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Since the start of the introduction of the Affordable Care Act (ACA), there’s been a growing demand for professionals with the knowledge and skills to provide assistance to enrollees. ACA certification and training are one of the ways agents can stay up-to date on plan options and proper enrollment practices. This allows agents to help individuals make informed decisions and get access to healthcare.

Learn about our ACA sales contracting

Certifications agents need to offer ACA plans

Agents who want to offer ACA plans through the federal exchange site (healthcare.gov), must complete the FFM (Federally Facilitated Marketplace) certification. Although the ACA plans operate differently than Medicare does, the CMS also oversees ACA training. Agents complete this certification through CMS’ MLMS (Marketplace Learning Management System). One important thing to note; the FFM certification doesn’t cover insurance products sold through any of the state-based marketplaces.

FFM certification does not cover products sold in states that have their own state-based marketplace, The following states have state-based marketplaces that require agents to take their specific certifications:

CA – the state’s marketplace is Covered California

CO – the state’s marketplace is Connect for Health Colorado

CT – the state’s marketplace is Access Health CT

Please note: Access Health CT certification for 2024 for both Brokers and CACs is closing on July 31. Certification for Open Enrollment and for 2025 will start in September (Date TBA).  Those who certify before 7/31 will need to certify again in September for 2025.

DC – the state’s marketplace is DC Health Link

ID – the state’s marketplace is Your Health Idaho

KY – the state’s marketplace is Kynect

ME – the state’s marketplace is CoverME

MD – the state’s marketplace is Maryland Health Connection

MA – the state’s marketplace is Health Connector

MN – the state’s marketplace is Mnsure

NV – the state’s marketplace is Nevada Health Link

NJ – the state’s marketplace is Get Covered NJ

NM – the state’s marketplace is beWellnm

NY – the state’s marketplace is New York State of Health

PA – the state’s marketplace is Pennie

RI – the state’s marketplace is HealthSource RI

VT – the state’s marketplace is Vermont Health Connect

VA – the state’s marketplace is Virginia’s Insurance Marketplace

WA – the state’s marketplace is Washington Healthplanfinder

When do agents need to complete certifications

Certifications for states on the Federal Exchange as well as many state-based marketplaces must be completed annually. However, although some state-based training, such as NY, is required every 2 years. When there are changes to the ACA, CMS provides updated training modules.

Find out why you should offer ACA plans through Crowe:

Watch a Youtube video on ACA contracting with Crowe and Associates

Click here to view a demo of our ACA portal for agents and agencies

FFM certification

Agents who need to complete FFM (Federally Facilitated Marketplace) can access CMS’s Enterprise Portal to complete their FFM certs. If you don’t already have an account, you can create one. Once you are in the portal, go to choose “Add Application” and click on the FFM/Request for MLMS Training Access and follow the instructions.

The states that require FFM training: AL, AK, AZ, AR, DE, FL, GA, HI, IL, IN, IA, KS, KY, LA, ME, MI, MS, MO, MT, NE, NH, NM, NC, ND, OH, OK, OR, SC, SD, TN, TX, UT, VA, WV, WI and WY.

New ACA agents vs. returning agents

Agents who are new to the ACA market must take the entire training course while returning agents can take a shortened version of the course.  

New agents: click here for the CMS Marketplace training guide for 2024

Returning Agents: click here for CMS’ Marketplace training guide for 2024

The entire FFM certification consists of 10 training modules and four test; this takes a few hours to finish. A score of 70% or higher is required to pass the tests although agents who do not pass them can retake them. The refresher training only takes about an hour and a half to finish. There is no cost to the agent to take either course.

To check that CMS has updated your FFM cert status, use your NPN on the  Agent and Broker FFM Registration Completion List (RCL), just enter your NPN to check. Please note, it may take a few days for CMS to update the system.

FFM certification assistance

CMS provides technical assistance for agent who experience issues while completing the FFM course. Call the Marketplace service desk at 1-855-267-1515 for portal password resets and issues as well as registration and training questions. Agents can also contact the help desk via email at: FFMProducer-AssisterHelpDesk@cms.hhs.gov

Offering ACA plans is a great way to grow your business and assist more members of your community.

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In general, Medicare is an affordable way for qualified individuals to receive healthcare coverage. However, there are some Medicare costs both agents and beneficiaries need to understand.

Plan Premiums

Premiums are a monthly fee the beneficiary pays for Medicare coverage.

Part A premiums

Although most beneficiaries do not pay a premium for Part A as long as they have worked for a Medicare-taxed job for a period of at least 10 years (40 quarters). In 2024, the premium for those who do not qualify for free Part A are between $278 to $505 monthly. The amount is based on the number of quarters the beneficiary or their spouse worked and paid Medicare taxes.

Part B premiums

Unlike Part A, almost everyone pays a Part B premium with the exception of those who meet certain income and asset levels and qualify for extra help. In general, most beneficiaries pay a standard amount for Part B. In 2024, the Part B premium amount is $174.70, although this amount may be adjusted according to each beneficiary’s income level. Those who earn over a specific thresh hold will pay an additional amount (IRMAA).

Part C (Medicare Advantage)premiums

Part C plans offer a variety of premiums, although many provide coverage for $0. The premium amount is based on the beneficiary’s location and plan availability. Please note; an IRMAA can also apply to a Medicare advantage plan if it includes Part D coverage.

Part D premiums

Similar to Part C premiums, the cost for Part D coverage varies by plan and coverage area. The national base beneficiary premium for 2024 is $34.70 per month. This is just a general premium amount CMS uses to calculate LEP penalties and not an actual premium amount. Premiums actually vary from $0 up to over $100 per month. Similar to Part B, individuals may pay a higher rate if they qualify for an IRMAA.

Find out how ancillary health insurance can cover some of the gaps in coverage.

IRMAA (Income Related Monthly Adjustment Amount)

An IRMAA is an additional amount CMS adds to the beneficiary’s monthly premium amount for Part B and Part D if their income exceeds the threshold amounts set by Medicare each year. The IRMAA is based on the individuals tax return from 2 years prior.

Click here to learn more about the income brackets for IRMAA 2024

LEP (Late enrollment penalty)

There are specific times beneficiaries must enroll in Medicare coverage. These are enrollment periods. If the beneficiary misses their enrollment period, they may pay an LEP. Medicare will add the penalty to their monthly premium.

Watch a YouTube video on OEPs, SEPs and Late Enrollments

Part A LEP

The LEP only applies to those who do not qualify for premium free Part A. Those who do not enroll on time have to pay a 10% higher Part A premium. Medicare applies the penalty for twice the number of years the beneficiary was eligible but didn’t enroll in Medicare. This means, if the beneficiary was eligible for Medicare but didn’t sign up for 3 years, they would pay an additional 10% for their Part A premium for 6 years.

Part B LEP

This penalty adds 10% times the number of years the beneficiary did not enroll in Medicare to the monthly premium and applies as long as the beneficiary has Medicare. In other words, if the beneficiary signs up for Medicare 3 years late, they pay 30% more for their premium. However, if they are actively working or have coverage through a spouse who is working, they can delay Part B enrollment without an LEP. Once they stop working, they qualify for an SEP and are eligible to enroll in Part B.

Part D and Part C plans that include drug coverage LEP

The LEP for Part D or Part C plans that include prescription drug coverage is 1% of the national base premium (this premium changes annually), multiplied by the number of months the beneficiary was eligible and did not enroll. This penalty is similar to the Part B penalty, because it lasts as long as the individual is enrolled in Medicare Part D. The federal government uses the standard rate (national base premium) to calculate Part D penalties not the individual’s actual plan premium. If the beneficiary delays Part D enrollment because they have another creditable drug plan, the penalty doesn’t apply to them.

Deductibles

Enrollees pay a deductible each year before their plan pays it’s portion of covered medical expenses.

While other Medicare plans have annual deductible, the deductible for Medicare Part A is $1,632 for each inpatient hospital stay. An individual could pay this deductible more than once a year depending on how many times they are admitted to the hospital. Each hospital admission counts as a new benefit period, unless the beneficiary is readmitted before the end of the benefit period.  Each benefit period ends 60 days after the enrollee is discharged.

Both Part B and Part D plans have one annual deductible. The Part B deductible is $240 in 2024. Although Part D deductibles vary according to plan, Medicare puts an annual limit on the maximum deductible allowed; in 2024 the maximum deductible is $545.

Copays and coinsurance

Both copays and coinsurance are fixed amounts the beneficiary pays for covered services or medications. These amounts apply after the beneficiary pays the deductible.

Part A coinsurance and copays

Once the beneficiary is in the hospital for over 60 days, they pay a coinsurance amount of $408 per day in 2024 for days 61 to 90. If the beneficiary is in the hospital for over 90 days, they can use some or all of their 60 lifetime reserve days. In 2024, each of these days cost $816. Each beneficiary qualifies for 60 reserve days for their lifetime. Once the beneficiary uses them all, they pay the entire remaining cost of their hospital stay.

Part A pays the first 20 days in a skilled nursing facility, once the beneficiary goes over the 20 days, they pay $204 per day for days 21-100. After day 100, the beneficiary is responsible for all costs. Many beneficiaries apply for Medicaid if they qualify, once they exhaust the Medicare coverage.

Part B coinsurance and copays

Part B normally provides coverage for 80% of approved Medicare expenses. That leaves the beneficiary with the remaining 20%. However, Medicare fully covers most preventative visits. Beneficiaries pay a higher co-insurance amount if their provider does not accept Medicare assignment.

Supplemental insurance can cover the 20% co-insurance cost and some of the copays with original Medicare. Click here to learn more.

Part C coinsurance and copays

Because Medicare Advantage plans work differently than Original Medicare, the coinsurance and copays work in a very different way. Medicare advantage plans use a specific network of providers who agree to accept the terms of payment. Each plan has it’s own co-pay amounts for doctor and specialist visits. Some plans provide coverage for visit to out of network providers at a higher cost share amount.

Each plan also has an out of pocket maximum. Once the beneficiary reaches this amount, the plan pays 100% of their approved medical costs.

Part D coinsurance and copays

Part D copays and coinsurance can vary quite a bit from one plan to another. That is why it is important to check all medications and cost sharing amounts before choosing a plan. In general, the cost for a prescription is higher for brand-name medications especially if they are on a higher tier in the plans formulary. If the beneficiary uses medications that are not on the formulary, they may have to pay the full costs of the medication.

There are other factors that decide the cost of medications such as the deductible, tier, the coverage gap and the catastrophic phase of coverage. Although there are changes coming in 2025 that will alter some of those cost shares. Plan enrollees should check their plan every year to ensure they are on the best plan to meet their coverage and budgetary needs.

Click here to learn about the Part D changes for 2025

Providers who don’t participate in Medicare

It is important to note: Not all doctors participate with Medicare. In some instances (rarely, but some), a provider has opted out of Medicare and does not accept Medicare as payment. This means the patient is responsible for paying any fees for service out of pocket.

Find out what Medicare Advantage plans don’t cover

As you can see, there are many potential costs associated with Medicare plans. We have not listed all of them. It is important to check the summary of benefits or evidence of coverage each year to ensure enrollment in the best plan option for each individual situation. A licensed Medicare agent can provide invaluable insights into plan choices and coverage options.

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There are a few different terms people use for supplemental Medicare insurance such as; Medigap, Medicare Supplement or Med Supp. Private insurance companies offer these health insurance policies to individuals who are eligible for Medicare coverage. In general, Medicare covers about 80 % of approved medical charges. Medicare supplement plans are designed to cover the 20% of approved medical charges not covered by Original Medicare. Essentially, Medicare supplement policies help reduce out-of-pocket costs. This ensures healthcare costs are predictable and manageable.

Why choose a Medicare Supplement

Although Original Medicare provides substantial coverage, it doesn’t cover everything. Here are some reasons to consider a Medicare Supplement:

Out-of-Pocket Costs: Original Medicare requires beneficiaries to pay for a percentage of their approved medical expenses. Because these can add up quickly, especially if you have frequent medical needs, a Medicare supplement pays these costs and saves enrollees money.

Find out more about Medicare costs

Foreign Travel: In general, Original Medicare doesn’t cover healthcare services outside the U.S.. Although some Medicare supplement plans provide coverage for emergency medical care during foreign travel.

Predictable Expenses: With a Medicare supplement plan, enrollees have predictable medical expenses, making it easier to manage their healthcare budget.

No Network Restrictions: Medicare supplement plans do not have network restrictions, this allows individuals to see any doctor or specialist that accepts Medicare.

Supplemental Medicare insurance plans

There are ten standard Medicare supplement plans, labeled A through N. Each plan provides a different level of coverage. The plan benefits of each plan letter are standardized, meaning Plan A from one insurance carrier offers the same benefits as Plan A from any other insurance carrier. These benefits are universal and don’t change by location. Although, plan availability varies by location. Insurance carriers do not offer all plans in every state.

Here is a basic over view of plan benefits:

• Plan A: This plan provides basic benefits, covers coinsurance and hospital costs (up to 365 additional days after Medicare benefit is used).
• Plan B: Benefits Include all the Plan A benefits plus it covers the Medicare Part A deductible.
• Plan C: Covers all of Plan B as well as skilled nursing facility care coinsurance and foreign travel emergency and also covers the Part B deductible.
• Plan D: This plan is similar to Plan C , although it does not cover the Part B deductible.
• Plan F: Provides comprehensive coverage, including the Part B deductible. Please note; this plan is no longer available to anyone who is eligible for Medicare after January 1, 2020.
• Plan G: These plans provide coverage very similar to Plan F although, they do not cover the Part B deductible.
• Plan K and L: Both these plans offer lower premiums but higher out-of-pocket costs, with coverage limits.
• Plan M and N: Plans provide a good cost-sharing option for specific benefits and lower plan premiums.

Click here to view a comparison chart of Medigap plans

Choosing the Right Plan

Selecting the right Medicare supplement plan requires careful consideration of both health needs and finances. Things to consider when choosing a plan. Please consider using the services of a licensed Medicare agent when making important health coverage decisions. This will ensure you have all the information you need to make an informed choice.

Assess Your Health Needs: Consider your current health status and any anticipated medical needs. If you require frequent medical services, a plan with more comprehensive coverage might be beneficial.

Budget Considerations: Evaluate your budget for monthly premiums versus out-of-pocket costs. Higher premiums generally mean lower out-of-pocket expenses.

Compare Plans: It is a good idea to use the services of a licensed Medicare agent when making important health coverage decisions. In most cases, they can access tools that can provide a comparison of the plans available in your area. This ensures you have all the information you need to make an informed choice.

Watch a YouTube video comparison of our quoting tools Sunfire vs Connecture

Check for Special Benefits: Some plans offer additional benefits, such as foreign travel emergency coverage or even a fitness benefit.

If you want to learn some of the differences between a Medicare Supplement and an Advantage plan, click here.

Enrollment Periods

The best time to buy a Medicare supplement policy is during your Open Enrollment Period, which starts the first month you have Medicare Part B and are 65 or older. During this period, you have a guaranteed issue right, meaning insurers cannot deny you coverage or charge higher premiums due to pre-existing conditions.

Always remember to meet with your agent each year to review your options and adjust your plan as your healthcare needs change.

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Because many people on Medicare require additional help at some point it is important to understand Medicare and home healthcare coverage. The main goal of home healthcare is help individuals recover from an illness or injury and regain independence.

Eligibility

In order for a beneficiary to qualify for home healthcare services under Medicare, the following criteria must be met:

1. A doctor or another licensed healthcare provider must have a face-to-face meeting with the beneficiary and certify that they require home health services.
2. The beneficiary must require part-time/intermittent skilled nursing care, physical therapy, occupational therapy or speech-language pathology services.
3. Patients must be homebound. In other words, it is difficult for them to leave the house without help due to their condition.
4. A Medicare certified home healthcare agency must provide the care.

Services Medicare covers

Once the eligibility criteria are met, Medicare covers many home health care services, including:

• Skilled Nursing Care: Provided on a part-time or intermittent basis.
• Therapy Services: Physical, occupational, and speech-language therapy to aid in recovery and rehabilitation.
• Home Health Aide Services: Assistance with personal care on a part-time basis if the patient is also receiving skilled care.
• Medical Social Services: Counseling and help finding community resources.
• Medical Supplies: Certain medical supplies like wound dressings.
• Durable Medical Equipment (DME): This includes equipment such as walkers or wheelchairs.

Services Medicare does not cover

• Full-time care: 24-hour-a-day care at home.
• Meals: Meals delivered to the home.
• Homemaker services: Medicare dose not cover services such as; shopping, cooking or cleaning if they are the only services needed.
• Personal care: If this is the only care required, Medicare will not pay a home health aide to provide basic personal care services such as bathing, dressing or using the bathroom (activities of daily living).

How to set up home healthcare services under Medicare

1. Make an appointment with your doctor or healthcare provider to go over your health needs and establish if home health care is a good choice.
2. Be sure you see your doctor face-to-face as required by Medicare.
3. Ask your doctor or insurance provider to help you find a Select a home health agency that is certified by Medicare.
4. Work with your doctor and the home health agency to develop a plan of care to fit your specific needs.

How Original Medicare covers home healthcare costs

In most cases, individuals enrolled in original Medicare pay nothing for covered home healthcare services. Although, there is a cost for DME durable medical equipment. In general, Medicare covers 80% of the approved amount while the individual is responsible for the remaining 20%.

Part A: Typically covers home health care services after the beneficiary has been in the hospital for a period of 3 days or more.

Part B: Covers home health services without the requirement of a prior hospital stay.

Watch a YouTube video the difference between Medicare Supplements and Medicare Advantage

Medicare Advantage Plans and Home Health Care

Medicare Advantage plans (Medicare Part C), are an alternative to Original Medicare. Private insurance companies that are approved by Medicare offer these plans. They must provide the same benefits as Medicare Part A and Part B. Many Medicare advantage plans also offer additional benefits that original Medicare does not cover, such as vision, dental, wellness programs, OTC as well as rides to medical appointments.

How Medicare Advantage plans cover home healthcare costs

Although Medicare Advantage plans must cover at least the same level of home health care services as Original Medicare, there are a few things you should know:

1. Network Restrictions: Unlike Original Medicare, Medicare Advantage plans often have network restrictions. Beneficiaries of most plans need to use home health agencies that are in the plan’s network.
2. Prior Authorization: Some Medicare Advantage plans require prior authorization for home health services. In other words, beneficiaries need approval from the plan before they receive certain services.
3. Additional Benefits: Many MA plans offer extra benefits beyond what Original Medicare provides. These could include additional support services, like caregiver support, home modifications, or wellness programs.
4. Cost Structure: Although Medicare Advantage plans must cover home health care at least as well as Original Medicare, the cost structure (copays, coinsurance, and deductibles) may be different. It’s important to understand your plan’s specific costs.

Find out how to cover the gaps left by Medicare advantage plans

Medicare’s home health care coverage can significantly benefit those who need medical care in the comfort of their own home. Understanding the eligibility criteria, the types of services covered, and how to initiate these services ensures that beneficiaries receive the appropriate care while minimizing out-of-pocket expenses.

Please note: before choosing a Medicare plan, it is best to consult a licensed healthcare agent to get accurate, personalized plan information.

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For the most part, Medicare clients are happy with their coverage and the services they recieve, although there are times they may have questions or complaints about Medicare service.

The problem could be due to issues with their plan, providers or customer service experiences. If problems occur, enrollees have the right to file a grievance. Unlike appeals, which address denials of coverage, a grievance is a formal complaint about other aspects of Medicare services or care. We explain what constitutes a complaint/grievance, the steps to file, and how to ensure your clients receive a resolution.

Medicare grievances/complaints

A Medicare grievance is a complaint about issues related to Medicare plans or care that are not about payment or coverage decisions. Here are a few common reasons for complaints:

1. The quality of care or service they recieved.
2. Patients may feel a facility is not clean or safe enough.
3. There may be issues with the behavior of a helathcare provider or plan representative.
4. Patients may experience unreasonable delays in getting an appointment or service they need.
5. The plan may have given enrollees incorrect or misleading information.

How to file a complaint

Identify the issue and gather information

Clearly identify the issue that prompted the complaint. Make sure you have all relevant details, including dates, names of individuals involved, and supporting documents such as; medical records, bills, or correspondence.

Contact the plan or healthcare provider

In order to resolve a grievance, the beneficiary must contact their Medicare plan or healthcare provider directly. In many cases, the issue is resolved through direct communication. This will eliminate the need to file a formal grievance.

Prepare the complaint/grievance

If the beneficiary is not satisfied with the resolution, they should file a formal complaint/grievance.

Write a Detailed Account: Clearly describe the problem, include who was involved, what happened, when and where it occurred, and why you are dissatisfied.

Include Supporting Documents: Attach copies of any relevant documents (medical records, bills or correspondence) that support your issue.

Submit the complaint

The submission process varies depending on the type of Medicare coverage.

Original Medicare: Enrollees file their complaints with the healthcare provider or facility where they received care.

Medicare Advantage (Part C) and Prescription Drug Plans (Part D): Enrollees file their complaint/grievance with their plan provider. They will find plan contact information and instuctions for filing in the plan’s member handbook or on their website.

Learn what Medicare advantage plans don’t cover; click here

Adhere to filing deadlines

Medicare requires beneficiaries to file complaints within 60 days of the event that caused the issue. The plan or provider must respond to the complaint within a specific timeframe. Urgent issues require an response within 24 hours while non-urgent issues have a 30 day repsonse timeframe.

Follow up

Plan enrollees should keep records of their complaint/grievance submission and follow up if they do not receive a reply in a reasonable amount of time. Persistance ensures that concerns are addressed in a timely and satisfactory manor.

Tips for Filing a Successful Grievance

Be clear and concise: Clearly state the issue and the desired outcome.

Document Everything: Keep thorough records of all interactions. Include dates, times, names, and what was discussed.

Be Polite but Firm: Maintain a professional tone, but be firm in expressing dissatisfaction and the desired outcome.

Seek Assistance: For those who need help filing a complaint/grievance, contact a State Health Insurance Assistance Program (SHIP). They provide free, unbiased counseling and assistance. The official Medicare website, medicare.gov, provides comprehensive information on filing grievances and appeals. Beneficiaries can also call 1-800-MEDICARE for help with Medicare related issues.

Although filing an official complaint/grievance with Medicare seems daunting, knowing your rights and understanding the process can help effectively address issues and improve the healthcare experience. Remember, client feedback is one important way to improve on the services provided to Medicare beneficiaries.

Agents provide support and assistance to clients

Although these issues may not involve agents directly, you are your clients’ point of contact for their health coverage needs. It is important to be available to them for guidance if they have healthcare or coverage issues. That is why a basic understanding of how to handle complaints/grievances is good to have.

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Medicare Out Of Pocket Maximums

Understanding the Medicare out-of-pocket maximums is important for agents as well as clients. The amount changes each year; it is imperative to stay up to date on this information. This number may be a big factor for those who want to manage their healthcare expenses.

Out of pocket maximums

An out-of-pocket maximum is the most a beneficiary pays each year for covered healthcare expenses. Once they reach this limit, their insurance plan covers 100% of the costs of covered benefits. Deductibles, copays, and coinsurance are all included in this amount. It does not include premiums, balance-billed charges, or services that Medicare does not cover.

Medicare and out of pocket costs

Medicare is divided into different parts, each has its own rules for out-of-pocket costs.

Original Medicare (Part A and Part B)

Original Medicare does not have an out-of-pocket maximum. In other words, there is no cap on the amount beneficiaries can pay each year for healthcare services. This concern beneficiaries who require extensive medical care, as there is no financial limit to their liability.

Part A (Hospital Insurance): Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Although is no out-of-pocket maximum, enrollees are responsible for deductibles and coinsurance payments.

Part B (Medical Insurance): Part B covers outpatient care, preventive services and medical supplies. Part B is similar to Part A, there is no out-of-pocket maximum; beneficiaries pay the deductible and coinsurance.

Medicare Supplements

Medicare supplements also do not have an out of pocket maximum. This is due to the fact that it is not necessary because of the benefits these plansprovide. They cover most of the costs left behind by original Medicare; therefore, a maximum out of pocket amount is unnecessary.

Medicare Advantage (Part C)

Medicare Advantage plans, (Part C), are offered by private insurance companies approved by Medicare are an alternative to Original Medicare. One of the benefits of Medicare Advantage plans is they include an annual out-of-pocket maximum.

Although CMS sets a maximum each year that these plans cannot exceed, each plan sets its own annual limit. In 2024, the maximum out-of-pocket limit is $8,850 for in-network services and $13,300 for combined in-network and out-of-network services. Once enrollees reach this limit, the plan covers 100% of eligible healthcare costs for the rest of the year.

Medicare Prescription Drug Plans (Part D)

Medicare Part D provides prescription drug coverage and is available as a stand-alone plan or included in some Medicare Advantage plans. Most enrollees of part D plans have a deductible, co-pays and coinsurance. These costs apply to prescription medications on certain tiers of the plan formulary. Part D plans also have a coverage gap that can affect out-of-pocket costs.

Coverage Gap and Catastrophic Coverage: In 2024, once the benficiary and their plan have spent $4,660 on covered drugs, they enter the coverage gap. During this period, they pay no more than 25% of the cost for prescription drugs. Once out-of-pocket costs reach $8,000, they enter catastrophic coverage, and pay nothing for covered medications for the rest of the year.

Watch a video about the changes in drug coverage for 2025

Manage Out-of-Pocket Costs

Because of the potential for high out of pocket costs, it is a good idea to try and mange them ahead of time.

Choose a Medicare Advantage Plan: Consider a Medicare Advantage plan with a low out-of-pocket maximum to help control medical costs. These plans can provide financial protection and predictability.

Supplemental Coverage: Purchase a Medicare Supplement plan if you have Original Medicare. These plans help cover some out-of-pocket costs left over after Original Medicare pays its share.

Review plan coverage: Each year, enrollees should review the annual notice of change from their Medicare plan to understand changes in coverage, costs, or out-of-pocket maximums. It is also important to meet with a licensed Medicare agent and go over all your options to ensure you have a plan that best meets your healthcare and financial needs.

Prescription Drug Assistance Programs: Look into programs that offer assistance with prescription drug costs, especially if you are in the Part D coverage gap.

Learn about changes to the coverage gap (donut hole) for 2025

Preventive Care: It is best to use preventive services from an in-network provider. Staying on top of your health helps to avoid serious problems down the road.

Understanding and managing out-of-pocket maximums is essential for anyone on Medicare. While Original Medicare lacks an out-of-pocket maximum, Medicare Advantage plans provide a valuable safety net. By exploring supplemental coverage options and being proactive about healthcare decisions, beneficiaries can better manage their medical expenses and ensure they receive the necessary care without financial strain.

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Sometimes Medicare coverage is great and other times it is a challange. This is especially true when it comes to denials of coverage. If your client receives a denial, it’s essential to let them know they have the right to appeal. Understanding the Medicare appeals process can help your clients get the coverage they need. In this post, we provide a guide to help with this process.

Understand your coverage

One very important thing agents can do to help avoid denials of coverage; ensure clients understand their coverage. Discuss what each plan covers and what the beneficiary is responsible for such as copays, deductibles and coinsurance amounts. Licensed Medicare agents can help beneficiaries go over plan choices and ensure the beneficiary has the best coverage for their personal situation.

Agents can also discuss gaps in coverage and offer additional ways clients can cover themselves if anunexpected health problem comes up.

Learn the benefits of ancillary products sales; watch a quick YouTube video

Medicare Appeals

Medicare appeals are requests to review and reconsider decisions about healthcare coverage and payments. These appeals may be necessary when Medicare denies a beneficiarie’s request for a healthcare service, supply, or prescription drug, or refuses to pay for services they have received.

Click here to access appeals forms on CMS.gov

How to appeal a Medicare decision

Review the Notice of Denial

It is important to carefully read and understand the notice of denial before initiating an appeal. This document, often called either a EOB (explanation fo benefits) for Medicare advantage (Part C) or Part D plans or a MSN (Medicare summary notice) for Original Medicare, explains why coverage of the service or item was denied.

The plan must explain how to appeal the denial in writing. After the beneficiary files the appeal, the plan reviews its decision. If they do not agree with the appeal, an independent Medicare organization reviews the decision.

Understand Appeal Rights and Deadlines

There are very specific deadlines in place to file an appeal. The deadline varies by the type of Medicare coverage an beneficiary has.

Original Medicare (Part A and Part B)

The beneficiary has 120 days from the date they receive the MSN to file an appeal.

Medicare Advantage (Part C) and Prescription Drug Plans (Part D)

When a beneficiary of one of these plans wants to file an appeal, they have 60 days from the date they receive the EOB to file the appeal.

Collect Supporting documentation

Beneficiaries should gather any medical records, doctor’s notes, and any other evidence that supports their case. A healthcare provider is an invaluable resource to help provide documentation and expert opinions to help make the appeal successful.

If the beneficiary’s doctor agrees that they have are at serious risk, worsened by waiting, the plan must make a decision within 72 hours of receiving the request.

Click here to learn more about getting a fast appeal

Submit the appeal

The appeals process for Original Medicare and Medicare Advantage/Part D plans differs slightly.

For Original Medicare (Part A and Part B)

Fill out the redetermination request form included with the MSN or write a letter to the address listed on the MSN. It is important to include the beneficiaries’ name, Medicare number, the specific item or service in the appeal as well as any supporting documents. A Medicare contractor reviews the appeal.

For Medicare Advantage (Part C) and Part D (Prescription Drug Plans)

Appeals are submitted directly to the plan for reconsideration. The EOB has instructions on how to submit the appeals. If the initial appeal is denied, enrollees can request an independent review by a third-party organization.

Levels of Appeal

If the initial appeal is denied, there are many ways to escalate it.

1. Request reconsideration by an independent review entity.
2. If the amount in question reaches a specific threshold, you can request a hearing by an administrative law judge.
3. If the beneficiary is dissatisfied with the administrative law judge’s decision, enrollees can request a Medicare appeals council review.
4. If all else fails, the enrollee can file a lawsuit in federal district court.

Follow Up

Make sure beneficiaries keep copies correspondence or records related to the appeal. Always follow up on the status of the appeal and be sure to adhere to all deadlines.

Ensure a successful appeal

Be persistent; because appeals can take some time, it is important to be persistent. Don’t let initial denials discourage you.

Ask for assistance; use State Health Insurance Assistance Programs (SHIPs), which provide beneficiaries free assistance with Medicare appeals.

Organize all helpful information: it is essential to maintain a well-organized file of documents, correspondence, and any notes related to the appeal.

For help filing an appeal, contact the SHIP State Health Insurance Assistance Program.

Although Medicare denials and the appeals process may be discouraging, understanding the beneficiaries’ rights and the necessary steps makes the process manageable. Being thorough, organized, and persistent, improves the chance of a successful outcome for the appeal.

Understand your coverage

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For an agent to explain Medicare coverage to a client, they need to understand the difference between coinsurance vs copays. These as well as other out-of-pocket costs affect the total cost of a Medicare beneficiaries’ annual healthcare.

Coinsurance

After an enrollee meets their annual deductible, the percentage of covered medical expenses they pay is coinsurance. If a beneficiary enrolls in Original Medicare, Medicare pays 80% of the cost for approved expenses (after the deductible is paid) the beneficiary pays the remaining 20% until they reach the annual out-of-pocket maximum.

Please note, if the beneficiary has expenses that are not Medicare approved, coinsurance does not apply to these expenses. In that case, the beneficiary must pay for the entire cost of the medical service.

Coinsurance and the deductible

Coinsurance is the percentage of healthcare costs the beneficiary pays after the cost for medical care goes beyond the deductible amount.

Copays

Are predetermined amounts plan enrollees pay medical providers when they receive approved medical services. Copay amounts can be as low as $10 and go up quite a bit from there. The amount varies by plan and is usually higher for specialist services. There are different copay amounts for each type of service such as primary care provider visits, specialists, urgent care, visits to the ER as well as for prescription medications.

Copays and deductibles

Even if you have not met your annual deductible, you will have to pay the copay amount in addition to the deductible. In most cases, copay amounts do not count toward the annual deductible. However, copays do count towards the out-of-pocket maximum for the year.

Watch a YouTube video of what you need to know before a Medicare sale

Coinsurance vs Copays summary

Coinsurance:

1. The amount is a percentage of the cost for a procedure.
2. All approved medical procedures charge the same percentage amount.
3. Coinsurance goes into effect once the enrollee meets the annual deductible.

Copays:

1. The copay is a predetermined amount enrollees pay for each visit.
2. Amounts change depending on the type of provider the enrollee uses for a procedure.
3. Enrollees pay the copay amount weather or not they meet the deductible.

Deductibles

In order to better understand how coinsurance and copays differ, we will explain deductibles. Deductibles are a set amount of money beneficiaries pay annually for their healthcare before their health care plan kicks in and pays its share of covered medical costs.

Summary

1. A copay is a set amount enrollees pay for primary care, specialists, ER and urgent care as well as prescriptions.
2. Coinsurance is a specific percentage of approved medical costs enrollees pay once they meet their annual deductible.
3. Deductibles are predetermined amounts enrollees pay for various types of medical care before coinsurance goes into effect.
4. If an enrollee meets the annual out of pocket maximum, their plan covers all approved medical expenses at 100%.

Learn more about Medicare costs, click here

Coinsurance vs copays

Additionally, copays and coinsurance does not usually apply to preventative services. In other words, most health plans cover these services at 100%. In most cases, plans with higher copay amounts have a lower premium.

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In the world of insurance sales, objections are inevitable. When it comes to selling Medicare, agents often encounter various objections from prospects. Often times, there are concerns about cost, coverage, or confusion about the options available. Addressing objections effectively is key to closing the sale. In this post, we explore practical strategies to overcome objections in Medicare sales.

As with all Medicare sales, be sure you follow all CMS guidelines and follow compliant sales practices .

Learn the key elements for a compliant phone recording

Listen

The most crucial skill in overcoming objections is active listening. When a client raises an objection, listen attentively to fully understand their concerns. Don’t interrupt or immediately start a counterargument. Instead, show genuine interest and empathy. This will establish rapport and provide valuable insights into the client’s needs and preferences.

Empathize

Acknowledge the client’s concerns and validate their feelings. Empathizing with their situation helps build trust and rapport. Express empathy by letting them know you understand their concerns and that their questions are valid. This shows you understand them and will try to make them feel confortable expressing them to you.

Educate

In many instances, objections come up due to a lack of information or a misunderstanding. Take the time to educate clients about Medicare coverage options, benefits and available plans. Provide clear explanations tailored to their specific needs and preferences. In some cases, you may need to send a brochure or use online resources like websites or zoom meetings to provide a visual aid to help expalin complex information.

Address concerns

Always remember, each client’s objections are unique. Tailor your responses, so tailor accordingly. If a client is concerned about out-of-pocket costs, discuss Medicare plans that offer cost-saving benefits, such as low premiums, low copays or value added benefits.

Offer solutions

Do not dismiss objections; provide solutions that address the client’s concerns. For example, if budget is the main objection, discuss Medicare plan options with varying premiums or if appropriate, discuss financial assistance programs. Providing personalized solutions shows the cleint you are able to meet their client’s coverage and budgetary needs.

Common objections and how to respond

Why are you calling

Let the prospect know where you got their information from and let them know you are a licensed agent who provides free consultations for Medicare enrollees. Tell them you called to answer any questions they have and from there see what products they are interested in discussing.

Not interested

Acknowledge the objection and request a few minutes to explain the potential to save a significant amount of money on healthcare costs and add needed coverage. Give them an idea of how your advice can benefit them.

Already have a plan/agent

Ask if anyone explained the differences of Medicare Advantage and Medicare Supplement plans. If they are not sure, go ahead and let them know you can check and make sure they have the best coverage for their needs.

Here are a few ways to maintain your Medicare book

Ask when they last spoke with their agent and offer to go over any changes in available benefits. Ask them a few questions to determine if they have any coverage gaps. Find out if their agent mentioned ancillary products like cancer or hospital indemnity insurance and discuss the value this coverage provides.

Watch a quick YouTube video on the benefits of ancillary sales

Not on Medicare yet

Find out if they plan to retire in the near future and see if they would like to schedule a call to put a plan in place. Make sure they understand the penalties for late enrollment and offer to assist in a smooth transition process.

Don’t want to change plans

Understand what they are saying, validate their response and ask if you can contact them at another date and time when you have updated plan information they may want to consider. Ask if you can mail them your contact information in case they have questions and want assistance.

Need to ask a friend/family member

Let them know you are happy to speak with that person as well to go over the information so they are all comfortable with any changes.

Don’t want to give information over the phone

Be understanding, you are a stranger to them asking for personal information. Many people are leery of phone scams and need to be reassured of the reasons why you need the information. If they are just not comfortable answering questions on the phone, if possible, schedule an in person meeting to go over their information and present coverage options.

Watch a YouTube about our pre-set Medicare lead program

Make the sale

After all objections are addressed, you have the opportunity to present them with coverage options that fit their medical and budgetary needs. Be sure to emphasize the benefits of enrolling in a plan tailored to their needs and reassure them you will provide ongoing support and guidance.

Get some tips for telesales

It is not always easy to overcome objections in Medicare sales. Successful agents provide a combination of active listening, empathy, education, and solution-focused communication. By understanding clients’ concerns, providing relevant information, and offering personalized solutions, agents can navigate objections with confidence and successfully make the sale.

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