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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.

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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.

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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.

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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.

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Are Copays and Coinsurance Different – Copays vs Coinsurance

When you’re reviewing Medicare or health insurance options with a client, one common question that comes up is; are copays and coinsurance different or are they the same. When you’re reviewing Medicare or health insurance options with a client, this can be a common point of confusion. Although both are types of cost-sharing; the portion of healthcare costs the beneficiary pays out of pocket, they work in different ways.

Let’s break it down so you can explain it simply and clearly to your clients.

What is a Copay

A copay is a fixed dollar amount a beneficiary pays for a covered service, no matter the actual cost of the service.

• Example: If a client’s plan lists a $20 copay for a primary care visit, they’ll pay $20 every time they see their doctor for a covered appointment; whether the visit costs $80 or $300.
• Common Copay Examples: Doctor visits, urgent care, prescription drugs.
• Key Point: Copays make healthcare costs predictable.

What is Coinsurance

Coinsurance is a percentage of the total cost of a covered service that the beneficiary pays.

• Example: If a plan has 20% coinsurance for outpatient surgery and the procedure costs $1,000, the client pays $200, and the insurance pays the rest.
• Common Coinsurance Examples: Hospital stays, durable medical equipment, specialist visits under certain plans.
• Key Point: Costs vary based on the service price—no set dollar amount.

How They Work Together

Some services have only a copay, some have only coinsurance, and others might have a combination. For example:

• A specialist visit might have a $40 copay.
• A hospital stay might require 20% coinsurance after the deductible.

Understanding when each applies can help clients better anticipate out-of-pocket costs.

Why It Matters for Medicare Beneficiaries

In Medicare Advantage (Part C) and Medicare Supplement (Medigap) plans, the mix of copays and coinsurance impacts:

• Affordability: Clients with frequent doctor visits may prefer fixed copays.
• Risk: Clients who may face high-cost procedures should understand coinsurance percentages.
• Budgeting: Predictable costs (copays) can make financial planning easier.

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In other words; copays are a set price you pay every time you visit a specific type of provider. While coinsurance is a percentage of the cost for a provider visit. By making sure your clients understand both, you help them avoid surprise bills and choose a plan that matches their healthcare needs and budget.

Understanding Your Medicare Plan ANOC: Why it Matters

If you have a Medicare Advantage (Part C) plan or a Medicare Part D prescription drug plan, you’ll receive an Annual Notice of Change (ANOC) every fall. While it might be tempting to toss it aside with other “Medicare mail,” Understanding your Medicare Plan ANOC is important. It explains changes to health coverage, costs, and benefits for the upcoming year.

What Is an ANOC

The ANOC is a letter both Medicare Advantage and Part D plan are required to send enrollees by September 30. It outlines any changes the plan will make for the next calendar year, starting January 1. Even if enrollees are happy with their current coverage, these changes can directly impact what they pay and the care they receive.

The ANOC will compare the current year’s benefits, costs, and coverage with what they’ll be next year, including:

• Monthly premium changes
• Copays and coinsurance updates
• Deductible adjustments
• Changes to your provider network (doctors, specialists, hospitals)
• Changes to your drug formulary (which prescriptions are covered and how much they cost)
• Any added or removed benefits like dental, vision, hearing, or fitness programs

Why Is the ANOC Important

The ANOC is an early warning system for how coverage will look in the year ahead. Ignoring it can lead to unpleasant surprises like; your doctor is no longer in-network or prescription costs have gone way up.

By reviewing the ANOC carefully, you can:

1. Spot coverage gaps. Make sure medications, providers, and benefits are still covered next year.
2. Avoid unexpected costs; premiums, copays, and deductibles can increase.
3. Compare other plan options. If you don’t like the changes, you can explore new plans during the Medicare Annual Enrollment Period (AEP), which runs from October 15 to December 7.
4. Plan ahead; knowing changes in advance allows you to budget for new costs or switch to another plan before the year starts.

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What to Do When You Get Your ANOC

1. Open it immediately. Don’t let it sit in a pile of unopened mail.
2. Review every section. Pay close attention to drug coverage, provider networks, and cost changes.
3. Make a comparison chart. List 2025 vs. 2026 benefits and costs to see differences clearly.
4. Ask questions. Call your plan or talk to a licensed Medicare agent if you need clarification.
5. Take action during AEP. If the changes aren’t favorable, you can switch to a new plan.

Bottom Line

The ANOC is more than just a piece of Medicare paperwork; it’s a guide to understanding how your plan will serve you next year. Reviewing it now could save you money, protect your access to care, and ensure you have the coverage you truly need. The best way to get the coverage you need is to speak with a licensed Medicare agent who can go over all your options.

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Medigap Plan N vs Plan G: Which Is Right for You

When shopping for a Medicare Supplement (Medigap) plan, there are many options. Plan G and Plan N are two of the most popular choices for people looking to fill in the coverage gaps of Original Medicare. While they share many similarities, there are key differences in cost, coverage, and how they handle out-of-pocket expenses. Understanding Medigap Plan N vs Plan G can help you choose the plan that best fits your healthcare needs and budget.

What Medigap Plans Have in Common

Both Plan G and Plan N are standardized Medicare Supplement plans, meaning the basic benefits are the same no matter which insurance company offers them. With either plan, you get:

• Coverage for Medicare Part A coinsurance and hospital costs (after the beneficiary uses up Medicare’s benefits) for up to 365 days
• Coverage for Part B coinsurance or copayment (with exceptions for Plan N – explained below)
• Blood coverage (first 3 pints per year)
• Part A hospice care coinsurance or copayment
• Skilled nursing facility coinsurance
• Part A deductible
• Foreign travel emergency coverage (up to plan limits)

Key Differences Between Plan G and Plan N

1. Part B Excess Charges

• Plan G: Covers 100% of Medicare Part B excess charges (extra costs you may be billed if your provider doesn’t accept Medicare’s standard payment).
• Plan N: Does not cover Part B excess charges; if your provider bills them, you’ll have to pay out of pocket.

2. Office Visit & ER Copays

• Plan G: No copays for office visits or ER (after Medicare pays its share).
• Plan N: You may pay up to $20 for some doctor visits and up to $50 for emergency room visits (waived if admitted to the hospital).

3. Monthly Premiums

• Plan G: Generally has higher monthly premiums because it covers more.
• Plan N: Often has lower monthly premiums but requires more cost-sharing through copays and the possibility of excess charges.

4. Part B Deductible

• Both plans require you to pay the annual Medicare Part B deductible before coverage kicks in (for 2025, it’s $257).

Watch our YouTube video on Medicare Advantage vs Medicare Supplements

Which Plan is The Best Fit

• Choose Plan G if:
  • You want the most comprehensive coverage available to new Medicare enrollees.
  • You prefer predictable costs and don’t want to worry about excess charges or visit copays.
  • You see specialists who may charge more than Medicare’s approved amount.
• Choose Plan N if:
  • You want a lower monthly premium and are okay with occasional copays.
  • You typically see Medicare-assigned doctors who don’t bill excess charges.
  • You’re healthy, visit doctors less often, and want to save on monthly costs.

Both Plan G and Plan N are strong options that can protect you from high out-of-pocket costs not covered by Original Medicare. The right choice depends on how often you use healthcare services, whether your providers accept Medicare’s payment terms, and how much you want to pay each month in premiums versus at the point of care.

When comparing, it’s smart to enlist the help of a licensed Medicare agent who get quotes for both plans from multiple carriers. Please note: premiums vary by carrier even though the benefits are standardized.

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Changing Medicare Supplement Plans: What to Know Before You Switch

Medicare Supplement (Medigap) plans are a great choice for covering the portion of out-of-pocket costs that Original Medicare doesn’t. However, as health needs and financial situations change, beneficiaries might consider changing Medicare supplement plans. Whether it’s to reduce premiums or adjust coverage, making a change requires some thought and planning.

Here’s what to keep in mind when considering a change to Medicare Supplement coverage.

Why People Change Medigap Plans

There are several reasons why someone might decide to change their Medigap plan:

• Overpaying for coverage: The current plan might offer more coverage than needed, meaning the policyholder may not use as much coverage as much as expected.
• Needing additional benefits: Health needs can change, and a different plan may provide better or more suitable coverage.
• Shopping for a better rate: Even if the benefits remain the same, switching to a different insurance carrier offering the same plan at a lower premium makes sense.
• Company dissatisfaction: Some beneficiaries want to change to a new insurer due to customer service or other experiences.

When You Can Switch

Changing Medigap plans isn’t quite as simple as enrolling in Medicare for the first time. There are only a few scenarios when someone can switch plans without facing potential roadblocks:

• During their six-month Medigap Open Enrollment Period: This period starts the month they turn 65 and are enrolled in Medicare Part B. During this time, they can buy any Medigap plan offered in their state or switch plans. Insurance companies cannot deny coverage based on health.
• 30 day free look period: After purchasing a new Medigap policy, you have 30 days to decide if you want to keep it. This allows beneficiaries to compare other plans with their your current plan. 
• With guaranteed issue rights: These are special protections that allow someone to buy certain Medigap plans without medical underwriting. Common situations that trigger guaranteed issue rights include losing employer coverage or moving out of a plan’s service area. However, there are currently 4 states that offer guaranteed issue rights regardless of the circumstance.

Please note: A new Medigap policy doesn’t automatically cancel the old one the way Medicare Advantage and PDP plans do. It is best not to cancel your old Medigap policy until you are sure you want to keep the new one.

Watch a YouTube video on Medicare Supplement underwriting.

Outside of the situations listed above, beneficiaries may need to go through medical underwriting to enroll in a new Medigap plan.

Understanding Medical Underwriting

Medical underwriting is a review process insurers use to assess an applicant’s health history and current conditions. Based on this review, a company can:

• Approve or deny the application.
• Charge a higher premium.
• Apply a waiting period for coverage of pre-existing conditions.

If a person applies for a Medigap plan outside their Open Enrollment Period and without guaranteed issue rights, their application could be declined based on health.

One common underwriting consideration is tobacco use. Smokers often face higher premiums, even if they are otherwise in good health.

No Waiting Period to Switch

There’s a common misconception that people have to keep their Medigap plan for a set amount of time before switching. The truth is, once someone has a Medigap policy, they can apply for a new one at any time. As long as they’re willing to go through underwriting if required.

Switching Medicare Supplement plans isn’t something to rush into, but with the right timing and a good understanding of the process, it can be a good idea for your health and finances. Whether it’s finding more appropriate coverage or simply lowering monthly costs, reviewing options regularly ensures your Medicare Supplement plan continues to meet your needs. It is best to speak with a licensed Medicare agent who can guide you through the options and find the best fit for your needs.A

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Agents helping clients navigate this process; be sure they understand the importance of timing and potential underwriting challenges. They must understand how their health status could impact their options.

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