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2026 Medicare Part D Costs & Drug Price Negotiations

Medicare Part D (the prescription drug benefit) has seen some major changes recently. For 2026, several provisions are coming into play that affect what enrollees pay, how much Medicare pays, and how drug prices are negotiated. Below are the key updates to the 2026 Medicare Part D costs.

Key Changes in Medicare Part D for 2026

Here are some of the most important cost‐related changes that beneficiaries should know:

What Is the Drug Price Negotiation Program

Under the Inflation Reduction Act of 2022, Medicare now has the power to directly negotiate prices for certain high-cost drugs covered under Part D (and later also Part B). Previously, Medicare was more restricted in its ability to force manufacturers to lower prices for prescription drugs.

Here’s how the negotiation program works in broad strokes:

• Each year, a certain number of “single-source” brand drugs (i.e. those without generics or biosimilars) that have been on the market for a set minimum time become eligible for negotiation.
• Medicare (through CMS) makes an initial offer (“maximum fair price” or MFP) based on drug spending, clinical benefit, manufacturer costs, price in comparable drugs, etc. Manufacturers can counter. There are meetings and data sharing to arrive at a negotiated price.
• If agreement is reached, the negotiated price becomes effective as of a certain date. For the first set of drugs, prices begin for 2026

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Which Drugs & Savings with Negotiation in 2026

• The first round of negotiation selects 10 Part D drugs.
• For 2026, these negotiated prices go into effect starting January 1, 2026.
• The discounts negotiated are substantial: for those 10 drugs, reductions range from 38% to 79% off list price.
• Estimated savings: If those new prices had been in effect earlier (e.g. in 2023), Medicare would have saved about $6 billion in overall drug spending on those drugs. For beneficiaries, out-of-pocket savings for those 10 drugs in 2026 are projected to be about $1.5 billion.

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How Negotiations & Costs Interact: What This Means for Beneficiaries

• Lower list/transaction prices for selected drugs should directly reduce what beneficiaries pay (especially in the initial and gap phases), because coinsurance or cost sharing is often a percentage of drug cost.
• The out-of-pocket cap ($2,100 in 2026) limits how high total costs for drugs can go in a year, making unexpected high drug bills somewhat more predictable.
• The negotiation program may also influence which drugs are placed on formularies or on preferred tiers, as plans respond to the new negotiated prices.
• However, the savings from negotiated drugs apply only to those drugs selected for negotiation; many other drugs will still be under traditional pricing structures.

Some Caveats & Things to Watch

• The negotiated max fair price is not always simply a percentage cut—there are statutory minimum discounts, comparisons with existing net prices, evaluation of alternatives, etc. Some drugs may see smaller reductions depending on existing rebates or other discounts.
• The program phases in over years: more drugs will be subject to negotiation in 2027, 2028, etc. So the full effects take time.
• Courts and industry challenges may affect implementation or enforcement.

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For 2026, people with Medicare should expect higher costs including; premiums, deductibles and out‐of‐pocket thresholds compared to previous years. Although there will be relief for certain high‐cost drugs thanks to the new Medicare drug price negotiation program. If you’re taking one of the drugs selected for negotiation, the discounts will reduce what you pay. Over time, broader negotiation and other reforms aim to make more drugs more affordable for all Part D enrollees.

Medicare Costs for 2026 – What Beneficiaries Need to Know

Each year, Medicare updates the premiums, deductibles, and coinsurance amounts for Parts A and B. These changes can have a significant effect on your budget; especially if you are living on a fixed income. Below we go over the projected Medicare costs for 2026. We have included a brief look at Part D and the high-deductible Medigap option.

Medicare Part A Costs for 2026

Medicare Part A covers inpatient hospital care, skilled nursing facility care, hospice, and some home health services. Most people do not pay a Part A premium, but you are still responsible for deductibles and coinsurance amounts.

• Part A deductible (per benefit period): Projected to rise from $1,676 in 2025 to about $1,716 in 2026.
• Hospital coinsurance (days 61–90): Expected to increase from $419/day to around $429/day.
• Lifetime reserve days (beyond day 90): Rising from $838/day to about $858/day.
• Skilled Nursing Facility coinsurance (days 21–100): Expected to increase to about $214.50/day.

Since the Part A deductible applies per benefit period, you could pay it more than once in a year if you have multiple hospital stays separated by 60+ days.

Medicare Part B Costs for 2026

Part B covers outpatient services, doctor visits, preventive care, and durable medical equipment.

• Standard Part B premium: Expected to increase from $185/month in 2025 to around $206.50/month in 2026.
• Part B annual deductible: Projected to rise from $257 to about $288 in 2026.

After you meet your Part B deductible, Medicare generally covers 80% of approved charges, leaving you responsible for the remaining 20% unless you have supplemental coverage.

Part D Prescription Drug Costs (Quick Note)

Even though Part D is separate from Parts A & B, it’s worth noting that the maximum Part D deductible is expected to increase from $590 in 2025 to $615 in 2026. There will also be a new out-of-pocket cap of $2,100 for covered drugs (it was $2,00 in 2025), which helps those with high prescription costs.

High-Deductible Medigap (HDG) Plans – A Quick Overview

For those who purchase a high-deductible Medigap plan (Plan G or F), the annual deductible must be met before the plan starts paying for costs that Original Medicare doesn’t cover.

• The 2025 high-deductible amount is $2,870.
• The 2026 amount has not yet been finalized but is expected to rise slightly in line with medical inflation.

These plans often have lower monthly premiums, making them attractive for healthier beneficiaries who expect lower healthcare usage, but you’ll need to budget for that large deductible in case of an unexpected illness or hospitalization.

Watch a YouTube video on High Deductible G Plans

Why This Matters

The projected increases in Part B premiums and deductibles could take a big bite out of Social Security cost-of-living adjustments. Planning ahead helps you avoid surprises.

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Here’s what clients should do:

• Budget for higher premiums and deductibles.
• Review supplemental coverage to ensure it still meets your needs and budget.
• Compare Part D plans during the Annual Enrollment Period (AEP) to find one that best covers medications at the lowest cost.
• Stay informed—CMS will finalize these numbers in Fall 2025, so check back for updates.

The Medigap Free Look Period and How to Use It

When clients are considering a Medicare Supplement (Medigap) plan, they want to be sure they’re making the right choice. Fortunately, Medicare gives beneficiaries a way to try out a new Medigap plan without fully giving up their old one; it’s called the Medigap Free Look Period.

As an agent, knowing how this works helps you guide clients through transitions confidently and avoid gaps in coverage.

What Is the Medigap Free Look Period

The Medigap Free Look Period is a 30-day window that allows Medicare beneficiaries to try out a new Medigap policy while keeping their current one.

This is helpful when a client isn’t sure if the new plan will meet their needs; for example, if they are switching from a Plan F to a Plan G or moving to a carrier with a lower premium.

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How the Free Look Period Works

Here’s how the process goes step by step:

1. Apply for the New Medigap Plan
   • Your client must be accepted by the new Medigap plan (and if underwriting is required, they must pass).
2. Keep Paying for the Old Policy
   • Even after the new plan starts, your client must keep paying premiums for their old Medigap policy during the 30-day free look period.
   • This ensures there’s no gap in coverage if they decide to go back.
3. Evaluate the New Coverage
   • Over the 30 days, your client can use the new Medigap plan and see how it works with their needs.
4. Decide Whether to Keep It
   • If they like the new plan, they can cancel the old one after the 30 days.
   • If they don’t, they can cancel the new plan and keep the old one; no harm done.

Important Things to Remember

• Two Premiums Are Due: Clients will pay two Medigap premiums during the free look period; one for the old plan and one for the new. This is often the biggest surprise for beneficiaries, so prepare them ahead of time.
• Coverage Overlap Is Intentional: The goal is to avoid any lapse in coverage while deciding which plan to keep.
• Act Within 30 Days: If the client decides to go back to their old policy, they must notify the new carrier before the free look period ends.

Why Agents Should Talk About It

Educating clients about the Medigap Free Look Period builds trust. Many people hesitate to switch plans out of fear of losing coverage or making the wrong choice. When you explain that they can try a new plan risk-free, you help them feel confident in making a change. That helps position you as a knowledgeable, client-first agent.

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The Medigap Free Look Period is a great tool to help beneficiaries compare coverage and costs without the stress of losing their existing plan. As an agent, you can guide them through the process, set clear expectations about paying two premiums, and help them decide which plan is the best long-term fit.

Empower your clients with this knowledge; it may be exactly what they need to take the next step toward better coverage and savings.

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What Is a Medicare Authorized Representative

Navigating Medicare can sometimes feel overwhelming; especially when it comes to forms, appeals, or plan decisions. That’s where a Medicare Authorized Representative comes in. If you need help dealing with Medicare, you can officially appoint someone to act on your behalf. But what is a Medicare authorized representative, and what are the limits to their authority? Let’s break it down.

What Is a Medicare Authorized Representative

A Medicare Authorized Representative is a person you choose to act for you in handling certain Medicare matters. You can name a trusted family member, friend, caregiver, or even a professional (like an attorney) to represent you.

To make this official, Medicare requires you to complete the “Appointment of Representative” form (CMS-1696) or provide a written statement that includes specific details. Once approved, Medicare recognizes this person as your representative for the issues you’ve specified.

What an Authorized Representative Can Do

When properly appointed, your authorized representative can:

• Communicate with Medicare on your behalf – including discussing claims, coverage, and appeals.
• File appeals or grievances – if you disagree with a coverage or payment decision.
• Submit plan enrollment or disenrollment requests – depending on your needs.
• Receive notices and correspondence from Medicare related to your case.
• Help you gather and send supporting documentation for appeals or claims.

Essentially, your representative steps into your shoes for specific Medicare-related matters, making the process less stressful for you.

What an Authorized Representative Cannot Do

It’s important to understand the limits of this role. A Medicare Authorized Representative cannot:

• Make medical decisions for you – They are not the same as a healthcare proxy or power of attorney for medical treatment.
• Automatically handle all financial or legal matters – Their authority is limited to Medicare issues.
• Act indefinitely without renewal – Representation typically applies to specific cases or timeframes and may need renewal if ongoing.
• Override your wishes – You remain in control, and you can revoke their authority at any time.

If you want someone to handle broader decisions about your finances or healthcare beyond Medicare, you would need a power of attorney or similar legal document.

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How to Appoint a Representative

1. Fill out Form CMS-1696 – This form is available on Medicare.gov or from your plan.
2. Submit the form – Send it to your Medicare Advantage, Part D, or other Medicare-related plan, or directly to Medicare if it’s about Original Medicare.
3. Wait for confirmation – Once accepted, your representative can begin acting on your behalf.

Why Appointing a Representative Can Help

Having a Medicare Authorized Representative can be especially useful if:

• You’re appealing a denial of coverage.
• You need help managing the paperwork.
• You have a trusted advocate who understands your situation.
• You want extra peace of mind that someone is handling your case correctly.

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Bottom line: A Medicare Authorized Representative is your advocate in dealing with Medicare, but their authority is limited to Medicare-related issues. They can help with forms, appeals, and communication, but they cannot make medical decisions or handle unrelated legal or financial matters.

Medicare Supplement Underwriting Explained

When clients start exploring Medicare Supplement (Medigap) plans, one topic that often causes confusion is underwriting. Unlike Medicare Advantage plans, which don’t require medical underwriting, Medigap coverage can involve health-related questions and approval requirements; depending on when and how someone applies. That is why we hope, Medicare supplement underwriting explained will provide an understanding of the process so agents can better assist clients.

What Is Medicare Supplement Underwriting

Underwriting is the process insurance companies use to determine whether to accept an applicant for a Medigap policy, and sometimes the determine the premium amount. This process often involves answering health questions, reviewing prescription history, or even checking recent hospitalizations.

Not every applicant will face underwriting, many people qualify for guaranteed issue rights or are in their Medigap Open Enrollment Period, which means they can get a plan without medical review.

When Is Underwriting Required

Underwriting typically comes into play in these situations:

• Applying outside the Medigap Open Enrollment Period (which lasts six months after a beneficiary first enrolls in Part B at age 65).
• Switching from one Medigap plan to another outside of specific state-mandated open enrollment or “birthday rules.”
• Losing coverage without qualifying for guaranteed issue rights.

In these cases, insurance carriers can:

• Approve coverage at the standard rate,
• Charge a higher premium,
• Impose a waiting period for pre-existing conditions, or
• Deny coverage altogether.

Guaranteed Issue Rights (No Underwriting Required)

There are special circumstances where a beneficiary can enroll in a Medigap plan without facing underwriting, such as:

• Losing employer or union coverage.
• Their Medicare Advantage plan leaving the service area or ending coverage.
• Moving out of a Medicare Advantage plan’s service area.
• Taking advantage of certain state-specific enrollment protections (like California and Oregon’s Birthday Rule, or Missouri’s Anniversary Rule).

During these times, carriers must offer coverage, regardless of health status.

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Common Health Questions in Underwriting

While exact questions vary by carrier, underwriting often includes:

• Recent heart attacks, strokes, or cancer diagnoses.
• Use of oxygen, dialysis, or organ transplants.
• Height, weight, and mobility concerns.
• Hospitalizations in the past 90 days.
• Use of certain expensive medications.

Carriers typically ask about conditions that are costly and ongoing. Clients with stable, controlled conditions may still qualify.

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Why Agents Should Understand Underwriting

As an agent, knowing the underwriting rules helps you:

• Advise clients on the best time to apply for Medigap coverage.
• Set realistic expectations about approvals, denials, or higher premiums.
• Protect clients by helping them avoid losing a plan they may not be able to requalify for later.

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Underwriting for Medicare Supplements can be straightforward if clients apply at the right time, but tricky if they wait too long or want to change plans later. By understanding the process and knowing when underwriting applies, you can help your clients secure coverage that supports their health and budget without unexpected roadblocks.

Levels of D-SNP Eligibility Explained for Medicare Clients

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

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

Full vs. Partial Dual Eligibility

Full Dual Eligible Members

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

Partial Dual Eligible Members

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

Watch a YouTube video on DSNP Changes for 2025

Types of D-SNPs

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

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

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Why This Matters for Agents

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

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

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

Medicare Prescription Drug Coverage: Why Agents Should Guide Their Clients

When it comes to Medicare, prescription drug coverage (Part D) is one of the most important decisions beneficiaries will make. Prescription costs can have a major impact on a person’s budget and quality of life, and the right plan can save thousands of dollars each year.

For Medicare agents, helping clients navigate their Part D options isn’t always about commissions, it’s about building long-term trust, maintaining strong relationships, and positioning yourself as a valuable resource.

Why Agents Should Assist With Part D Decisions

Client Trust and Retention

Even if you aren’t earning a commission on every Medicare Prescription Drug Plan, guiding your clients through their choices shows that you care about their overall well-being. Beneficiaries notice when an agent takes the time to help without a financial incentive. That trust builds loyalty, which translates to long-term client retention.

The Importance of Enrolling on Time

Many beneficiaries don’t realize that failing to enroll in Medicare prescription drug coverage when first eligible or going without creditable drug coverage for more than 63 continuous days can lead to a lifetime late enrollment penalty (LEP). This penalty is added to the monthly Part D premium and grows the longer someone goes without coverage.

As an agent, explaining this to clients ensures they understand the financial consequences of delaying enrollment. Helping them avoid unnecessary penalties is another way to build trust and showcase your expertise.

Strengthening Relationships

By reviewing drug coverage options, you’re demonstrating your commitment to helping clients find the most cost-effective and comprehensive plan. This not only makes clients more likely to refer friends and family, but it also establishes you as their go-to resource for future Medicare needs.

Positioning Yourself for Additional Sales Opportunities

Helping with prescription drug coverage is often the first step toward uncovering other gaps in coverage. Once trust is built, clients may be more open to discussing:

• Medicare Supplement plans (Medigap): To help with out-of-pocket costs not covered by Original Medicare.
• Ancillary products: Such as dental, vision, hearing, short-term care, or critical illness coverage. These plans can provide extra protection and peace of mind for expenses Medicare doesn’t cover.

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Showing That You Put Clients First

Beneficiaries can feel overwhelmed by the number of plan choices. When you guide them, without focusing on commissions, you prove that your priority is their best interest. This approach differentiates you from competitors and builds long-term credibility.

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The Bottom Line

Helping clients choose the right Medicare Prescription Drug Plan isn’t just about filling out enrollment forms; it’s about demonstrating integrity, earning trust, and protecting clients from costly mistakes like lifetime penalties.

Even when commissions aren’t involved, the time you invest in helping clients with their Part D decisions will pay off in other ways: stronger retention, new sales opportunities, and a reputation for truly putting clients first. With the client’s permission, agents can run the comparison and send the recommendation through a quick email. If the best option is a non-commissionable plan, clients can easily self-enroll through medicare.gov or a phone call to the carrier.

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Please keep in mind, it is always important to follow all CMS enrollment rules.

By taking a holistic approach, you not only help clients get the coverage they need, you also ensure your business continues to grow through loyalty, referrals, and expanded product offerings.

Why Choose an HMO

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

Lower Monthly Premiums

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

Predictable Costs

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

Coordinated Care

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

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Extra Benefits Beyond Original Medicare

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

Lower Out-of-Pocket Maximums

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

Local Network Focus

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

Is an HMO Right for You

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

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

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Why Offer Medicare HDG Plans

The question; why offer Medicare HDG Plans, because the Medicare market is changing rapidly. Agents must stay ahead of the curve to remain successful. Many major carriers are scaling back their Medicare Advantage (MA) offerings and even cutting commissions on some plans. This leaves agents with fewer options to present to clients. This is where HDG Plans can make all the difference.

The Current Landscape of Medicare Advantage

In recent years, Medicare Advantage has been one of the most popular plan options among seniors. However, for the last couple years, carriers are:

• Pulling plans from the market – especially PPOs, which have traditionally been popular for their provider flexibility.
• Reducing commissions – some carriers are paying no commission on certain MA products, leaving agents with fewer options to offer.
• Tightening supplemental benefits – carriers are scaling back some of the extra benefits that once attracted clients, making MA plans less competitive.

For agents, this creates a challenge: how do you provide value to your clients while maintaining a sustainable business model?

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Why HDG Health Plans Stand Out

HDG Health Plans provide a strong alternative that agents should be offering. Here’s why:

1. Plan Stability

Unlike some Medicare Advantage carriers that are exiting markets or restructuring benefits, HDG Health Plans are built for long-term stability. This ensures agents can confidently enroll clients without worrying about sudden disruptions.

2. Expanded Client Options

As carriers discontinue PPOs and other MA plans, seniors need reliable choices that meet their healthcare and financial needs. HDG offers products that can help fill the gaps left by Original Medicare. This gives agents a competitive edge in retaining and growing their book of business.

3. Consistent Compensation

With some carriers cutting or eliminating commissions on MA plans, agents need products that continue to provide fair, reliable compensation. HDG Health Plans recognize the value of the agent’s role and support them with commission structures that make sense.

4. Strong Value Proposition for Clients

Carriers design HDG Plans with seniors in mind, balancing affordability, access to care, and flexibility. This makes them attractive alternatives for clients who may be frustrated with shrinking MA networks or reduced plan options.

5. Ability to seek care from most providers

Unlike MA plans, Medicare supplements allow the enrollee to seek care form any provider that accepts Medicare. This can be a huge advantage to any enrollee.

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The Opportunity for Agents

As the Medicare market shifts, agents who adapt quickly will come out ahead. By offering HDG Health Plans, agents can:

• Differentiate themselves from competitors still relying heavily on shrinking MA offerings.
• Provide solutions to clients facing plan cancellations or limited coverage options.
• Build a more stable book of business with products that pay fairly and retain members long-term.

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The Medicare Advantage space is in transition, and relying solely on it may leave both agents and clients at a disadvantage. By incorporating HDG Health Plans into your portfolio, you can protect your business, serve your clients more effectively, and position yourself as a trusted advisor during a time of change.

Now is the time to diversify your offerings, and HDG Health Plans should be at the top of your list.

SEPs for Medicare Part B Enrollment

For Medicare beneficiaries, the timing of enrollment is very important. While most people enroll in Medicare Part B during their Initial Enrollment Period (IEP) when they first become eligible, life circumstances don’t always fit neatly into those timelines. That’s where SEPs for Medicare Part B enrollment come in.

SEPs provide and opportunity for beneficiaries to sign up for Part B outside of their IEP or the GEP(General Enrollment Period), without facing late enrollment penalties, provided they meet certain conditions.

What is Medicare Part B

Medicare Part B helps cover outpatient care, doctor visits, preventive services, lab work, durable medical equipment, and more. Since it comes with a monthly premium, some people delay enrolling—especially if they’re still working and covered under an employer health plan.

When Can You Qualify for a Part B SEP

SEPs are designed to protect people who already had other coverage or experienced specific life events. Some of the most common situations include:

1. Employer or Union Coverage

• If you (or your spouse) are still working past 65 and covered by a group health plan, you can delay enrolling in Part B.
• Once that employment ends, or the employer coverage ends; you qualify for an 8-month SEP to sign up for Part B without penalty.

2. Coverage Through a Spouse

• If you’re covered under your spouse’s employer plan, the same SEP protections apply.
• This is important for individuals who retire before their spouse does, or vice versa.

3. Losing Other Creditable Coverage

• If you lose health insurance that’s considered “creditable” by Medicare standards (meaning coverage that’s at least as good as Medicare), you’ll likely qualify for an SEP.

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4. Special Circumstances (New Rules Starting in 2023)

CMS expanded SEPs to include situations such as:

• Emergency or disaster situations (declared by FEMA or other agencies).
• Employer or plan error where you were misinformed about enrollment.
• Medicaid coverage ending.
• Other exceptional conditions as determined by Medicare.

Forms you’ll need for a PArt B SEP enrollment

When enrolling in Medicare Part B during a Special Enrollment Period, most beneficiaries will need to complete two key forms:

• CMS-40B — Application for Enrollment in Medicare Part B (Medical Insurance); this is the standard enrollment form used to request Part B coverage. The beneficiary must complete this form.
• CMS-L564 — Request for Employment Information; this is the standard enrollment form beneficiaries use to request Part B coverage. It is completed by the beneficiary and their employer to verify that you had group coverage based on employment. Medicare uses it to confirm penalty free eligibility.

Please note: If your employer cannot fill out the CMS-L564, you can still submit it along with other proof of creditable coverage, such as pay stubs showing insurance deductions or health plan ID cards.

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Why SEPs Matter

Missing your enrollment period for Part B can lead to late enrollment penalties that increase your premium by 10% for each 12-month period you could have had Part B but didn’t enroll. These penalties usually last for as long as you have Medicare.

SEPs help people avoid those lifelong penalties if they had valid reasons for delaying enrollment.

Key Takeaways for Beneficiaries and Agents

• Always confirm whether an employer plan is considered creditable coverage before delaying Part B.
• Keep records of your health coverage and employment dates; Medicare often requires documentation.
• Complete both CMS-40B and CMS-L564 when applying for a Part B SEP.
• Educate clients that timing is everything. Even with an SEP, strict deadlines apply.

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Special Enrollment Periods give Medicare beneficiaries flexibility and protection when life events affect their coverage. Knowing the rules and having the right forms ready can save money, prevent penalties, and ensure continuous access to healthcare.