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Medicare Part D Extra Help: What Agents and Beneficiaries Need to Know

When it comes to Medicare, prescription drug coverage can be a very confusing and expensive component for beneficiaries. Fortunately, there’s a federal program called Extra Help, also known as the Low-Income Subsidy (LIS), that can significantly reduce those costs. As a Medicare agent, you need to be able to answer the question; what’s Medicare part D Extra Help. Understanding and explaining this benefit can be a game-changer for your clients.

What Is Medicare Part D Extra Help

Extra Help is a program administered by the Social Security Administration (SSA) and Centers for Medicare & Medicaid Services (CMS) to assist individuals with limited income and resources in paying for their Medicare Part D prescription drug plan costs. This includes premiums, deductibles, and copayments.

The value of this benefit can be substantial—worth an average of about $5,300 per year (2024 estimate).

Who Qualifies for Extra Help?

To qualify for Extra Help, beneficiaries must meet certain income and resource limits. As of 2025 (these numbers are adjusted annually):

• Income Limits:
  • Individuals: Up to $23,715 annually
  • Married couples: Up to $31,965 annually
• Resource Limits (includes bank accounts, stocks, and bonds; excludes home, car, personal items):
  • Individuals: Up to $17,600
  • Married couples: Up to $35,130

Click here for a LIS Extra Help chart for 2025

Note: People who automatically qualify for Extra Help include those who:

• Have full Medicaid coverage
• Receive Supplemental Security Income (SSI)
• Qualify for an MSP (Medicare Savings Program)

What Extra Help Covers

Depending on the level of help a beneficiary qualifies for, Extra Help can:

• Reduce or eliminate monthly Part D premiums
• Lower or remove the annual Part D deductible
• Cap out-of-pocket drug costs

In most cases, those receiving Extra Help will pay:

• Low or no monthly premiums for a benchmark Part D plan
• A small deductible as low as $0
• Low copays (as little as $4.80 for generics and $12.15 for brand-name drugs in 2025) Full-Duals pay $1.60 for generic and $4.80 for brand name drug copays

Watch a quick YouTube video on the Quarterly SEP for Dual and Drug Help Elimination in 2025

How to Apply for Extra Help

• Online at www.ssa.gov/extrahelp
• By calling 1-800-772-1213 (SSA)
• Or by visiting the local Social Security office

As an agent, you can guide clients through the application process, help gather the right documentation, and verify eligibility.

Why Agents Should Care

Helping clients apply for Extra Help not only strengthens your relationship with them but also ensures they can afford necessary medications. When a client qualifies, they may be more willing and able to enroll in or stick with a Part D plan; making this an ideal opportunity to offer value and grow your book of business.

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SEP for Extra Help Recipients

Don’t forget, beneficiaries who qualify for Extra Help are eligible for a Special Enrollment Period (SEP). This means they have an SEP to change their Medicare Part D plan once they are approved for extra help.

learn about the SEP Changes for Dual, Partial Dual and LIS members in 2025

Extra Help can be life-changing for Medicare beneficiaries who struggle with prescription drug costs. As an agent, your role in identifying eligibility and guiding your clients through the application process is crucial. It’s a win-win: clients get meaningful financial relief, and you build long-term trust and loyalty.

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Understanding Medicare Part B LEPs: How to Avoid Them and Dispute Errors

Enrolling in Medicare is a crucial step to secure affordable healthcare for those who qualify. However, missing the enrollment window can be a costly mistake. If this happens, a beneficiary will face Medicare Part B LEPs (Late Enrollment Penalties). In this post, we explain what the penalty is, how to avoid it, and how to dispute it if it is applied in error.

Watch a video on OEP, SEPs & late Part B enrollment

What Is a Medicare Part B LEP

Medicare Part B covers outpatient services like doctor visits, preventive care, durable medical equipment, and more. If the beneficiary doesn’t sign up for Part B when they’re first eligible, and they don’t qualify for a Special Enrollment Period (SEP), they may receive a monthly penalty that lasts a lifetime.

Here’s how it works:

• The penalty is 10% of the standard Part B premium for every 12-month period the beneficiary was eligible but didn’t enroll.
• CMS adds it to the monthly premium as long as you have Part B; most likely for the rest of your life.

Example:

If the beneficiary delays Part B for 2 full years without a valid reason, the penalty will be 20% of the standard monthly premium.

When Can You Delay Enrollment Without Penalty

You can delay Part B without a penalty if you have creditable coverage. This generally means you receive coverage under an employer-sponsored plan through your (or your spouse’s) active employment.

You qualify for a Special Enrollment Period (SEP) if:

• You or your spouse are still working past age 65.
• You’re covered under a group health plan from that employment.
• You enroll in Part B within 8 months of losing that coverage or stopping work; whichever comes first.

How to Avoid the Part B LEP

1. Know Your Initial Enrollment Period (IEP). The IEP is a 7-month window. It begins 3 months before th emonth you turn 65, includes your birth month , and ends 3 months later.
   
2. Enroll During a Special Enrollment Period (if eligible). Those working past 65 and have employer coverage shoul dkeep proof of coverage. This may qualify them for an SEP.
   
3. Get Written Confirmation of Creditable Coverage. Keep documents from your employer or insurance provider to prove your coverage was creditable.
   
4. Don’t Assume COBRA or Retiree Coverage Counts. These type of coverage do not qualify as creditable to delay Part B enrollment without a penalty.

What If You’re Penalized by Mistake

If you receive a notice of a Part B LEP and believe it’s in error, you have the right to appeal.

Steps to Dispute a Medicare Part B LEP:

1. Request a Reconsideration
   Contact the Social Security Administration (SSA) and request Form CMS-L564 (Request for Employment Information) and Form CMS-40B (Application for Enrollment in Medicare – Part B).
2. Gather Proof
   Obtain proof of your creditable coverage, such as:
   • Employer letters
   • Pay stubs showing active health coverage
   • Group health insurance policy documents
3. Submit Documentation Promptly
   Include a letter explaining your situation and attach your documentation. Send it to your local Social Security office or follow instructions provided with the reconsideration request.
4. Follow Up
   Appeals can take several weeks. Keep a record of all communication and follow up regularly.

Medicare Part B LEPs are more than just a financial nuisance; they’re a lifelong burden if not handled correctly. Fortunately, with proper planning and awareness of enrollment timelines, they are entirely avoidable. If a mistake does occur, don’t panic. There is a clear process in place for disputes, and with strong documentation, many errors can be successfully overturned.

If you’re approaching Medicare eligibility or navigating coverage options, consider consulting with a licensed Medicare agent to help guide you through the process.

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Medicare Enrollment: When It’s Automatic and When You Need to Sign Up

Medicare enrollment can be confusing, especially when it’s not clear whether you’ll be enrolled automatically or if you need to take the first step yourself. As either a Medicare agent or beneficiary, knowing when is Medicare enrollment automatic is critical to avoid late enrollment penalties and coverage gaps.

Here’s a breakdown of when Medicare enrollment happens automatically and when beneficiaries need to sign up on their own.

When Medicare Enrollment Is Automatic

Individuals are automatically enrolled in Medicare Part A and Part B at age 65 if:

They already receive Social Security or Railroad Retirement benefits

Individuals who collect either Social Security or Railroad Retirement Board (RRB) benefits for at least four months before their 65th birthday are automatically enrolled in:

• Medicare Part A (hospital insurance)
• Medicare Part B (medical insurance)

In most cases, These individuals receive their Medicare card about three months before their 65th birthday.

Those under 65 and have a qualifying disability

Individuals who receive Social Security Disability Insurance (SSDI) for 24 consecutive months, are automatically enrolled in Medicare once they reach the 25th month of disability benefits.

Please Note: Individuals with ALS (Lou Gehrig’s disease) receive Medicare automatically the month their disability benefits begin.

When You Need to Sign Yourself Up

Individuals must enroll themselves in Medicare if:

They’re not receiving either Social Security or RRB benefits

In many cases, people decide to delay the receipt of Social Security until after age 65 to maximize their benefit amount. Those individuals are not automatically enrolled in Medicare; they must sign themselves up during their IEP (Initial Enrollment Period).

The IEP is a 7-month window that starts 3 months before, includes the month of, and ends 3 months after the beneficiary’s 65th birthday.

Individuals who have employer coverage and delay Part B enrollment

Those still working and receive health coverage from a large employer (20+ employees) group health plan may choose to delay Part B and avoid paying the monthly premium. In that case, they must sign up later during a SEP (Special Enrollment Period). This is an 8 month window when individuals can sign up for Part B once their employer coverage ends or they stop working (whichever comes first).

Watch a YouTube video on OEP, SEPs and Late Part B enrollment

Important: COBRA and retiree coverage do not count as active employer coverage. Individuals may face penalties if they delay Medicare enrollment and rely on these plans.

What If You Miss Enrollment

If you miss your IEP and don’t qualify for an SEP, you’ll have to wait for the General Enrollment Period (GEP):

• January 1 – March 31 each year
• Coverage begins the month after you enroll
• You may owe a late enrollment penalty for Part B (and Part D if applicable)

Tips for Clients & Agents

• Mark your calendar: Your IEP starts 3 months before your 65th birthday.
• Enroll on time: Even if you’re healthy, missing the window can cost more later.
• Coordinate carefully: If still working, check with HR or your agent before delaying Medicare enrollment.
• Check coverage: Compare Original Medicare vs. Medicare Advantage (Part C) and add Part D or Medigap as needed.

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Need Help Enrolling

Whether you’re approaching 65 or advising clients, navigating enrollment can be tricky. Medicare.gov provides tools to check eligibility and apply online; agents can help guide clients through the process to avoid delays and penalties.

Knowing when Medicare enrollment is automatic and when you need to enroll yourself helps avoid costly mistakes. As an agent, walking clients through this process adds tremendous value. If you’re a beneficiary, planning ahead ensures a smooth transition into Medicare with the coverage you need.

Have questions about a specific situation? Reach out to a licensed Medicare agent who can provide personalized guidance based on your health needs and budget.

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How Medicare Covers Diabetic Supplies And Where to Get Help

Managing diabetes effectively is extremely important and requires reliable access to the necessary supplies. For Medicare beneficiaries living with diabetes, understanding what’s covered and how insurance pays for it is essential. As a Medicare agent, helping clients navigate these benefits can make a real difference in their quality of life. We will go over Medicare payment of diabetic supplies and provide information on how to get help locating and paying for them.

Diabetic Supplies Medicare Covers

Medicare Part B (Medical Insurance) covers certain diabetic supplies for all beneficiaries who have diabetes, whether they use insulin or not. Here’s what they typically cover:

• Blood glucose monitors
• Blood sugar test strips
• Lancets and lancet devices
• Glucose control solutions
• Continuous Glucose Monitors (CGMs) and related supplies

For beneficiaries who use insulin, Medicare also covers insulin pumps and pump-related supplies under Part B if the pump qualifies as durable medical equipment (DME).

Important: Insulin itself (unless used with a pump) syringes, needles, alcohol swabs, and gauze are generally covered under Medicare Part D (the prescription drug benefit).

How Much Medicare Pays

Under Medicare Part B, Medicare pays 80% of the Medicare-approved amount for covered diabetic supplies after the beneficiary meets the Part B deductible. The beneficiary is responsible for the remaining 20% unless they have additional coverage (like a Medigap plan or Medicaid) that helps with cost-sharing.

If diabetic supplies are obtained through a Medicare-enrolled supplier, the beneficiary avoids unnecessary out-of-pocket costs. That’s why it’s essential to work with reputable providers who are participating providers under Medicare.

Where to Get Supplies: Advanced Diabetic Supply Group

One of the most trusted names in diabetic supply delivery is the Advanced Diabetic Supply Group (ADS).

Here’s why Medicare beneficiaries and agents should consider ADS:

Watch a YouTube video on Advanced Diabetes Supply and how they can help your clients

• Medicare-Enrolled Supplier: ADS is an accredited Medicare DME provider, which means they meet strict compliance and billing standards.
• Home Delivery: Supplies are shipped directly to the beneficiary’s home—saving time and eliminating pharmacy trips.
• Bilingual Support: ADS offers customer service in English and Spanish, making communication easier for diverse clients.
• Insurance Coordination: They work directly with Medicare and many private insurance plans to verify coverage and handle paperwork.

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As an agent, you can refer clients to ADS knowing they’ll receive quality care and proper billing, which leads to better health outcomes and fewer surprises.

Tips for Agents and Beneficiaries

• Stay enrolled: Ensure your client’s Medicare coverage is active and updated.
• Verify suppliers: Always use Medicare-approved suppliers to avoid denied claims or excessive costs.
• Review needs annually: Reassess whether your client’s current plan covers all their diabetic needs, especially during the Annual Enrollment Period (AEP).

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As a Medicare agent, you’re not just helping clients find the right plan, they depend on your advice to help them navigate through all the complexities of Medicare. One important thing agents do is explaining Medicare penalties, this ensures clients avoid costly surprises.

Educating clients early using understandable terms on how to avoid these charges helps build trust and reinforces your value as a trusted advisor. Here’s a breakdown of the most important penalties clients need to understand and how to help them stay ahead of the game.

Start with the Enrollment Timeline

Some clients are unaware of the IEP (Initial Enrollment Period) and how crucial timing is. As you know, the IEP is a seven-month window:

• Three months before the month of their 65th birthday,
• The birthday month,
• And three months after their birthday month.

If they don’t enroll in Medicare Part B or Part D during this period, and they don’t qualify for an SEP (Special Enrollment Period), they could face lifelong penalties.

Encourage clients to begin planning their Medicare enrollment early; at least 3 to 6 months before turning 65. Use this time to review their current coverage and explain how Medicare will coordinate (or replace) it.

Clarify Each Type of Penalty

Clients rarely understand the specific consequences of delaying enrollment. Be sure to cover these key penalties in your consultations:

Medicare Part B Late Enrollment Penalty

• What It Is: A 10% increase in the monthly premium for every full 12-month period the client delayed enrollment without other creditable coverage.
• How Long It Lasts: For life, and CMS will add it to their Part B premium.
• Common Misunderstanding: Clients often believe they can just delay Part B if they’re healthy or not using care without knowing there is a penalty and it keeps growing.

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

Part D Late Enrollment Penalty

• What It Is: 1% of the national base premium (currently $36.78 in 2025) multiplied by the number of full uncovered months they went without creditable prescription drug coverage.
• How Long It Lasts: For life, and it’s added to their monthly Part D premium.
• Common Misunderstanding: Clients are often unaware of this penalty and if they don’t need drug coverage now, they do not have to enroll in a plan. Although, not having creditable coverage triggers the penalty anyway.

Medicare Part A Penalty

Penalty: 10% increase in the premium for twice the number of years they delayed enrollment.

Applies only to clients who do not qualify for premium-free Part A (usually those with less than 10 years of Medicare-covered work history).

Explain Employer Coverage and SEPs

This is where your expertise can be very useful.

Many clients working past 65 assume they can delay Medicare without issue. However, eligibility for an SEP (Special Enrollment Period) depends on their employment and the type of coverage they have.

Key Points:

• Employer coverage must be from active employment (not COBRA or retiree plans).
• The employer must have 20 or more employees for the coverage to delay Medicare enrollment without penalty.
• They must enroll in Medicare within 8 months of losing employer coverage to avoid penalties.

Review your client’s group health plan documents or provide them with specific questions to ask their HR department. It’s critical they confirm whether their plan is considered creditable coverage for both Part B and Part D.

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Conduct Annual Reviews

Clients’ needs, income levels, and coverage can change year to year. Use the AEP (Annual Enrollment Period) that runs Oct 15–Dec 7 to:

• Verify their current coverage.
• Check for plan changes that could increase costs.
• Remind them of potential penalties if they drop coverage without a replacement.

Document Everything and Communicate Clearly

Because it is easy for some clients to misunderstand Medicare rules, it’s essential to:

• Take notes that summarize the appointment after each consultation, some clients may want a copy for their own records.
• Track enrollment deadlines and follow up as key dates approach.
• Encourage clients to keep copies of any employer or plan letters that state their coverage is creditable.

Medicare penalties are preventable; only if your clients have the right information at the right time. As an agent, your ability to explain these rules in simple terms and guide clients through timely enrollment is a key part of your value.

By proactively addressing fees and penalties in your process, you not only protect clients financially you also strengthen your reputation as a knowledgeable and trustworthy advisor in a competitive marketplace.

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Medicare beneficiaries who have a limited income may be eligible for help paying for some healthcare costs. That’s where a Medicare agent can provide some insight into understanding the Medicare savings program. This can be a great resource for individuals who qualify. The Medicare Savings Programs (MSPs) are state-run programs that help pay Medicare premiums, deductibles, copays, and coinsurance, depending on the individual’s financial situation.

There are four main MSP categories, each with slightly different income and resource limits; each provides a different level of help. We will break them down to provide a better understanding of each level.

QMB (Qualified Medicare Beneficiary)

QMB provides the most comprehensive benefits. It helps pay for:

• Medicare Part A premiums (if applicable)
• Medicare Part B premiums
• Medicare deductibles
• Medicare coinsurance and copays
• Help paying for prescription drugs (beneficiaries pay no more than $12.15 for each prescription covered by their Medicare drug plan).

If an individual qualifies at the QMB level, doctors and medical providers do not bill them for services covered by Medicare; except in very limited situations.

2025 QMB income and resource limits:

• Individual: monthly income limit $1,325; resource limit $9,660
• Married couple: monthly income limit $1,783; resource limit $14,470
  (Limits vary by state)

What counts in resource limits: Money in checking, savings and retirement accounts, stocks and bonds. States do not count: Your home, furnishings, household and personal items, one car, burial plots, up to $1,500 for burial expenses if that money is put aside.

SLMB (Specified Low-Income Medicare Beneficiary)

The SLMB Program is more limited than the QMB Program but still provides assistance. The only premium it helps pay for is the Medicare Part B premium (beneficiaries must have both Part A & Part B to qualify for the program).

The program also provides help paying for prescription drugs. Individuals pay no more than $12.15 for any drug covered by their Medicare drug plan.

This program is useful for people with limited income slightly above the QMB threshold.

2025 Income and resource limits:

• Individual: monthly income of $1,585 with a resource limit of $9,660.
• Married couple: monthly income of $2,135 with a resource limit of $14,470.

QI (Qualifying Individual)

The QI Program also helps pay the Medicare Part B premium, just like the SLMB program, but with slightly higher income limits. QI beneficiaries also receive extra help paying for their prescription drugs and pay no more than $12.15 in 2025 for any drug covered on their Medicare plan. The QI benefit is provided on a first come, first served basis, and individuals must apply every year to continue receiving benefits.

Important: Individuals who are eligible for Medicaid do not qualify for QI program.

2025 Income and resource limits:

• Individual: monthly income limit of $1,781 with resource limits of $9,660 (the same as QMB & SLMB).
• Married couple: monthly income limit of $2,400 with resource limits of $14,470 (the same as QMB & SLMB).

QDWI (Qualified Disabled and Working Individuals)

The QDWI Program is specifically for individuals under age 65 who are disabled but have returned to work and lost their Social Security disability benefits and premium-free Medicare Part A.

QDWI helps pay the Medicare Part A premium for these individuals.

2025 Income and resource limits:

• Individual: monthly income limit of $5,302 with resource limits of $4,000.
• Married couple: monthly income limit of $7,135 with resource limits of $6,000.

Please note: Income limits vary by states. The amounts listed in this post are federal limits. Individuals with slightly higher incomes may still qualify in their states.  Check your state to find out.

Apply for MSP (Medicare Savings Program)

Because MSPs are administered by each state’s Medicaid office; the application process varies by state. In general, individuals will need to provide:

• Proof of income (such as Social Security or pension statements)
• Information about assets (like savings, investments, etc.)
• Medicare card and ID

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Medicare Savings Programs can make a huge difference in the lives of people within the income limits. They provide assistance for important medical services that are essential for quality of life. It is free to apply, and the potential savings can be substantial.

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When it comes to navigating the maze of Medicare, choosing the right supplemental coverage can make a significant difference in both healthcare coverage and out-of-pocket costs. One option that remains popular is Medigap Plan N. We will outline the benefits of Medigap Plan N and highlight it’s balance of coverage and affordability. This post includes both the benefits and downsides of Medigap Plan N.

Medigap Plan N

Medigap (Medicare Supplement Insurance) helps pay for healthcare costs that Original Medicare (Part A and Part B) doesn’t cover, such as copays, coinsurance, and deductibles. Plan N is one of 10 standardized Medigap plans available in most states. It offers a good blend of coverage and cost savings, making it appealing to Medicare enrollees who want solid protection without having to pay the highest premiums.

Benefits of Medigap Plan N

Lower Monthly Premiums

In general, Plan N has lower premiums than more comprehensive plans like Plan F or Plan G. This makes it a good option for individuals who are relatively healthy and want to save on fixed monthly costs.

Plan N Covers Cost Gaps

• 100% of Part A coinsurance and hospital costs
• 100% of Part B coinsurance (with a few exceptions)
• Skilled nursing facility care coinsurance
• Part A deductible
• Emergency care during foreign travel (up to plan limits)

Nationwide Access

Like all Medigap plans, any provider that participates with Medicare will accept Plan N. Enrollees do not have to worry about provider networks or referrals. Enrollees can see any doctor or specialist who accepts Medicare.

Predictable Inpatient Costs

Because inpatient services are well covered by Plan N, beneficiaries can feel confident with their choice, if they are hospitalized or require skilled nursing care. Their costs should generally be predictable.

Downsides of Medigap Plan N

Copays for Doctor and ER Visits

While most Part B coinsurance is covered by Plan N, beneficiaries must still make some copays:

• Up to $20 for office visits
• Up to $50 for emergency room visits (waived if the patient is admitted)

These copays can add up for anyone who frequently requires the care of a doctor.

Doesn’t Cover Part B Deductible

Like all Medigap plans issued to new enrollees after January 1, 2020, Plan N does not cover the Medicare Part B deductible, which is $257 in 2025.

Excess Charges Not Covered

Plan N does not cover Part B excess charges. These are extra charges from providers who don’t accept Medicare assignment. These providers are allowed to bill up to 15% over the Medicare-approved amount. While this isn’t common, it can be a concern for those who live in or travel to areas where non-participating providers are prevalent.

Not Ideal for High Users of Care

Beneficiaries who require frequent doctor visits, lab work, or outpatient treatments may cause the recurring copays and potential for excess charges to outweigh the savings of the lower premiums. When that is the case, Plan G could be a better value despite higher monthly premiums.

Plan N can be an excellent choice for

• People in relatively good health
• Those who prefer lower monthly premiums
• Individuals who rarely see non-participating Medicare providers
• Enrollees who are comfortable paying small copays in exchange for premium savings

Plan N may not be ideal for

• People who visit the doctor frequently
• Those who live in areas where excess charges are more common
• Individuals who want the most comprehensive coverage available

Watch a video on Physicians Mutual Innovative Plan G

Medigap Plan N is a well-balanced choice for Medicare beneficiaries who want solid protection without paying top-dollar premiums. Its design provides comprehensive healthcare at an affordable rate. As always, choosing the right Medigap plan depends on health needs, budget, and lifestyle. Comparing Plan N with other options like Plan G can help beneficiaries make the most informed decision. A licensed Medicare agent can help compare plans and weigh all the options.

As the population ages, many individuals are seeking care while in the comfort of their own homes. One of the most common questions people ask is: how Medicare covers home healthcare? In some cases Medicare provides some coverage; although there are some important limitations and conditions Medicare enrollees and their families need to be aware of.

In-Home Health Care

In-home health care refers to a range of medical services patients may receive at home. This can include skilled nursing, physical therapy, occupational therapy, speech-language pathology, and certain types of personal care.

What Medicare Covers

Medicare Part A and/or Part B may cover in-home health services if the beneficiary meets specific conditions. These include:

1. They Must Be Homebound

Medicare defines “homebound” as being unable to leave your home without considerable effort or assistance due to illness or injury. The beneficiary may leave for things like medical appointments or religious services, however they must not be able to leave home on regular outings.

2. Care Must Be Medically Necessary

Any Medicare services received must be (medically necessary) a doctor or a qualified healthcare provider must order the care. They must also create and regularly review a care plan for the beneficiary.

3. Individuals Must Require Skilled Services

Medicare provides coverage for home health services such as; intermittent skilled nursing care, physical therapy, speech-language pathology, or continued occupational therapy. If a beneficiary requires services for personal care alone (dressing or bathing), Medicare will not cover them unless it’s part of a broader medical plan involving skilled care.

4. Only Medicare-Certified Home Health Agencies Can Provide Care

To receive coverage, services must be provided by an agency that is certified by Medicare.

What’s Covered

• Skilled nursing care (part-time or intermittent only)
• Physical, occupational, or speech therapy
• Medical social services
• Home health aide services (if you’re also receiving skilled care)
• Durable medical equipment (DME) like walkers, oxygen tanks, or wheelchairs (covered under Medicare Part B)

Please Note: Medicare does not cover; 24-hour home care, meals delivered to your home, or homemaker services if they are the only care you need.

Out-of-Pocket Costs

For most eligible home health services:

• Beneficiaries pay $0 for covered home health care services.
• Typically, the out-of-pocket amount for Medicare-approved durable medical equipment is 20% of the cost.

No copay or deductible is required for the care itself, assuming the beneficiary meets the qualifying criteria.

Examples of How Medicare Covers In-Home Health Services

Let’s say Jack, age 78, recently had hip surgery and his doctor prescribes in-home physical therapy for recovery. This is prescribed in-home because; he is temporarily unable to travel to outpatient therapy due to mobility issues. Because he meets the homebound requirement and the care is medically necessary and ordered by a doctor, Medicare will likely cover the services.

In contrast, if Leo needs help cooking, cleaning, and taking medications but does not need skilled nursing or therapy, Medicare would not cover a home health aide for him.

How to Initiate In-Home Healthcare Through Medicare

1. Beneficiaries must talk to their doctor. A doctor’s order is required before any service is authorized for payment.
2. Choose a Medicare-certified home health agency. Beneficiaries can request suggestions from their doctor’s office or their Medicare insurance carrier or the Home Compare Tool Link below.
3. The beneficiary’s provider and the agency will work together to develop a care plan.

The Medicare’s Home Health Compare tool to find certified agencies in the local area.

Medicare can be an important source of support for those recovering at home or managing chronic health conditions. However, its coverage of in-home health care comes with specific conditions that must be met. Understanding these rules helps beneficiaries and caregivers plan effectively and avoid unexpected expenses.

As a Medicare agent, mastering all the different enrollment periods is crucial to ensure smooth enrollment for your clients. It also helps you stay compliant and that is also very important. Understanding IEP vs ICEP is essential to anyone in Medicare sales. Although these two sound similar, they serve distinct purposes and apply to different parts of Medicare.

IEP (Initial Enrollment Period)

First we will go over The IEP. Most agents know that this is the first window of time when someone is eligible to enroll in Original Medicare; specifically Parts A and B.

• Who is eligible to apply: Individuals turning 65 who worked and paid Medicare taxes for a period of at least 10 years (40 quarters) or their spouse or ex-spouse. Those who are under 65 with a qualifying disability, ESRD or ALS are also eligible to enroll.
• Timing: For those who are turning 65; The IEP spans 7 months: it begins 3 months before their 65th birthday, includes their birth month and ends 3 months after the month they turn 65.
• Timing: Individuals who are under 65 and qualify due to a disability; the IEP begins 3 months before the 25th month of their disability benefit entitlement.

Example: If a client turns 65 in May, their IEP runs from February 1st to August 31st.

What beneficiaries can do during IEP

1. Enroll in Medicare Part A and/or Part B
2. Enroll in a Medicare Part D plan (if they have Part A and/or Part B)
3. If they enroll in both Part A & Part B, they may also opt for either a Medicare Advantage (Part C) plan or a Medicare Supplement (Medigap) plan.

ICEP (Initial Coverage Election Period)

When an individual is first eligible for Medicare, the ICEP can specifically be used to enroll in a Medicare Advantage (Part C) plan.

• Who can use the ICEP: Individuals who are first enrolling in both Medicare Part A and B, and want to join a Medicare Advantage plan.
• Timing: Usually, the ICEP coincides with the IEP. However if an individual delays Part B enrollment (e.g., due to employer coverage), the ICEP does not start until they have both Part A and Part B and ends the last day of the month before their Part B coverage begins.

Example 1 (standard case): Client enrolls in A & B to begin July 1. Their ICEP runs from April 1 to June 30.

Example 2 (delayed Part B): Client took Part A at 65; delayed Part B until they retired at 67. Their ICEP begins when they enroll in Part B and ends the last day of the month before Part B becomes effective.

What beneficiaries can do during ICEP

1. Enroll in a Medicare Advantage (Part C) plan, with or without drug coverage (MAPD or MA-only).

Differences at a Glance

Why Understanding IEP vs ICEP Matters to Agents

Confusing IEP and ICEP could lead to enrollment mistakes, missed opportunities, and compliance issues. Knowing when each applies ensures:

• You recommend the right plans at the right time.
• You help clients avoid penalties for delayed Part D enrollment.
• You position yourself as a knowledgeable and trusted resource.

Watch a YouTube video on Medicare enrollment periods

Important: Always ask clients if they’ve enrolled in both Part A and B before discussing Medicare Advantage options. This small question helps determine whether they’re in their ICEP.

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Individuals enrolled in Original Medicare probably have a pretty good understanding of Medicare Part B and what it covers. Many Medicare beneficiaries are surprised when they receive an unexpected bill; these unexpected costs may come from excess charges. Some of you may not have heard of excess charges. We will answer the question; What are Part B excess charges and hopefully help some of you avoid them.

Medicare Part B Excess Charges

Medicare Part B excess charges occur when a doctor or healthcare provider does not accept Medicare assignment and charges more than the Medicare-approved amount for a covered service.

Here’s how it works:

• Medicare sets an “approved amount” for every Part B service.
• Doctors who accept Medicare assignment agree to accept this amount as payment-in-full.
• Providers who don’t accept assignment can charge up to 15% over the Medicare-approved rate.
• The extra 15% is called an excess charge; the beneficiary must pay that amount out of pocket, unless they have supplemental coverage that pays it.

Example of a Part B Excess Charge

Let’s say a beneficiary has met his annual deductible and receives a procedure from his doctor; the Medicare-approved amount for the procedure is $200.

• If the doctor accepts assignment, they’ll charge $200. Medicare pays 80% of the cost ($160). The beneficiary pays the remaining 20% ($40).
• If the doctor does not accept assignment, they can charge up to 15% more: $200 + $30 = $230. Medicare will still pay 80% of the approved $200 ($160), but the beneficiary owes not only their 20% ($40) they also have to pay the excess charge of $30, therefore their total out-of-pocket cost is $70.

When Do Excess Charges Apply

Excess charges only apply to Medicare Part B services and only when:

1. It is a service that Part B covers.
2. The provider does not accept Medicare assignment.
3. The provider charges more than the Medicare-approved amount.

Important: Not all states allow excess charges. For example, Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont have laws that prohibit excess charges for Medicare beneficiaries.

How to Avoid Excess Charges

1. Use Participating Medicare Providers
   Always ask the provider if they accept Medicare assignment before receiving care. This ensures the beneficiary does not pay more than the Medicare-approved amount.
2. Consider a Medicare Supplement Plan (Medigap)
   Individuals who are worried about excess charges, consider a Medigap Plan. The Plan G or Plan F (if you were eligible before 2020) both cover 100% of Medicare Part B excess charges. This provides protection from surprise bills.
3. Check State Rules
   Those who live in states that bans excess charges don’t need to worry about them; providers in those states can’t legally charge more than the Medicare-approved rate.

Unfortunately, some agents or beneficiaries overlook Medicare Part B excess charges when discussing Medicare coverage. That cost can surprise even savvy Medicare beneficiaries. However, with the right knowledge and the right plan, beneficiaries can avoid them altogether.

Click here to watch a quick YouTube video on Medicare Enrollment Periods

Please note; It is important to verify the provider accepts Medicare assignment and beneficiaries may want to consider supplemental coverage for full protection.