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When helping clients plan for their healthcare coverage needs, it’s important to discuss not just what Medicare does cover, but also what it doesn’t. Understanding these gaps can help clients avoid unexpected expenses and make informed decisions about supplemental insurance options. Let’s take a closer look at some of what Medicare won’t cover.

Long-Term Care

One of the biggest misconceptions about Medicare is that it covers long-term care, like nursing home stays or in-home care for chronic conditions. In reality, Medicare only covers short-term skilled nursing care under specific conditions. Clients may need separate long-term care insurance or other financial strategies to cover these considerable costs. Learn about short-term care vs long-term care plans.

Most Dental Care

Routine dental services such as cleanings, fillings, tooth extractions, dentures, and dental implants are generally not covered by Medicare. If dental care is important to your client, you should explore standalone dental insurance or Medicare Advantage plans that offer dental benefits.

Learn about stand-alone dental coverage available in all 50 states

Vision Care

Medicare does not cover routine eye exams for glasses or contacts. It will, however, cover eye exams related to medical conditions like glaucoma or cataracts. Clients needing regular vision care might consider standalone vision insurance or a Medicare Advantage plan with vision coverage.

Hearing Aids and Exams

Original Medicare doesn’t cover hearing aids or exams for fitting them, which can be a significant expense. Some Medicare Advantage plans offer hearing benefits, so this is worth exploring based on client needs.

Routine Foot Care

Routine foot care, such as treatment for corns, calluses, or nail trimming, is not covered unless it’s deemed medically necessary due to a condition like diabetes.

Overseas Health Care

Most care received outside the United States is not covered by Medicare. For clients who plan to travel internationally, consider recommending a Medigap plan that includes foreign travel emergency coverage or a separate travel insurance policy.

Elective Surgery

Medicare won’t cover elective cosmetic surgeries, such as facelifts or liposuction. It will however, cover surgeries that deemed medically necessary, such as reconstructive surgery after an accident or some forms of cancer.

Key Takeaways for Agents

This is just an idea of what is not covered by Medicare, for a complete lists click here.

• Discuss Supplement Options: Educate clients on the benefits of Medigap (Medicare Supplement) plans, Medicare Advantage plans, or standalone insurance options for things like dental, vison & hearing or other ancillary products to fill the coverage gaps.
• Tailor Recommendations: Understand each client’s lifestyle and health priorities to recommend the right supplemental coverage.
• Plan for the Unexpected: Help clients build a financial plan that anticipates out-of-pocket healthcare expenses.

Being proactive about Medicare’s limitations helps clients better prepare for retirement. As agents, we can offer tremendous value by guiding clients through their options to ensure they have the comprehensive healthcare coverage they need.

To get some tips to maintain your book of business; click here

Medicare helps millions of Americans 65 and over and those with qualified disabilities and ESRD access the healthcare they need. Unfortunately, it also attracts scammers who are looking to take advantage of unsuspecting beneficiaries. One of the most common tools scammers use is the phone. In this post, we discuss some of the most common Medicare phone scams and how to avoid them.

Anyone on Medicare or helping someone who is should know the red flags to help guard against fraud.

Common Medicare Phone Scams

“We’re issuing you a new Medicare card”

Scammers may call claiming that Medicare is sending out new cards (often with a chip or updated feature), and that they just need to “verify” your Medicare number or Social Security number.

In reality, some individuals were issued new Medicare cards but no one called beneficiaries on the phone; click here for more details.

Important: Medicare will never call you to ask for personal information out of the blue. If there were truly a new card, you’d get a letter or notice in the mail.

“You qualify for free medical equipment”

This one often targets people with diabetes or chronic pain. The caller might offer free back braces, knee braces, or glucose monitors in exchange for your Medicare number.

In reality: These “free” items are often billed to Medicare fraudulently. You could end up responsible for the cost or even flagged for abuse of your benefits.

Fake Medicare representatives

Some scammers impersonate Medicare employees or contractors and use urgent language to scare you: “Your benefits will be cut off” or “We detected suspicious activity.”

Remember: Medicare officials do not call unsolicited to threaten or pressure you. Real communication will be by mail, and you can verify legitimacy before responding.

COVID-19 test scams

During the pandemic (and even now), scammers offered free COVID tests or vaccines in exchange for your Medicare info. These have since evolved into offers for “new virus screenings” or “preventive health checkups.”

Keep in mind: While COVID tests and vaccines are covered by Medicare, they do not require phone enrollment or any payment up front.

“We can lower your Medicare premiums”

Some calls promise to reduce your monthly Medicare costs or enroll you in a “better” plan; usually with limited information and a high-pressure sales pitch. Learn more about these Medicare scams.

Important: Legitimate plan changes should go through licensed agents or official Medicare channels, not someone who refuses to send information in writing or insists on getting personal data over the phone.

How to Protect Yourself

• Hang up on unsolicited calls. If it feels fishy, it probably is.
• Never give out your Medicare number, Social Security number, or banking information over the phone; unless you initiated the call to a trusted number.
• Contact your Medicare agent or use the 1-800-MEDICARE number or visit medicare.gov if you have questions or are unsure about something.
• Check your Medicare Summary Notices (MSNs) regularly to spot unfamiliar charges.
• Report scams to Medicare at 1-800-MEDICARE or to the FTC at reportfraud.ftc.gov.

Remember

Scammers are smart and persistent but with a little awareness, you can stay one step ahead of them. Medicare will never call you out of the blue to ask for your information, and anything that sounds too good to be true usually is.

Know the red flags, trust your instincts, and share this information with friends and loved ones. A quick heads-up could prevent someone you care about from falling victim to fraud.

We will use this post to discuss why use local Medicare agents as opposed to call center agents. When it comes to Medicare, one size doesn’t fit all. Choosing the right plan means considering health needs, prescriptions, doctors and even budget. So when trying to sort through all the options, who provides the advice can make all the difference.

Here are some reasons that using a local Medicare agent might be a smarter move than a call center representative:

Personalized, Face-to-Face Service

Local agents often offer in-person consultations, so beneficiaries are not just a number on a screen agents actually get to know their clients. This allows agents to better understand client’s healthcare needs and walk them through their options in a clear, personal way. For beneficiaries who prefer a handshake over hold music, a local agent wins every time.

Ongoing Support

Call center agents are usually focused on getting prospects enrolled, then moving on to the next call. Local agents, on the other hand, build relationships. They often provide support throughout the year. They can provide help with billing issues, coverage questions, or preparing for the next Annual Enrollment Period. Local agents can be a trusted advisor, not just a voice on the phone.

More Than Just Enrollment Help

Local agents can assist with:

• Plan comparisons
• Prescription drug coverage analysis
• Medicare Savings Programs
• Low Income Subsidy (Extra Help) applications
• Coverage questions that come up
• Annual plan reviews

They often go the extra mile to make sure clients understand their options; not just during enrollment, but year-round.

Independent Unbiased Advice

Many local Medicare agents are independent brokers who can compare plans from multiple insurers. That means they’re not tied to one company or incentivized to push a single product. Call center agents, by contrast, often work for a single insurer or are bound by contracts that limit what they can offer. Call center agents often work on meeting a quota for the carriers and do not have the ability to ensure prospects receive the best available, personal coverage.

Local agents also have quoting and enrollment tools to provide plan comparisons clietns can see plans side by side. This makes choosing the right coverage easy.

Watch a YouTube video on Sunfire BlazeSync customer intake form

Learn about the changes to Connecture and Sunfire for 2025

Understanding of Local Networks

Local agents know which doctors, hospitals, and pharmacies are in-network in the prospect’s local area. They’re familiar with regional plan availability, local provider preferences, and even which plans tend to have the fewest issues. That kind of insight is hard to get from a national call center.

No Cost – It’s Free

Here’s the kicker: local Medicare agents are typically free to use. They’re paid by the insurance companies (not out of the client’s pocket), and the price of a plan is the same whether enrolllees go through an agent or enroll themselves.

Agents; learn the value of maintaining your Medicare book

Medicare coverage is too important to leave to a rushed phone call with someone who may never talk to the beneficiary again. Local agents offer real relationships, local knowledge, and ongoing support that can help clients feel more confident about their healthcare coverage choices. This is a relationship that is on going not just for one day.

Agents; click here for a SCOPE

In this post, we discuss the basics of Medicare enrollment for those approaching 65 and for agents getting started in Medicare sales. Trying to navigate all the ins and outs of Medicare may be a bit confusing, but it does not have to be. Understanding when and how to enroll in Medicare is key to ensuring beneficiaries receive the best coverage for their needs.

Original Medicare

Original Medicare consists of Part A & Part B. It is a federal health insurance program put in place for individuals aged 65 and older or younger individuals with a qualifying disability or those with End-Stage Renal Disease (ESRD). Medicare provides coverage for many healthcare services, including hospital stays (Part A), and doctor visits (Part B).

It is important to note; Medicare covers approved expenses at about 80% after beneficiaries meet the Part B deductible.

The Parts of Medicare

Before diving into enrollment, it’s helpful to understand the different parts of Medicare:

• Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care.
• Part B (Medical Insurance): Covers outpatient care, doctor visits, preventive services, and some home health care services.
• Part C (Medicare Advantage): An alternative to Original Medicare (Parts A and B) offered by private insurers. Often includes additional benefits like vision, dental, and prescription drug coverage.
• Part D (Prescription Drug Coverage): Helps cover the cost of prescription medications. Beneficiaries may receive coverage through a Medicare Advantage plan or a stand-alone PDP plan.

Medicare Enrollment Periods

There are several enrollment periods to be aware of:

Initial Enrollment Period (IEP)

This is the first opportunity to sign up for Medicare. It lasts seven months:

• Begins three months before the month individuals turn 65
• Includes their birth month
• Ends three months after the month they turn 65

In most cases, those already receiving Social Security benefits are auto-enrolled in Original Medicare (Parts A and B). If they are not, they must enroll via the Social Security Administration.

General Enrollment Period (GEP)

Individuals who miss their Initial Enrollment Period can use the GEP to enroll between January 1 and March 31 each year. Coverage starts the first day of the month following enrollment. Please note; those who miss their initial enrollment period and don’t have other creditable coverage (usually through an employer) may face late enrollment pentalties.

Special Enrollment Period (SEP)

In some cases, individuals qualify for a Special Enrollment Period if they delayed Medicare because they had coverage through an employer or union. This SEP allows them to enroll without penalty when their other coverage ends.

Annual Enrollment Period (AEP)

AEP Each year from October 15 to December 7, beneficiaries can:

• Switch between Original Medicare and Medicare Advantage
• Switch from a Medicare Advantage plan back to Origianl Medicar
• Change from one Medicare Advnatage plan to another
• Join, switch, or drop a Part D plan

Medicare agents watch a YouTube video on marketing rules for AEP

How to Enroll in Medicare

There are a few ways to enroll in Medicare:

• Online at ssa.gov/medicare
• By phone by calling Social Security at 1-800-772-1213
• In person at your local Social Security office (call ahead for an appointment)

A Few Tips

• Beneficiaries should mark their calendar so they do not miss their enrollment window. Delaying enrollment can lead to gaps in coverage and penalties.
• Ask questions! Medicare can be complex, and there are plenty of free resources available to help. This is where it is important to have a reputable , licensed Medicare agent to provide guidance.
• Because Medicare does ot cover 100% of medical expenses, beneficiaries need to consider additional coverage options; Medicare Advantage or Medicare Supplement and Prescrption Drug plans.

Learn how to appeal a Medicare LEP

Understanding the basics of Medicare enrollment is a vital first step in managing healthcare needs. With a little preparation and the right information, beneficiaries can make good decisions that provide peace of mind and the coverage that best suits their needs.

Agents:

If you need a scope of appointment – click here

Ready to join the team at Crowe – click here for online contracting

Because there are so many regulations for Medicare sales, agents need to constantly be learning. That is why we will discuss Medigap Guaranteed Issue Rights in this post. This is a subject that is crucial to understand but often misunderstood.

Medigap Guaranteed Issue Rights

Guaranteed Issue (GI) Rights are protections under federal law that provide beneficiaries the right to purchase certain Medigap (Medicare Supplement) policies without having to go through medical underwriting. That means insurance companies can’t:

• Deny the beneficiary enrollment in a policy
• Charge enrollees more based on health
• Impose waiting periods for pre-existing conditions (in most cases)

These rights kick in during specific situations, often tied to changes in your health coverage or life circumstances.

When Guaranteed Issue Rights Apply

Here are some common scenarios that trigger GI rights:

Turning 65

Anyone who turns 65 has a 6 month period where they can enroll in a Medigap plan without having to go through underwriting.

Loss of Employer or Union Coverage

Individuals that have health coverage through an employer or union (including COBRA) that ends have 63 days from the end of that coverage to buy a Medigap policy using GI rights.

Medicare Advantage Plan Leaves a service Area

If a Medicare Advantage (MA) plan no longer provides service the enrollee’s area, is terminated, or they move out of the plan’s service area, they can return to Original Medicare and buy a Medigap policy under GI protections.

Beneficiary Tries a Medicare Advantage Plan for the First Time

Those who joined an MA plan when they were first eligible for Medicare at 65 and switch back to Original Medicare within the first 12 months can buy any Medigap policy offered in their state.

Medigap Insurance Company Goes Bankrupt or Misleads You

If the Medigap insurer goes out of business or the beneficiary is misled into buying a policy, they have GI rights to purchase another policy.

Trial Rights

In some cases, beneficiaries have “trial rights” that allow them to try out an MA plan and return to a Medigap plan under GI protections. This typically applies if they dropped a Medigap policy for an MA plan and want to switch back within 12 months.

Rules and Timelines

• Typically individuals have a 63-day window from the date previous coverage ends to use their GI rights.
• The plans that are guaranteed issue depend on eligibility and location. The standard Medigap plans are Plans A, B, C, F, K, or L.
• The federal government mandates guaranteed issue rights, although some states offer broader protections. It is important to check the rules for each state.

Watch a YouTube video on Medicare Supplement Underwriting GI & non-GI states

Why Guaranteed Issue Rights Matter

Without GI rights, applying for Medigap outside the initial enrollment period often means going through medical underwriting. Those who have pre-existing conditions could be denied coverage or charged more.

GI rights are a safeguard. They ensure that when life throws a curveball like; losing coverage, moving, or simply changing your mind, beneficiaries can access supplemental coverage without penalty.

Birthday Rule

There are 6 states that allow beneficiaries to change Medigap plans without underwriting during a specific period before/after their birthday each year on a GI basis. The states that have this rule are: CA, ID, IL,KY, LA, MD, NV, OK & OR. Each of these states has it’s own specific rules for this.

Important:

Some states allow beneficiaries to change Medigap plans any time or at specific times without undergoing medical underwriting. These states are: CT, NY, MA & ME.

In CT & NY enrollees change Medigap plans anytime of the year without underwriting. Massachusetts offers an annual open enrollment where beneficiaries do not have to go through underwriting. In Maine there is an open enrollment in June where Medicare Supplement enrollees can switch to a similar or lower benefit plan without underwriting.

Anyone applying under GI rights; insurance companies may request documentation (like letters from the former insurer). Keeping all notices and paperwork handy makes the application process smoother.

Medigap Guaranteed Issue Rights are an important part of the Medicare landscape, especially for those navigating transitions. Understanding when and how they apply allows you to help clients make informed choices and avoid gaps in healthcare coverage.

Understanding Medicare Advantage enrollment periods; when to join, switch or leave a plan is crucial to receive necessary healthcare coverage. Although even if you know which plan you want, when you can enroll in a Medicare Advantage plan isn’t always straightforward.

In this post, we break down the Medicare Advantage enrollment periods so beneficiaries do not miss an opportunity to get teh coverage they need.

Medicare Advantage

Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare. In other words, these plans provide coverage for Part A (hosptial) & Part B (medical) expenses. They are offered by private insurance companies that are approved by Medicare. The plans often include extra benefits like vision, dental, hearing, and Part D (prescription drug coverage).

However, individuals can’t just sign up any time they want to. There are specific rules that specific govern when individuals can join or make changes.

Initial Enrollment Period (IEP)

This enrollment period is for those who are either turning 65 or newly eligible for Medicare.

The Initial Enrollment Period is a 7-month window:

• Starts 3 months before the month individuals turn 65
• Includes the birthday month
• Ends 3 months after the birthday month

During this time, individuals can enroll in Original Medicare (Parts A and/or B). They can also choose to enroll in either a Medicare Advantage plan with or without Part D or a Medicare Supplement and a stand-alone Part D plan.

Annual Enrollment Period (AEP)

Medicare’s AEP runs from October 15 through December 7 each year. This enroll,ment period is a time whe anyone enrolled in a Medicare plan should meet with theor Medicare agent and go over their options for the coming year.

During this time, beneficiaries can:

• Switch from Original Medicare to a Medicare Advantage plan
• Switch from one Medicare Advantage plan to another
• Drop a Medicare Advantage plan and return to Original Medicare
• Join, drop, or switch a Part D prescription drug plan

Changes made during AEP take effect January 1 of the following year.

Medicare Advantage Open Enrollment Period (MA OEP)

Each year the MA OEP runs from January 1 through March 31. This enrollment period is available to those already enrolled in a Medicare Advantage plan

During this time, beneficiaries can:

• Switch to a different Medicare Advantage plan
• Drop Medicare Advantage and return to Original Medicare (and optionally join a Part D plan)

Please Note: Medicare beneficiaries cannot join a Medicare Advantage plan for the first time during MA OEP.

Watch a quick YouTube video on Medicare OEP best practices.

Special Enrollment Periods (SEPs)

Medicare SEP are available to beneficiaries who experience specific life events.

Individuals may qualify for an SEP ( Special Enrollment Period) if they:

• Move out of their plan’s service area
• Lose other health coverage (like employer sponsored insurance)
• Qualify for Extra Help or Medicaid
• Live in or move into a nursing home
• Miss a valid election period due to a FEMA declared emergency
• Experience plan contract changes (e.g., plan termination)

The time allowed to use an SEP varies. Therefore, it is important for eligible beneficiaries to act promptly so they don’t miss the enrollment opportunity.

5-Star Special Enrollment Period

If a Medicare Advantage plan earns a 5-star rating from CMS, beneficiaries can switch from their current plan to the 5 star plan from December 8 – November 30 of the following year. Plan enrollees can use this election period only once per calendar year.

This allows plan enrollees to move to a top-rated plan outside of the usual enrollment windows.

When it comes to Medicare Advantage enrollment, timing is important. Missing an enrollment window can mean waiting months for another opprotunity to change coverage. This can leave beneficiaries in a plan that no longer fits their coverage needs.

Each year, Medicare eligible indivduals wonder which type Mediare plan will cover their helath care needs best. Many beneficiareis wonder if they should enroll in a Medicare Supplement or a Medicare Advantage plan. Although both options provide comprehensive coverage, it is important for individuals to consider their needs and budget to make the best choice. In this post, we will go over some ways to decide the best candidates for MAPD Plans.

People Who Want All-in-One Coverage

MAPD plans are good for; anyone who prefers having all their healthcare benefits managed under a single plan. Plan enrollees only need to carry one ID card and pay for Part B and 1 plan premium. Although, some plans do not even charge a premium.

Private insurers offer Medicare Advantage plans (Part C) and bundle together:

• Part A (hospital coverage)
• Part B (medical insurance)
• Often Part D (prescription drug coverage)
• Plus extra perks like vision, dental, hearing, and wellness benefits

Budget-Conscious Individuals

Many MA plans offer low or even $0 monthly premiums. This is in contrast to Medigap plans (used with Original Medicare), which usually have higher premiums.

While enrollees are still responsible for copays and out-of-pocket costs, Medicare Advantage plans have annual out-of-pocket maximums. The maximums provide financial protection Original Medicare alone doesn’t offer. In other words, these plans are a great choice for those on a fixed income trying to cap their annual healthcare costs.

People Who Don’t Travel Often

Because Medicare Advantage plans generally have local provider networks, enrollees must see doctors and hospitals within the plan’s service area for non-emergency care.

These plans are a good choice for individuals who don’t travel often and usually receive care in their local area. MAPDs might not be a good fit for those who live in multiple states throughout the year.

Those Who Value Extra Benefits

Because Medicare Advantage plans usually offer additional benefits beyond what Original Medicare provides, some people prefer them over other options.

Some of the additional benefits (not included in Original Medicare) plans may offer are:

• Dental exams
• Vision exams and an eye wear allowance
• Hearing exams and hearing aid coverage
• Gym memberships
• Transportation to medical appointments
• OTC items
• Healthy food cards

Please note; this list varies by carrier plan type and area. Not all benefits are included in every plan.

Comfortable with Managed Care

Many Medicare Advantage plans involve managed care structures, like HMOs or PPOs, that coordinate your services and may require referrals or prior authorizations.

People who are comfortable navigating provider networks, or calling their plan for care coordination support may find these plans are a good option.

Those in Good Health

Because MA plans often come with copays for services, they may be more cost-effective for individuals who don’t expect to need frequent medical treatment. In other words, Medicare Advantage plans may be a good fit for healthy retirees who normally see a doctor a few times a year for annual checkups or minor services.

Best Candidates for MAPD Plans

Choosing the right Medicare plan depends on personal health needs, budget, and lifestyle. A Medicare Advantage plan can offer convenience, cost savings, and extra benefits,, only if it aligns with how much and where helathcare is needed.

Before enrolling, consider:

• Current doctors (are they in the plan’s network?)
• Medications (are they covered?)
• How often you travel
• Comfort level with managed care.

Medicare Advantage plans are not one-size-fits-all, but for the right person, they can be a useful, value-packed healthcare solution.

Agents click here to learn how Connecture and Sunfire can make quoting and enrollment easier

Before switching or enrolling for the first time, be sure to review options carefully. It is important to check each year during Medicare’s Annual Enrollment Period (AEP) for the plan that best suits current health care needs and budget. A licensed Medicare agent can provide options and help find the most suitable coverage option.

Physicians Mutual Preventive Benefits are part of their Medicare Supplement plans designed to enhance Original Medicare by covering additional healthcare expenses. Notably, certain plans include coverage for preventive health care services and may offer access to fitness programs like Silver&Fit.​

Preventive Health Care

Preventive health care is essential for early detection and management of health conditions. Because of this, Physicians Mutual provides benefits for preventive services in most of their Medicare Supplement plans, excluding Plan A. These benefits are not subject to high deductibles, ensuring that policyholders can access necessary preventive services without significant out-of-pocket costs.

The Preventive Benefits Rider

This Medicare Supplement portfolio is unique to the market. It offers a Preventive Benefits Rider that not only covers preventive care but adds the Silver & Fit program as well.
This wellness combination is not available from any other insurance carrier.

The rider offers extra benefits for physical exams, health screenings and routine blood work not covered by Orignal Medicare.

The Silver & Fit Program

This program provides useful benefits such as; memberships at one of thousands of participating fitness centers as well as discounts at premium fitness centers. Additionally they provide each member with a choice of one home fitness kit per year and assces to thousands of on-demand workout videos.

Watch our YouTube video for all the details

Silver&Fit Fitness Program

Staying active is vital for overall health, especially for seniors. The Silver&Fit program offers access to a network of fitness centers and resources to help seniors stay fit. While Original Medicare does not cover Silver&Fit, some Medicare Supplement and Medicare Advantage plans include similar programs. Physicians Mutual offers Silver&Fit benefits in specific states, often as part of their preventive benefits rider. Availability and terms can vary, so it’s important to review plan materials or consult with a licensed agent to determine if Silver&Fit is included in your area.

Considerations For Choosing a Plan

When selecting a Medicare Supplement plan with Physicians Mutual, consider the following:

• Plan Availability: Physicians Mutual offers various plans, including Plan A and Plan G. They also offer Innovative Plan G options which feature lower premiums with a deductible for the initial years.
• Preventive Benefits: Confirm whether the plan includes preventive health care services and understand any associated costs or limitations.​
• Fitness Programs: If access to fitness programs like Silver&Fit is important to you, verify the availability within your chosen plan and state.​Medicare Plan Finder
• Discounts: Physicians Mutual may offer discounts for non-tobacco users, automatic bank withdrawals, or household discounts when another adult aged 60 or older resides with you.

For personalized information and to explore plan options that best suit your healthcare needs and lifestyle, consider contacting a licensed Medicare agent.

If you are an agent who woul dlike to offer these plans; click here for online contract and become part of the Crowe team!

On Monday April 7,2025, the Medicare industry received some good news; CMS raises Medicare Advantage Pay. The Centers for Medicare & Medicaid Services (CMS) announced a 5.1% increase in payments to Medicare Advantage plans for the upcoming year, 2026. This number surpasses the initial projections. This adjustment is a response to rising healthcare costs within traditional Medicare, particularly inpatient hospital expenses. ​

Impact on Health Insurers

During the last 2 years, Medicare Advantage insurers have stated the federal payments did not keep up with rising medical costs they incur. They also had issue with CMS‘ stringent quality reviews, payment audits and marketing rules of the previous administration.

The adjusted payment amount provides the Medicare Advantage industry some room to breathe. It gives the Medicare industry hope for a positive interaction with the new administration moving forward.This is the most signifigant boost the payment rate in the last decade. The raise proposed by the last administration was said to be 4.33%.

Following the announcement, major health insurance companies experienced significant stock market gains:

• Humana: Shares rose by 14%.​
• CVS Health: Experienced a 7% increase.​
• Elevance Health: Saw an 8% gain.​
• UnitedHealth Group: Shares climbed by 6%.​

Click here to read how raise affects stock prices

These increases reflect investor optimism regarding the enhanced revenue prospects for insurers offering Medicare Advantage plans.​ Hopefully this upward trend will continue.

Underlying Challenges

Despite the positive market reaction, industry experts caution that the payment increase does not fully address the issue of escalating healthcare costs. Factors such as increased service utilization and wage inflation continue to add stress to the healthcare system. Providers facing inflation issues may find ways to pass additional costs onto employers and retirees if Medicare reimbursements do not cover their costs sufficiently.

There is also the issue of some CMS policies that are unpopular with the carries such as; the revised risk adjustment system. This system may be challenging to insurance carriers with it’s limits on their ability to acccurately code their member’s helath conditions. Possibly resulting in insufficient reimbursements for services.

Watch a quick YouTube video on the proposed 2026 final rule

Future Outlook

While the payment boost provides some financial relief, the sustainability of Medicare Advantage plans remains uncertain. Insurers may need to adjust supplemental benefits and premiums to align with actual costs. The broader challenge of controlling healthcare expenses persists, necessitating ongoing policy adjustments and industry strategies.​

Unfortunately, as people age, the risk for chronic conditions like heart disease, diabetes, and cancer increases. Although with the right preventive measures in place, many of these conditions can be delayed, managed effectively, or even avoided. That is why we will go over the importance of preventative services for Medicare beneficiaries.

Preventive Healthcare

The objective of Preventive healthcare is to maintain wellness and discover health issues before they become serious. It includes regular checkups, screenings, immunizations, counseling, and lifestyle intervention. These services are all designed to detect potential health problems early or prevent them from happening.

Why Preventative Service for Medicare Beneficiaries Matters

Early Detection

Some serious conditions, such as colorectal cancer or high blood pressure, may not show symptoms until they’ve progressed. That is why routine screenings are important. They can catch these conidtions early, when they’re easier to treat. This helps the beneficiary have a better qualityof life and save money on treatments.

Managing Chronic Conditions

Due to the fact that, over two-thirds of Medicare beneficiaries suffer from multiple chronic conditions, preventative care is essential. Preventive care helps manage these illnesses more effectively, avoiding emergency visits, hospitalizations, and complications. Annual wellness visits give beneficiaries an opportunity to review medications, coordinate care, and update personalized prevention plans.

Immunizations

Keep in mind; Flu shots, shingles vaccines, and COVID-19 boosters can be life-saving for older adults whose immune systems may not be as strong as younger individuals. Medicare Part B covers many of these vaccines. Staying up-to-date with immunizations can help prevent avoidable illness and hospital stays.

Mental and Cognitive Health

Preventive care also includes screenings for depression and cognitive impairment that are critical as people age. These services allow early interventions that can improve quality of life and help individuals maintain independence.

Health Education and Lifestyle Support

Through programs like smoking cessation counseling and diabetes self-management training, Medicare supports healthier living. Lifestyle changes such as, eating healthier foods, excercising or quitting smoking can dramatically reduce the risk of future health problems.

Overcoming Barriers to Access

Despite the clear benefits, many beneficiaries don’t fully utilize preventive services. Reasons include lack of awareness, confusion about coverage, transportation challenges, or simply not knowing what’s available to them. That’s why education and outreach; especially from healthcare providers, caregivers, and community organization are so crucial.

In the event a client wants to have better coverage for an illness, agents should understand the benefitof ancillary products to avoid gaps in coverage.

Agents: Watch a quick YouTube video on why and how to sell ancillary products

Preventive healthcare isn’t just about avoiding illness. It’s about living better, longer, and keeping your independence. For Medicare beneficiaries, taking advantage of all the preventive services Mediare covers is one of the smartest health decisions they can make.