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Medicare Savings Program: What It Is, How It Works, and Who Qualifies

Healthcare costs can be overwhelming, especially for people living on a fixed income. That’s where Medicare Savings Programs (MSPs) come in. If you are either new to Medicare or a new agent, you might ask; what is the Medicare savings Program. This program is designed to help individuals who meet specific income requirements with Medicare-related costs such as; premiums, deductibles, and coinsurance.

Let’s break down what these programs are, how they work, and who qualifies.

What Is the Medicare Savings Program

The Medicare Savings Program (MSP) is a set of federally funded, state-run programs that help eligible individuals pay for some or all of their Medicare Part A and/or Part B costs. This includes:

• Monthly premiums
• Annual deductibles
• Copays or coinsurance amounts

There are four main types of MSPs, each with slightly different income and asset limits and benefits.

The Four Types of Medicare Savings Programs

1. Qualified Medicare Beneficiary (QMB) Program
   • Pays for Medicare Part A & Part B premiums
   • Also covers deductibles, coinsurance, and copayments
   • Very limited income and asset limits apply
2. Specified Low-Income Medicare Beneficiary (SLMB) Program
   • Helps pay for Part B premiums only
   • Slightly higher income limits than QMB
3. Qualifying Individual (QI) Program
   • Also helps with Part B premiums
   • Available on a first-come, first-served basis
   • You must reapply each year
4. Qualified Disabled and Working Individuals (QDWI) Program
   • Pays for Part A premiums
   • For people under 65 who lost their premium-free Part A due to returning to work

How the Program Works

If you qualify for any of the Medicare Savings Programs:

• Your state pays your Medicare premiums directly to Medicare.
• In the case of QMB, providers are prohibited from billing for services covered by Medicare (except for a small copay in some cases).
• Enrollment in an MSP automatically qualifies you for Extra Help, a program that reduces prescription drug costs under Medicare Part D.

Who Qualifies for a Medicare Savings Program

Eligibility is based on monthly income and assets. The exact limits vary slightly by state, but general federal guidelines for 2025 are:

1. QMB (Qualified Medicare Beneficiary)

• Income: Below $1,325/month (individual), $1,783/month (married couple)
• Resources: Below $9,660 (individual), $14,470 (couple)

2. SLMB (Specified Low-Income Medicare Beneficiary)

• Income: $1,585/month (individual), $2,135/month (couple)
• Resources: Same as QMB

3. QI (Qualifying Individual)

• Income: $1,781/month (individual), $2,400/month (couple)
• Resources: Same as QMB

4. QDWI (Qualified Disabled and Working Individual)

• Income: Up to $5,302/month (individual), $7,135/month (couple)
• Resources: $4,000 (individual), $6,000 (couple)

Note: These limits are approximate and may vary slightly by state and year. Some states do not count all income or resources when determining eligibility.

Another way to save is by using the Canadian Medstore for some non-formulary or higher cost medications. Click here to watch a video on this program.

How to Apply

You must apply through your state Medicaid office, even though the program is funded by the federal government. You can apply at any time during the year; there’s no annual enrollment window for MSPs.

When applying, you’ll typically need to provide:

• Proof of income (such as pay stubs or Social Security statements)
• Bank statements
• Medicare card
• Identification documents

Individuals living on Medicare with a limited income shouldn’t overlook the Medicare Savings Programs. These programs can save hundreds or even thousands of dollars annually, making it easier to access needed care without worrying about the financial burden.

Those who might be close to the income or asset limits should still apply. Some states have flexible guidelines or exclude certain resources from their calculations.

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A licensed Medicare agent or your local State Health Insurance Assistance Program (SHIP) can provide guidance with the process.

Understanding Medicare Part B Coverage

Both Medicare Part B (medical insurance) and Part A (hospital insurance), make up Original Medicare and play a vital role in healthcare for millions of Americans. Because Part B provides essential coverage for outpatient care, doctor visits, preventive services, and more; understanding Medicare Part B coverage is essential.

What’s Covered by Medicare Part B

Part B helps pay for a range of services and supplies, including but not limited to:

• Doctor’s visits (primary care and specialists)
• Wellness and preventive visits
• Urgent care services
• Laboratory tests (e.g., blood work, urinalysis)
• Diagnostic imaging (X‑rays, scans)
• Emergency ambulance transportation
• Mental health services (outpatient therapy, counseling)
• Durable medical equipment/DME (e.g., wheelchairs, oxygen tanks)
• Rehabilitative services (physical, occupational, speech therapy)
• Preventive services (e.g., flu shots, pap smears, cancer screenings)

Beneficiaries may receive these services in doctors’ offices, hospitals, clinics, and other outpatient facilities.

Medicare Part B Costs (2025 Rates)

Premium

• Standard monthly premium: $185.00 in 2025; up from $174.70 in 2024.
• Beneficiaries who receive Social Security payments have this amount automatically deducted from their Social Security checks. Those who opt not to take Social Security payments receive a quarterly bill for $555.00.

High-income earners pay higher premiums under IRMAA (Income‑Related Monthly Adjustment Amounts), with surcharges ranging from an additional $74 to $443.90, depending on tax filing status and income level.

Deductible & Coinsurance

• Annual deductible: $257 for 2025, this amount is up from $240 in 2024
• Coinsurance: Once the beneficiary meets the deductible, they pay 20% of the Medicare-approved cost for most services after Medicare pays it’s share (80%).

Late Enrollment Penalty

Those who don’t sign up for Part B when first eligible (and don’t qualify for a Special Enrollment Period), incur a 10% penalty for each full 12 months they were eligible but didn’t enroll. This penalty is added to the monthly premium and lasts for as long as they have Part B.

Watch a YouTube video on OEP, Special Elections & Late Part B Enrollments

How to Enroll

You can sign up for Medicare Part B online via the Social Security Administration, by phone at 1-800-772-1213 (TTY: 1-800-325-0778), or in person at your local Social Security office.
Ready to sign up for Part B? Click here to enroll now.

We’re Here to Help

Medicare agents can be a valuable source of information and guidance. There is no fee for the appointment. Whether you’re new to Medicare or looking to optimize your coverage, licensed agents are ready to assist.

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Keeping up with annual updates, such as; Part B premiums and deductible as well as nay plan changes, can help you budget effectively and avoid surprises.

What Medicare Doesn’t Cover: Avoid Costly Surprises

When you think about Medicare, it’s easy to assume it covers everything you might need as you age, but that’s far not quite the truth. While Medicare provides important and often lifesaving benefits, there are several healthcare services and items that Original Medicare (Parts A and B) simply doesn’t pay for. If you’re not aware of these gaps, you could face unexpected bills. Let’s take a closer look at what Medicare doesn’t cover and how you can protect yourself from high out-of-pocket costs.

Long-Term Care (Custodial Care)

One of the biggest misconceptions about Medicare is that it covers long-term care. In reality, Medicare does not cover custodial care, which includes help with daily activities like bathing, dressing, or eating; if it’s the only care you need.
Medicare may cover short stays in a skilled nursing facility after a hospital stay, but not ongoing assistance in a nursing home or at home.

How to plan: Look into long-term care insurance or other alternatives, such as life insurance with long-term care riders or setting aside personal savings.

Most Dental Care

Original Medicare doesn’t cover routine dental cleanings, fillings, extractions, root canals, dentures, or implants.
It will only cover dental procedures if they’re medically necessary as part of another covered procedure; like jaw surgery in a hospital.

Your options: Some Medicare Advantage (Part C) plans include limited dental coverage. Standalone dental plans are also available.

Vision Care

Medicare doesn’t cover routine eye exams for glasses or contact lenses. It also won’t pay for eyeglasses or lenses unless you’ve had cataract surgery.

Exceptions: Medicare does cover exams for certain conditions like glaucoma, diabetic retinopathy, or macular degeneration.

Your options: Many Medicare Advantage plans offer some vision benefits and like dental plans there are stand alone options as well as dental & vision packages.

Hearing Aids and Exams for Fitting Them

Hearing loss is common with age, but Medicare won’t cover hearing aids or the exams needed to fit them.
This can be a big financial hit, with hearing aids often costing thousands of dollars per pair.

Your options: Check Medicare Advantage plans or look for a stand alone plan, discount programs and clinics offering more affordable devices.

Routine Foot Care

Unless you have a qualifying condition like diabetes, Original Medicare doesn’t cover routine foot care like callus removal, nail trimming, or orthotics.

Your options: Some Medicare Advantage plans may cover podiatry services.

Over-the-Counter Medications and Most Prescription Drugs

Medicare Parts A and B don’t cover most prescription drugs or any over-the-counter medications. For that, you’ll need to enroll in a Medicare Part D plan (Prescription Drug Plan) or choose a Medicare Advantage plan that includes drug coverage.

Important: Even with drug coverage, some expensive medications may not be on your plan’s formulary; always check!

Foreign Travel Emergency Care

Generally, Medicare doesn’t cover healthcare you receive outside the U.S., except in very limited circumstances.

Your options: Some Medigap plans (like Plan G or Plan N) include limited foreign travel emergency benefits. You can also buy standalone travel insurance.

Cosmetic Surgery

Medicare doesn’t cover cosmetic procedures unless they’re needed due to accidental injury or to improve function from a deformity or illness (e.g., breast reconstruction after a mastectomy).

Acupuncture (Beyond Limited Use)

Medicare only covers acupuncture for chronic lower back pain, and only under specific guidelines. Other types of acupuncture, or treatment for other conditions, aren’t covered.

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How to Fill the Gaps

To protect yourself from unexpected expenses, consider:

• Medigap (Medicare Supplement Insurance): Helps pay for deductibles, copays, and coinsurance.
• Medicare Advantage (Part C): May include extra benefits like dental, vision, hearing, and wellness.
• Prescription Drug Plan (Part D): Adds drug coverage to Original Medicare.
• Dental, Vision, and Hearing Insurance: Available as standalone policies.

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Medicare is an important program, but it’s not all-inclusive. Being proactive and understanding what it doesn’t cover can help you make smarter choices and avoid surprise bills. Talk to a licensed Medicare agent to help assess your needs and explore coverage options that close the gaps.

Common Medicare Enrollment Mistakes (and How to Avoid Them)

Enrolling in Medicare is one of the most important steps many of us take when we transition into retirement or experience a qualifying medical condition. But with multiple parts, deadlines, and plan types, it’s easy to make costly mistakes that could lead to penalties, gaps in coverage, or higher out-of-pocket expenses. We have listed some common Medicare Enrollment mistakes below with the hope that your clients can avoid them.

Missing the Initial Enrollment Period (IEP)

The Mistake: Waiting too long to enroll in Medicare Parts A and B can lead to late enrollment penalties, some of which are permanent.

How to Avoid It:
You’re eligible to enroll during a 7-month window:

• Starts 3 months before your 65th birthday month
• Includes your birthday month
• Ends 3 months after

If you’re not working or don’t have credible employer coverage, enroll during your IEP to avoid penalties.

Not Enrolling in Part B on Time

The Mistake: Some people mistakenly delay enrolling in Medicare Part B (medical insurance), thinking they don’t need it — even when they don’t have other credible coverage.

The Penalty: A 10% increase in premiums for every 12-month period you were eligible but didn’t enroll. This penalty lasts as long as the beneficiary has Part B coverage (for life).

How to Avoid It:
If you’re not actively working and don’t have employer-sponsored coverage, you should enroll in Part B when you’re first eligible. COBRA, retiree coverage, and the Marketplace do not count as credible coverage for Part B delays.

Not Enrolling in Part D (Drug Coverage)

The Mistake: Delaying enrollment in a Part D drug plan, thinking you don’t need one because you don’t take medications.

The Penalty: A permanent late enrollment penalty added to your Part D premium.

How to Avoid It:
Even if you don’t take prescriptions now, it’s wise to enroll in a low-cost Part D plan when you’re first eligible. You’ll avoid penalties and have coverage in place when you need it.

Watch a YouTube Video on Medicare Enrollment Periods

Assuming Medicare Covers Everything

The Mistake: Many people think Medicare is free and will cover 100% of their healthcare needs. Unfortunately, that’s not the case.

How to Avoid It:
Learn what Medicare does and doesn’t cover. For example:

• Part A covers hospital care but has a deductible
• Part B covers doctor visits and outpatient care, but only 80% after the deductible
• Medicare doesn’t cover routine dental, vision, hearing aids, or long-term care

Supplemental plans or Medicare Advantage can help fill these gaps.

Not Comparing Plan Options Annually

The Mistake: Sticking with the same plan year after year without reviewing changes.

How to Avoid It:
Use the AEP (Annual Enrollment Period) that runs from Oct 15 – Dec 7 to review:

• Premium changes
• Drug formularies
• Doctor networks
• Copays and out-of-pocket maximums

Plans change annually, and so do your health needs. An annual review ensures you’re in the most cost-effective and appropriate plan.

Relying on Friends or Online Info Without Expert Help

The Mistake: Taking advice from well-meaning friends or reading generic info online without speaking to a licensed agent.

How to Avoid It:
Medicare is personal. Plans vary by location, health needs, income, and prescription use. A licensed Medicare agent can help you compare plans and avoid costly oversights.

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Making the wrong choice with Medicare can cost hundreds, even thousands, over time. Whether you’re helping someone new to Medicare or reviewing your own plan, the smartest thing you can do is work with a licensed Medicare agent who understands the rules, timelines, and local options.

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Medicare for People Under 65: What Benefits and Plans Are Available

When most people think of Medicare, they think of individuals turning 65. But Medicare also covers millions of Americans under age 65 who qualify due to disability or specific medical conditions. Because understanding benefits and plan options is essential to getting the best possible care, we will discuss Medicare for people under 65.

Who Qualifies for Medicare Under Age 65

You may be eligible for Medicare before turning 65 if:

• You’ve been receiving Social Security Disability Insurance (SSDI) for 24 months (consecutive or non-consecutive).
• You have Amyotrophic Lateral Sclerosis (ALS); you automatically get Medicare the same month your SSDI benefits begin.
• You have End-Stage Renal Disease (ESRD); you may qualify for Medicare without waiting 24 months, depending on your treatment and transplant status.

What Medicare Benefits Do You Get

Medicare coverage for those under 65 generally includes:

• Part A (Hospital Insurance): Covers inpatient care, skilled nursing facility care, hospice, and some home health care. Usually premium-free if you worked 40 quarters (or qualify through a spouse).
• Part B (Medical Insurance): Covers doctor visits, outpatient care, preventive services, and durable medical equipment. You pay a monthly premium (standard amount is $174.70/month in 2025, though income can affect this).
• Part D (Prescription Drug Coverage): You can enroll in a standalone drug plan or get drug coverage through a Medicare Advantage plan.

Medicare Advantage (Part C) Plans for People Under 65

Private insurance companies offer Medicare Advantage plans. These plans must cover everything Original Medicare covers and often more, like dental, vision, hearing, gym memberships, and over-the-counter allowances.

Important notes:

• Not every state or county offers Medicare Advantage plans for beneficiaries under 65.
• You must be enrolled in both Part A and Part B to join a Medicare Advantage plan.
• Availability can depend on your ZIP code and health condition.

Some Advantage plans are designed for people with chronic conditions (C-SNPs), which could be a great fit for those with a qualifying illness.

Watch a YouTube video on Chronic Condition MAPD Plans

Medicare Supplement (Medigap) Plans for Individuals Under 65

Medicare Supplement plans (also called Medigap) help pay out-of-pocket costs like deductibles, copays, and coinsurance. They work with Original Medicare (not with Advantage plans).

Here’s the catch:

• Federal law does not require insurance companies to sell Medigap plans to people under 65. But many states do require it.
• If your state allows it, premiums may be higher than for people 65 and older.
• You may not be offered the full range of plans (A–N), and plan availability is very limited and varies widely by state.

Important: Even if you’re under 65 now, you’ll get another Medigap Open Enrollment Period when you turn 65; at that point, you can enroll in any plan with guaranteed issue rights and generally at lower rates.

Prescription Drug Coverage for Under-65 Beneficiaries

If you’re on Original Medicare, you’ll need a standalone Part D plan to cover your medications. These plans vary by region and formulary, so it’s important to review which plan best fits your prescriptions and pharmacy preferences.

If you choose a Medicare Advantage plan with prescription coverage, you don’t need to enroll in a separate Part D plan.

Don’t skip drug coverage! If you delay enrolling in Part D when first eligible and don’t have other credible coverage, you may face a late enrollment penalty later.

Getting Help with Costs: Extra Help & Medicaid

If you’re under 65 and have limited income or resources, you may qualify for:

• Medicare Savings Programs (help pay for Part A and B premiums and other costs)
• Extra Help with prescription drug costs
• State Medicaid programs, which can provide additional services and cost coverage

Medicare for people under 65 can be complex, but it’s also a lifeline. Plan options may differ from those turning 65, especially when it comes to Medigap and Medicare Advantage availability. It’s essential to:

• Review your state-specific rules
• Check if you’re eligible for Extra Help or Medicaid
• Compare Medicare Advantage vs. Original Medicare + Medigap carefully

Remember; coverage options may improve (and become more affordable) when you reach age 65, so be sure to reassess at that time.

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Need help understanding your Medicare options under 65? Contact a licensed Medicare agent who can walk you through what’s available in your area and help you make the most of your benefit.

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Understanding SEPs for Medicare Chronic Special Needs Plans (C-SNPs)

Medicare Advantage Special Needs Plans (SNPs) provide targeted care and coordinated benefits to specific groups of beneficiaries. One common type of SNP is the Chronic Condition Special Needs Plan (C-SNP), which is available to individuals diagnosed with specific chronic health conditions. For agents, understanding C-SNP SEPs can ensure your clients receive the best coverage for the care they need.

To help eligible beneficiaries enroll in these plans, Medicare offers Special Enrollment Periods (SEPs) that allow people to join or switch into a C-SNP outside the standard Annual Enrollment Period (AEP).

Let’s explore what C-SNPs are, who qualifies, and how SEPs work to ensure timely access to care.

What is a Chronic Special Needs Plan (C-SNP)

A C-SNP is a type of Medicare Advantage plan tailored for people with certain severe or disabling chronic conditions. Private Medicare-approved insurance companies offer these plans. Plans must include the same benefits Medicare Part A and B provide, and usually include Part D prescription drug coverage.

C-SNPs often provide:

• A care team specializing in the chronic condition
• Coordinated services to help manage the enrollee’s health
• Lower costs on services that relate to the specific condition

Examples of eligible chronic conditions for C-SNPs include:

• Diabetes
• Congestive Heart Failure (CHF)
• Chronic Obstructive Pulmonary Disease (COPD)
• Cardiovascular Disease
• End-Stage Renal Disease (ESRD)

*Note: Medicare rules around ESRD and plan access changed in 2021; people with ESRD can now enroll in most Medicare Advantage plans, but ESRD-specific SNPs still exist in many regions.

Special Enrollment Period (SEP) for C-SNPs

Medicare offers a Special Enrollment Period when an individual is newly diagnosed with a qualifying chronic condition. This allows them to join a C-SNP as soon as they are eligible.

When Does the SEP Apply

You can enroll in a C-SNP:

When you are first diagnosed with a qualifying chronic condition
If you already have a qualifying condition but have not enrolled in a C-SNP before
If you move into or out of a service area that offers your C-SNP
If you lose your C-SNP eligibility because you no longer meet the chronic condition criteria

This SEP allows a one-time enrollment into a C-SNP for each qualifying diagnosis.

How the C-SNP SEP Works

Once diagnosed with a qualifying condition, beneficiaries typically have a Special Enrollment Period that lasts for 3 months, beginning:

• The month they’re diagnosed, or
• The month they are notified of the diagnosis

During this SEP, you can:

• Enroll in a new C-SNP specific to the condition
• Switch from another Medicare Advantage plan or Original Medicare into a C-SNP

Documentation Required

Enrollment into a C-SNP requires proof of the chronic condition, usually in the form of:

• A doctor’s attestation
• Medical records or diagnosis documentation
• A form provided by the plan for the provider to complete

What if Your Condition Improves

If you no longer have the qualifying condition (for example, your doctor no longer considers your diabetes as chronic or disabling), you may be disenrolled from the C-SNP. In that case, you’ll qualify for another SEP to enroll in a different Medicare Advantage plan or return to Original Medicare.

Why Agents Need to Understand C-SNP SEPs

If you’re a Medicare agent, being well-versed in the rules around C-SNPs and SEPs help:

• Connect chronically ill clients with better care coordination
• Avoid unnecessary wait times for clients who need immediate support
• Assist clients with navigating documentation and eligibility

Remember, not all areas offer C-SNPs, so always check plan availability by ZIP code.

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Special Enrollment Periods for Chronic Special Needs Plans offer a vital lifeline to beneficiaries who need enhanced care and support for their chronic conditions. Understanding how and when these SEPs apply ensures that eligible individuals don’t miss out on essential benefits tailored to their health needs.

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Medicare Advantage Enrollment: When and How to Join a Plan

Medicare Advantage (also known as Medicare Part C) is a popular alternative to Original Medicare, offering coverage through private insurance companies approved by CMS. These plans often include additional benefits like dental, vision, hearing, and prescription drugs. For anyone considering Medicare Advantage enrollment, it’s essential to understand the different enrollment periods and special situations that may qualify you for coverage; including the Medicare Advantage Trial Right.

Enroll in Medicare Advantage

There are a few windows when beneficiaries can sign up for a Medicare Advantage plan:

1. Initial Enrollment Period (IEP)

When an individual first becomes eligible for Medicare, they have a 7-month window to enroll:

• Begins 3 months before the month they turn 65
• Includes their birthday month
• Ends 3 months after their birthday month

When an individual qualifies for Medicare due to a disability, their IEP will begin three months before the 25th month of disability benefits and end three months after that month.

2. Annual Enrollment Period (AEP): October 15 – December 7

During AEP, anyone with Medicare can:

• Join a Medicare Advantage Plan
• Switch from one plan to another
• Drop their Medicare Advantage Plan and return to Original Medicare

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

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3. Medicare Advantage Open Enrollment Period (MA OEP): January 1 – March 31

This period is for individuals who are already enrolled in a Medicare Advantage Plan. During MA OEP, you can:

• Switch to a different Medicare Advantage Plan
• Drop your plan and return to Original Medicare (with or without a Part D plan)

Click here to learn more about MA OEP

Special Enrollment Periods (SEPs)

Life happens and Medicare understands that. That’s why certain life events qualify beneficiaries for a Special Enrollment Period (SEP), allowing you to make changes outside the usual windows.

You may qualify for an SEP if:

• You move to a new address that isn’t in your plan’s service area
• You lose other coverage, such as employer, union, or Medicaid coverage
• Your plan is no longer available
• You get coverage through Medicaid or a State Pharmaceutical Assistance Program (SPAP)
• You’re diagnosed with certain conditions, allowing you to enroll in a Special Needs Plan (SNP)
• You’re released from incarceration
• You live in, move into, or move out of a nursing home or other long-term care facility

Each SEP has its own rules and timeframe, typically lasting 2 to 3 months around the qualifying event.

Medicare Advantage Trial Right

The Medicare Advantage Trial Right is a special protection for those trying a Medicare Advantage Plan for the first time. Here’s how it works:

Who Qualifies:

You qualify if:

1. You joined a Medicare Advantage Plan when you were first eligible for Medicare at age 65, and
2. Within the first 12 months, you decide you want to go back to Original Medicare
3. You dropped a Medigap (Medicare Supplement) policy to try a Medicare Advantage Plan for the first time, and within 12 months you want to switch back.

What You Can Do:

• Return to Original Medicare
• Enroll in a Part D prescription drug plan if needed
• In most cases, buy the same Medigap policy you had before, even if the insurance company normally wouldn’t sell it to you

Note: The Trial Right is only available once in your lifetime. It’s designed to offer peace of mind for those unsure whether a Medicare Advantage Plan is the best choice.

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How to Enroll

Enroll in a Medicare Advantage Plan:

• Online at Medicare.gov
• Directly with a carrier – there are a couple ways to do this including: online or over the phone
• Through a licensed Medicare agent or broker, who can help compare options and guide you through the process. This is our favorite option and the service is free!

Be sure to have:

• Your Medicare number
• The effective dates for Parts A and B

Medicare Advantage Plans offer convenience, extra benefits, and sometimes lower costs, but it’s important to choose the plan that fits health needs and lifestyle. Knowing enrollment rights and timing windows helps avoid penalties, gaps in coverage, or being locked out of better options.

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Working While Collecting Social Security

Many Americans choose to continue working while collecting Social Security; whether to stay active, boost income, or ease into retirement. Although those who are not yet at full retirement age, need to understand how working can affect their benefits. The Social Security Administration (SSA) may withhold a portion of their payments if their earnings exceed certain limits.

Can You Work and Collect Social Security

Yes, In fact; you can collect Social Security benefits while working. However, depending on your age and income, benefits may be temporarily reduced.

What Is Full Retirement Age (FRA)

The full retirement age depends on the year an individual was born. For most people retiring today, the FRA ranges from 66 to 67. Earnings limits apply to those who collect Social Security before reaching FRA and continue to work.

2025 Social Security Income Limits & Penalties

In 2025, if an individual is under the full retirement age for the entire year, the SSA deducts $1 from their benefits for every $2 they earn over $22,320/year (approx. $1,860/month).

Example:
Individuals who earn $30,000 while receiving Social Security before FRA are $7,680 over the limit. This means; SSA would withhold $3,840 of their benefits.

For those who reach full retirement age in 2025, the limit is higher:
You can earn up to $59,520 in the months before your birthday, with only $1 withheld for every $3 earned over the limit.

Once you reach full retirement age, there are no penalties; you can work and earn as much as you want without a reduction in benefits.

Learn about Medicare penalties

What Happens to Withheld Benefits

The good news: the money isn’t gone forever. When you reach full retirement age, the SSA will recalculate your benefit amount and increase it to account for the months when benefits were withheld due to excess earnings.

Are There Tax Implications

The answer is; yes, Social Security benefits may be taxable depending on total income (including wages, investments, and other retirement income).

If combined income (defined as adjusted gross income + nontaxable interest + half of your Social Security benefits) is:

• Between $25,000–$34,000 (individual) or $32,000–$44,000 (married), up to 50% of benefits may be taxed.
• Above $34,000 (individual) or $44,000 (married), up to 85% of benefits may be taxable. 

Impact on Medicare premiums

• If you receive Social Security benefits, your Medicare Part B premiums can be automatically deducted from your monthly payment.
• The standard Part B premium for 2025 is $185, but it can be higher based on your income from two years prior. 

Watch a video on OEP, SEPs an Late Part B Enrollment

Other considerations

• You will continue to pay Social Security and Medicare taxes on your earnings while working, regardless of age.
• Working might increase your future Social Security benefits, especially if your current earnings are higher than those in some previous years used to calculate your benefit.
• Some states also tax Social Security benefits. 

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When Working Makes Sense

Even with temporary benefit reductions or taxes, working while collecting Social Security may be worth it. Additional income can help:

• Cover rising expenses
• Delay tapping into savings
• Boost your Social Security by increasing your lifetime earnings record

Key Takeaways

• You can work and collect Social Security
• Earnings limits apply before full retirement age
• Benefits may be withheld, but are recalculated later
• Your benefits may be taxable depending on total income

Before deciding to work while on Social Security, consider speaking with a financial advisor or using the Social Security Earnings Test Calculator at SSA.gov. It’s a smart move to understand how your job may affect your benefits so you can make the most of your income now and in the future.

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Prior Authorization For Original Medicare

Starting January 1, 2026, those on Original Medicare who reside in New Jersey, Ohio, Oklahoma, Texas, Arizona, or Washington, will be required to get a prior authorization for Original Medicare before you receive some covered services. This will cause a major shift in how some beneficiaries use their Medicare benefits.

Medicare is launching a pilot program called the WISeR Model; short for Wasteful and Inappropriate Services Reduction and with it comes something traditionally associated with Medicare Advantage plans: prior authorization.

What Is Prior Authorization

Think of prior authorization as an ok from Medicare. Before your doctor can move forward with certain procedures such as; back surgery, an epidural, or a knee replacement, they have to get Medicare’s approval first. If Medicare doesn’t approve the service, the beneficiary will be on the hook for the entire cost.

This step is designed to prevent beneficiaries undergoing unnecessary or risky treatments, but it also means more paperwork, potential delays, and a new layer of bureaucracy for Original Medicare beneficiaries.

Why Is Medicare Doing This

According to CMS, the WISeR model has three main goals:

• Cutting down on fraud and wasteful spending
• Protecting patients from unnecessary or potentially harmful care
• Using technology and expert review teams to promote high-quality, cost-effective treatment

Medicare emphasizes that the goal is not to deny care, but to ensure the care being provided is truly necessary.

Which Services Will Require Prior Authorization

The WISeR pilot affects 17 outpatient services Medicare has identified as potentially overused or subject to misuse. These include:

• Back and neck surgeries
• Knee and joint surgeries
• Epidural injections and other pain treatments
• Skin grafts
• Nerve stimulators

What You Need to Know if You Have a Medigap Plan

Even if you have a Medicare Supplement plan (Medigap) like Plan G or Plan N, this change still affects you:

Watch a quick video on High Deductible Plan G

• Medicare Must Approve First: Medigap only helps pay your portion after Medicare approves the service. If Medicare denies it, Medigap won’t cover anything.
• Longer Wait Times: Prior authorization can delay access to care while your provider waits for Medicare’s decision.
• Less Flexibility: Traditional Medicare has long been valued for its ease of access to services—this new layer limits that freedom for certain procedures.
• No Formal Appeals: Under the WISeR pilot, there’s no standard appeal process. If denied, your doctor can submit more info, but there’s no official right to appeal like there is in broader Medicare.

How Does This Compare to Medicare Advantage

If this sounds familiar, it’s because Medicare Advantage plans have used prior authorization for years. However, there are key differences:

• Traditional Medicare is administered by the federal government, while Medicare Advantage is offered by private insurers.
• The WISeR model only requires PA for 17 specific outpatient services, while Medicare Advantage may require approval for hundreds of services and medications.

What’s Next

Right now, this is a pilot program affecting just six states. But if it’s successful, Medicare could expand it nationwide or add more services to the list.

Even if you don’t live in one of the six pilot states, it’s wise to stay informed—these changes could affect you in the future.

What Medicare Beneficiaries Should Do

1. Talk to Your Doctor
   Ask if any upcoming procedures might require prior authorization.
2. Plan Ahead
   Build in extra time for possible delays when scheduling certain treatments.
3. Stay Informed
   Keep up with updates from CMS and talk to your Medicare agent, especially if you plan to travel or move to another state.

The WISeR model represents a big change for Traditional Medicare, especially for those who’ve enjoyed its simplicity and flexibility. While the goal is to protect patients and reduce waste, many worry it could delay care or add confusion.

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Stay up-to-date on agent events and information

For now, being proactive is your best defense. Know which services are affected, communicate clearly with your doctor, and keep up with Medicare updates. This pilot could be the first step in a broader transformation of how Original Medicare works.

Medicare Advantage Trial Right Rules: What You Need to Know

For beneficiaries who understand the Medicare Advantage Trial Right Rules, this SEP provides a second chance to find a plan to best fit their needs. Switching health plans is stressful; especially if you’re not sure whether your new Medicare Advantage (MA) plan will meet your needs. Fortunately, Medicare offers a special protection called the Trial Right. This provides MA plan enrollees a one-time opportunity to go back to Original Medicare and Medigap as well as a PDP plan if their MA plan isn’t a good fit.

In this blog, we explain Trial Rights, who qualifies, and how to use it so both Medicare agents and beneficiaries are well informed of all the options.

What is a Medicare Advantage Trial Right

The Trial Right is a federally protected enrollment right under Medicare. It allows certain individuals who try a Medicare Advantage plan for the first time to switch back to Original Medicare. When they switch to Original Medicare, in most cases, purchase a Medigap (Supplement) plan without medical underwriting.

This protection ensures that people aren’t stuck in a plan that doesn’t meet their healthcare needs, especially if they’re new to Medicare or trying out Medicare Advantage for the first time.

When Do Trial Rights Apply

There are the two situations when someone is entitled to a Medicare Advantage Trial Right:

Trial Right #1: First Time Joining a Medicare Advantage Plan

If a beneficiary joined a Medicare Advantage plan for the first time ever (at age 65 or older) and has been enrolled in that plan for less than 12 months, they can:

• Disenroll from the MA plan
• Return to Original Medicare (Part A & B)
• Purchase a Medigap plan (Medicare Supplement) with guaranteed issue rights; no medical underwriting
• Purchase a PDP plan to cover prescription drugs

Example:
Mary turned 65 and enrolled in a Medicare Advantage PPO instead of Original Medicare and Medigap. After 6 months, she realizes she prefers the flexibility of seeing any doctor and wants to switch. She has a trial right to go back to Original Medicare and buy a Medigap plan and PDP plan, even if she now has health issues.

Trial Right #2: Dropping a Medigap Plan to Try an MA Plan

If a beneficiary had a Medigap plan but switched to a Medicare Advantage plan for the first time, and it’s been less than 12 months, they can:

• Drop the MA plan
• Go back to Original Medicare
• Re-enroll in the same Medigap plan (if it’s still available) or buy a similar one from another company; with guaranteed issue rights

Example:
Joe had Plan G for two years, then switched to a Medicare Advantage HMO in January. By September, he misses his Medigap freedom. He can use his trial right to return to Original Medicare and get a Medigap plan without underwriting.

How to Use a Trial Right

Beneficiaries can typically switch during a valid election period such as:

• Annual Election Period (AEP) – Oct 15 to Dec 7
• Medicare Advantage Open Enrollment Period (MA OEP) – Jan 1 to Mar 31
• Special Enrollment Period (SEP) triggered by the trial right

Watch a YouTube video on Medicare OEP, SEPs and LEPs

Once the carrier process the disenrollment:

• Original Medicare (Parts A & B) coverage resumes
• The beneficiary can apply for a Medigap plan with guaranteed issue rights
• Beneficiaries must select Part D (drug coverage) separately, unless already built into the Medigap package

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Benefits of the Trial Right

• No medical underwriting for Medigap; even if you have pre-existing conditions
• A second chance to choose Original Medicare + Medigap coverage
• Ensures flexibility and peace of mind for new enrollees or first-time MA users

Important Rules and Limitations

• MA Plan enrollees must leave their current MA plan before the 12 months ends.
• It’s a one-time only right; once the beneficiary uses it, they cannot use it again.
• Your Medigap plan must still be available from the insurer, or you can choose another one. You must also apply for a Medigap plan as early as 60 days before the date your MA plan will end or no later than 63 day after your coverage ends.
• The beneficiary must consider prescription drug coverage:
  • If you return to Original Medicare, you’ll likely need to enroll in a standalone Part D plan.
• Not all agents are familiar with this rule; make sure your client knows their rights!

How Agents Can Use This in Sales

• Educate new-to-Medicare clients: They can try MA with confidence knowing they have a Trial Right.
• Use it as a consultative tool; not to push one product over another but to help the client choose what best fits their health and financial needs.
• Document Trial Right eligibility in your CRM or client file; especially if they switch from Medigap to MA.

Stay up-to-date on agent events and information – click here.

Medicare’s Trial Right protections give beneficiaries peace of mind when trying something new. As an agent, it’s your responsibility to educate clients on their rights and help them make informed decisions if their first choice doesn’t work out.

Helping a client use their Trial Right can be an important opportunity to show your value as a Medicare resource.