set up an online Medicare account.

1. Go to the Medicare website; Medicare.gov
2. Scroll down until you see the linbk to log in or create an account.
3. Once you are in there, follow the prompts and enter your personal information. such as (Medicare number & birthdate).
4. Once the account is set up, you can access all the tools and inforamtion you need.

Why create an online Medicare account:

Save current prescriptions and pharmacies to help keep track of your medications as well as easily compare health and drug plans in your service area.

Click here to watch a YouTube video on the new prescription payment program

1. Enroll in digital information. This provides a quick and easy way to access materials without waiting for the mail to arrive.
2. The site uses encryption and other security measures to ensure the safety of personal data. This proivides peace of mind to Medicare beneficiaries.
3. In the event you can’t find your Medicare card, you can use this site to print out a copy of your card.
4. Access all your Medicare information in minutes.

Fast and Easy

An online Medicare account provides easy access to important information. It also allows Medicare beneficiaries a way to manage health information from home anytime they like. They can check coverage, review claims, or update personal information with just a few clicks. There is no need to waste time on hold or fill out paperwork. All the Medicare information is accessible whenever it’s needed.

Medicare Coverage

The online account provides an up-to-date look at Medicare benefits. Beneficiaries can find out what their plan covers and keep track of deductible payments. It is easy to check on recent cliams without waiting for mail to arrive.

Claims and Payments

Online Medicare accounts are an easy way to track claims and payments. In addition, this can help beneficiaries spot discrepancies or billing errors. Finding mistakes early is a great way to correct them quickly and avoid delays in payments and aggrevation.

Replace a lost Medicare card

Losing your Medicare card can be stressful, but with an online account, requesting a replacement is simple and straightforward. You can order a new card online and have it sent to you without the hassle of phone calls or office visits.

Tools and Resources

Medicare’s online portal provides many tools and resources to help beneficiaries make informed decisions about healthcare. By entering an updated list of medications, beneficiaries can compare drug prices. They can view Medicare plan information or estimate out-of-pocket costs for specific services. These tools help beneficiaries understand what’s available and lets them look at plans that best suit their needs.

Please note: It is always a good idea to enlist the help of a licensed insurance agent to discuss coverage need and sort out all the options.

Paperless

When an individual sets up an online Medicare account, they can choose to recieve paperless communications. In other words, they can avoid some of the paper mail cluttering their counter tops. This provides a way to view important documents in a timely manor and eliminates the need to file them and search for them later.

Additionally; an online Medicare account is useful for Medicare beneficiaries. It is an easy and secure way to access important health coverage information.

If you like the image in this post, click here to view more by this artist.

CMS will begin their Medicare drug price negotiations 2026 with 10 popular high cost prescription medications. CMS has announced the first 10 drugs that will be subject to price negotiations.  The negotiations are part of the Inflation Reduction Act.  Until recently, Medicare was able to negotiate prices for the medical care beneficiaries receive; this did not include the costs of medications.  As of January 1, 2026, this will change and the negotiated drug prices begin to go into effect.

Watch a YouTube video on Medicare Part D changes 

Medicare will negotiate the cost for some of the more expensive prescrption medications with drugmakers. Please note; the negotiations do no tapply to drugs that have a generic equivalent.

The first 10 medications CMS will negotiate are:

1. Eliquis (a blood thinner)
2. Enbrel (for rheumatoid arthritis)
3. Entresto (for heart failure)
4. Farxiga (for diabetes, heart failure & chronic kidney disease)
5. Fiasp & Novalog (for diabetes)
6. Imbruvica (for blood cancers)
7. Januvia (for diabetes)
8. Jardiance (for diabetes)
9. Stelara (for psoriasis & Chron’s disease)
10. Xarelto (a blood thinner)

As per CMS, the 10 drugs listed above make up about 20% of the Medicare Part D spending from June 2022 through the end of May 2023.  Medicare Part D covers prescriptions beneficiaries take at home.  Part D does not cover medications administered by medical providers in medical facilities. When this is the case, Medicare Part B covers the necesary drugs. This applies to treatment of cancer or other health conditions. 

Take a look at the drug price negotiation fact sheet 

Medicare beneficiaries spend billions on prescription drugs

Due to the incredibly high cost of some essential medications, some beneficiaries have to either forgo basic needs or the drugs that maintain their quality of life. 

CMS has also put a prescrption payment program in pace to help spread out the cost of prescriptions for beneficiaries.

Learn about the Medicare prescription payment program.

The first 10 drugs are just the start

This list of 10 drugs is only the beginning of the price negotiations.  In 2027, Medicare plans to add 15 more drugs and more in the following years.  As long as the rug manufacturers continue to be unsuccessful in their attempts to stop price negtiations, the list will continue to expand each year.

Drug manufacturers

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

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

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

In 2025, one of the changes to the Part D program is a $2,000 out-of-pocket maximum for MAPD/PDP beneficiaries.  CMS will also put a prescription payment plan program in place.  The program is referred to as “smoothing” and begins Jan 1, 2025. It is part of the Inflation Reduction Act of 2022. What is Medicare Smooothing; this program gives beneficiaries an opportunity to use a payment plan to spread out the cost of prescription medications over the year. CMS put this program together to help mitigate the cost of prescrption drugs.

Click here to learn more about the prescription payment program

What is Medicare Smoothing

Medicare Smoothing is a way to even out the out-of-pocket costs that Medicare beneficiaries may incur each year. Unlike other health insurance plan costs, such as premiums, coinsurance and co-pays that vary significantly each year, Medicare Smoothing provides a predictable expense for Medicare drug plan beneficiaries.

This approach spreads out medication costs over a period of time, rather than allowing them to spike in any given month. Beneficiaries who take advantage of this program can reduce the financial strain of sudden large medication expenses.

How Does Smoothing work

As of January 1, 2025, Medicare beneficiaries have the option of smoothing out-of-pocket costs for Part D coverage. Every Medicare Part D plan sponsor must provide plan enrollees the option to pay their cost-sharing in monthly payment amounts.

Beneficiaries can enroll in the smoothing program at the start of each plan year or any time during the plan year.

Once the beneficiary elects to use this option for payment of their covered medications, the carrier determines the first payment amount. This amount is based on a maximum monthly cap. The cap is determined by calculating the annual out-of-pocket maximum ($2000 in 2025), minus the out-of-pocket costs incurred to date, divided by the number of months left in the current year.

To determine payment amounts for subsequent months, the maximum monthly cap is calculated using the total remaining out-of-pocket costs from the previous month that the beneficiary has not been billed for and any additional out-of-pocket costs incurred divided by the number of months remaining in the plan year.

Benefits of Smoothing

Financial Predictability

By spreading out expenses, Medicare Smoothing provides beneficiaries with a clearer picture of their healthcare costs. This is one way to help them control the budget and also provides some peace of mind.

Reduced Financial Strain

Large, unexpected medical bills can be a burden for anyone on a fixed income. Medicare Smoothing helps mitigate some financial risks by providing a consistent cost structure.

Enhanced Access to Care

With more predictable costs, beneficiaries may be more likely to seek necessary medical care without fear of incurring overwhelming expenses.

Additionally

Medicare Smoothing is a great way to manage healthcare costs, especially for those on a fixed income. By spreading out expenses and using the advice of a licensed Medicare agent, beneficiaries can achieve greater financial stability. As with any financial strategy, a professional should consider individual needs to develop a plan tailored to each specific situation.

Medicare agents – watch a quick YouTube video on the Medicare commission 2025 final update

Please note: in 2026 price negotiations will start for expensive drugs that do not have a generic alternative.

Learn the details of the price negotiation program

To view more images by this artist, click here

As of July 18 2024, CMS published an update on the Medicare Final Rule. The update states that all commission payments will stay as they were prior to the CMS Final Rule changes. Commissions payments for MA and PDP plans remain the same for the rest of 2024 and 2025 while the stay is in effect. This means, the addtional $50 and $100 payments to brokers and uplines is no longer an option. Uplines will continue to receive over ride payments as they do now.

At some point, in 2025, the will be a final decision on the CMS Final Rule. Once that happens, the commission payment structure is subject to change.

Click here to download commission chart for 2025

Due to the fact that; a lawsuit was filed against the validity of some provisions in the Medicare Final Rule. Many organizations feel that CMS and the Department of Health and Human Services does not have the authority to place restrictions on their income. The lawsuit also states parts of the rule are arbitrary and were put in place without following proper procedure.

A federal court in Texas put a stay on some provisions of the CMS contract rule 2025 Final Rule on July 3, 2024, to amend current broker compensation for Part D and Medicare Advantage plan sales.  Medicare Advantage insurers and marketers now have to wait and see what the final outcome will be for their businesses.

Once the judge makes his decision, all parties involved will have an opportunity to appeal the decision. If this happens, there is no way to predict when we will know the final outcome.

The 2025 AEP and the carriers

There are only a few short months before the start of AEP on October 15th. Because of this, each carrier seems to be making an independent decision on how to proceed with their 2025 benefits. The decision how to pay agents/brokers until the court makes a final ruling also seems to depend on the carrier.

Many carriers have already decided to reduce benefits and plan service areas due to the increased financial burden CMS has placed on them. Some carriers may exit the market altogether and a few will expand into new markets.

What all this means for Agents

As of today, agents are feeling very uncertain as to what their future business looks like. No matter what the outcome, this AEP will be interesting with all the plan changes and the uncertainty of the PDP market

CMS designed specific policies to stop incentivizing the sale of one Medicare product over another. They aimed to pull back MA/MAPD marketing money that carrieres were providing agents. There is a some speculation that smaller companies do not have the same budget to work with as the large competitiors. This gives the bigger companies an unfair advantage.

Click here to learn more about the proposed compensation changes

Because carriers are responsible for the actions of anyone marketing their plans, all advertisements must pass CMS guidelines before they are approved for use.

To view more images by this artist, click here

In general, Medicare is an affordable way for qualified individuals to receive healthcare coverage. However, there are some Medicare costs both agents and beneficiaries need to understand.

Plan Premiums

Premiums are a monthly fee the beneficiary pays for Medicare coverage.

Part A premiums

Although most beneficiaries do not pay a premium for Part A as long as they have worked for a Medicare-taxed job for a period of at least 10 years (40 quarters). In 2024, the premium for those who do not qualify for free Part A are between $278 to $505 monthly. The amount is based on the number of quarters the beneficiary or their spouse worked and paid Medicare taxes.

Part B premiums

Unlike Part A, almost everyone pays a Part B premium with the exception of those who meet certain income and asset levels and qualify for extra help. In general, most beneficiaries pay a standard amount for Part B. In 2024, the Part B premium amount is $174.70, although this amount may be adjusted according to each beneficiary’s income level. Those who earn over a specific thresh hold will pay an additional amount (IRMAA).

Part C (Medicare Advantage)premiums

Part C plans offer a variety of premiums, although many provide coverage for $0. The premium amount is based on the beneficiary’s location and plan availability. Please note; an IRMAA can also apply to a Medicare advantage plan if it includes Part D coverage.

Part D premiums

Similar to Part C premiums, the cost for Part D coverage varies by plan and coverage area. The national base beneficiary premium for 2024 is $34.70 per month. This is just a general premium amount CMS uses to calculate LEP penalties and not an actual premium amount. Premiums actually vary from $0 up to over $100 per month. Similar to Part B, individuals may pay a higher rate if they qualify for an IRMAA.

Find out how ancillary health insurance can cover some of the gaps in coverage.

IRMAA (Income Related Monthly Adjustment Amount)

An IRMAA is an additional amount CMS adds to the beneficiary’s monthly premium amount for Part B and Part D if their income exceeds the threshold amounts set by Medicare each year. The IRMAA is based on the individuals tax return from 2 years prior.

Click here to learn more about the income brackets for IRMAA 2024

LEP (Late enrollment penalty)

There are specific times beneficiaries must enroll in Medicare coverage. These are enrollment periods. If the beneficiary misses their enrollment period, they may pay an LEP. Medicare will add the penalty to their monthly premium.

Watch a YouTube video on OEPs, SEPs and Late Enrollments

Part A LEP

The LEP only applies to those who do not qualify for premium free Part A. Those who do not enroll on time have to pay a 10% higher Part A premium. Medicare applies the penalty for twice the number of years the beneficiary was eligible but didn’t enroll in Medicare. This means, if the beneficiary was eligible for Medicare but didn’t sign up for 3 years, they would pay an additional 10% for their Part A premium for 6 years.

Part B LEP

This penalty adds 10% times the number of years the beneficiary did not enroll in Medicare to the monthly premium and applies as long as the beneficiary has Medicare. In other words, if the beneficiary signs up for Medicare 3 years late, they pay 30% more for their premium. However, if they are actively working or have coverage through a spouse who is working, they can delay Part B enrollment without an LEP. Once they stop working, they qualify for an SEP and are eligible to enroll in Part B.

Part D and Part C plans that include drug coverage LEP

The LEP for Part D or Part C plans that include prescription drug coverage is 1% of the national base premium (this premium changes annually), multiplied by the number of months the beneficiary was eligible and did not enroll. This penalty is similar to the Part B penalty, because it lasts as long as the individual is enrolled in Medicare Part D. The federal government uses the standard rate (national base premium) to calculate Part D penalties not the individual’s actual plan premium. If the beneficiary delays Part D enrollment because they have another creditable drug plan, the penalty doesn’t apply to them.

Deductibles

Enrollees pay a deductible each year before their plan pays it’s portion of covered medical expenses.

While other Medicare plans have annual deductible, the deductible for Medicare Part A is $1,632 for each inpatient hospital stay. An individual could pay this deductible more than once a year depending on how many times they are admitted to the hospital. Each hospital admission counts as a new benefit period, unless the beneficiary is readmitted before the end of the benefit period.  Each benefit period ends 60 days after the enrollee is discharged.

Both Part B and Part D plans have one annual deductible. The Part B deductible is $240 in 2024. Although Part D deductibles vary according to plan, Medicare puts an annual limit on the maximum deductible allowed; in 2024 the maximum deductible is $545.

Copays and coinsurance

Both copays and coinsurance are fixed amounts the beneficiary pays for covered services or medications. These amounts apply after the beneficiary pays the deductible.

Part A coinsurance and copays

Once the beneficiary is in the hospital for over 60 days, they pay a coinsurance amount of $408 per day in 2024 for days 61 to 90. If the beneficiary is in the hospital for over 90 days, they can use some or all of their 60 lifetime reserve days. In 2024, each of these days cost $816. Each beneficiary qualifies for 60 reserve days for their lifetime. Once the beneficiary uses them all, they pay the entire remaining cost of their hospital stay.

Part A pays the first 20 days in a skilled nursing facility, once the beneficiary goes over the 20 days, they pay $204 per day for days 21-100. After day 100, the beneficiary is responsible for all costs. Many beneficiaries apply for Medicaid if they qualify, once they exhaust the Medicare coverage.

Part B coinsurance and copays

Part B normally provides coverage for 80% of approved Medicare expenses. That leaves the beneficiary with the remaining 20%. However, Medicare fully covers most preventative visits. Beneficiaries pay a higher co-insurance amount if their provider does not accept Medicare assignment.

Supplemental insurance can cover the 20% co-insurance cost and some of the copays with original Medicare. Click here to learn more.

Part C coinsurance and copays

Because Medicare Advantage plans work differently than Original Medicare, the coinsurance and copays work in a very different way. Medicare advantage plans use a specific network of providers who agree to accept the terms of payment. Each plan has it’s own co-pay amounts for doctor and specialist visits. Some plans provide coverage for visit to out of network providers at a higher cost share amount.

Each plan also has an out of pocket maximum. Once the beneficiary reaches this amount, the plan pays 100% of their approved medical costs.

Part D coinsurance and copays

Part D copays and coinsurance can vary quite a bit from one plan to another. That is why it is important to check all medications and cost sharing amounts before choosing a plan. In general, the cost for a prescription is higher for brand-name medications especially if they are on a higher tier in the plans formulary. If the beneficiary uses medications that are not on the formulary, they may have to pay the full costs of the medication.

There are other factors that decide the cost of medications such as the deductible, tier, the coverage gap and the catastrophic phase of coverage. Although there are changes coming in 2025 that will alter some of those cost shares. Plan enrollees should check their plan every year to ensure they are on the best plan to meet their coverage and budgetary needs.

Click here to learn about the Part D changes for 2025

Providers who don’t participate in Medicare

It is important to note: Not all doctors participate with Medicare. In some instances (rarely, but some), a provider has opted out of Medicare and does not accept Medicare as payment. This means the patient is responsible for paying any fees for service out of pocket.

Find out what Medicare Advantage plans don’t cover

As you can see, there are many potential costs associated with Medicare plans. We have not listed all of them. It is important to check the summary of benefits or evidence of coverage each year to ensure enrollment in the best plan option for each individual situation. A licensed Medicare agent can provide invaluable insights into plan choices and coverage options.

If you like the image used in this post, click here to view more by this artist.

There are a few different terms people use for supplemental Medicare insurance such as; Medigap, Medicare Supplement or Med Supp. Private insurance companies offer these health insurance policies to individuals who are eligible for Medicare coverage. In general, Medicare covers about 80 % of approved medical charges. Medicare supplement plans are designed to cover the 20% of approved medical charges not covered by Original Medicare. Essentially, Medicare supplement policies help reduce out-of-pocket costs. This ensures healthcare costs are predictable and manageable.

Why choose a Medicare Supplement

Although Original Medicare provides substantial coverage, it doesn’t cover everything. Here are some reasons to consider a Medicare Supplement:

Out-of-Pocket Costs: Original Medicare requires beneficiaries to pay for a percentage of their approved medical expenses. Because these can add up quickly, especially if you have frequent medical needs, a Medicare supplement pays these costs and saves enrollees money.

Find out more about Medicare costs

Foreign Travel: In general, Original Medicare doesn’t cover healthcare services outside the U.S.. Although some Medicare supplement plans provide coverage for emergency medical care during foreign travel.

Predictable Expenses: With a Medicare supplement plan, enrollees have predictable medical expenses, making it easier to manage their healthcare budget.

No Network Restrictions: Medicare supplement plans do not have network restrictions, this allows individuals to see any doctor or specialist that accepts Medicare.

Supplemental Medicare insurance plans

There are ten standard Medicare supplement plans, labeled A through N. Each plan provides a different level of coverage. The plan benefits of each plan letter are standardized, meaning Plan A from one insurance carrier offers the same benefits as Plan A from any other insurance carrier. These benefits are universal and don’t change by location. Although, plan availability varies by location. Insurance carriers do not offer all plans in every state.

Here is a basic over view of plan benefits:

• Plan A: This plan provides basic benefits, covers coinsurance and hospital costs (up to 365 additional days after Medicare benefit is used).
• Plan B: Benefits Include all the Plan A benefits plus it covers the Medicare Part A deductible.
• Plan C: Covers all of Plan B as well as skilled nursing facility care coinsurance and foreign travel emergency and also covers the Part B deductible.
• Plan D: This plan is similar to Plan C , although it does not cover the Part B deductible.
• Plan F: Provides comprehensive coverage, including the Part B deductible. Please note; this plan is no longer available to anyone who is eligible for Medicare after January 1, 2020.
• Plan G: These plans provide coverage very similar to Plan F although, they do not cover the Part B deductible.
• Plan K and L: Both these plans offer lower premiums but higher out-of-pocket costs, with coverage limits.
• Plan M and N: Plans provide a good cost-sharing option for specific benefits and lower plan premiums.

Click here to view a comparison chart of Medigap plans

Choosing the Right Plan

Selecting the right Medicare supplement plan requires careful consideration of both health needs and finances. Things to consider when choosing a plan. Please consider using the services of a licensed Medicare agent when making important health coverage decisions. This will ensure you have all the information you need to make an informed choice.

Assess Your Health Needs: Consider your current health status and any anticipated medical needs. If you require frequent medical services, a plan with more comprehensive coverage might be beneficial.

Budget Considerations: Evaluate your budget for monthly premiums versus out-of-pocket costs. Higher premiums generally mean lower out-of-pocket expenses.

Compare Plans: It is a good idea to use the services of a licensed Medicare agent when making important health coverage decisions. In most cases, they can access tools that can provide a comparison of the plans available in your area. This ensures you have all the information you need to make an informed choice.

Watch a YouTube video comparison of our quoting tools Sunfire vs Connecture

Check for Special Benefits: Some plans offer additional benefits, such as foreign travel emergency coverage or even a fitness benefit.

If you want to learn some of the differences between a Medicare Supplement and an Advantage plan, click here.

Enrollment Periods

The best time to buy a Medicare supplement policy is during your Open Enrollment Period, which starts the first month you have Medicare Part B and are 65 or older. During this period, you have a guaranteed issue right, meaning insurers cannot deny you coverage or charge higher premiums due to pre-existing conditions.

Always remember to meet with your agent each year to review your options and adjust your plan as your healthcare needs change.

If you are an agent looking for an upline, click here for online contracting with Crowe

If you like the image in this post, click here to view more by this artist.