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To answer the question; what is the Medicare GEP; The Medicare GEP is an opportunity for individuals who missed their initial chance to sign up for Medicare Part A and/or Part B to enroll. It runs from January 1 to March 31 each year. This allows eligible individuals to enroll in Medicare coverage, though late penalties may apply.

Who needs the GEP

The GEP is for individuals who did not sign up for Medicare during their IEP (Initial Enrollment Period) and do not qualify for an SEP (Special Enrollment Period).

When does coverage begin

As of 2023, individuals who enroll in Medicare during the GEP will have their coverage begin the month after they enroll. Prior to 2023, coverage did not begin until July 1, which led to significant delays in accessing benefits.

Late enrollment penalties

Individuals who sign up during the GEP may have to pay an LEP (late enrollment penalty). This can increase monthly Medicare costs:

Part A penalty

For those who must pay a premium for Part A, the monthly premium could increase by 10%. This will be in place for twice the number of years they were eligible but didn’t sign up.

Part B Penalty

The monthly Part B premium will increase by 10% for each full 12-month period the beneficiary was eligible but didn’t enroll. This penalty is permanent and remains in place for as long as they have Part B.

Medicare Advantage, Part D and Supplement enrollment

If an individual enrolls in Medicare during the GEP, they can sign up for a Medicare Advantage (Part C) or a Medicare Part D prescription drug plan at this time. Coverage for these plans begins on the month following the enrollment. Although late enrollment in Part D or Medicare Advantage plans that include prescription drug coverage may include a lifelong penalty.

Medicare supplements can be a little more difficult to get after the individual’s Medigap open enrollment has passed. When this is the case, some states require enrollees to undergo underwriting which can lead to denial or higher premiums.

Avoiding the need for the GEP

Beneficiaries can avoid using the GEP (General Enrollment Period) and getting potential LEPs:

Sign up for Medicare during the Initial Enrollment Period, which starts three months before the 65th birthday and ends three months after.

Those who have employer-sponsored coverage should confirm whether they qualify for a Special Enrollment Period (SEP) when that coverage ends. If they do, be sure to enroll before the SEP ends.

The Medicare GEP is an important opportunity for those who miss their initial chance to enroll in Medicare. However, because of potential late penalties and delays in coverage, it’s best to sign up during the Initial Enrollment Period or a Special Enrollment Period when possible. Understanding enrollment deadlines helps ensure that beneficiaries get the healthcare coverage they need and avoid unnecessary costs.

If you’re a Medicare agent, you may receive calls from clients asking if Medicare covers their annual checkup. Most likely, your answer will confuse them. Many do not understand the difference between Medicare wellness visits vs checkups. Some people use these terms interchangeably. However, these are actually two different types of appointments. Understanding the distinction can help beneficiaries make the most of their Medicare benefits.

What is an annual wellness visit

An annual wellness visit is a preventive service that Medicare Part B covers. This visit helps beneficiaries and their providers create or update a personalized prevention plan based on current health and risk factors.

During this visit, the doctor reviews the beneficiary’s medical history, medications, height, weight, and blood pressure. They also assess cognitive function and risk factors for conditions like dementia. The beneficiary receives personalized health advice and screenings. The doctor and beneficiary may use this visit to discuss advance care planning and develop or update a prevention plan.

Medicare covers 100% of the cost for an annual wellness visit. In other words, there is no copay or deductible if your provider accepts Medicare assignment.

What is an annual checkup

An Annual Checkup (Routine Physical Exam) is a comprehensive medical evaluation that goes beyond the preventive focus of an annual wellness visit. Unlike the annual wellness visit, Medicare does not cover routine physicals. Those who request an annual checkup, may pay out of pocket unless they have insurance that covers it. During an annual checkup, the doctor may perform a physical exam, listen to the heart and lungs as well as order lab tests such as blood work. The provider assess overall organ function and diagnose medical issues.

Because an annual checkup involves diagnostic and treatment-related services, Medicare does not cover this visit unless it is used to address health concerns under medical necessity.

Why this matters for Medicare beneficiaries

Many Medicare beneficiaries schedule an “annual physical” expecting it to be fully covered, only to find out later that Medicare does not pay for it.

In order to avoid unexpected costs; beneficiaries who want a preventive visit covered by Medicare should ask for an “annual wellness visit.”

Click here to learn more about Medicare annual wellness visits

Anyone who needs a full physical exam including diagnostic tests, or lab work should check on the potential costs.

Understanding the difference between these visits ensures beneficiaries receive needed care and helps them avoid unexpected medical bills.

Before an agent can contact a potential client, they must be aware of the Medicare permission to contact rules. CMS puts these rules in place to protect Medicare beneficiaries.

Permission to Contact

Before we go over the permission to contact rules, we will explain what PTC (permission to contact) is. The PYTC guidelines were put in place to protect Medicare beneficiaries from receiving unsolicited communications and high pressure sales tactics. Any agent who wants to contact a potential client must follow all CMS marketing and communications guidelines.

For an agent to receive permission to contact in a complaint way, the potential client must initiate contact. In other words, the potential client must grant permission for the agent to contact them before the agent can do so.

Please note; agents do not need a PTC to contact their current Medicare clients.

Watch a YouTube video on Medicare marketing rules

Click here for a quick updated one-to-one consent rule video

When you need PTC

When an agent wants to speak with a potential Medicare client, they must have PTC. This is important especially if you plan to discuss either Medicare Advantage or PDP plans. Keep in mind; if you discuss Medicare Supplement plans, you will probably discuss PDP plans as well.  Even though CMS rules do not apply to Medicare Supplements, the TCPA guidelines do apply. That is why, it is important to get PTC whenever you plan to contact a potential client for any sales meeting.

Please note; you do not need a PTC to send out unsolicited emails to potential clients. All emails must contain an option to opt-out and the email must not contain information that would classify it as marketing material. That is anything with specific benefits or plan information that could sway a potential client towards a specific plan choice. All email communications must follow the CAN SPAM Act laws.

How to collect a Medicare Permission to contact

What you can do:

1. Always keep business cards with your contact information available for events you attend or just in case a potential client needs one. That makes it easy for people to contact you. Additionally; current clients may want a couple cards to give friends or family if they need an agent.
2. If you have a website, make sure there is a contact form on it so clients can request that you contact them.
3. When you send out emails, be sure to include your contact information as well as a contact form if they want more information or assistance.
4. Business reply cards are also a way to obtain PTC. If the prospect wants more information, they just fill out the card and send it back to you.

What you can’t do:

1. Agents are not permitted to go door-to-door looking for clients. If you do not have a scheduled appointment, you cannot go to someone’s home.
2. Do not send a direct message to a prospect through any social media platform.
3. Never cold call prospects to sell either a Medicare Advantage or PDP plan.
4. Do not contact a friend or relative of a current client without their consent. Each person must provide PTC.

After you have the PTC, it is good for up to 12 months. If you have not contacted the prospect within that time frame, you will need another PTC before attempting to contact them.

Permission to Contact and Scope of Appointment differences

Although both the SOA and the PTC serve a similar purposes, there are some important differences. Each protects Medicare beneficiaries from unfair sales practices. You need to have PTC before you contact the prospect and then you can collect a SOA.

The SOA is a form that specifies which healthcare products the beneficiary wants to discuss during their appointment with the agent. Learn more about SOAs.

If you are ready to join the team at Crowe, click here for online contracting

Medicare Part B is an important part of Original Medicare, covering many medical services such as; doctor visits, outpatient care, preventive services, and durable medical equipment. Individuals getting close to Medicare eligibility need to understand how to apply for Medicare Part B. Understanding the enrollment process can help avoid penalties and ensure healthcare coverage is not interrupted.

Who Needs to Enroll in Medicare Part B

Not everyone is automatically enrolled in Part B. Below is a list of the Individuals who need to self-enroll in Part B:

1. Those who are not receiving either Social Security or Railroad Retirement Board (RRB) benefits at least 4 months before they turn 65.
2. Anyone who delayed enrolment because they were enrolled in employer sponsored health coverage.
3. Some disabled individuals that qualify for Medicare need to enroll in Part B.

When can you enroll

1. Initial Enrollment Period (IEP)

This is a seven-month window starting three months before the 65th birthday, including the birthday month, and ending three months after. For those who enroll early, coverage begins the first day of the birth month.

2. Special Enrollment Period (SEP)

Individuals may qualify for a SEP if they delayed Part B due to employer-sponsored coverage. They have eight months from the end of employment or loss of health plan to enroll without penalty.

3. General Enrollment Period (GEP)

Those who miss their IEP and don’t qualify for an SEP can enroll during the GEP. The GEP runs from January 1 to March 31, with coverage starting the first day of the month following the enrollment submission. When this is the case, a late enrollment penalty may apply.

Learn more about Medicare enrollment periods

How to enroll in Part B

Determine Your Enrollment Method

Those who are already receiving Social Security benefits will be automatically enrolled in Part B. When that is not the case, you must apply manually through SSA (Social Security Administration).

There are a few ways to apply for Part B

Online: Visit SSA.gov and complete the online application.
By Phone: Call the Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778).
In-Person: Visit your local Social Security office (appointment recommended).

Step 3: Submit Form CMS-40B

If you’re enrolling due to a Special Enrollment Period, you must complete Form CMS-40B (Application for Enrollment in Medicare Part B) and possibly Form CMS-L564 (Request for Employment Information) to prove employer coverage.

Step 4: Wait for Confirmation

Once your application is processed, you’ll receive a Medicare card with your Part B coverage start date.

Delayed Part B

If you have employer coverage, you can opt out of Part B when first eligible. However, ensure that your employer plan qualifies for delayed enrollment without penalties.

Avoid Late Enrollment Penalties

For every 12-month period you delay enrollment without qualifying coverage, your Part B premium increases by 10%—for life. Enrolling on time prevents unnecessary costs.

Watch a YouTube video on OEP, SEPs & LEPs

Enrolling in Medicare Part B is a straightforward process, but timing is key to avoiding penalties and ensuring seamless healthcare access. If you’re unsure about your eligibility or enrollment timeline, consult the Social Security Administration or a Medicare advisor for guidance.

Medicare Supplements, also called Medigap plans, are insurance policies private insurance companies offer to fill the “gaps” after Original Medicare pays it’s portion of approved medical expenses. Understanding what Medicare Supplements cover is essential for Medicare agents and anyone considering enrollment in a Medigap plan to reduce healthcare costs and enhance Medicare benefits.

Medicare Supplement plan overview

Medicare Supplement plans are standardized by the federal government, meaning the coverage provided by each plan of the same name (Ex. all Plan Ns) is the same across all insurance carriers. However, premiums vary based on provider and service area. There are 10 standard Medigap plans available in many states, labeled A, B, C, D, F, G, K, L, M, and N. Each plan letter provides a different level of coverage to meet varying healthcare needs and budgets.

Learn about Medicare premiums & deductibles

What Medicare Supplements cover

Medicare Supplement plans provide coverage once Original Medicare pays its portion of the cost for approved healthcare costs. See below for what Medicare supplements cover:

Medicare Part A coinsurance for hospital costs

All Medigap plans cover the coinsurance for hospital costs under Medicare Part A for up to an additional 365 days after Medicare benefits are exhausted.

Medicare Part B Coinsurance or Copays

Many Medigap plans cover the 20% coinsurance for outpatient services under Medicare Part B. Plan K and Plan L provide partial coverage, while Plan N may require a small copay.

Blood (First 3 Pints)

Original Medicare does not cover the first three pints of blood needed for some medical procedures. Medigap plans cover this expense.

Part A Hospice Care Coinsurance

Hospice care is covered by Medicare, but beneficiaries may have to pay coinsurance for certain medications and respite care. Medigap plans cover these costs.

Skilled Nursing Facility (SNF) Coinsurance

After 20 days in a skilled nursing facility, Medicare requires a daily coinsurance payment. Most Medigap plans cover this expense.

Medicare Part A Deductible

The Part A deductible for hospital stays can be substantial. Many Medigap plans, including Plans B, C, D, F, G, and N, cover this deductible.

Medicare Part B Deductible (Only for Plans C and F)

Plans C and F cover the Medicare Part B deductible; however, these plans are only available to beneficiaries who were eligible for Medicare before January 1, 2020.

Medicare Part B Excess Charges

If a healthcare provider does not accept Medicare’s approved amount as full payment, they may charge an additional amount of up to 15%. Plans F and G cover these excess charges.

Foreign Travel Emergency Care

Some Medigap plans (C, D, F, G, M, and N) provide coverage for emergency medical care during international travel, up to plan limits.

What Medicare Supplements don’t cover

Although Medigap plans cover many out-of-pocket expenses, there are some services they do not cover:

Prescription Drugs

Medigap plans do not include drug coverage. Beneficiaries must enroll in a Medicare Part D plan for prescription drugs.

Long-Term Care

Supplements do not cover services like custodial care in a nursing home or assisted living facility.

Dental, Vision, and Hearing

Routine dental, vision, and hearing services are not included in Medigap coverage.

Private-Duty Nursing

Typically, these services are not covered.

Watch a YouTube video on Medicare enrollment periods

What to consider when choosing a supplement

It is important to evaluate current healthcare needs and potential medical expenses to help determine the level of coverage needed. Budget is another big consideration before choosing a plan. One more important factor before enrollment is eligibility. Some plans require underwriting for anyone who is outside a guaranteed issue period. There are plans (C & F) that are no longer available to anyone who turned 65 after Jan 1, 2020.

Medicare Supplements provide invaluable financial protection by covering the out-of-pocket expenses left by Original Medicare. By understanding what these plans cover and how they work, you can make an informed decision that ensures peace of mind and comprehensive healthcare coverage. For those considering enrollment in a Medigap plan, a licensed Medicare agent can help provide guidance and compare options to find the plan that best meets coverage needs.

There are a some important things to think about for those on Medicare and working past 65. This can be a tricky question to answer. Do you need Medicare Part A or Part B?  Will you have a penalty for taking them later?  What counts as a valid reason not to take Medicare?  Read below for the details.

Medicare Part A

We will keep Medicare Part A brief as it is free to most people as long as they have worked and paid Medicare taxes for a period of 40 quarters (10 years). In other words, why would you not sign up for it; it is free and can be sued in addition to employer coverage. You can sign up for premium free Part A up tp 3 months before turning 65 or any time after you turn 65.

Those who do not qualify for premium free Part A will follow similar rules as enrollment into Part B. Please read below to learn more:

Do you need part B if you are still working

Many people need to enroll in Medicare Part B when they turn 65.  Although there are some exceptions. One of the most common exceptions is for individuals working past 65. Because Part B is not free to most people, there are a few things to consider when making this decision:

Those who are working or have a working spouse and getting coverage through their employer can delay Part B enrollment in most cases.  The key is that the individual must be working and getting coverage.  Both must be happening in order delay enrolling in part B.

Receiving coverage through an actively working spouse is also a valid reason not to enroll in Medicare Part B. 

The number of employees matters

Additionally, the employer must have 20 or more employees.  In either situation above, the person must be receiving coverage through an employer of 20 or more employees.  If the employer has less than 20, Part B of Medicare should be elected at age 65.

The 20 or more employees has always been the rule. although in the past, it was rarely enforced. As a result, people working with coverage through an employer of less than 20 often waived part B without issue.  In the last few years, this rule has been enforced. This can lead to the denial of medical claims.

Click here to sign up for Medicare online

Working past 65 with Medicare: Cobra and other mistakes

It is very common for people to think they do not need to enroll in Medicare Part B if they have COBRA.  COBRA is not a valid waiver for delaying Part B enrollment.  Keep in mind, either the individual or their spouse must be working as well as getting employer coverage.  People with COBRA are not actively working.

Getting coverage through an employer without actively work for them is also an issue.  Those who work and have coverage or coverage through a working spouse, must be covered through their current employer.  For example, if John is working and loses his job and enrolls in COBRA and then immediately gets a job somewhere else.  Although he is actively working and has coverage, it is not through the employer he is currently working for.

VA coverage

VA coverage is a waiver for Medicare Part D.  It is not a waiver for Medicare B.  The standard rules apply for those with VA coverage.

What happens if someone neglects to enroll in Part A and or Part B

Those who do not enroll in Medicare when they should are likely to pay a penalty. The penalty is 10% of the Medicare Part A or Part B premium for each year they didn’t sign up and did not have creditable coverage (through employment).

Watch a YouTube video on Medicare enrollment periods to learn more

Those who lose coverage due to retirement or a loss of group coverage qualify for an SEP. The special election period for Medicare runs 8 months from the date individuals either retire or lose group coverage. 

Individuals who miss their IEP and SEP for either Part A and or Part B have to wait for the Medicare general election period .  This enrollment period runs from January 1 through March 31 each year. Medicare benefits begin the month following the month of enrollment.

Why Switch from Medicare Supplement Plan F to Plan G

There are some good reasons to switch from Plan F to Plan G. We will compare Medicare supplement Plan F vs Plan G to help illustrate. For years, Medicare Supplement Plan F has been a popular choice for beneficiaries seeking comprehensive coverage. However, recent changes and market trends have led many to consider switching from Plan F to Plan G. While both plans offer great benefits, Plan G provides similar coverage at a lower premium cost.

Key Similarities Between Plan F and Plan G

Both Plan F and Plan G are Medigap plans designed to fill the gaps in Original Medicare (Part A and Part B). Both plans offer comprehensive coverage, including:

1. Medicare Part A deductible
2. Medicare Part A coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are exhausted)
3. Medicare Part B coinsurance or copayments
4. Part B excess charges (the amount a provider can charge above Medicare’s approved amount)
5. The first three pints of blood
6. Skilled nursing facility (SNF) care coinsurance
7. Foreign travel emergency coverage (80% up to plan limits)

The only difference is that Plan F covers the Medicare Part B deductible, while Plan G does not.

Why Switch to Plan G

Plan F Is No Longer Available to New Beneficiaries

As of January 1, 2020, Plan F is no longer available to individuals who became eligible for Medicare after that date. This change, part of the Medicare Access and CHIP Reauthorization Act (MACRA), was implemented to reduce overall healthcare costs.

Due to the fact that Plan F is closed to enrollees who turn 65 after Jan, 1, 2020, its risk pool is aging. This can lead to higher premiums over time as the pool becomes more expensive to insure.

Lower Premiums

Plan G often has significantly lower monthly premiums than Plan F does. While Plan G requires beneficiaries to pay the Medicare Part B deductible out-of-pocket ($257 for 2025), the savings in premiums can more than make up for this cost.

For example, if Plan F costs $50 more per month than Plan G, you’d save $600 each year by switching to Plan G. The savings would easily offset the $257 deductible.

Similar Comprehensive Coverage

Aside from the Part B deductible, Plan G provides identical coverage to Plan F. After meeting the deductible, Plan G covers all Medicare-approved expenses just like Plan F does.

Premium Stability

Because Plan G is open to new enrollees, its risk pool is younger and more diverse compared to Plan F. This dynamic helps keep premiums more stable over time.

In contrast, Plan F’s closed risk pool may lead to disproportionately higher premium increases as it’s enrollee population ages.

Making the switch sooner rather than later ensures you can take advantage of Plan G’s cost savings without disruption to your coverage.

Things to consider

Health Underwriting

Beneficiaries outside their initial enrollment period or guaranteed-issue period, may need to go through medical underwriting to switch plans. This means, insurers evaluate health status and may deny coverage or charge higher premiums based on pre-existing conditions.

Evaluate Your Healthcare Needs and budget

All potential enrollees should carefully calculate out-of-pocket costs, including the Part B deductible, to ensure Plan G is a cost-effective choice.

Enlist the help of a licensed agent

Because navigating Medigap plan changes can be complex, a licensed Medicare agent can help compare premiums, evaluate options, and explain the implications of switching plans. Agents can help submit the application to ensure it is done correctly as well as advise clients when to cancel their current coverage.

It is very important to confirm eligibility to enroll in or change plans and be aware if underwriting will apply.

Learn about Medicare enrollment periods – watch a quick YouTube video

More thoughts on Plan G

Switching from Medicare Supplement Plan F to Plan G is a practical choice for many beneficiaries seeking to reduce their healthcare costs without sacrificing coverage. With lower premiums, stable pricing, and nearly identical benefits, Plan G offers exceptional value especially for those who don’t mind paying the Part B deductible.

Those considering the switch should consult a licensed Medicare agent to ensure a seamless transition and take advantage of the savings and benefits Plan G has to offer. Making an informed decision now can lead to significant cost savings and peace of mind in the years to come.

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The Next 15 Drugs for Medicare Price Negotiations

In a landmark move aimed at reducing prescription drug costs, HHS has announced the new drugs for price negotiations. The list contains 15 drugs. This initiative, part of the Inflation Reduction Act (IRA), represents another step toward making life-saving medications more affordable for millions of Medicare beneficiaries.

What started the Medicare drug price negotiations

In the past, Medicare was prohibited from negotiating drug prices directly with pharmaceutical companies. However, in 2022 the IRA was signed into law and Medicare gained the authority to negotiate prices for some specific high-cost drugs covered by Medicare Part B and Part D. The object of this program is to lower out-of-pocket medication costs for beneficiaries and reduce healthcare spending.

The list of drugs for the second cycle of negotiations:

1. Ozempic, Rybelsus, Wegovy
2. Trelegy Ellipta
3. Xtandi
4. Pomalyst
5. Ibrance
6. Ofev
7. Linzess
8. Calquence
9. Austedo, Austedo XR
10. Breo Ellipta
11. Tradjenta
12. Xifaxan
13. Vraylar
14. Janumet, Janumet XR
15. Otezla

More about the negotiations

The second cycle of the price negotiations allow drug companies with a selected drug until February 28, 2025 to make the decision weather or not to participate. CMS will consider the clinical benefits of the selected drug. It will also take into consideration how it meets medical needs as well as it’s impact on specific populations. CMS also considers the manufacturers’ Costs for research, development, production and distribution.

The first 10 drugs  

The first 10 drugs chosen for negotiations were announced by the Dept. of HHS in August 2023. During the first cycle of negotiations, Medicare reached an agreement with the drug manufacturers on all 10 of the drugs. The new lower prices for those drugs is due to go into effect as of January 1, 2026.

The negotiated rates for the first 10 drugs will be between 38 to 79 % less than their current list prices. In 2026, could save Medicare beneficiaries about $1.5 billion in out of pocket costs.

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

Moving forward, CMS plans to choose 15 more drugs in the third cycle of negotiations. After the third cycle, they plan to choose as many as 20 additional drugs for the subsequent cycles.

Take a look at the CMS fact sheet on the drugs chosen for the Drug Price Negotiation Program

For millions of beneficiaries, Medicaid provides a much needed lifeline. This ensures they receive access to essential healthcare services. However, one common question Medicaid beneficiaries have is does Medicaid coverage renew automatically. Although the answer depends on the state and specific circumstances of each enrollee, understanding the Medicaid renewal process helps avoid a lapse in coverage.

Medicaid renewal, also known as redetermination, is the process each state uses to determine if a beneficiary is still eligible for Medicaid benefits. Periodically, each state must verify the beneficiary’s income, household size, and other factors to ensure they still qualify for the program.

Click here to apply for Medicaid in each state

Does Medicaid coverage renew automatically

The short answer is: In some cases, Medicaid renewals are automatic, while others require the beneficiary to provide information to their resident state for renewal.

Automatic (passive) renewal

In many states, if the Medicaid office can verify eligibility through their databases (e.g., tax records, Social Security information, or unemployment benefits), coverage may renew automatically. If this happens, beneficiaries receive a notice in the mail informing them that coverage has been renewed without further action required.

Active Renewals

If eligibility cannot be verified automatically, beneficiaries must complete a renewal form and provide the requested documentation. States may typically send a renewal notice by mail or email depending on the beneficiary’s preferences. The notice includes instructions as well as a deadline to submit the required information.

What Triggers the Need for Renewal

Medicaid renewal usually occurs annually, though the exact timing varies according to when each beneficiary first receives Medicaid. Some reasons for renewal are a change in household size or a change in income. State policies differ and may change and require information for a renewal.

How to prepare for Medicaid renewal

Whether renewal is automatic(passive) or requires action, the following tips can help ensure a smooth process:

Beneficiaries must notify their state Medicaid office immediately if their address, phone number, or email changes. This ensures they receive renewal notices and other important information. They should also watch their mail for important notices and respond quickly. It is also important to keep recent pay stubs, or tax returns as proof of income.

Be aware of the deadline for renewal to respond in a timely manor and avoid a lapse in coverage.

Click here to learn the difference between Medicare and Medicaid

What If the renewal deadline passes

Failing to complete the renewal on time can result in a termination of benefits. However, most states offer a grace period that allows beneficiaries to submit renewal documents and have coverage reinstated retroactively.

Whether renewal is automatic or requires action, keeping your information updated and responding promptly to notices are imperative to maintain benefits.

Additional information

Most states have expanded Medicaid programs that cover anyone with a household income below a specific level.

In each individual state, the Medicaid qualification is based on several factors including income, size of the household, disability or other factors. The specific qualifications vary by state. Some states have expanded Medicaid coverage. When that is the case, Medicaid qualification is based solely on income. Most states accept those with household income less than 133% of the federal poverty level.

It is important to know: every state has a different renewal process for Medicaid beneficiaries. To locate a department of Social services in your area; click here for the department of Social Services.

All Medicare agents and potential clients need to understand the Medicare Advantage OEP 2025 Rules to make the most of this opportunity. The Medicare Advantage (MA) Open Enrollment Period (OEP) is an important time when beneficiaries can reassess their healthcare coverage and make changes that better align with their needs. The MA OEP provides one last opportunity for beneficiaries to make an annual plan change and get the coverage they need. It is essential to understand these rules to make informed decisions.

Medicare Advantage OEP

The Medicare Advantage OEP takes place annually from January 1 through March 31. This is an additional opportunity for individuals currently enrolled in a Medicare Advantage plan to:

1. Switch to another Medicare Advantage plan (with or without prescription drug coverage).
2. Return to Original Medicare and, if they want, enroll in a stand-alone Medicare Part D prescription drug plan.

Important: the OEP is available only to the following individuals:

Rules for the MA OEP

1. One-Time Change Rule: Beneficiaries can make only one change during the OEP. Once a beneficiary makes a change, they cannot revise it during the same period. This underscores the importance of careful consideration before making a decision.
2. No New Enrollments: Unlike the Annual Enrollment Period (AEP), the OEP doesn’t allow individuals to enroll in a Medicare Advantage plan for the first time. It is strictly for those already in an MA plan or transitioning back to Original Medicare.
3. Coverage Start Date: Changes a beneficiary makes during the OEP take effect on the first day of the following month. For example, if the beneficiary changes their plan in March, their coverage begins on April 1.
4. Plan Comparison and Guidance: Beneficiaries should compare plans carefully. Factors such as premiums, provider networks, out-of-pocket costs, and prescription drug coverage can vary significantly among plans.
5. Special Enrollment Periods (SEPs): The OEP is separate from Special Enrollment Periods, which allow beneficiaries to make changes due to specific circumstances, such as moving out of a plan’s service area or losing other health coverage.

Why the OEP is so important

The Medicare Advantage OEP is a critical time for beneficiaries to evaluate weather their current plan meets their healthcare needs and financial situation. In some instances, they may not have been aware of changes in their current health plan and this provides an opportunity to make necessary changes. Other factors such as changes in health, prescription drug coverage, or provider preferences may contribute to the need to switch plans.

Watch a quick YouTube video on MA OEP best practices

Additionally, each plan updates their benefits and costs annually. Those who did not review their plan details during the AEP have one last opportunity during OEP to make a change. This helps ensure that beneficiaries are not caught off guard by changes that impact their access to care or expenses.

Navigating the 2025 OEP

1. Review the annual notice of change (ANOC): Each fall, MA plans send out an ANOC outlining coverage, costs, and provider networks for the upcoming year. Reviewing this document is a great place to start.
2. Consult a licensed Medicare agent: Navigating the complexities of Medicare can be overwhelming. A licensed Medicare agent provides personalized advice and can help identify plans that align with each beneficiaries needs.
3. Don’t Wait Until the Last Minute: Although the MA OEP runs from January 1 through March 31, making changes early will ensure the beneficiary does not make a hasty decision and provides time to address any issues. Additionally, starting a plan early in the year helps avoid paying multiple plan coverage deductibles.

MA OEP Rules for agents

It is important to remember: agents are prohibited from sending marketing materials targeted to the MA OEP.  This is to ensure that agents don’t use the OEP as a specific opportunity to make more sales. 

Agents cannot:

• Send unsolicited marketing materials related to the OEP. 
• Attempt to convince individuals to use the OEP to make changes. This request must be initiated by the beneficiary who is inquiring about alternative coverage options.
• Agents cannot solicit beneficiaries who enrolled in a plan in the most recent AEP . Again, the beneficiary initiates this not the agent.

Agents who are ready to join the team at Crowe – click here for online contracting

Understanding the rules and opportunities of the Medicare Advantage OEP for 2025 allows agents to help beneficiaries make informed decisions about their healthcare coverage.