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Many Medicare enrollees are wondering what the costs for Medicare Part B 2025 will be. Medicare Part B is a critical part of healthcare coverage for Medicare beneficiaries. It covers outpatient services, preventive care, doctor visits, and durable medical equipment. Knowing the expected premiums and deductible amounts can help beneficiaries plan their healthcare budgets effectively.

Medicare Part B Premiums in 2025

The Medicare Part B premium is the monthly amount that beneficiaries pay for medical coverage. In recent years, premium costs have steadily increased due to rising healthcare expenses, which include the cost of outpatient services and medical advancements.

For 2025, the CMS (Centers for Medicare and Medicaid Services) has projected an increase in the standard monthly premium for Medicare Part B to $185. This is up from $174.70 in 2024.

Please note; individuals who have an income over the specified threshold will pay an IRMAA and therefore the cost of their Part B coverage will be higher. For 2024, the high-income threshold was 103,000 for an individual and $206,000 for a couple. For 2025, it increases to $106,000 for an individual and $212,000 for couples.

Individuals who enroll in Part B coverage late may pay a penalty and therefore their monthly premiums are also higher.

Medicare Part B Deductible in 2025

In addition to the monthly premium, Medicare Part B enrollees must meet an annual deductible before Medicare starts covering most of the costs. For 2024, the Part B deductible was $240. For 2025 the deductible is predicted to be about $257.

Once the deductible is met, Medicare generally covers 80% of the Medicare approved costs leaving the beneficiary responsible for the remaining 20%. Factoring in the deductible as well as anticipated co-payments help with healthcare budgets.

Planning for Higher Costs

With the cost increases in 2025, there are a few ways beneficiaries can prepare:

Beneficiaries with a low income and limited assets may be able to apply for MSP. MSP may pay for Medicare Part B for those who qualify.

Those who are near the income threshold for IRMAA adjustments, consider strategies to manage your taxable income to potentially reduce your premium amount.

Consider a Medicare Advantage (Part C). These plans bundle Parts A and B and often Part D. They may also include additional benefits, like vision, dental, hearing and more. They sometimes offer lower out-of-pocket costs compared to traditional Medicare.

Look into a Medigap plan (Medicare Supplement). Medigap/supplemental policies help cover costs not paid by Medicare, such as co-pays and deductibles, which can help offset increases in Part B costs.

Navigating Medicare Costs

Medicare costs can be complicated, and even a small increase can have a significant impact on a fixed income. Resources like licensed Medicare agents and the State Health Insurance Assistance Program (SHIP) offer free advice for Medicare beneficiaries. This helps them understand their options and make the best possible choices.

Are you a licensed Medicare agent; join our team at Crowe – click here for online contract

Agents – Click here to watch a YouTube video of updates to Connecture and Sunfire for 2025

Knowing what to expect in terms of Medicare Part B costs helps enrollees make informed decisions about healthcare coverage.

Understanding Medicare Part D Costs in 2025

Medicare Part D, the part of Medicare that covers prescription drugs for millions of Americans, provides significant savings but comes with costs that beneficiaries need to plan for. Each year, adjustments are made to premiums, deductibles, and other costs associated with Part D. There will be some significant changes to the Medicare Part D costs 2025. We will discuss the Part D costs, what changes to expect, and tips to manage these expenses.

Watch a YouTube video on the Part D drug cap

Key Cost Components of Medicare Part D

Medicare Part D plans are offered by private insurance companies. Each plan has varying costs depending on the specific plan chosen. In 2025, the cost structure will include four main components:

Monthly Premiums

Medicare Part D premiums vary significantly, depending on plan and location. The average monthly premium for 2025 is around $40. Keep in mind, premiums for individual plans may be as high as $150 or as low as $0. Additionally, some beneficiaries qualify for the Medicare Extra Help program, which can help reduce premiums and other Part D costs.

Annual Deductible

In 2025, Medicare Part D’s standard annual deductible is capped at $590, though not all plans charge the maximum deductible. In general, plans use tiered pricing, meaning they might charge no deductible for lower-tiered drugs.

Initial Coverage Phase

Once the enrollee meets the deductible, they enter the initial coverage phase. During this phase, enrollees are responsible for a copayment or coinsurance for each prescription. In 2025, the initial coverage limit will be set at $2,000. This means that once the amount spent by the plan and the beneficiary reaches this threshold, enrollees transition to the catastrophic phase.

Catastrophic Coverage

In past years, after reaching the coverage gap or donut hole, beneficiaries would enter the catastrophic phase, with Medicare covering the bulk of prescription costs. A major shift in 2025 is the elimination of coverage gap/donut hole phase, meaning enrollees won’t have to pay coinsurance or copayments after reaching the catastrophic coverage limit of $2,000 in true out-of-pocket costs. This limit provides significant relief, especially for those needing high-cost medications.

Changes and Reforms Affecting Part D Costs in 2025

The Inflation Reduction Act (IRA) of 2022 brought changes to Medicare Part D in an effort to improve cost predictability and help enrollees manage high prescription drug expenses. Here’s a breakdown of the key IRA-related reforms that apply in 2025:

$2,000 Annual Out-of-Pocket Cap
Starting in 2025, Medicare Part D beneficiaries will have an out-of-pocket cap of $2,000 per year on prescription drugs. This landmark change helps beneficiaries with high drug costs avoid excessive spending and will particularly benefit those with high-cost prescriptions as long as they are on their plan’s formulary.

Monthly Payment Options
Medicare will introduce a “smoothing” option for beneficiaries with high prescription costs. This allows enrollees to spread out payments over the course of the year, rather than facing steep costs in any one month.

Managing Medicare Part D Costs in 2025

Compare Plans Carefully

Each Part D plan varies in terms of premiums, deductibles, and formulary (the list of covered drugs). Enrollees should review all available options carefully each year during the Medicare AEP (October 15 – December 7). A licensed Medicare agent can help to ensure beneficiaries choose a plan that best meets their needs and budget.

Use preferred pharmacies

Most Medicare Part D plans have preferred pharmacy networks where beneficiaries can get lower costs. Using these pharmacies can reduce copayments and coinsurance expenses. If enrollees use an out of network pharmacy, prescription drugs will usually cost more.

Ask your provider about lower-cost options

In some cases, when a beneficiary has a high-cost medication that is not on their plan’s formulary, they may want to ask their healthcare provider if there are generic or alternative medication that may be more affordable. Sometimes, a small change in medication can lead to considerable savings. If there is no generic available, their provider may need to ask for a formulary exception. When this is the case, the PDP plan provider agrees to pay for a non-formulary medication.

Evaluate Extra Help Options or patient assistance programs

Those who have a limited income and resources, may qualify for Medicare’s Extra Help program, which can help cover premiums, deductibles, and copayments. This program offers significant savings and could reduce costs drastically.
Additionally, many pharmaceutical companies offer assistance programs that provide discounts on high-cost drugs. Checking for available assistance can be a good strategy, especially for high-cost or specialty medications.

Preparing for 2025 and Beyond

The changes coming to Medicare Part D in 2025 are a step towards making prescription drugs more affordable for Medicare beneficiaries. The introduction of an annual out-of-pocket cap and the smoothing program can help provide Medicare enrollees better predictability of their prescription drug costs.

Anyone who relies on Medicare Part D, should review plan details and explore resources to manage these costs effectively. By understanding the structure of Part D and the recent changes, beneficiaries can maximize savings and access their medications without breaking the bank.

There are many good ways to get Medicare referrals. Medicare referrals are a great way to build your book of business without spending a lot of money on leads that may not work out.

Make sure you have a good relationship with existing clients

A good agent is available when their client has questions or concerns. It is important to build a relationship with your clients. The most important way to so this is by listening to their wishes and understanding their coverage needs. Once you do this, they are happy to share your contact with their friends and family. You must stay in contact with your clients, so they remember you are there for them and they do not ask another agent for help.

Be sure to contact them before AEP so you can help them update their information and choose the best plan for the coming year.

Watch a YouTube on Sunfire and Connecture quoting and enrollment updates for 2025

Collecting your client’s contact information such as email and phone number can help you stay in contact. Agents can send out informational emails to clients or even contact a specific client if needed.  The phone numbers are another way to contact clients. They are also good in the event you decide to send text messages for general updates.

If clients are happy with the service you provide, you can ask them for referrals if you do it in a tactful way that makes you both comfortable.

Click here to watch a quick YouTube video on AEP marketing rules

Build relationships with local healthcare professionals

Do not be afraid to introduce yourself to area healthcare providers, clinics or other care facilities. Once they are familiar with you and the service you provide, they may be willing to form a partnership. Having a good rapport with these providers can open doors to a whole new stream of leads.

It is always a good idea to volunteer at local healthcare events and workshops to connect with providers. These professionals can refer people who need assistance with Medicare coverage. This will help establish you as a reliable resource for individual’s coverage needs.

Build an online presence

In today’s digital age, a strong online presence is essential. Agents should create a business profile on social media. After the profile is created, it is important to keep the platform updated with pertinent information potential clients may find useful.  Including information on Medicare choices and answers to common questions are good ways to engage readers and encourage visitors to go back to your platform. An online presence reaches a broad audience and presents you as knowledgeable resource in the field of Medicare.

We can help you build an insurance website

Educational workshops

Hosting either free Medicare workshops or webinars help educate the community about coverage options and changes in Medicare. Providing valuable information to those who need help you gain credibility as a valuable resource.  Those who attend may be inclined to refer friends or family to you for guidance when they are seeking help with their Medicare choices.

Learn the best practices for educational seminars, click here

Offer Referral Incentives

Create a referral program to reward current clients or anyone who refers new clients to you. Incentives for clients cannot include a gift card or anything appropriate with a value over $15. It is important to remain complaint when you offer a referral gift. Acknowledging and appreciating referrals encourages your existing clients to actively promote your business.

Referral gifts of up to $100 per sales is acceptable for other agents or professionals (ACA agents, P&C agents, other Medicare agents).  Do not forget to pay them so they will refer more clients to you in the future.  Please note in most cases, financial planners cannot accept the referral gift.

Collaborate with Local Businesses

Look into forming relationships with local businesses that cater to the senior population. Consider creating connections with senior centers, fitness clubs, or retirement communities. These relationships can be mutually beneficial, you can each refer clients to one another.

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Stay up to date on Medicare plans and regulations

Because Medicare plans make annual changes, agents need to be educated on all available plan options. It is also imperative to stay updated on compliance rules and attend product training sessions, workshops and conferences.  Building relationships with broker managers and other agents in the industry. These are both sources of potential referrals if they have a beneficiary who needs assistance in your area.  Informed well-known agents are more likely to attract referrals from clients and other professionals.

Medicare sales agents need to build a large referral network to achieve long-term success. By focusing on client satisfaction, and following the suggestions above, agents can build a successful referral-based business that brings in new clients and more opportunities.

Each year CMS provides the costs for Medicare. the 2025 Medicare costs include some expected adjustments to premiums, deductibles, and out-of-pocket expenses. This year the changes are based on inflation, healthcare demand, and legislative impacts. Below, we go over the anticipated cost structure, reasons behind the adjustments, and what it means for beneficiaries.

Hospital Insurance – Medicare Part A

Premium

Itis important to note; most people qualify for premium-free Part A due to their work history. However, those who do not qualify will pay an estimated $281 monthly for those with at least 30 quarters of work history, and $510 monthly for those with less than 30 quarters of work history.

Deductible

The Part A deductible is projected to increase to approximately $1,684. The Part A deductible is the cost a beneficiary pays if admitted into either the hospital or a skilled nursing facility.

Coinsurance Costs

Medicare Part A also has daily coinsurance for longer hospital stays. For 2025, beneficiaries can expect coinsurance rates for extended stays to go up to about $421 per day. This reflects the overall rate of inflation in hospital service costs.

Medical Insurance – Medicare Part B

Standard Premiums:

The Part B standard premium, in 2024 is $174.70. This amount will increase to about $185 per month. This increase primarily reflects higher outpatient and physician service costs.

Income-Related Adjustments:

Beneficiaries with higher incomes pay an Income-Related Monthly Adjustment Amount (IRMAA), which will also see a slight increase. These adjustments are based on yearly income, with the highest earners potentially paying over $600 per month in premiums.

Deductible:

The Part B deductible is expected to rise to about $257. Once the beneficiary meets the annual deductible, Medicare usually covers 80% of Medicare approved Part B services. The beneficiary is responsible for the remaining 20%.

Medicare Advantage Plans – Medicare Part C

Medicare Advantage plans (Part C) offer an alternative to original Medicare and include Part A, Part B, and in most cases, Part D (prescription drug) coverage. Private insurance companies offer these plans, and the pricing varies from $0 and go up from there.

Medicare Advantage plan, costs vary based on the plan and insurer, enrollees will also see some increases in premiums and out-of-pocket maximums. CMS caps out-of-pocket maximums. In 2025, they are expected to reach roughly $8,500. This could mean higher costs for enrollees with extensive health needs. There are many plans that will reduce extra benefits such as OTC, vision and dental to name a few.

Prescription Drug Plans – Medicare Part D

Premiums

Part D premiums for standalone prescription drug plans have an average cost of about $40, although this amount varies from $0 up to $150 per month. Overall, there are fewer plan choices available for 2025. Some plans have left the market, and some plans have consolidated their options. The actual plan cost depends on the specific plan and region.

Watch a quick YouTube video on the $2,000 drug cap

Deductibles and Coverage Gap

The maximum allowable deductible for Part D has increased to $590 for 2025. Additionally, the “donut hole” or coverage gap, where beneficiaries pay a greater share of drug costs, has been removed for 2025. Additionally, out-of-pocket drug costs are capped at $2,000. This may significantly reduce expenses for high-cost medications as long as they are on the plan’s formulary.

Why costs are increasing

Medicare cost adjustments reflect a variety of economic and healthcare factors:

Rising Healthcare Costs

Inflation in healthcare affects everything from hospital services to drug prices, driving up Medicare costs.

An Aging Population

As more people enroll in Medicare, especially those with high health needs, the overall program costs increase.

Legislative Changes

Recent legislation, such as the Inflation Reduction Act, introduced caps on Part D costs, in an attempt to reduce prescription drug expenses for seniors. This is causing many changes in the industry while insurance carriers figure out how to pay the billions of dollars this program will cost them. Unfortunately, insurance agents will lose commission on many plans and various plan costs will go up for many enrollees to make up for these changes.

What Can Beneficiaries Do

Use the help of a licensed Medicare agent to compare coverage options each year. A licensed agent can help find the coverage you want as well as a cost that is within your budget. Comparing plans each year is crucial as benefits and plan formularies change each year.

The Medicare cost increases for 2025 underscore the need for beneficiaries to review their coverage options and consider their healthcare needs. Beneficiaries should take advantage of Medicare’s annual open enrollment period to reassess and choose the best coverage.

Be sure to look into financial assistance programs such as MSP and Extra Help. These programs can make a huge difference with Part B and D costs.

Just like the other Medicare coverage options, there are specific rules for Medicare supplement changes. In general, beneficiaries enroll in a Medicare Supplement plan during their Medigap Open Enrollment Period.

Those who wish to apply for or change Medicare Supplement plans outside the Medigap OEP, may have to go through medical underwriting. However, there are some instances when beneficiaries qualify for a guaranteed issue right. This depends on which sate a beneficiary lives in.

Medigap open enrollment

The suggested time to enroll in a Medicare Supplement is during the Medigap OEP. This is a 6-month period that starts when the beneficiary enrolls in Medicare Part B and is at least 65 years of age. Those who enroll during this time do not have to go through medical underwriting. Underwriting is when an insurance carrier can deny coverage due to an underlying medical condition.

Keep in mind, the Medicare Supplement Open Enrollment is entirely different than the Medicare Open Enrollment that takes place annually from October 15th through December 7th.

During the Medicare AEP, beneficiaries can change or drop their Medicare Advantage (Part C) or PDP (Part D) plan. Be sure not to confuse this with the fall Medicare open enrollment period. This period runs from October 15 to December 7 every year. During fall open enrollment, you can enroll in, change, or drop your Medicare Part D prescription drug plan or your Medicare Advantage (Part C) plan. In many states, enrollees do not use this enrollment period to change Medicare Supplement plans.

Guaranteed issue rights

Those who miss their Medicare Supplement OEP may still qualify for guaranteed issue to enroll in or change their Medicare Supplement without underwriting. There are specific circumstances that offer enrollees guarantee issue rights. Review some circumstances that allow for GI rights below:

1. Enrollees who live in one of the four GI issue states (CT, NY, NH or MA).
2. Individuals who have Medicare A and B as well as employer coverage and are losing their employer plan.
3. Beneficiaries who enroll in a MA/MAPD or PACE program when they are first eligible and change their mind within the first year of coverage.
4. Those who have a MA/MAPD plan and are moving out of their plan’s service area.
5. The MA/MAPD plan the beneficiary enrolls in leaves the service area.
6. The Medicare Supplement provider ends coverage through no fault of the enrollee.
7. Enrollees who left a Medicare Supplement plan to try an MA/MAPD plan for the first time can re-enroll in a Medicare Supplement within the first year of trying a MA/MAPD plan.

Click here to learn more about GI rights for Medicare Supplement enrollment

What if you don’t qualify for a GI right

Those who do not qualify for a guaranteed issue right but still wish to change their Medicare Supplement plan may need to go through underwriting. If the beneficiary is healthy, most likely they will pass medical underwriting and receive approval for a new plan.

Beneficiaries with pre-existing conditions may be approved for a new plan although they may pay higher premiums. In some instances, the carrier may deny the beneficiary coverage.

Free look period

A free look period is a 30-day window that some Medicare Supplement enrollees can use to decide if they are happy with their new plan choice. This free look is available if a beneficiary changes from one Medicare Supplement to another.

What to remember when switching Supplements

When considering making a change in Medicare coverage, it is a good idea to get advice from a licensed Medicare agent. A licensed agent understands all your coverage options as well as your needs. They can sort out area plans and help guide you to making an informed decision.

Those who enroll in a new plan should not cancel their old plan until their new enrollment is confirmed. Beneficiaries may also want to pay for both plans for the first month in the event they decide not to keep the new plan.

Once the beneficiary is accepted into the new plan, they must cancel their current Medicare Supplement plan. If they do not, they will be charged for both plans. Those who are unsure about keeping the new plan can wait a month and pay for both to make sure they are happy with the new coverage.

Beneficiaries can request cancellations over the phone or in writing. Those who request the disenrollment over the phone should record a reference number for the call. It is also a good idea to make sure payment for the old plan does not continue.

Learn more about Medicare enrollment periods

More Rules for Medicare Supplement changes:

If a beneficiary moves to another state, they can remain in their current Medicare Supplement plan even if it is not offered in the new state. Although the new state may have its own Medicare Supplements that offer a better price point. A licensed Medicare agent can help find plan options in the new area.

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Understanding Medicare enrollment periods is crucial if you plan to offer Medicare plans to potential clients. It is also important to those becoming eligible for Medicare or hoping to make changes to an existing plan. We will break down the different Medicare enrollment periods and help beneficiaries make informed decisions.

Initial Enrollment Period (IEP)

The Initial Enrollment Period (IEP) is when a beneficiary first becomes eligible for Medicare. This period is a 7-month window, starting three months before the month you turn 65, including your birthday month, and ending three months after. For example, if your 65th birthday is in May, your IEP runs from February 1st to August 31st.

During your IEP, you can enroll in:

• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)
• Medicare Advantage (Part C) or Part D (Prescription Drug Plan)

Individuals under 65 who qualify due to disability, have their own IEP. The IEP starts the 25th month of receiving Social Security Disability Insurance (SSDI).

Medicare General Enrollment Period (GEP)

If a beneficiary misses their Initial Enrollment Period, they can sign up for Medicare during the General Enrollment Period (GEP). The GEP runs from January 1st to March 31st each year. Coverage begins the 1st of the month after the beneficiary enrolls.

Although the GEP provides a second chance to get Medicare coverage, it’s important to note there may be late enrollment penalties for those who did not sign up for Medicare Part B when they were first eligible, unless they qualify for a Special Enrollment Period (SEP).

Medicare Annual Enrollment Period (AEP)

The Annual Enrollment Period (AEP) is a critical time for those already enrolled in Medicare to make changes to their plans. It occurs every year from October 15th to December 7th. During this period, you can:

• Switch from Original Medicare (Part A & B) to a Medicare Advantage (Part C) plan, or vice versa
• Change from one Medicare Advantage plan to another
• Add or drop a Part D (Prescription Drug Plan)
• Switch from one Part D plan to another

Click here for strategies for the 2025 AEP

Changes made during AEP will take effect on January 1st, 2025. This is the time to review your coverage, compare plans, and ensure that your healthcare needs will be met in the upcoming year.

Medicare Advantage Open Enrollment Period (MA OEP)

Those enrolled in a Medicare Advantage (Part C) plan, can use the Medicare Advantage Open Enrollment Period (MA OEP) to make a one-time change. This period runs from January 1st to March 31st annually. During the MA OEP, beneficiaries can make the following changes:

• Switch from one Medicare Advantage plan to another
• Disenroll from a Medicare Advantage plan and return to Original Medicare
• Join a Part D plan if you return to Original Medicare

Please note, beneficiaries cannot switch from Original Medicare to a Medicare Advantage plan during this period; changes are available only to those enrolled in MA/MAPD (Part C) plans.

Special Enrollment Periods (SEP)

Special Enrollment Periods (SEP) allow beneficiaries to enroll in or change Medicare plans outside of the usual enrollment periods as long as they qualify for them. A few reasons for SEP eligibility include:

• Loss of an employer-sponsored health plan
• Moving to a new location outside the current plan’s service area
• If the beneficiary gains eligibility for Medicaid or other financial assistance programs
• Disaster related emergencies may offer an SEP if an enrollment opportunity was missed
• Those who leave incarceration

SEPs vary in length and timing, depending on the reason for eligibility. For instance, those losing employer coverage, generally have an 8-month SEP starting from the month after their employment ends or group coverage ends (whichever comes first).

5-Star Special Enrollment Period

Both Medicare Advantage and Part D plans are rated on a 5-star scale by Medicare. The 5-star plans are the highest rated. If there is a 5-star plan available the beneficiaries’ service area, beneficiaries can enroll in it using the 5-Star Special Enrollment Period. This SEP allows a one-time switch to a 5-star plan at any point between December 8th and November 30th of the following year.

This election period provides an excellent opportunity to switch to a high-quality plan if there is one available in the beneficiaries’ area.

Key Tips for Navigating Enrollment in 2025

• Know the dates for each enrollment period to ensure an opportunity is not missed.
• Review the current coverage. During AEP, it is important to review your existing coverage and compare it with other available plans. Changes to premiums, coverage options, and provider networks may impact your decision.
• Use the beneficiaries should use all the tools available to them including Medicare agents Annual Notice of change ANOC, evidence of coverage and the Medicare Plan Finder tool on Medicare.gov. All these tools can help to compare plans, coverage, and costs.
• Understanding Medicare can be complex, Medicare agents are available to guide beneficiaries on available plans and options to best fit their needs. Reach out to a Medicare advisor or SHIP (State Health Insurance Assistance Program) counselor for guidance.

Agents, click here to fill out an online contract and join the team at Crowe

Understanding Medicare enrollment periods for 2025 is essential for making the right coverage is provided at the right time. Whether enrolling for the first time, looking to change, or there is a need for a special enrollment opportunity, it is important to stay informed about key dates and rules to help manage enrollment options effectively.

For many agents, this year has been a bit frustrating and that is putting it mildly. The 2025 Medicare commissions have been the topic of many conversations. The commission amounts were up in the air for several months before the lawsuits that caused a federal judge to put a stay on a portion of the Medicare Final Rule that directly affects agent commission. As a result of the lawsuits, CMS issued some updates to 2025 Medicare Advantage and Part D broker commissions on July 18, 2024. The new amounts supersede those originally reported by CMS for 2025.

Medicare commission final update – YouTube Video

Important:

The additional administrative fee amounts of $100 for initial enrollments and $50 for renewals of both PDP and MA/MAPD Plans is no longer applicable. In other words, the additional money will not be added to commissions for 2025.

If the judge approves CMS Final rule at some point, the commission rates may increase by $100 for initial enrollments and $50 for renewals. This will be used as a one-time administrative fee to offset the loss of carrier marketing funds.

Although the increase we talked about in the previous paragraph will not be put in place, CMS has approved commission increases for both MA and PDP plan sales. This is due to a FMV (Fair Market Value) increase.

2025 Medicare Advantage commissions

Please keep in mind; the commission rates are not all the same and vary state to state.

In the states of CA and NJ, there will be an increase for initial commissions from $762 per member to $780 per member for 2025.  Renewal commissions for CA and NJ are going from $381 per member to $390 per member for 2025. 

For CT, DC and PA initial commissions will go from $689 per member for the first year to $705 per member.  Renewal commissions for CT, DC and PA will increase from $345 per member annually to $353 per member in 2025.

Puerto Rico as well as the U.S. Virgin Islands initial MA commissions will go from $418 per member annually to $428 per member for 2025.  The renewal commissions have increased from $209 a member for the year to $214 per member for the year.

For any state not listed above, initial MA commission amounts have increased from $611 per member annually to $626 per member for 2025. The commission rates for renewals have increased from $306 per member annually to $313 per member for 2025.

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PDP commissions for 2025:

In the case of PDP commissions, commission rates are the same in all states.

Initial commission rates for PDP plans have risen from $100 per member per year to $109 per member per year.  Commissions for PDP plan renewals have also increased from $50 per member each year to $55 per member each year.

Medicare Advantage Commissions 2025

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While the introduction of the Medicare drug cap in 2025 is a significant step towards making prescription medications more affordable, there are still some limitations and challenges to consider. Here are some key limitations of the Medicare drug cap:

The $2,000 Cap May Still Be Too High for Some Beneficiaries

• Although the $2,000 out-of-pocket cap is a substantial improvement, it might still be unaffordable for low-income beneficiaries who do not qualify for extra financial assistance. For individuals on a fixed income, $2,000 a year can still be a significant burden, particularly if they have other medical expenses.
• Some patients may still struggle with costs in the earlier part of the year, even if the cap limits their total annual expenses.

Only applies to Medicare Part D drugs

• The cap is specifically for Medicare Part D (stand-alone PDPs or MAPD plans) and does not cover drugs administered under Medicare Part B, such as certain cancer medications or infusion therapies. Beneficiaries who need these Part B drugs might still face high out-of-pocket expenses without the same cap protection.
• Many beneficiaries may not understand that the cap only applies to drugs that are on your plan’s formulary. If the client uses drugs that are not on their plan’s formulary, the cost of these drugs does not count towards the $2,000 cap. When the client uses a prescription drug that is off formulary, they should have their doctor request a formulary exception if possible.
• While the cap limits spending on prescriptions from a pharmacy, it doesn’t address the costs of drugs received during a hospital stay or in a doctor’s office, which can still be significant.

Potential for Premium Increases

• To offset the reduced out-of-pocket costs, some Part D plans might raise their monthly premiums. This means that, while beneficiaries may pay less at the pharmacy, they could see higher premiums throughout the year.
• Premium increases could make plans less affordable, especially for beneficiaries who use fewer medications and might not reach the $2,000 cap.

Does Not Impact Drug Prices Directly

• The $2,000 cap limits what beneficiaries pay out-of-pocket but does not control or reduce the actual prices of drugs set by pharmaceutical companies.
• Without addressing the root issue of high drug prices, there is still the potential for overall spending in Medicare Part D to rise, which could lead to higher premiums and other costs for beneficiaries over time.

Complex Smoothing Mechanism

• The smoothing mechanism introduced with the cap allows beneficiaries to spread out their out-of-pocket expenses throughout the year. While this can be helpful, it may also be complicated for some people to understand and use effectively.
• Beneficiaries might need assistance with opting into the smoothing mechanism and managing payments, and there could be administrative challenges that make it difficult for some to take full advantage of this feature.

Learn more about Medicare Smoothing

Watch a quick YouTube video on the Medicare prescription payment program

Limited Impact on Brand-Name and Specialty Drugs

• The cap does not change the formulary (list of covered drugs) or pricing tiers for plans that include Part D coverage. In other words, beneficiaries might still face high costs for certain brand-name and specialty drugs until they reach the $2,000 limit.
• Specialty drugs for conditions like cancer, multiple sclerosis, and rheumatoid arthritis are often very expensive, and while the cap limits total spending, beneficiaries may still need to pay large sums before they hit the cap, especially early in the year.

Variability Across Part D Plans

• All Part D plans vary in coverage, formularies, and cost-sharing structures. Beneficiaries may still face challenges finding a plan that covers all their medications at a reasonable cost, even with the new cap in place. Click her to learn why you should use a licensed Medicare agent
• Some plans may be better at managing costs than others, and beneficiaries will need to carefully compare their options during the Medicare AEP to ensure they get the best coverage for their needs.

Click here to learn why you should use a licensed Medicare agent.

Although the $2,000 out-of-pocket cap for Medicare Part D drugs is a step forward in making prescription drugs more affordable, it is not a perfect solution and does not address all the concerns associated with drug pricing and affordability.

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.