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

Initial Enrollment Period (IEP)

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

During your IEP, you can enroll in:

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

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

Medicare General Enrollment Period (GEP)

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

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

Medicare Annual Enrollment Period (AEP)

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

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

Click here for strategies for the 2025 AEP

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

Medicare Advantage Open Enrollment Period (MA OEP)

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

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

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

Special Enrollment Periods (SEP)

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

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

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

5-Star Special Enrollment Period

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

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

Key Tips for Navigating Enrollment in 2025

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

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

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

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

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

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

Only applies to Medicare Part D drugs

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

Potential for Premium Increases

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

Does Not Impact Drug Prices Directly

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

Complex Smoothing Mechanism

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

Learn more about Medicare Smoothing

Watch a quick YouTube video on the Medicare prescription payment program

Limited Impact on Brand-Name and Specialty Drugs

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

Variability Across Part D Plans

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

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

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

When a client receives a denial for a Medicare claim, they may be frustrated. It is important to let them know they have options. If Medicare refuses to cover a service or item, or if there is a question about how much Medicare paid, clients need to understand the Medicare claim appeal process.

What Is a Medicare Appeal

A Medicare appeal is a formal request asking Medicare to review and reconsider a coverage or payment decision. You can appeal if:

• Medicare denies coverage for a service or item you think should be covered.
• You disagree with the amount Medicare paid for a service or item.
• Medicare decides to stop services you are currently receiving, like skilled nursing care or home health services.

Types of Medicare Appeals

The appeal process may differ depending on the type of Medicare you have. Here’s a breakdown:

1. Original Medicare (Part A and Part B) Appeals
2. Medicare Advantage (Part C) Appeals
3. Medicare Prescription Drug Plan (Part D) Appeals

Each type follows a specific set of rules, but the general steps remain similar across all parts.

Review the Medicare Summary Notice (MSN) or Explanation of Benefits (EOB)

Before beginning your appeal, review your Medicare Summary Notice (MSN) if you have Original Medicare or the Explanation of Benefits (EOB) if you have a Medicare Advantage or Part D plan. This document outlines what services Medicare paid for and what it denied. It will also tell you why the service was denied, which is critical information for your appeal.

Understand Your Appeal Rights

It’s important to understand your rights. Medicare guarantees that you can appeal their decisions, and there are five levels of appeals you can go through:

1. Redetermination by Medicare contractor
2. Reconsideration by a Qualified Independent Contractor (QIC)
3. Hearing before an Administrative Law Judge (ALJ)
4. Review by the Medicare Appeals Council
5. Judicial review in Federal District Court

You don’t have to go through all five levels, but it’s good to know that you have multiple opportunities to present your case if needed.

Filing a Level 1 Appeal

The first step in the appeal process is filing a request for redetermination. Here’s how to do it:

1. Fill Out the Medicare Redetermination Request Form (Form CMS-20027): You can download this form online, or you can write a letter that includes your name, Medicare number, the specific service or item you’re appealing, and the reason you disagree with the decision.
2. Attach Supporting Documents: Include any documents that support your claim. This might include doctor’s notes, medical records, or a letter from your provider explaining why the service is necessary.
3. Send Your Appeal: The address for sending your appeal is on your MSN or EOB. You must submit your request within 120 days of the date on your MSN or EOB.

Waiting for a Response

Medicare contractors are required to respond to your appeal within 60 days. If they approve your appeal, Medicare will cover the service or pay the amount you requested. If your appeal is denied, you can proceed to the next level.

Level 2 Appeal – Reconsideration by a Qualified Independent Contractor (QIC)

If your redetermination is denied, you can request a reconsideration from a Qualified Independent Contractor (QIC). This must be done within 180 days of receiving the redetermination notice.

1. File a Request for Reconsideration (Form CMS-20033): Similar to the first appeal, you can download this form or write a letter. Clearly state why you believe the initial decision was wrong and include any additional documentation to support your claim.
2. Send the Request to the QIC: The address is included in the denial notice from your redetermination.

The QIC must respond to your request within 60 days. If they uphold the denial, you can proceed to the next level.

Level 3 Appeal – Administrative Law Judge (ALJ) Hearing

If your reconsideration request is denied, you can appeal to an Administrative Law Judge (ALJ). This option is available if the amount in question meets a minimum threshold (in 2025, this amount is approximately $180).

1. Request a Hearing: You can request a hearing within 60 days of receiving the QIC decision. You can also request to participate in person, by video conference, or by phone.
2. Prepare for Your Hearing: This is your chance to present your case directly to an impartial judge. You may wish to have an attorney or advocate to help represent your interests.

The ALJ will issue a decision within 90 days of your hearing request.

Level 4 Appeal – Medicare Appeals Council Review

If the ALJ denies your appeal, you can request a review by the Medicare Appeals Council. This must be done within 60 days of receiving the ALJ’s decision. The Appeals Council can either make a decision or send your case back to the ALJ for another review.

Level 5 Appeal – Federal District Court

The final level of appeal is a judicial review in Federal District Court. This is typically reserved for cases where a significant amount of money is at stake (in 2025, the threshold is approximately $1,850). You must file your case within 60 days of the Appeals Council decision.

Tips for a Successful Appeal

1. File Your Appeal On Time: Always pay attention to deadlines to avoid missing your opportunity to appeal.
2. Provide Detailed Information: Include all relevant documents, medical records, and a clear explanation of why you disagree with the decision.
3. Get Help If You Need It: You have the right to get help from a Medicare advocate or attorney. You can also contact your State Health Insurance Assistance Program (SHIP) for free assistance.

Click here to join the team of licensed Medicare agents at Crowe and Associates

Filing a Medicare claim appeal may seem daunting, but understanding the steps can make the process more manageable. Whether you’re challenging a coverage denial or disputing the amount paid, following these guidelines can help you navigate the appeal process more effectively.

It is important to remember to always keep copies of all documents and correspondence, and don’t hesitate to seek assistance if you need it.

Medicare scope of appointment rules

The Medicare SOA rules 2025 are put in place by CMS.  The SOA (scope of appointment) is a form clients/potential clients as well as agents must complete before meeting to discuss Medicare plans. The SOA is mandatory when discussing either Medicare Advantage or PDP plans. It is always a good idea to collect a SOA before client meetings to protect both agents and clients.

Watch a quick video on the scope of appointment rules for 2024

Verbal scope of appointment

During the pandemic, agents did not host in-person meetings to discuss coverage options.  At that time, many appointments took place over the phone.  That led to the use of recorded, verbal SOAs. 

Watch a video on Connecture & Sunfire updates for 2025

Both Connecture and Sunfire offer easy ways to collect client intake forms and include SOAs.

View the RetireFlo intake demo for Connecture 

Take a look at the BlazeSync intake form on Sunfire

SOA information

• If the client calls the agent (inbound call), the 48-hour rule does not apply.
• The scope is good for 12 months from the date it is signed.  You must complete the appointment within that time or obtain a new scope. The scope is still good if the call drops and the same agent calls the client back.
• If additional benefits are added to the discussion, a new scope is necessary.

How long is an SOA good

A scope of appointment is good for 12 months from the signature date. During the appointment, it is important to discuss only products that were agreed to and included in the scope.  If additional products are added, the beneficiary needs to sign a new scope.

If the client needs to sign a new SOA,  this restarts the 48-hour waiting period and may move your meeting date further out.  This rule applies to any product regulated by CMS.

Click here for a generic SOA

CMS guidelines

In order to be complaint with CMS, agents need to have their clients complete a SOA form. The CMS final rule went into effect September 30. 2023 and added changes to how agents collect an SOA.

The SOA rules apply to agents and brokers who discuss Medicare coverage options and plans.  The 48-hour rule was put in place so beneficiaries could avoid the high-pressure sales tactics some agents use.  The 48-hour period provides beneficiaries time to consult friends, relatives or anyone they like to research their options. This time also provides agents time to prepare for the discussion.

Agents are able to contact the beneficiary once the SOA is completed for up to 12 months. It is essentially permission to contact until the meeting takes place.  The beneficiary has the option to opt out annually.

Please note, if the beneficiary does not select a coverage option on the SOA, Medicare requires the agent to avoid discussing that option without a new SOA where the option is clearly selected.

Exceptions to the 48-hour rule

If the beneficiary is in the last four days of a valid election period, agents may collect a same-day SOA.

When the beneficiary walks into your office and initiates a conversation about coverage options, agents can take a same-day SOA.  This same rule applies to inbound call initiated by the beneficiary to the agent requesting advice.

How long do you need to keep a SOA

Agents must be able to access the SOA form for ten years. Clients have the right to request a copy anytime within that time frame without any issues.  The SOA can provide help in the event that an issue or dispute occurs.  The Scope is in place to protect the consumer, but it can also protect the agent.

What qualifies as preventative under Medicare and how do you ensure you take full advantage of these benefits? Because preventive care is an essential part of staying healthy and managing potential health risks before they become serious, Medicare recognizes the importance of preventive care and offers a range of services to help beneficiaries maintain their health.

What Is Preventive Care

Preventive care refers to medical services that aim to prevent illness, detect conditions early, or promote overall good health. These services can include screenings, vaccines, counseling, and much more. By focusing on prevention, Medicare helps beneficiaries proactively manage their health and reduce the need for more costly treatments in the future.

Click here to download a copy of a comprehensive list or covered preventative services

Medicare Coverage for Preventive Services

Medicare provides a wide array of preventive services under Part B (Medical Insurance). Many of these services are available to beneficiaries at no cost. These services may help detect health problems early when treatment is sometimes more effective and less expensive.

Some common types of preventive care Medicare covers:

Wellness Visits

Within the first 12 months a beneficiary enrolls in Medicare Part B, they are entitled to a “Welcome to Medicare” preventive visit. This one-time visit includes a review of your medical and family history, as well as basic measurements like height, weight, and blood pressure.

After your initial visit, Medicare covers an annual wellness visit each year. This can help create or update a personalized prevention plan. This plan can help beneficiaries stay on top of their health by identifying risk factors and setting health goals.

Vaccinations and Immunizations

Medicare covers vaccines that help prevent serious illnesses, including:

1. Flu Shot (Influenza): Covered once per flu season, typically every fall or winter.

2. Pneumococcal Vaccines: Medicare covers two different pneumococcal shots. The initial shot as well as a second shot a year later if appropriate.

3. Hepatitis B Vaccine: Available to those at medium or high risk for Hepatitis B.

4. COVID-19 Vaccines and Boosters: Medicare covers COVID-19 vaccines and booster shots as recommended by health authorities.

5. The Shingles Vaccine: This vaccine is administered in two doses. The second dose is given two to six months after the first. Medicare covers the cost of both doses.

Read more about Medicare coverage of vaccines

Screenings and Tests

Medicare offers a variety of preventive screenings and tests to help detect health issues early, including:

1. Mammograms: Medicare covers mammograms for the purpose of screening once every 12 months for women aged 40 and older. Medicare may also cover diagnostic mammograms if medically necessary.

2. Colon Cancer Screenings: Medicare covers multiple types of colon cancer screenings, including fecal occult blood tests, multi-target stool DNA tests (like Cologuard), flexible sigmoidoscopy, and colonoscopy. The frequency of these tests depends on the specific test and risk factors.

3. Bone Density Tests: Covered once every two years (or more often if medically necessary) for individuals at risk for osteoporosis.

4. Diabetes Screenings: Medicare covers up to two diabetes screenings per year for individuals at risk. This includes those with a history of high blood pressure, high cholesterol, obesity, or a family history of diabetes.

5. Cardiovascular Screenings: Medicare covers a screening blood test every five years to check for conditions like high cholesterol and triglyceride levels.

Cancer Screenings

Because early detection of cancer can lead to better treatment outcomes. Medicare covers:

1. Cervical and Vaginal Cancer Screenings: Medicare covers pap tests and pelvic exams are once every two years, or every year for women at high risk

2. Prostate Cancer Screenings: Annual prostate-specific antigen (PSA) tests and digital rectal exams for men aged 50 and older.

3. Lung Cancer Screenings: Low-dose CT scans are covered annually for individuals at high risk, particularly heavy smokers or those who have quit smoking within the past 15 years.

Cardiovascular Health

Medicare covers several services to help maintain cardiovascular health, including:

1.Cardiovascular Behavioral Therapy: This includes counseling on diet and exercise to help reduce the risk of heart disease.

2. Blood Pressure Screenings: These are typically part of your annual wellness visit.

Diabetes Prevention Program

The Medicare Diabetes Prevention Program offers lifestyle coaching and resources to help beneficiaries at risk for diabetes prevent the onset of the disease. The program is designed to encourage weight loss, healthy eating, and regular physical activity.

Mental Health and Wellness

Medicare also covers preventive services aimed at mental health, including:

1. Depression Screenings: Medicare includes an annual screening for depression as part of the yearly wellness visit.

2. Alcohol Misuse Counseling: Medicare covers counseling for beneficiaries who are screened and found to have alcohol misuse issues.

3. Smoking Cessation Programs: Medicare covers up to eight counseling sessions per year to help beneficiaries quit smoking.

Obesity Screening and Counseling

For individuals with a body mass index (BMI) of 30 or higher, Medicare covers counseling sessions to help promote weight loss and healthy living. This coverage includes regular face-to-face meetings with a healthcare provider.

Screenings for Infectious Diseases

Medicare also offers coverage for screenings to detect infectious diseases, including:

1. HIV Screenings: Covered once every 12 months, or more frequently for individuals at higher risk.

2. Hepatitis C Screenings: Covered once if born between 1945 and 1965, or annually for those at high risk.

3. Sexually Transmitted Infections (STIs): Medicare covers both screenings and counseling sessions annually for individuals at risk.

Make the Most of Medicare Preventive Services

1. Schedule an annual wellness visit: This visit is a great opportunity to discuss overall health and get a personalized prevention plan. It’s also a good time to make sure you’re up to date on all the preventive services you’re eligible for.
2. Know What Medicare Covers: Familiarize yourself with the list of preventive services Medicare covers and discuss these options with your healthcare provider. They can help determine which screenings and vaccines are appropriate for you.
3. Keep Track of When You’re Eligible: Medicare covers some services once a year or every few years. Make a note of when you’re eligible for your next screening or vaccination.

Preventive care is an important part of Medicare coverage and can help you stay healthier, detect potential problems early, and avoid costly treatments. Whether it’s a simple flu shot, a cancer screening, or an annual wellness visit, Medicare makes it easy for beneficiaries to access a wide range of preventive services. Understanding what’s covered and taking advantage of these benefits can play a key role in maintaining health and well-being.

If you need help choosing a Medicare plan, click here to learn why you should use a licensed Medicare agent

When it comes to Medicare Advantage plans, HMOs (Health Maintenance Organizations) are a popular option. Many Medicare carriers offer HMOs as a coverage option. They offer comprehensive healthcare coverage and focus on coordination and preventive care, however they come with advantages and limitations. Before suggesting enrollment in an HMO plan, it’s important for beneficiaries to understand Medicare HMOs Pros and cons. There are both benefits and drawbacks for those enrolling in a Medicare HMO plan.

What is an HMO

A Medicare HMO is a kind of Medicare Advantage plan (Part C). It provides coverage through a specific network of doctors, hospitals, and healthcare providers. Plan enrollees generally must receive care from in-network providers, except in emergency situations. Medicare HMOs typically include coverage for:

• Medicare Part A (hospital insurance)
• Medicare Part B (medical insurance)
• Medicare Part D (prescription drug coverage), if included in the plan
• Many plans include additional benefits such as dental, vision, hearing, fitness programs and OTC benefits.

Now let’s take a closer look at the pros and cons of Medicare HMOs.

Medicare HMO Pros

Lower Out-of-Pocket Costs

In some cases, Medicare HMOs have lower monthly premiums and out-of-pocket costs compared to Original Medicare (Parts A & B) or other types of Medicare Advantage plans, like PPOs.

Medicare HMO plans also set a maximum limit on out-of-pocket spending for covered services. Once you reach this limit, the plan covers 100% of the costs for covered services for the remainder of the year.

Comprehensive Coverage

Medicare HMOs often include benefits beyond what Original Medicare offers, such as dental, vision, hearing, fitness programs, and even OTC benefits and in some cases, rides to and from medical appointments. They also may include wellness services like acupuncture or chiropractic care.

Many Medicare HMO plans also include Part D prescription drug coverage. This makes it easier to manage all healthcare needs with one plan.

Coordinated Care

With Medicare HMOs, healthcare is often more coordinated. The enrollee’s PCP (primary care physician) acts as the point of contact for all healthcare needs. The PCP coordinates care and refers enrollees to in-network specialists as needed.

This coordinated approach may lead to better preventive care and management of chronic conditions, as all healthcare providers are working together and have access to your health records.

Focus on preventative care

Many Medicare HMO plans emphasize preventive care services, such as regular check-ups, screenings, and vaccinations. By encouraging preventive care, HMOs aim to keep enrollees healthier and reduce the need for more expensive treatments down the road.

Medicare HMO Cons

Limited Provider Network

The most significant downside to Medicare HMOs is the restricted provider network. In general enrollees must use doctors and specialists within the plan’s network, except in emergencies. HMO plans do not provide coverage for healthcare administered by out of network providers for non-emergency situations. If the potential enrollee has doctors that are not part of the HMO network, they will need to change providers.

Those who receive care outside the network without a referral or in a non-emergency situation, may be responsible for the entire cost of service. This can be a major inconvenience for those who prefer the freedom to see any doctor or specialist.

Referrals Required for Specialist Visits

If a specialist is needed, the enrollee must get a referral from their primary care physician. Although this can improve care coordination, it also adds an extra step that can delay receiving needed care. This may be true, especially if the beneficiary has multiple health concerns that require a specialist.

Some people opt not to join an HMO based on the need for referrals alone. The referral requirement may be too restrictive. Some Medicare beneficiaries may prefer PPO plans, that allow direct access to specialists without needing a PCP referral.

Not All Services Are Covered

Although Medicare HMOs often provide additional benefits, not all services are covered. For example, certain treatments, procedures, or medications may not be included in the plan’s formulary or service list, even if they are covered by other Medicare Advantage plans.

Regional Coverage Limitations

Medicare HMO networks are typically regional, in other words, the plan’s network of providers is centered around a specific area. Those who travel frequently or spend part of the year in a different location, may find it challenging to access in-network care outside the plan’s primary service area.

Some plans offer a limited network for non-emergency care while traveling, but it’s important to check the specifics of each HMO plan to understand how it handles out-of-area coverage.

Higher Costs If Out-of-Network

While Medicare HMOs generally have lower out-of-pocket costs, these savings only apply if enrollees stick to in-network providers. If they receive care outside the network (non-emergency and without a referral), the costs can add up quickly, and they will most likely be responsible for the entire cost of their care.

This can be a big disadvantage for those that require specialized care that isn’t available within the network or when traveling and need non-emergency medical attention.

Is an HMO the right coverage choice

Deciding whether a Medicare HMO is the best choice of coverage depends on healthcare needs, preferences, and budget. Here are a few things beneficiaries need to consider:

• Are they comfortable having a primary care physician coordinate their care?
• Do they mind getting referrals for specialist visits?
• Are all their doctors and healthcare providers part of the plan’s HMO network?
• Do they travel often and need flexibility in accessing care outside their local area?
• Are the costs and benefits offered in line with what you are looking for in a healthcare plan?

Medicare HMOs offer a range of benefits, including lower costs, comprehensive coverage, and coordinated care. However, the restricted network and referral requirements can be drawbacks for those who prefer more flexibility. Carefully reviewing the pros and cons can help determine if a Medicare HMO is the best choice for your client’s healthcare needs.

If you are interested in helping people find the best coverage options and are ready to join the team at Crowe and Associates, click here for online contracting

Many agents have asked this question year; What’s Different for AEP 2025. As we all know, Medicare AEP is a critical time for beneficiaries to review and adjust their health insurance coverage. The AEP takes place each year, from October 15th to December 7th. During this time, Medicare enrollees have the opportunity to make changes to their plans. This year’s AEP comes with some significant changes and updates that could impact coverage, costs, and benefits. Let’s go over some of the changes for Medicare AEP 2025.

Agents, click here to watch a quick YouTube video on strategies to manage this AEP

Medicare Part B Premiums and Deductibles

For 2025, the Medicare Part B premiums and deductibles will be adjusted as they have in previous years. The 2025 Part B premium is projected to increase about 5.9% to $185 per month. The deductible projection is approximately $257. This cost increase is largely due to inflation adjustments and increasing healthcare costs. Beneficiaries with higher incomes will also notice changes in their IRMAA (income-related monthly adjustment amounts). It is important for beneficiaries to review these updates and understand how they might impact their budget.

Changes to Part D drug plan benefits

The Medicare Prescription Drug (Part D) plans have made some significant changes. These changes will improve affordability for some beneficiaries:

• Removal of the Coverage Gap (Donut Hole) in 2025 there will be no coverage gap for PDP or MAPD plans.
• In 2025, catastrophic coverage begins once the beneficiary reaches the annual cap of $2,000 spent for prescriptions on their plan’s formulary.
• All plans that provide Medicare prescription drug coverage will be required to offer a payment plan option for beneficiaries. This will help enrollees spread out the cost of expensive prescriptions over the course of the plan year.
• The maximum deductible amount for PDP coverage will go up from $545 in 2024 to $590 in 2025.
• The $35 monthly insulin cost cap will continue in 2025. This ensures those with diabetes won’t pay more than $35 per month for insulin products covered under their Part D/MAPD plans.
• Necessary adult immunizations will be 100% covered by the plan providers. This includes flu shots, shingles shots and other adult immunizations.
• Some plan providers will no longer allow agents/brokers to sell their plans and plans will become non-commissionable.
• Some plan providers will leave the market all together while others will consolidate their product offerings.

Medicare Advantage Plans

• Many MA/MAPD plan providers will scale back benefits for 2025. This includes reductions in some dental and vision coverage amounts as well as a reduction in or removal of OTC benefits.
• Some MAPD plans will leave the market all together while others will reduce their market footprint. There are a few plans that will use this as an opportunity to expand their market area.
• The change in the number of available plans in certain areas may prove challenging for agents this year. It may be harder to find a plan that offers all the benefits your client wants as well as that their providers are in network with.

Expanded Coverage for Mental Health Services

There’s a growing recognition of the importance of mental health, and Medicare has responded by increasing its coverage for mental health services. More plans are now offering benefits like counseling, therapy sessions, and even virtual behavioral health services. This change addresses the rising mental health needs and to provides better access to care.

Medigap Policy Changes

While the main focus during AEP tends to be on Medicare Advantage and Part D plans, it’s important not to overlook Medigap (Medicare Supplement) policies. In some cases, AEP is a good time to see if clients are in the most cost-effective Medicare supplement available in their area. If another carrier offers the same plan at a lower cost, this is a great time to change plans.

Emphasis on Preventive Services

Medicare has increased focus on preventive care, encouraging beneficiaries to take advantage of annual wellness visits, vaccinations, and other screening services. Many preventive services are covered at no additional cost, depending on the plan. This makes it easier for enrollees to maintain their health without added expenses.

Key Takeaways for Beneficiaries:

• Review Current Coverage: Look at current Medicare Advantage, Medigap, and Part D plans, and see if the changes for 2025 affect coverage or costs.
• Compare Plan Options: This is the time to shop around. Use tools like the Medicare Plan Finder or a licensed Medicare agent to compare options and find the best plan for your needs and budget.
• Understand the New Benefits: Be sure to understand new benefits that may benefit you.

This year’s Medicare AEP brings many changes, as well as an attempt to make healthcare more affordable for some members.

It is always important to review your client’s plan options and provide assistance in navigating the changes. By staying informed, you can make the most of this year’s AEP and secure the healthcare coverage that best meets your client’s needs.

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You can’t turn on the TV and not hear about one weight loss drug or another. That has led to many people asking the question; what insurance covers Wegovy (GLP-1s)?

As of March 2024, the House Ways and Means Committee voted to pass the Treat and Reduce Obesity Act of 2024. This bill will allow Medicare Part D plans to cover GLP-1s (glucagon-like peptide agonists) to treat obesity when the enrollee is prescribed the drug before enrolling in Medicare. CMS approved Part D coverage of the weight loss drugs when prescribed for individuals with heart disease or strokes. The drugs are not approved for coverage when prescribed for weight loss alone.

Weight loss for prevention

The Ways and Means Committee suggested that covering drugs for weight loss alone makes sense as weight loss can prevent several illnesses triggered by obesity. By preventing obesity, medical treatment costs can be lower in the future.

It is a fact that obesity is a risk factor for several other medical conditions including diabetes, heart disease and even cancer. Many of these diseases are leading causes of mortality.

What is the cost of Obesity

It is estimated that obesity will cost the federal government over $4 trillion in the next 10 years due to rising healthcare costs for overweight Americans.

If this legislation does not pass, millions of people who are enrolling in Medicare lose coverage for potentially life-saving medications. These drugs have given many people back their lives and provided an opportunity for a healthier, active lifestyle.

If you need help enrolling in a Medicare plan; click here and learn why you should use a Medicare agent.

What if the legislation does pass

If the legislation passes and becomes a law, the already high demand for these drugs would grow even more. That in turn, could present greater supply issues than already exist. Manufacturers have imposed restrictions on off label use to try and deal with supply issues.

If this is legislation passes, the cost would be about $1.7 billion over the course of 10 years. This is the estimated cost only for drug coverage of those who had the prescription before they enrolled in Medicare. Some members want to be sure people do not lose this coverage just because they retire.

Future considerations

Some consider this bill as a step toward broader coverage. According to the Senate Health, Education, Labor and Pensions Committee, this could cause a significant impact on federal spending of about $400 billion annually if half of obese Americans took the drug.

Some committee members oppose the bill stating that; if even 10% of Medicare enrollees used the drug, it would cost approximately $27 billion each year. Although, other members would like to compel manufacturers to lower the cost of GLP-1s.

There are good arguments on both sides of this issue. We will all have to wait and see what happens next.

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The recent changes to Medicare SEPs for full, partial and LIS only members has caused some people to ask questions about Full vs Partial Dual Eligibility.

Watch a quick YouTube video on the Dual eligible SEP changes

Full Dual Eligibility

Individuals who are eligible for both Medicaid and Medicare are dual eligible. In other words, To have full dual eligibility, it means you qualify for full Medicaid benefits from your state as well as Medicare. Medicare covers most healthcare benefits, although Medicaid pays some out-of-pocket costs such as premiums, copays, coinsurance and deductibles as well as long-term care.

Those who are dual eligible may qualify for a DSNP plan. A DSNP plan is a kind of Medicare Advantage plan that provides additional benefits not provided by Medicare or Medicaid.

Partial Dual Eligibility

If an individual is Partial dual eligible, it means their income level qualifies them for an MSP (Medicare Savings Program). Each state manages the MSPs using their Medicaid program. MSPs cover some Medicare costs, such as Part A & Part B premiums. It is important to note; partial dual eligibility doesn’t provide the same medical benefit coverage as full Medicaid.

Some individuals who qualify as partial dual may also qualify for a DSNP (Dual Special Needs) plan. Although Medicare pays most of the health care benefits, partial duals are responsible for out-of-pocket costs.

How a MSP helps partial duals

When Medicare enrollees receive medical care, Medicare doesn’t cover the entire cost of the services. There is usually an amount that’s left over. This amount is the beneficiaries’ responsibility and is called cost share or out-of-pocket cost and includes copays, coinsurance premiums and deductibles. This amount is the responsibility of the member. This who are enrolled in an MSP may receive help from Medicaid in paying for some of those costs. The amount of help (or cost sharing) received from Medicaid depends on income level and assets (such as real estate).

The 4 types of partial dual eligibles

QMB – Qualified Medicare Beneficiary

Members who receive help at the QMB level receive helps paying for premiums for Medicare Parts A & B as well as some cost shares for deductibles, copays and coinsurance.

SLMB – Specified Low Income Medicare Beneficiary

The SLMB program provides help with Part B premiums only.

QI – Qualified Individual

Those at the QI level receive help with Part B premium payments, these individuals may have a higher income than SLMB recipients.

QDWI – Qualified Disabled and Working Individuals

Individuals on QDWI program receive helps paying Medicare Part A premiums (hospital insurance) . This level of help applies to disabled individuals who have returned to work and lost their premium-free Medicare Part A coverage.

The new SEPs for DNPs and LIS 2025 change when a dual eligible can leave or switch Medicare Advantage Plans. The Final Rule changed existing SEPs and put a new SEP for D-SNPs in place. Starting in 2025, dual eligible and LIS (Low-Income Subsidy) recipients can change their Medicare Advantage plan enrollment once per month. The rules vary according to the beneficiary’s level of help and include full-benefit dual eligibles, partial-benefit dual eligibles, and individuals enrolled in the LIS program but are not also enrolled in Medicaid (LIS-only).

Watch our recorded webinar on the changes to SEPs for DSNPS

SEP changes starting Jan 1, 2025:

1. The current SEP for Dual eligibles and LIS only individuals is available once per quarter. It lets individuals switch or disenroll from a Medicare Advantage plan. This SEP will be end as of Jan 1, 2025.
2. A new monthly SEP for all dual eligibles and LIS only individuals to disenroll from a MAPD plan and go back to Original Medicare and a stand-alone PDP plan.
3. There will be a new SEP for all Dual eligibles and LIS only individuals to switch PDP plan enrollment.
4. A new monthly SEP for full duals to enroll in an integrated and aligned D-SNP plan.

Monthly SEP for Dual Eligibles and LIS recipients

As of 2018, CMS put a quarterly SEP in place. This SEP allowed duals & LIS recipients to either enroll or disenroll in a MAPD or PDP plan. The enrollment or disenrollment goes into effect the first day of the following month after the enrollee makes a plan change during the first three quarters. If the change is made in the last quarter AEP from Oct 15 – Dec 7, the plan goes into effect as of January 1st of the following year.

CMS created a new SEP to replace the quarterly SEP. In 2025, dual eligible individuals and LIS-only individuals can change their MAPD and PDP enrollment one a month.  Those who qualify can switch to another standalone PDP plan or disenroll from a Medicare Advantage plan and go back to Original Medicare and a standalone PDP plan. Individuals cannot use this SEP to enroll in another Medicare Advantage plan.

Integrated SEP

The CMS Final Rule created an SEP that will help facilitate enrollment for Dual eligibles into integrated Medicare Advantage plans. Each month, Full-benefit dual eligibles have the option to enroll in, or switch between, integrated D-SNPs. This SEP is only available to full-benefit dual eligible individuals who wish to enroll in integrated plans. Doing this will align enrollment between their Medicare and Medicaid coverage.

Those eligible can use this SEP to enroll in either a FIDE SNP (Fully Integrated Dual Eligible Special Needs Plan); or a HIDE SNP (Highly Integrated Dually Eligible Special Needs Plan); or a D-SNP that is an AIP (Applicable Integrated Plan).

What you can’t do with the SEP

Individuals cannot use the SEP to enroll in a Coordination only D SNP that is not an AIP, or a standard Medicare Advantage plan. The goal CMS has with this AEP is to have dual eligible individuals enroll in aligned plans if they are available in their home state.

Who can use this SEP

This SEP is only available to full-benefit dual eligible individuals who have access to an integrated, aligned plan. The following individuals cannot use this SEP: partial-benefit dual eligible individuals, and Medicare-only individuals cannot use this SEP. Presently, partial-benefit dual eligible individuals and LIS-only individuals have a quarterly SEP they can use to switch Medicare Advantage Plans. Keep in mind, this SEP will end as of Jan 1. 2025.

What happens if a person uses both the monthly and integrated SEP in the same month?

If an individual attempts to use the monthly SEP and the integrated SEP the same month, the SEP used last in will be effective. For example, Ms. Smith uses the monthly SEP to go back to Original Medicare on March 10th and on March 16th, she uses the integrated SEP to enroll in an Integrated Plan A, the integrated SEP is last used, and Ms. Smith will be enrolled into Integrated Plan A on April 1st.

SEP Changes for DSNPS & LIS 2025

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