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Medicare Supplement Underwriting Explained

When clients start exploring Medicare Supplement (Medigap) plans, one topic that often causes confusion is underwriting. Unlike Medicare Advantage plans, which don’t require medical underwriting, Medigap coverage can involve health-related questions and approval requirements; depending on when and how someone applies. That is why we hope, Medicare supplement underwriting explained will provide an understanding of the process so agents can better assist clients.

What Is Medicare Supplement Underwriting

Underwriting is the process insurance companies use to determine whether to accept an applicant for a Medigap policy, and sometimes the determine the premium amount. This process often involves answering health questions, reviewing prescription history, or even checking recent hospitalizations.

Not every applicant will face underwriting, many people qualify for guaranteed issue rights or are in their Medigap Open Enrollment Period, which means they can get a plan without medical review.

When Is Underwriting Required

Underwriting typically comes into play in these situations:

• Applying outside the Medigap Open Enrollment Period (which lasts six months after a beneficiary first enrolls in Part B at age 65).
• Switching from one Medigap plan to another outside of specific state-mandated open enrollment or “birthday rules.”
• Losing coverage without qualifying for guaranteed issue rights.

In these cases, insurance carriers can:

• Approve coverage at the standard rate,
• Charge a higher premium,
• Impose a waiting period for pre-existing conditions, or
• Deny coverage altogether.

Guaranteed Issue Rights (No Underwriting Required)

There are special circumstances where a beneficiary can enroll in a Medigap plan without facing underwriting, such as:

• Losing employer or union coverage.
• Their Medicare Advantage plan leaving the service area or ending coverage.
• Moving out of a Medicare Advantage plan’s service area.
• Taking advantage of certain state-specific enrollment protections (like California and Oregon’s Birthday Rule, or Missouri’s Anniversary Rule).

During these times, carriers must offer coverage, regardless of health status.

Watch a quick YouTube video on Medicare Supplement Underwriting

Common Health Questions in Underwriting

While exact questions vary by carrier, underwriting often includes:

• Recent heart attacks, strokes, or cancer diagnoses.
• Use of oxygen, dialysis, or organ transplants.
• Height, weight, and mobility concerns.
• Hospitalizations in the past 90 days.
• Use of certain expensive medications.

Carriers typically ask about conditions that are costly and ongoing. Clients with stable, controlled conditions may still qualify.

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Why Agents Should Understand Underwriting

As an agent, knowing the underwriting rules helps you:

• Advise clients on the best time to apply for Medigap coverage.
• Set realistic expectations about approvals, denials, or higher premiums.
• Protect clients by helping them avoid losing a plan they may not be able to requalify for later.

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Underwriting for Medicare Supplements can be straightforward if clients apply at the right time, but tricky if they wait too long or want to change plans later. By understanding the process and knowing when underwriting applies, you can help your clients secure coverage that supports their health and budget without unexpected roadblocks.

Medicare’s 2026 Drug Price Negotiations: A New Era of Affordability

Starting January 1, 2026, Medicare will implement its first-ever negotiated prescription drug prices; a historic change that could lower costs for millions of beneficiaries. In this post, we discuss Medicare’s 2026 Drug Price Negotiations. This is a direct result of the Inflation Reduction Act of 2022, which for the first time gave Medicare the authority to negotiate the prices of certain high-cost medications.

Why This Matters

For decades, Medicare was prohibited from negotiating directly with drug manufacturers. Instead, it relied on private Part D plan sponsors to manage drug costs. The 2026 negotiations mark a turning point. Medicare will now establish a Maximum Fair Price (MFP) for select drugs, reducing both what the government pays and what beneficiaries spend at the pharmacy counter.

• Projected Medicare savings: About $6 billion in 2026
• Projected out-of-pocket savings for beneficiaries: About $1.5 billion

The First 10 Drugs Negotiated for 2026

CMS chose these drugs because; they are some of the highest-cost Part D medications. In addition; there are no generic or biosimilar medications available, and are widely prescribed.

1. Eliquis – blood thinner for preventing stroke and blood clots
2. Xarelto – blood thinner for reducing risk of clotting
3. Januvia – diabetes medication (DPP-4 inhibitor)
4. Jardiance – diabetes, heart failure treatment (SGLT2 inhibitor)
5. Farxiga – diabetes, heart failure, kidney disease treatment (SGLT2 inhibitor)
6. Entresto – heart failure medication
7. Enbrel – rheumatoid arthritis and autoimmune conditions
8. Stelara – psoriasis, Crohn’s disease, ulcerative colitis
9. Imbruvica – blood cancers (leukemias and lymphomas)
10. NovoLog / Fiasp – fast-acting insulin for diabetes

How Beneficiaries Will Benefit

• Lower copays and coinsurance: Out-of-pocket costs will drop for patients taking these medications.
• Broader affordability: Even if you don’t take one of these drugs, Medicare’s overall savings help stabilize Part D premiums.
• Expanded impact in future years: In 2027 and beyond, CMS has scheduled more drugs for negotiation.

Watch a YouTube video on the Inflation Reduction Act and Changes to Medicare

What Comes Next

• 2027: Fifteen more high-spend drugs are already set to be negotiated, with prices effective January 1, 2027.
• 2028 and beyond: CMS will continue expanding the program, selecting additional drugs each year.
• Rulemaking: Starting in 2026, the program shifts to a formal rulemaking process, adding more transparency.

Challenges and Legal Pushback

The pharmaceutical industry has filed multiple lawsuits challenging Medicare’s new authority, arguing that price negotiations are unconstitutional. At the same time, new legislation has delayed or exempted certain blockbuster drugs, such as Keytruda, from early negotiation. While these challenges could affect the program’s scope, the 2026 savings are locked in and moving forward.

What You Should Do

• Review your Medicare Part D plan during open enrollment to ensure it covers your prescriptions at the lowest cost.
• Talk to your agent if you take any of the drugs on the 2026 negotiation list, you could see meaningful savings.
• Stay informed about future negotiation cycles, as more medications are added each year.

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Medicare’s 2026 drug price negotiations represent a historic shift in prescription drug policy. For the first time, Medicare is actively reducing the cost of some of the most expensive and widely used medications in the program. While legal and political challenges remain, the immediate savings for beneficiaries and taxpayers are significant—and this is only the beginning.

Levels of D-SNP Eligibility Explained for Medicare Clients

Dual Eligible Special Needs Plans (D-SNPs) are Medicare Advantage plans designed for people who qualify for both Medicare and Medicaid. These plans can be a tremendous help to clients who have limited income and resources, but understanding the levels of DSNP eligibility and plan types can sometimes be confusing.

As of 2025, understanding the levels of D-SNP eligibility and how they connect to different plan structures is more important than ever for agents. Here’s a simplified breakdown.

Full vs. Partial Dual Eligibility

Full Dual Eligible Members

• Who qualifies
  Clients in categories such as Qualified Medicare Beneficiary Plus (QMB+), Specified Low-Income Beneficiary Plus (SLMB+), or Full Benefit Dual Eligible (FBDE).
• What does this mean
  These are individuals with the highest financial or health-related needs. States decide who qualifies, often based on strict income, asset, or disability requirements.
• Why it matters in 2025:
  Only full dual members can use the monthly D-SNP Special Enrollment Period (SEP) if there’s a HIDE or FIDE plan in their area.

Partial Dual Eligible Members

• Who qualifies
  Categories include Qualified Medicare Beneficiary (QMB), Specified Low-Income Beneficiary (SLMB), Qualified Individual (QI), and Qualified Disabled Working Individual (QDWI).
• What does this mean?
  These members get some help with Medicare costs, such as Part B premiums, but they do not qualify for full Medicaid benefits.
• Why it matters:
  Partial duals can join certain D-SNPs, but they don’t have access to the monthly SEP; only the regular Medicare enrollment windows (AEP, OEP).

Watch a YouTube video on DSNP Changes for 2025

Types of D-SNPs

D-SNPs are also categorized by how much Medicare and Medicaid benefits are integrated. Here’s what agents should know:

• Highly Integrated D-SNP (HIDE):
  • Covers Medicaid services such as behavioral health or long-term services and supports (LTSS).
  • As of 2025, the Medicaid contract must cover the D-SNP’s entire service area.
• Fully Integrated D-SNP (FIDE):
  • Combines both Medicare and Medicaid under one entity.
  • Must include primary and acute Medicaid services, plus LTSS (at least 180 days of nursing facility coverage).
  • Offers the highest level of integration and coordination between Medicare and Medicaid benefits.
• Applicable Integrated Plan (AIP):
  • A FIDE or HIDE plan with exclusively aligned enrollment.
  • Works directly with Medicaid managed care organizations tied to the D-SNP’s parent company.
• Coordination-Only D-SNP (CO):
  • Meets CMS minimum requirements but doesn’t integrate as fully as HIDE or FIDE plans.
  • Still required to coordinate Medicare and Medicaid services and share information between programs.
• Exclusively Aligned Enrollment (EAE):
  • Limits enrollment to full duals whose Medicaid is through the same company that operates the D-SNP.
  • Allows for better integration (single ID card, unified appeals and grievances, simplified materials).

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Why This Matters for Agents

• Enrollment rules are changing. As of 2025, only full duals with HIDE or FIDE plans in their service area can use the monthly SEP.
• Integration levels affect care. The more integrated the plan (like FIDE or HIDE), the easier it is for clients to navigate benefits and reduce confusion.
• Educating clients builds trust. Explaining eligibility clearly helps clients understand why they qualify (or don’t) for certain plans and enrollment periods.

The levels of D-SNP eligibility; full vs. partial, determine not just what benefits clients receive but also when they can enroll. On top of that, the type of D-SNP (HIDE, FIDE, CO, AIP) affects how well Medicare and Medicaid benefits work together.

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For agents, simplifying these distinctions is key. By guiding clients through their eligibility level and helping them choose the right type of D-SNP, you can ensure they get the maximum financial protection and coordinated care available.

Medicare Prescription Drug Coverage: Why Agents Should Guide Their Clients

When it comes to Medicare, prescription drug coverage (Part D) is one of the most important decisions beneficiaries will make. Prescription costs can have a major impact on a person’s budget and quality of life, and the right plan can save thousands of dollars each year.

For Medicare agents, helping clients navigate their Part D options isn’t always about commissions, it’s about building long-term trust, maintaining strong relationships, and positioning yourself as a valuable resource.

Why Agents Should Assist With Part D Decisions

Client Trust and Retention

Even if you aren’t earning a commission on every Medicare Prescription Drug Plan, guiding your clients through their choices shows that you care about their overall well-being. Beneficiaries notice when an agent takes the time to help without a financial incentive. That trust builds loyalty, which translates to long-term client retention.

The Importance of Enrolling on Time

Many beneficiaries don’t realize that failing to enroll in Medicare prescription drug coverage when first eligible or going without creditable drug coverage for more than 63 continuous days can lead to a lifetime late enrollment penalty (LEP). This penalty is added to the monthly Part D premium and grows the longer someone goes without coverage.

As an agent, explaining this to clients ensures they understand the financial consequences of delaying enrollment. Helping them avoid unnecessary penalties is another way to build trust and showcase your expertise.

Strengthening Relationships

By reviewing drug coverage options, you’re demonstrating your commitment to helping clients find the most cost-effective and comprehensive plan. This not only makes clients more likely to refer friends and family, but it also establishes you as their go-to resource for future Medicare needs.

Positioning Yourself for Additional Sales Opportunities

Helping with prescription drug coverage is often the first step toward uncovering other gaps in coverage. Once trust is built, clients may be more open to discussing:

• Medicare Supplement plans (Medigap): To help with out-of-pocket costs not covered by Original Medicare.
• Ancillary products: Such as dental, vision, hearing, short-term care, or critical illness coverage. These plans can provide extra protection and peace of mind for expenses Medicare doesn’t cover.

Watch a quick YouTube video on how to deal with non-commissionable PDP plans

Showing That You Put Clients First

Beneficiaries can feel overwhelmed by the number of plan choices. When you guide them, without focusing on commissions, you prove that your priority is their best interest. This approach differentiates you from competitors and builds long-term credibility.

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The Bottom Line

Helping clients choose the right Medicare Prescription Drug Plan isn’t just about filling out enrollment forms; it’s about demonstrating integrity, earning trust, and protecting clients from costly mistakes like lifetime penalties.

Even when commissions aren’t involved, the time you invest in helping clients with their Part D decisions will pay off in other ways: stronger retention, new sales opportunities, and a reputation for truly putting clients first. With the client’s permission, agents can run the comparison and send the recommendation through a quick email. If the best option is a non-commissionable plan, clients can easily self-enroll through medicare.gov or a phone call to the carrier.

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Please keep in mind, it is always important to follow all CMS enrollment rules.

By taking a holistic approach, you not only help clients get the coverage they need, you also ensure your business continues to grow through loyalty, referrals, and expanded product offerings.

Why Choose an HMO

When selecting a Medicare Advantage plan, one of the most common choices is a Medicare HMO (Health Maintenance Organization) plan. While Medicare Advantage plans come in different forms; such as PPOs, PFFS, and SNPs, HMO plans continue to be a popular option for many beneficiaries. But what makes them attractive, and why choose an HMO plan over other types of Medicare Advantage coverage?

Lower Monthly Premiums

HMO plans often come with lower monthly premiums compared to PPOs and some Medigap options. In fact, many HMO Medicare Advantage plans are available with a $0 monthly premium (though you must still pay your Part B premium). This makes them a budget-friendly choice, especially for retirees on fixed incomes.

Predictable Costs

With set copays for doctor visits, hospital stays, and prescriptions, Medicare HMO plans can make it easier to budget healthcare expenses. Instead of worrying about large unexpected bills, members often have a clearer idea of what their out-of-pocket costs will be.

Coordinated Care

The HMO plan designed encourages coordinated care. Beneficiaries select a primary care physician (PCP) who manages their overall health and provides referrals to specialists when needed. This system helps reduce unnecessary testing and ensures care is streamlined across providers.

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Extra Benefits Beyond Original Medicare

Original Medicare (Parts A and B) does not cover certain benefits like dental, vision, hearing, or fitness programs. Many HMO Medicare Advantage plans include these extras, along with prescription drug coverage (Part D). This makes HMO plans a convenient “all-in-one” package for many beneficiaries.

Lower Out-of-Pocket Maximums

Unlike Original Medicare, which does not cap spending, Medicare HMO Advantage plans include an annual out-of-pocket maximum. Once this limit is reached, the plan pays 100% of covered costs for the rest of the year, offering an important layer of financial protection.

Local Network Focus

Because HMO plans require members to use a network of doctors and hospitals, they often negotiate better rates, helping keep costs down. For beneficiaries who primarily receive care close to home, an HMO network may be more than sufficient.

Is an HMO Right for You

While HMO plans offer many advantages, everyone is different and has their own coverage needs. The main limitation is that you must use providers within the plan’s network (except in emergencies). If you prefer flexibility to see specialists without referrals or want coverage that extends more broadly outside your area, a PPO or Medigap plan may be a better choice.

However, for Medicare beneficiaries looking for affordable, coordinated, and benefit-rich coverage, a Medicare HMO is often an excellent option.

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When is a Referral Required – Which Medical Services Require a Referral

Navigating the healthcare system can sometimes feel overwhelming, especially when it comes to understanding when you need a referral to see a specialist. A referral is essentially a written order from your primary care provider (PCP) that allows you to receive care from another doctor, specialist, or healthcare service. But referrals aren’t always required, when is a referral required; that depends on the health insurance plan and the type of care needed.

Why Referrals Exist

Referrals are designed to coordinate care, avoid unnecessary tests, and ensure your treatment is medically appropriate. They also help insurance companies manage costs by making sure patients start with a PCP who oversees their overall health.

When a Referral is Required

Here are common situations where you’ll likely need a referral:

1. HMO (Health Maintenance Organization) Plans
   • Most HMO plans require you to have a referral before seeing a specialist.
   • Without a referral, the plan may not cover the service, leaving you responsible for the full cost.
2. Specialty Care
   • Services like dermatology, cardiology, orthopedics, and other specialist visits often need a referral under certain insurance plans.
3. Imaging and Diagnostics
   • Advanced tests such as MRIs, CT scans, or certain lab work may require a referral or prior authorization.
4. Out-of-Network Care
   • If your plan allows out-of-network services, you may need a referral and pre-approval for coverage.
5. Medicare Advantage (Part C) Plans
   • Many Medicare Advantage HMOs require referrals to see specialists.
   • PPO-style Medicare Advantage plans usually allow you to see specialists without referrals, though costs may be higher if you go out-of-network.

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When a Referral May Not Be Required

Not every plan or situation requires a referral. Examples include:

• PPO (Preferred Provider Organization) Plans – Generally, you can see specialists without a referral, but in-network providers will be more cost-effective.
• Emergency Care – True emergencies do not require a referral.
• Preventive Services – Annual wellness exams, certain screenings, and vaccinations are usually covered without a referral.
• Original Medicare – If you have Medicare Part A and Part B (without a Medicare Advantage plan), you typically do not need referrals to see specialists.

Watch a YouTube video on Medicare enrollment periods

How to Know if You Need a Referral

• Check Your Plan Documents – Your insurance card or plan booklet will outline referral requirements.
• Ask Your PCP – If you’re unsure, your primary doctor can confirm whether you need a referral for the service you’re seeking.
• Call Your Insurance Provider – The member services number on your card can clarify referral rules for your coverage.

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Why This Matters

Getting care without the proper referral could result in unexpected bills or denied claims. Knowing when referrals are required can save you time, money, and stress—and ensure your care stays coordinated across providers.

Using HSAs with Medicare: What Beneficiaries and Agents Need to Know

Health Savings Accounts (HSAs) are a valuable tool for people with high-deductible health plans (HDHPs), allowing them to set aside pre-tax dollars for qualified medical expenses. However, once Medicare enters the picture, the rules change. For Medicare beneficiaries and the agents who guide them, it’s important to understand how using HSAs with Medicare works. There are important changes when Medicare begins, so educating your clients help them use those funds wisely.

Can You Contribute to an HSA While on Medicare

The short answer: no.

Once someone enrolls in any part of Medicare (Part A, Part B, or both), they are no longer eligible to make contributions to an HSA. Because Medicare is not considered a high deductible health plan, The IRS prohibits contributions after Medicare enrollment.

Key timing note:

• Many people are automatically enrolled in Medicare Part A at age 65 if they are already taking Social Security benefits. This means their HSA contribution eligibility ends immediately.
• If a person delays Medicare enrollment (and Social Security benefits) while still working and covered by an employer-sponsored HDHP, they can continue contributing to their HSA until Medicare coverage begins.

Watch a YouTube video about Medicare and employer coverage

Using HSA Funds After Enrolling in Medicare

While contributions must stop, the good news is that HSA funds remain available for future use. Beneficiaries can use those dollars tax-free on a wide range of expenses, including many costs associated with Medicare.

Eligible Medicare-related expenses include:

• Medicare Part A, Part B, and Part D premiums
• Medicare Advantage (Part C) plan premiums
• Out-of-pocket costs like deductibles, copays, and coinsurance
• Dental, vision, and hearing expenses not covered by Medicare
• Prescription drugs (both covered and not covered by Medicare)

Important restriction: Beneficiaries cannot use HSA funds to pay for Medigap (Medicare Supplement) plan premiums.

Tax Benefits of Using an HSA with Medicare

• Tax-free withdrawals: As long as beneficiaries use funds for qualified medical expenses, withdrawals are tax-free.
• Penalty-free withdrawals after age 65: Even if funds are used for non-medical expenses, the 20% penalty is waived after age 65. However, the IRS taxes those withdrawals as regular income.

This flexibility makes HSAs a powerful retirement planning tool—especially for covering health costs, which typically rise with age.

Guidance for Medicare Agents

For agents advising clients, it’s helpful to remember:

1. Ask about employer coverage: If clients are still working past 65 and covered under an HDHP, delaying Medicare could allow them to continue building HSA savings.
2. Review timing carefully: Enrolling in Medicare Part A retroactively (up to 6 months) can affect HSA contribution eligibility and may trigger penalties if excess contributions are made.
3. Highlight the benefits of saved funds: Even if contributions stop, those HSA balances can play a big role in covering Medicare premiums and out-of-pocket costs.

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HSAs and Medicare don’t work together in the traditional sense; contributions must stop once Medicare begins. But the funds already in the account can provide significant financial relief for medical costs in retirement. For Medicare beneficiaries, understanding the rules ensures they maximize both their HSA and Medicare benefits. For agents, this knowledge is another way to bring clarity and value to client conversations.

SEPs for Medicare Part B Enrollment

For Medicare beneficiaries, the timing of enrollment is very important. While most people enroll in Medicare Part B during their Initial Enrollment Period (IEP) when they first become eligible, life circumstances don’t always fit neatly into those timelines. That’s where SEPs for Medicare Part B enrollment come in.

SEPs provide and opportunity for beneficiaries to sign up for Part B outside of their IEP or the GEP(General Enrollment Period), without facing late enrollment penalties, provided they meet certain conditions.

What is Medicare Part B

Medicare Part B helps cover outpatient care, doctor visits, preventive services, lab work, durable medical equipment, and more. Since it comes with a monthly premium, some people delay enrolling—especially if they’re still working and covered under an employer health plan.

When Can You Qualify for a Part B SEP

SEPs are designed to protect people who already had other coverage or experienced specific life events. Some of the most common situations include:

1. Employer or Union Coverage

• If you (or your spouse) are still working past 65 and covered by a group health plan, you can delay enrolling in Part B.
• Once that employment ends, or the employer coverage ends; you qualify for an 8-month SEP to sign up for Part B without penalty.

2. Coverage Through a Spouse

• If you’re covered under your spouse’s employer plan, the same SEP protections apply.
• This is important for individuals who retire before their spouse does, or vice versa.

3. Losing Other Creditable Coverage

• If you lose health insurance that’s considered “creditable” by Medicare standards (meaning coverage that’s at least as good as Medicare), you’ll likely qualify for an SEP.

Watch a YouTube video on Medicare enrollment periods

4. Special Circumstances (New Rules Starting in 2023)

CMS expanded SEPs to include situations such as:

• Emergency or disaster situations (declared by FEMA or other agencies).
• Employer or plan error where you were misinformed about enrollment.
• Medicaid coverage ending.
• Other exceptional conditions as determined by Medicare.

Forms you’ll need for a PArt B SEP enrollment

When enrolling in Medicare Part B during a Special Enrollment Period, most beneficiaries will need to complete two key forms:

• CMS-40B — Application for Enrollment in Medicare Part B (Medical Insurance); this is the standard enrollment form used to request Part B coverage. The beneficiary must complete this form.
• CMS-L564 — Request for Employment Information; this is the standard enrollment form beneficiaries use to request Part B coverage. It is completed by the beneficiary and their employer to verify that you had group coverage based on employment. Medicare uses it to confirm penalty free eligibility.

Please note: If your employer cannot fill out the CMS-L564, you can still submit it along with other proof of creditable coverage, such as pay stubs showing insurance deductions or health plan ID cards.

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Why SEPs Matter

Missing your enrollment period for Part B can lead to late enrollment penalties that increase your premium by 10% for each 12-month period you could have had Part B but didn’t enroll. These penalties usually last for as long as you have Medicare.

SEPs help people avoid those lifelong penalties if they had valid reasons for delaying enrollment.

Key Takeaways for Beneficiaries and Agents

• Always confirm whether an employer plan is considered creditable coverage before delaying Part B.
• Keep records of your health coverage and employment dates; Medicare often requires documentation.
• Complete both CMS-40B and CMS-L564 when applying for a Part B SEP.
• Educate clients that timing is everything. Even with an SEP, strict deadlines apply.

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Special Enrollment Periods give Medicare beneficiaries flexibility and protection when life events affect their coverage. Knowing the rules and having the right forms ready can save money, prevent penalties, and ensure continuous access to healthcare.

What Value Based Care Means

Healthcare has been shifting away from the “fee-for-service” model, and Medicare is at the center of that transformation. Traditionally, doctors and hospitals were paid based on the number of tests, procedures, or visits they provided, regardless of whether patients got healthier. What Value Based Care means is a little different. VBC rewards providers for improving patient health and keeping costs down.

The Basics of Value Based Care

Value Based Care is about quality over quantity. Instead of simply paying for services rendered, Medicare ties payments to outcomes such as:

• Better health results – like reduced hospital readmissions or better management of chronic diseases.
• Improved patient experience – including communication, accessibility, and overall satisfaction.
• Lower overall costs – through preventive care, care coordination, and reduced unnecessary treatments.

How Medicare Uses Value-Based Care

Medicare has introduced several programs and models to encourage providers to embrace VBC. Some of the key examples include:

• Accountable Care Organizations (ACOs): Groups of doctors, hospitals, and other providers who work together to give coordinated, high-quality care to Medicare patients. If they save money while meeting quality goals, they share in those savings.
• Bundled Payments for Care Improvement (BPCI): Instead of billing separately for every service, providers receive a single payment for an entire episode of care, like a hip replacement or heart surgery.
• Hospital Readmissions Reduction Program (HRRP): Hospitals receive rewards for keeping patients healthier after discharge and avoiding costly readmissions.
• Medicare Advantage Plans (MA): Many MA plans already use value-based arrangements with providers to improve preventive care and manage chronic conditions.

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Why Value-Based Care Matters

For Medicare beneficiaries, Value-Based Care means:

• More preventive services: Encouragement to get screenings, vaccines, and wellness visits.
• Better coordinated care: Doctors and specialists share information to avoid duplication and gaps.
• Healthier outcomes: The focus is on managing conditions and preventing complications, not just treating problems when they arise.

For the healthcare system overall, VBC helps reduce wasteful spending and ensures taxpayer dollars are used more effectively.

Watch a YouTube video on SEP changes for Dual, Partial Dual & LIS members

The Future of Value-Based Care

Medicare’s long-term goal is to have most of its payments tied to value instead of volume. This means more providers will be incentivized to deliver patient-centered care that is proactive, efficient, and focused on health rather than procedures.

Value-Based Care is Medicare’s way of rewarding healthcare providers for keeping patients healthier, not just for doing more. As this model continues to grow, beneficiaries can expect better care coordination, more preventive services, and a stronger focus on long-term health.

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Understanding Medicare’s SSBCI Benefits: What They Are and Who They Help

If you’re a Medicare beneficiary or a Medicare agent working with clients you may have come across the term SSBCI. It stands for Special Supplemental Benefits for the Chronically Ill; it’s part of Medicare Advantage plans (not Original Medicare). Understanding Medicare SSBCI benefits is important. These benefits are designed to help people with certain chronic health conditions live healthier, more independent lives by addressing needs that traditional Medicare doesn’t usually cover.

Let’s break down what SSBCI is, how it works, and why it’s so important.

What Are SSBCI Benefits

SSBCIs allow Medicare Advantage plans to offer non-medical supportive benefits to enrollees with serious chronic illnesses. These can include things like:

• Preloaded grocery or utility cards
• Home modifications (e.g., grab bars, ramps)
• Air purifiers or pest control
• Meal delivery
• Social or physical activity programs

The benefits come with an important rule: each benefit must show a reasonable expectation of improving, or at least maintaining, the enrollees’ health or functional status. These targeted benefits can help prevent hospital visits and keep members healthier at home.

Who Qualifies for SSBCI Benefits

To be eligible, an enrollee must meet a three-part definition of “chronically ill,” including:

1. Having one or more complex or serious chronic conditions
2. Being at high risk of hospitalization or adverse outcomes
3. Needing intensive care coordination

Eligibility standards align with what qualifies for Chronic Condition Special Needs Plans (C-SNPs), though not all plans offer SSBCIs.

How SSBCI Differs From “Regular” Medicare Advantage Benefits

Most Medicare Advantage benefits are “primarily health-related.” SSBCI benefits expand that definition to include supports that aren’t strictly medical, as long as they address a specific health condition and can reasonably be expected to improve or maintain health.

Although regular supplemental benefits might include gym memberships or dental coverage for everyone in the plan, SSBCI benefits are customized to the needs of individuals who meet specific health criteria.

Why SSBCI Benefits Matter

Holistic Support: SSBCIs target real-life challenges; nutrition, safety, social connection, that can worsen health.

Flexibility: They can be customized to meet local needs and conditions.

Preventive Benefit: Reducing real-world barriers may lower healthcare costs down the line.

Personalized Care: Plans determine how SSBCIs are structured, shaping the benefits based on member needs.

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What’s New in 2026

Stricter Rules on What Plans Can’t Offer

Starting in 2026, Medicare Advantage plans will face a tightened definition of SSBCI. CMS has codified a list of non-allowable benefits, meaning some popular extras are now prohibited under SSBCI, including:

• Junk food, unhealthy groceries
• Alcohol, tobacco, or cannabis-related items
• Life insurance or funeral benefits
• Cosmetic procedures not covered by Original Medicare
• Insurance discounts unrelated to health care
• Hospital indemnity or unrelated insurance products

Mandatory Mid-Year Notifications

Also beginning in 2026, MAOs (Medicare Advantage Organizations) must send personalized mid-year notices (between June 30 and July 31) to members who have unused supplemental benefit allowances. These notices must include:

• Which benefits the enrollee hasn’t used (from Jan 1–Jun 30)
• Eligibility criteria and limitations
• Instructions on how to access the benefits and provider networks

This ensures beneficiaries don’t miss out on benefits they’re entitled to because they weren’t aware of them.

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Other Medicare-Wide 2026 Changes (Broader Context)

While not SSBCI-specific, here are some broader 2026 updates that complement the Medicare Advantage landscape:

• Automatic Renewal of the Medicare Prescription Payment Plan (MPPP); opt-outs must be processed within three days
• Part D Out-of-Pocket Cap increasing to $2,100 (up $100 from 2025)
• Part D Deductible capped at $615 (up by $25)
• Insulin Cost Cap: Still $35 or less, whichever is lower of negotiated or maximum fair price—now effectively enforced annually
• Adult Vaccines under Part D remain free with no cost-sharing as a permanent policy

Bottom Line

SSBCIs remain a powerful innovation within Medicare Advantage pushing beyond clinical coverage to tackle the lived experiences of chronically ill beneficiaries. But in 2026, plans must tighten the focus and communicate more clearly, including:

• No more non-health-related extras under SSBCI
• Required mid-year check-ins to help enrollees use their benefits effectively

Those who rely on SSBCIs, should:

Always review your 2026 ANOC for SSBCI benefit changes. Pay close attention to mid-year notices and unused benefits. Contact a licensed Medicare agent if you have questions about your current coverage or to look at your options during AEP or other available enrollment periods.

Agents stay up-to-date on events and information