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TRICARE and Medicare Coverage: How the Two Work Together

Both agents and military retirees need to understand how TRICARE and Medicare coverage works in tandem. While both programs provide robust healthcare coverage, the rules around enrollment, coordination of benefits, and plan options may be confusing.

In this post, we’ll break down what TRICARE is, how it works with Medicare, key eligibility requirements, and what agents and beneficiaries need to know to ensure continuous and cost-effective coverage.

What Is TRICARE

TRICARE is the health care program for:

• Uniformed service members (active duty and retired)
• Their families
• National Guard/Reserve members
• Survivors and some former spouses

Administered by the Defense Health Agency (DHA), TRICARE provides coverage similar to private insurance plans and includes prescription drug benefits.

When a TRICARE Beneficiary Becomes Medicare-Eligible

When a TRICARE beneficiary turns 65 (or qualifies for Medicare earlier due to disability), they typically must enroll in Medicare Part A and Part B to maintain their TRICARE coverage.

Once they enroll in Medicare, TRICARE becomes TRICARE for Life (TFL).

What Is TRICARE For Life (TFL)

TRICARE for Life is the coverage that kicks in after a beneficiary becomes eligible for Medicare and enrolls in both Part A and Part B. TFL acts as a secondary payer to Medicare. Here’s how it works:

• Medicare pays first (as the primary insurance)
• TFL pays second, covering most or all of the remaining costs
• Out-of-pocket costs are minimal or nonexistent for covered services

Important: If a TRICARE beneficiary does not enroll in Medicare Part B, they will lose TRICARE coverage, unless they are an active-duty service member or family member of one.

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Coverage Details: Medicare TRICARE for Life

Service	Medicare Pays	TFL Pays	Beneficiary Pays
Doctor visits	80%	Remaining 20%	$0 (in most cases)
Hospital stay	Medicare-approved	TFL covers deductible	$0
Prescription drugs	N/A	TFL (through Express Scripts)	Varies (copays)
Services not covered by Medicare (e.g., overseas)	N/A	TFL may pay	May vary

Can TFL Beneficiaries Enroll in Medicare Advantage

Technically, yes; TFL beneficiaries can enroll in a Medicare Advantage (MA) plan, but this often creates coverage conflicts and doesn’t offer cost savings.

Agents should caution beneficiaries:

• TFL does not coordinate well with MA plans.
• Some services covered by TFL may be denied if the MA plan doesn’t approve them.
• MA plans may interfere with how TFL pays claims.

Most beneficiaries are better off staying with Original Medicare + TRICARE for Life.

Do TFL Beneficiaries Need Medicare Part D

No, TFL includes a robust pharmacy benefit through Express Scripts. Enrolling in a separate Medicare Part D plan may result in:

• Loss of TRICARE pharmacy coverage
• Unnecessary monthly premiums
• Coordination issues

Agents: When working with TRICARE beneficiaries, always ask if they use the Express Scripts program before discussing Part D options.

Key Points for Medicare Agents

• Do not sell Medicare Advantage or Part D plans to TFL beneficiaries without reviewing the consequences.
• Always verify TRICARE status before recommending plan changes.
• Turning 65 is a triggering event that requires Medicare Part A & B enrollment to keep TRICARE.
• TFL works best with Original Medicare not Advantage plans.
• Help clients plan for premium costs; Medicare Part B still has a monthly premium, even with TFL.

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Key Takeaways for Beneficiaries

• Enroll in Medicare Part A and B when eligible to keep your TRICARE benefits.
• TRICARE for Life + Medicare offers comprehensive, low-cost healthcare.
• Avoid Medicare Advantage or Part D unless you understand the impact on your TRICARE benefits.
• You do not need Medigap; TFL acts as your Medicare supplement.

For military retirees and their families, TRICARE for Life is a valuable benefit that pairs seamlessly with Medicare; when used correctly. As an agent, your role is to educate and protect beneficiaries from making decisions that could disrupt their healthcare.

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Whether you’re a veteran trying to understand your coverage or an agent assisting a retired service member, remember: when in doubt, stick with Original Medicare + TRICARE for Life.

Prescription Discount Cards And Medicare

Even with Medicare Part D or a Medicare Advantage plan that includes drug coverage, many beneficiaries still find themselves facing high out-of-pocket costs for certain medications. Some drugs may carry expensive copays, while others may not be covered by your plan at all. That is when beneficiaries might alternate using prescription discount cards and Medicare Part D to cover their costs.

Fortunately, there are discount prescription programs that can offer real savings; even for those enrolled in Medicare. In this post, we explore how cards like GoodRx, SingleCare, and Glic work, and when it may make sense to use them instead of your Medicare plan.

Prescription Discount Cards

Prescription discount cards and programs are free tools that help consumers pay less for medications by accessing negotiated rates at participating pharmacies. These cards are not insurance; they’re a form of cash payment assistance.

A few of the most popular programs include; GoodRx, SingleCare and a more recent option; Glic. These programs provide price comparisons of specific medications across local pharmacies. The programs all work in a similar manner; although one may offer a better price on a specific medication than another. Each program provides access to the discount with either digital, printable coupons or discount cards.

Each program allows the consumer to pay the discounted rate out of pocket, bypassing their insurance. This sometimes results in lower costs than a Medicare Part D copay or coinsurance, especially for medications not on your plan’s formulary.

Learn about the Medicare prescription payment program – watch a quick YouTube video

When Medicare Beneficiaries Might Use a Discount Card

There are specific scenarios where it makes sense to use a discount program rather than Medicare Part D or Medicare Advantage drug coverage:

1. The medication isn’t covered (non-formulary)

If the plan doesn’t include a drug on its formulary, or it’s in a very high-cost tier, a discount card may offer a lower out-of-pocket price.

2. During the deductible phase

In 2025, most Medicare Part D plans may have an annual deductible (up to $590). During this phase, the beneficiary pays 100% of the cost of medications classified as tier 2 or 3 as well as higher tiers, depending on the specific plan they are enrolled in. A discount card may offer a lower price than the plan’s retail cost during this period.

Of course, the beneficiary may eventually have to pay the deductible anyway depending on their prescriptions.

3. The plan copay is higher than the discount price

For brand-name or specialty drugs in higher tiers, your Medicare plan’s copay may be more than the out-of-pocket cost using a discount program.

Please keep in mind: these programs do not usually cover brand name drugs better than your Medicare plan, but it never hurts to check.

Important Considerations

• Purchases with discount cards do NOT count toward your Medicare Part D out-of-pocket spending (TrOOP)
  If you use a discount card, your payment will not help you progress toward your deductible or maximum out-of-pocket limit.
• You can’t use both Medicare and a discount card at the same time
  It’s one or the other; tell the pharmacy to process it either through your insurance or the discount card. Most pharmacies will check to see which price is better if you ask them to.
• Prices vary by pharmacy
  Always check the card’s website or app to compare pharmacy prices before filling a prescription.

How to Use a Discount Program

1. Search for the drug on the program’s website or app(be sure you enter the correct dose and amount of each medication)
2. Compare prices across pharmacies in your area
3. Show the coupon or card to the pharmacist before paying
4. Pay out of pocket at the discounted rate

Tip: Keep a screenshot or printed copy of your discount code in case your phone doesn’t have service inside the pharmacy.

Medicare Agents

Encouraging clients to explore discount programs when appropriate can strengthen client trust and help with medication adherence. If a prescription is not covered, or too costly, these programs can be a smart short-term solution. Agents should always remind clients that discount purchases do not count toward Medicare drug spending.

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Please remember; beneficiaries may be able to get a formulary exception if their medication is not on their plan’s formulary.

Programs like GoodRx, SingleCare, and Glic Rx can provide real relief when Medicare drug costs are high, or when certain medications aren’t covered at all. They’re simple to use, free to access, and often a good backup when Part D coverage doesn’t go far enough.

Just remember: discount cards are not a replacement for a comprehensive drug plan, but they can be a smart tool in your healthcare savings toolbox.

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Medicare vs. Employer Insurance: Which One Pays First

When you’re eligible for Medicare and also have employer-sponsored health insurance, things can get a little confusing. One question that comes up often: is Medicare or employer coverage primary?

The answer depends on employment status, the size of the employer, and the type of Medicare you have. Here’s what you need to know about how Medicare coordinates with employer coverage and who pays first.

Primary Payer

When you have more than one type of health coverage, the primary payer is the insurance that pays first for your healthcare services. The secondary payer may cover remaining costs, such as copayments, coinsurance, or deductibles.

Knowing which plan is primary ensures:

• Your claims are processed correctly
• You avoid unexpected bills
• You stay compliant with Medicare rules

General Rule: Employment Size Determines Priority

If You’re 65 or Older and Still Working

If your employer has 20 or more employees:

• Employer insurance is primary
• Medicare is secondary

If your employer has fewer than 20 employees:

• Medicare is primary
• Employer insurance is secondary

Note: The same rule applies if you’re covered under your spouse’s employer plan.

Watch a video on how Medicare works with employer coverage

Under 65 and Have Medicare Due to Disability:

If your (or your spouse’s) employer has 100 or more employees

• Employer insurance is primary
• Medicare is secondary

If the employer has fewer than 100 employees

• Medicare is primary

Retiree Coverage or COBRA

• Medicare is always primary
• Retiree plans and COBRA are considered secondary

In fact, if you delay enrolling in Medicare while on COBRA, you could lose COBRA coverage. Always sign up for Medicare Part B when first eligible to avoid penalties and gaps in coverage.

What About Veterans Benefits or TRICARE

If you have VA coverage, TRICARE, or other federal health benefits, the rules may differ:

• VA only covers care at VA facilities. If you go to a non-VA provider, Medicare pays first.
• TRICARE for Life acts as secondary coverage to Medicare for eligible military retirees.

Beneficiaries

• Don’t assume employer insurance will always pay first; check the size of the employer.
• Always inform Medicare and your employer plan that you have dual coverage so they can coordinate benefits properly.
• If Medicare is supposed to be primary and you haven’t enrolled in Part B, your employer plan may refuse to pay claims.

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Medicare OEP Open Enrollment Period

The Medicare Open Enrollment Period (OEP) runs annually from January 1 to March 31. It is specifically for individuals already enrolled in a Medicare Advantage (Part C) plan as of January 1.

This period does not apply to those with Original Medicare (Part A and B) only; it’s strictly for Medicare Advantage plan members who may want to make a one-time change.

What Changes Can You Make During OEP

Those enrolled in a Medicare Advantage plan, can make one change during the OEP. The options include:

• Switching to a different Medicare Advantage plan, with or without drug coverage
• Dropping your Medicare Advantage plan and returning to Original Medicare, with the option to add a Part D prescription drug plan

Changes You Cannot Make:

• Switch from Original Medicare to a Medicare Advantage plan
• Enroll in Part D drug coverage if you’re on Original Medicare and missed your IEP or AEP
• Make multiple changes; OEP only allows one switch

Watch a video on Medicare enrollment periods

Why Use the OEP

Here are a few common reasons beneficiaries take advantage of the Medicare OEP:

• Their current Medicare Advantage plan doesn’t cover a needed medication or provider
• They discovered higher costs or restrictions after using the plan in January
• They had a change in health and want a different plan with better specialist coverage
• They were unaware of better plan options during the Annual Enrollment Period (AEP), which runs from October 15 to December 7

How Is OEP Different from AEP

Important Considerations

• If you switch to Original Medicare during OEP, you may not be guaranteed Medigap (Medicare Supplement) coverage; unless you’re in a trial right or qualify for a Special Enrollment Period.
• Any changes made during the OEP become effective the first day of the month after the change is made (e.g., a change in February takes effect March 1).
• It’s important to review coverage early in the year to determine if your current plan still meets your needs.

Work with a Licensed Agent

The Medicare OEP is a valuable but limited opportunity to make corrections or improvements to your coverage. If you’re unsure whether your plan fits your health needs or budget, speak with a licensed Medicare agent. They can help you compare options, check provider networks and drug formularies, and make confident decisions about your healthcare.

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Understanding Medicare Coverage of Physical Therapy

Physical therapy can play a vital role in recovery from injury or illness, helping individuals regain strength, mobility, and independence. However, it can also be a time-consuming and costly process. If you’re a Medicare beneficiary, it’s important to understand Medicare coverage of physical therapy.

When Physical Therapy May Be Necessary

Physical therapy (PT) is designed to evaluate and treat conditions that limit the ability to function in daily life. The goals of PT may include:

• Restoring lost mobility or strength
• Slowing physical decline
• Managing chronic conditions
• Preventing further injury

Medicare Coverage of Physical Therapy

Most outpatient physical therapy services are covered under Medicare Part B, which includes:

• Medically necessary physical therapy
• Occupational therapy (OT)
• Speech-language pathology (SLP)

If you receive physical therapy during an inpatient stay (such as in a hospital or skilled nursing facility), Medicare Part A may cover those services as part of your inpatient benefits.

Medicare Advantage (Part C) members should refer to their plan’s Evidence of Coverage or contact the plan’s member services for specific benefits, as coverage may vary by plan.

Eligibility & Medical Necessity

For Medicare to cover physical therapy:

• The services must be medically necessary
• A doctor or healthcare provider must prescribe and supervise the treatment
• The patient must receive care at a facility that accepts Medicare assignment

Services must target a diagnosed condition and be part of a treatment plan with documented goals and progress reviews.

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Therapy Thresholds and the KX Modifier Rule (2025 Limits)

In 2018, Medicare eliminated the hard cap on therapy services, replacing it with a “soft cap” or threshold. This allows continued access to necessary care while tracking usage and ensuring services are medically necessary.

In 2025, the therapy thresholds are:

• $2,330 for combined Physical Therapy (PT) and Speech-Language Pathology (SLP) services
• $2,330 for Occupational Therapy (OT) services

Once a patient exceeds these thresholds, the provider must apply a KX modifier on Medicare claims to confirm that services continue to be medically necessary.

Important: These thresholds are not a hard limit. As long as therapy is medically necessary and properly documented, Medicare will continue to cover services beyond the threshold.

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What Will You Pay?

Under Medicare Part B:

• You pay the annual Part B deductible (which is $240 in 2025)

• After meeting the deductible, you’re responsible for 20% coinsurance of the Medicare-approved amount

If you have a Medicare Supplement (Medigap) plan, it may cover the 20% coinsurance. Be sure to confirm your provider accepts Medicare assignment, which ensures you’re not billed more than Medicare’s approved rates.

Agents watch a quick video on AEP Planning

Who Can Provide Covered Therapy Services?

To be covered by Medicare, therapy must be delivered by:

• A licensed Physical Therapist (PT)

• A licensed Occupational Therapist (OT)

• A licensed Speech-Language Pathologist (SLP)

These professionals must meet Medicare’s credentialing and billing requirements.

Documentation and Progress Tracking

For continued Medicare coverage, your therapy provider must:

• Track and document your progress

• Demonstrate ongoing medical necessity

• Review and update your care plan as needed

Active participation in your therapy plan and attending all scheduled sessions are key to both recovery and continued coverage.

With understanding and guidance, accessing the necessary physical therapy services is easy and comes without added financial stress. 

Beneficiaries enrolled in a Medicare Advantage plan should review plan-specific benefits or contact their Medicare agent or your plan’s customer service for details. 

Understanding the Different Types of Medicare Advantage Plans

Medicare Advantage (Part C) plans offer an all-in-one alternative to Original Medicare, often including additional benefits like dental, vision, hearing, and even prescription drug coverage. These plans are offered by private insurance companies approved by Medicare. Whether you’re a Medicare beneficiary or an agent helping clients make informed decisions, understanding the different types of Medicare Advantage plans is essential.

There are many types of Medicare advantage plans to consider when choosing coverage that best fits your needs. Here’s a breakdown of the main types of MA plans available:

HMO (Health Maintenance Organization) Plans

Key Features:

• Requires members to use a network of doctors and hospitals.
• Members must choose a Primary Care Physician (PCP).
• Referrals are usually needed to see a specialist.
• Most HMO plans include prescription drug coverage (Part D).

Best for: People who are comfortable with a coordinated care approach and staying within a specific provider network to keep costs low.

PPO (Preferred Provider Organization) Plans

Key Features:

• Offers more flexibility in choosing healthcare providers.
• You can see out-of-network providers, usually at a higher cost.
• No need to choose a PCP or get referrals for specialists.
• Often includes Part D prescription drug coverage.

Best for: Those who want the freedom to see any doctor or specialist without a referral and are willing to possibly pay a bit more for that flexibility.

SNPs (Special Needs Plans)

Key Features:

• Tailored for individuals with specific diseases, health conditions, or financial needs.
• Types include:
  • C-SNPs: For people with chronic conditions (e.g., diabetes, heart disease).
  • D-SNPs: For dual-eligible individuals (Medicare and Medicaid).
  • I-SNPs: For people in institutional care (like nursing homes).
• Always includes prescription drug coverage.
• Offers care coordination and case management.

Best for: Individuals with specific medical, financial, or living circumstances who need a personalized care approach.

PFFS (Private Fee-for-Service) Plans

Key Features:

• Allows you to see any Medicare-approved provider who agrees to the plan’s payment terms.
• No need to choose a PCP or get referrals.
• Some PFFS plans include drug coverage; others don’t.

Best for: People who want flexibility and are comfortable checking whether their provider will accept the plan’s terms.

POS (Point of Service) Plans

Key Features:

• A hybrid of HMO and PPO.
• You can go out-of-network for certain services, often with higher copays or coinsurance.
• Requires a PCP and referrals for specialists (when in-network).
• May include drug coverage.

Best for: Beneficiaries who like the care coordination of an HMO but want some out-of-network flexibility.

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MSA (Medical Savings Account) Plans

Key Features:

• Combines a high-deductible health plan with a savings account that Medicare deposits money into.
• Funds can be used to pay for qualified medical expenses.
• Does not include Part D coverage; must be purchased separately.

Best for: Those who prefer managing their own health savings and expenses and are comfortable with high deductibles.

Watch a quick YouTube video on why agents should include ancillary products with MA sales

Choosing the Right Medicare Advantage Plan

When evaluating which type of plan is best for you or your client, consider:

• Provider access: Do you want to stay in-network or have more flexibility?
• Prescription needs: Is Part D coverage important?
• Cost preferences: Would you rather pay higher premiums for lower out-of-pocket costs or vice versa?
• Health conditions: Are there chronic conditions or Medicaid eligibility that might qualify for an SNP?

Each Medicare Advantage plan type offers different benefits, restrictions, and costs. Understanding these differences is the key to selecting the most suitable coverage.

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Medicare TrOOP Costs: What Beneficiaries and Agents Need to Know

When it comes to Medicare Part D prescription drug coverage, there’s one term that often causes confusion but plays a big role in how much a beneficiary pays: TrOOP. In this post, we explain Medicare Part D TrOOP Costs and their effect on the client’s costs for prescription medication.

Whether you’re a Medicare beneficiary trying to understand your coverage or a Medicare agent helping clients navigate their plans, understanding TrOOP is essential.

What Is TrOOP

TrOOP (True Out-of-Pocket) costs refers to the amount a Medicare beneficiary pays for covered prescription drugs before reaching catastrophic coverage under a Part D plan. These costs include deductibles, copays, and coinsurance for medications covered by the plan.

TrOOP is used to track a beneficiary’s spending so that Medicare knows when to move them through the different Part D coverage phases.

What Counts Toward Medicare Part D TrOOP Costs

Not everything a beneficiary pays will count toward TrOOP. Only qualified out-of-pocket spending applies. Here’s what counts:

• Annual deductible (if applicable)
• Copays and coinsurance for formulary drugs (covered by your plan)
• Payments made by:
  • The beneficiary
  • A family member
  • State Pharmaceutical Assistance Programs (SPAPs) or the Federal Government’s Extra Help Program.

What Doesn’t Count Toward Medicare Part D TrOOP Costs

Some expenses don’t count toward your TrOOP total, including:

• Monthly premiums for the Part D plan
• Drugs not covered by the plan (not on the plan’s formulary). Although, if the drug is approved via exception or appeal, it does count towards the TrOOP
• Over-the-counter (OTC) drugs
• Drugs purchased outside of the U.S.
• Payments by other insurance (e.g., employer group plans or TRICARE)

TrOOP and the 3 Phases of Part D

To understand how TrOOP affects drug costs, it helps to review the stages of Medicare Part D:

1. Deductible Phase
   • The beneficiary pays 100% of their drug costs until they meet the deductible.
2. Initial Coverage Phase
   • Beneficiaries pay about 25% of the cost for formulary drugs in the form of copays or coinsurance until they reach $2,000 out of pocket (the initial coverage limit).
3. Catastrophic Coverage Phase
   • After TrOOP reaches a set amount ($2,000 in 2025, increasing in 2026), the beneficiary pays $0 for covered drugs once they have hit the TrOOP under the new 2025 rules.

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Key Takeaways for Beneficiaries and Agents

• TrOOP helps Medicare track spending to determine when beneficiaries qualify for better cost-sharing.
• Only qualified out-of-pocket costs count.
• In 2025, TrOOP maxes out at $2,000; a major win for Medicare enrollees.
• Medicare agents should explain TrOOP carefully when helping clients compare drug plans or estimate yearly costs.

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CMS 2026 Part D Redesign & the Executive Order on Drug Prices

Starting January 1, 2026, CMS will implement Medicare Part D redesign 2026 updates that were put in place by the Inflation Reduction Act. They will also enact the new Most-Favored-Nation (MFN) Executive Order issued May 12, 2025. The goal of these actions is to better align U.S. drug prices with those paid by other high-income nations.

CMS 2026 Part D Redesign: Key Cost Updates

• $615 deductible before coverage kicks in.
• Initial Coverage Phase: beneficiary pays 25% coinsurance; 65% is plan-covered, and manufacturers cover 10% (plus CMS provides a 10% subsidy on select negotiated drugs)
• Out-of-Pocket Cap: annual TrOOP limit rises to $2,100 in 2026
• Catastrophic Phase: beneficiaries pay $0; plans cover 60%, manufacturers 20%, CMS 20–40%

Watch a video on the CMS Medicare Final Rule Proposal

Selected Drug Subsidy Program & Negotiated Prices

The Direct price negotiations initiated under the IRA (Inflation Reduction Act) for the first 10 high-cost Part D drugs begins in 2026. These selected drugs also qualify for a 10% subidy, provided by CMS during the initial coverage phase.

Additionally; the expected savings for medicare is estimated at about $6 billion with an estimate of $1.5 billion in savings on beneficiary out-of-pocket costs.

Executive Order: Most-Favored-Nation Pricing (May 12, 2025)

• Directs agencies (HHS, CMS, Commerce, USTR) to benchmark U.S. drug prices against the lowest prices in OECD nations
• Encourages direct-to-consumer drug purchasing programs at these international prices
• Includes authority to impose tariffs or regulatory action if manufacturers don’t comply within 30 days
• Targets anti-competitive practices, middlemen reforms, accelerated generic and biosimilar availability, and simplified importation
• Reform measures also extend to Medicaid and facilitate value-based pricing and site-neutrality
• Implementation faces legal uncertainties, with pharmaceutical leaders raising concerns over future innovation and practicality

Medicare Prescription Payment Plan (MPPP) Updates

• Auto re-enrollment with a 3-day opt-out window for returning participants
• No extra fees and pharmacy reimbursement within 14 days (e-claims) or 30 days (paper)
• All plans must include smoothed monthly billing as an alternative to per-fill copays

What Agents Can Do

Emphasize cost cap increases: deductible ($615) and TrOOP ($2,100), and detail catastrophic phase structure.

Promote savings with negotiated drug program: mention the overall savings after the TrOOP is reached.

Educate clients about MPPP; how monthly smoothing can reduce sticker shock and how to opt out.

Highlight executive order impacts; both MFN implications and ongoing drug price negotiations that can give them additional price drops or new purchasing options.

Address drug import possibility from Canada, pending MFN implementation.

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What This Means for Agents & Clients

• Lower costs for select medications due to CMS negotiations and MFN pricing policies
• Enhanced predictability and affordability via MPPP
• Opportunities in marketing: position these changes as saving tools during Open Enrollment
• Stay alert to implementation updates and legal progress on MFN rules

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What Is Long Term Care and How Do You Pay for It

As we age, many of us require help with the activities of daily living such as; bathing, dressing, eating, or using the bathroom. When you receive assistance for these activities, this is called long-term care. Understanding what is long term care, what it includes and how to pay for it is essential to plan a secure and dignified future.

Long-Term Care

Long-term care (LTC) refers to a wide range of services and supports that help people with chronic illnesses, disabilities, or aging-related conditions. Unlike acute medical care that treats illness or injury, LTC focuses on personal care rather than a cure.

Long-term care can include:

• Help with Activities of Daily Living (ADLs): bathing, dressing, toileting, eating, transferring, and continence.
• Skilled nursing care in a facility
• In-home care and personal care aides
• Adult day programs
• Assisted living facilities
• Memory care for individuals with Alzheimer’s or dementia

Who Needs Long-Term Care

According to government estimates, about 70% of people turning 65 today will need some form of long-term care during their lifetime. The need may appear gradually due to aging or suddenly after a stroke, fall, or medical event.

Long-Term Care Cost

Please note; costs vary widely based on location and the type of care, but here are national averages (as of 2025):

• In-home care aide: $33/hour
• Assisted living facility: $6,077/month
• Nursing home (semi-private room): $9,555+/month

As you can see, these services are expensive and can quickly deplete savings, making it critical to understand the options for covering them.

Paying For Long-Term Care

Medicare

Medicare does not cover most long-term care. It may pay for short-term, skilled nursing care or rehab (up to 100 days following a hospital stay), but does not cover custodial care (help with dressing or bathing).

Medicaid

Medicaid is the largest payer of long-term care services, but it’s needs-based. You must meet strict income and asset limits to qualify. Some states offer Medicaid waiver programs that allow people to receive care at home instead of in a facility.

Helpful tip: Planning ahead can help individuals spend down assets legally and qualify for Medicaid when needed.

Long-Term Care Insurance

LTC insurance helps cover costs in various settings; home, assisted living, or nursing facilities. These policies vary by coverage and price, and premiums are lower if purchased earlier (typically in your 50s or early 60s).

Some modern alternatives include:

• Hybrid life/LTC policies: Combine life insurance with long-term care benefits
• Critical illness or short-term care plans

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Veterans Benefits

Eligible veterans may qualify for Aid and Attendance or other VA programs that help pay for in-home care or facility care.

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Personal Savings and Assets

Many people use retirement savings, home equity (via reverse mortgage or sale), or income to pay for care out of pocket. This is often the first source of funding before qualifying for Medicaid.

Family Support

Informal caregiving from family members is common, although it can be emotionally and financially draining. Some states offer compensation for family caregivers under Medicaid waiver programs.

Long-term care is an important but often overlooked part of retirement planning. Understanding what services may be needed and exploring funding options early can protect assets, ensure quality care, and reduce the emotional burden on loved ones.

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If you’re helping clients or preparing for your own future, consider speaking with a financial advisor, insurance professional, or elder law attorney to explore your options and build a solid plan.

Understanding Medicaid Spend Downs: What It Is and How It Works

For many individuals, especially older adults and those with disabilities, affording healthcare and long-term care can be a significant financial challenge. Medicaid offers crucial support, but not everyone qualifies based on income or asset limits. That’s where understanding Medicaid Spend Downs is important. It is a pathway to eligibility for those who exceed Medicaid’s financial thresholds but still have high medical costs.

What Is Medicaid Spend Down

Medicaid Spend Down is a process that allows individuals with income or assets above Medicaid eligibility limits to “spend down” their excess resources on medical expenses to qualify for Medicaid coverage. It’s similar to an insurance deductible; once you’ve paid out a specific amount in medical bills, you become eligible for Medicaid assistance for the rest of the period.

There are two common types of spend down:

• Income Spend Down: For people whose monthly income is too high but who have recurring medical expenses.
• Asset Spend Down: For those whose savings or property exceed Medicaid’s asset limits.

Who Needs a Spend Down

Spend down is often needed by:

• Seniors over age 65
• Individuals with disabilities
• People in need of long-term care
• Those receiving home and community-based services

For example, someone with a small pension or Social Security income that slightly exceeds their state’s Medicaid income limit might still qualify if they have regular out-of-pocket medical costs like prescription drugs, doctor visits, or even insurance premiums.

How Does It Work

Each state administers Medicaid differently, so spend down rules and procedures vary. However, the basic process looks like this:

1. Determine Excess Income/Assets: Compare income or resources to the state’s Medicaid limits.
2. Calculate the Spend Down Amount: This is the amount you must use for medical expenses to qualify.
3. Submit Proof: Provide receipts or bills to your state Medicaid office as evidence of your medical expenses.
4. Become Eligible: Once you meet your spend down requirement, Medicaid covers your additional medical costs for a certain period; often between one and six months.

Agents, watch a quick video on the quarterly SEP for dual and drug help elimination 2025

What Counts Toward a Spend Down

Expenses that may count include:

• Unpaid medical bills
• Prescription drugs
• Health insurance premiums
• Doctor and hospital visits
• In-home care services
• Medical equipment

Important Considerations

• Timing Matters: Medicaid coverage through spend down is usually limited to specific timeframes (e.g., a one- or six-month period). Beneficiaries will need to re-qualify at the end of each spend down period. The length of each spend down varies by state.
• Asset Rules Are Strict: Some assets are exempt (like your home or one vehicle), but others may need to be spent down or placed in a trust.
• Documentation Is Key: Keep all receipts and records of medical expenses as proof.

Medicaid Spend Down can be a lifeline for those who need healthcare but don’t meet traditional financial eligibility criteria. It requires careful planning and documentation, but it opens the door to critical services like long-term care and in-home support.

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If you or a client may benefit from Medicaid but don’t meet the income or asset limits, a CMP (Certified Medicaid Planner) or elder law attorney can provide spend down options and help beneficiaries make informed decisions.