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Common Medicare Enrollment Mistakes (and How to Avoid Them)

Enrolling in Medicare is one of the most important steps many of us take when we transition into retirement or experience a qualifying medical condition. But with multiple parts, deadlines, and plan types, it’s easy to make costly mistakes that could lead to penalties, gaps in coverage, or higher out-of-pocket expenses. We have listed some common Medicare Enrollment mistakes below with the hope that your clients can avoid them.

Missing the Initial Enrollment Period (IEP)

The Mistake: Waiting too long to enroll in Medicare Parts A and B can lead to late enrollment penalties, some of which are permanent.

How to Avoid It:
You’re eligible to enroll during a 7-month window:

• Starts 3 months before your 65th birthday month
• Includes your birthday month
• Ends 3 months after

If you’re not working or don’t have credible employer coverage, enroll during your IEP to avoid penalties.

Not Enrolling in Part B on Time

The Mistake: Some people mistakenly delay enrolling in Medicare Part B (medical insurance), thinking they don’t need it — even when they don’t have other credible coverage.

The Penalty: A 10% increase in premiums for every 12-month period you were eligible but didn’t enroll. This penalty lasts as long as the beneficiary has Part B coverage (for life).

How to Avoid It:
If you’re not actively working and don’t have employer-sponsored coverage, you should enroll in Part B when you’re first eligible. COBRA, retiree coverage, and the Marketplace do not count as credible coverage for Part B delays.

Not Enrolling in Part D (Drug Coverage)

The Mistake: Delaying enrollment in a Part D drug plan, thinking you don’t need one because you don’t take medications.

The Penalty: A permanent late enrollment penalty added to your Part D premium.

How to Avoid It:
Even if you don’t take prescriptions now, it’s wise to enroll in a low-cost Part D plan when you’re first eligible. You’ll avoid penalties and have coverage in place when you need it.

Watch a YouTube Video on Medicare Enrollment Periods

Assuming Medicare Covers Everything

The Mistake: Many people think Medicare is free and will cover 100% of their healthcare needs. Unfortunately, that’s not the case.

How to Avoid It:
Learn what Medicare does and doesn’t cover. For example:

• Part A covers hospital care but has a deductible
• Part B covers doctor visits and outpatient care, but only 80% after the deductible
• Medicare doesn’t cover routine dental, vision, hearing aids, or long-term care

Supplemental plans or Medicare Advantage can help fill these gaps.

Not Comparing Plan Options Annually

The Mistake: Sticking with the same plan year after year without reviewing changes.

How to Avoid It:
Use the AEP (Annual Enrollment Period) that runs from Oct 15 – Dec 7 to review:

• Premium changes
• Drug formularies
• Doctor networks
• Copays and out-of-pocket maximums

Plans change annually, and so do your health needs. An annual review ensures you’re in the most cost-effective and appropriate plan.

Relying on Friends or Online Info Without Expert Help

The Mistake: Taking advice from well-meaning friends or reading generic info online without speaking to a licensed agent.

How to Avoid It:
Medicare is personal. Plans vary by location, health needs, income, and prescription use. A licensed Medicare agent can help you compare plans and avoid costly oversights.

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Making the wrong choice with Medicare can cost hundreds, even thousands, over time. Whether you’re helping someone new to Medicare or reviewing your own plan, the smartest thing you can do is work with a licensed Medicare agent who understands the rules, timelines, and local options.

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Medicare for People Under 65: What Benefits and Plans Are Available

When most people think of Medicare, they think of individuals turning 65. But Medicare also covers millions of Americans under age 65 who qualify due to disability or specific medical conditions. Because understanding benefits and plan options is essential to getting the best possible care, we will discuss Medicare for people under 65.

Who Qualifies for Medicare Under Age 65

You may be eligible for Medicare before turning 65 if:

• You’ve been receiving Social Security Disability Insurance (SSDI) for 24 months (consecutive or non-consecutive).
• You have Amyotrophic Lateral Sclerosis (ALS); you automatically get Medicare the same month your SSDI benefits begin.
• You have End-Stage Renal Disease (ESRD); you may qualify for Medicare without waiting 24 months, depending on your treatment and transplant status.

What Medicare Benefits Do You Get

Medicare coverage for those under 65 generally includes:

• Part A (Hospital Insurance): Covers inpatient care, skilled nursing facility care, hospice, and some home health care. Usually premium-free if you worked 40 quarters (or qualify through a spouse).
• Part B (Medical Insurance): Covers doctor visits, outpatient care, preventive services, and durable medical equipment. You pay a monthly premium (standard amount is $174.70/month in 2025, though income can affect this).
• Part D (Prescription Drug Coverage): You can enroll in a standalone drug plan or get drug coverage through a Medicare Advantage plan.

Medicare Advantage (Part C) Plans for People Under 65

Private insurance companies offer Medicare Advantage plans. These plans must cover everything Original Medicare covers and often more, like dental, vision, hearing, gym memberships, and over-the-counter allowances.

Important notes:

• Not every state or county offers Medicare Advantage plans for beneficiaries under 65.
• You must be enrolled in both Part A and Part B to join a Medicare Advantage plan.
• Availability can depend on your ZIP code and health condition.

Some Advantage plans are designed for people with chronic conditions (C-SNPs), which could be a great fit for those with a qualifying illness.

Watch a YouTube video on Chronic Condition MAPD Plans

Medicare Supplement (Medigap) Plans for Individuals Under 65

Medicare Supplement plans (also called Medigap) help pay out-of-pocket costs like deductibles, copays, and coinsurance. They work with Original Medicare (not with Advantage plans).

Here’s the catch:

• Federal law does not require insurance companies to sell Medigap plans to people under 65. But many states do require it.
• If your state allows it, premiums may be higher than for people 65 and older.
• You may not be offered the full range of plans (A–N), and plan availability is very limited and varies widely by state.

Important: Even if you’re under 65 now, you’ll get another Medigap Open Enrollment Period when you turn 65; at that point, you can enroll in any plan with guaranteed issue rights and generally at lower rates.

Prescription Drug Coverage for Under-65 Beneficiaries

If you’re on Original Medicare, you’ll need a standalone Part D plan to cover your medications. These plans vary by region and formulary, so it’s important to review which plan best fits your prescriptions and pharmacy preferences.

If you choose a Medicare Advantage plan with prescription coverage, you don’t need to enroll in a separate Part D plan.

Don’t skip drug coverage! If you delay enrolling in Part D when first eligible and don’t have other credible coverage, you may face a late enrollment penalty later.

Getting Help with Costs: Extra Help & Medicaid

If you’re under 65 and have limited income or resources, you may qualify for:

• Medicare Savings Programs (help pay for Part A and B premiums and other costs)
• Extra Help with prescription drug costs
• State Medicaid programs, which can provide additional services and cost coverage

Medicare for people under 65 can be complex, but it’s also a lifeline. Plan options may differ from those turning 65, especially when it comes to Medigap and Medicare Advantage availability. It’s essential to:

• Review your state-specific rules
• Check if you’re eligible for Extra Help or Medicaid
• Compare Medicare Advantage vs. Original Medicare + Medigap carefully

Remember; coverage options may improve (and become more affordable) when you reach age 65, so be sure to reassess at that time.

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Need help understanding your Medicare options under 65? Contact a licensed Medicare agent who can walk you through what’s available in your area and help you make the most of your benefit.

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Understanding SEPs for Medicare Chronic Special Needs Plans (C-SNPs)

Medicare Advantage Special Needs Plans (SNPs) provide targeted care and coordinated benefits to specific groups of beneficiaries. One common type of SNP is the Chronic Condition Special Needs Plan (C-SNP), which is available to individuals diagnosed with specific chronic health conditions. For agents, understanding C-SNP SEPs can ensure your clients receive the best coverage for the care they need.

To help eligible beneficiaries enroll in these plans, Medicare offers Special Enrollment Periods (SEPs) that allow people to join or switch into a C-SNP outside the standard Annual Enrollment Period (AEP).

Let’s explore what C-SNPs are, who qualifies, and how SEPs work to ensure timely access to care.

What is a Chronic Special Needs Plan (C-SNP)

A C-SNP is a type of Medicare Advantage plan tailored for people with certain severe or disabling chronic conditions. Private Medicare-approved insurance companies offer these plans. Plans must include the same benefits Medicare Part A and B provide, and usually include Part D prescription drug coverage.

C-SNPs often provide:

• A care team specializing in the chronic condition
• Coordinated services to help manage the enrollee’s health
• Lower costs on services that relate to the specific condition

Examples of eligible chronic conditions for C-SNPs include:

• Diabetes
• Congestive Heart Failure (CHF)
• Chronic Obstructive Pulmonary Disease (COPD)
• Cardiovascular Disease
• End-Stage Renal Disease (ESRD)

*Note: Medicare rules around ESRD and plan access changed in 2021; people with ESRD can now enroll in most Medicare Advantage plans, but ESRD-specific SNPs still exist in many regions.

Special Enrollment Period (SEP) for C-SNPs

Medicare offers a Special Enrollment Period when an individual is newly diagnosed with a qualifying chronic condition. This allows them to join a C-SNP as soon as they are eligible.

When Does the SEP Apply

You can enroll in a C-SNP:

When you are first diagnosed with a qualifying chronic condition
If you already have a qualifying condition but have not enrolled in a C-SNP before
If you move into or out of a service area that offers your C-SNP
If you lose your C-SNP eligibility because you no longer meet the chronic condition criteria

This SEP allows a one-time enrollment into a C-SNP for each qualifying diagnosis.

How the C-SNP SEP Works

Once diagnosed with a qualifying condition, beneficiaries typically have a Special Enrollment Period that lasts for 3 months, beginning:

• The month they’re diagnosed, or
• The month they are notified of the diagnosis

During this SEP, you can:

• Enroll in a new C-SNP specific to the condition
• Switch from another Medicare Advantage plan or Original Medicare into a C-SNP

Documentation Required

Enrollment into a C-SNP requires proof of the chronic condition, usually in the form of:

• A doctor’s attestation
• Medical records or diagnosis documentation
• A form provided by the plan for the provider to complete

What if Your Condition Improves

If you no longer have the qualifying condition (for example, your doctor no longer considers your diabetes as chronic or disabling), you may be disenrolled from the C-SNP. In that case, you’ll qualify for another SEP to enroll in a different Medicare Advantage plan or return to Original Medicare.

Why Agents Need to Understand C-SNP SEPs

If you’re a Medicare agent, being well-versed in the rules around C-SNPs and SEPs help:

• Connect chronically ill clients with better care coordination
• Avoid unnecessary wait times for clients who need immediate support
• Assist clients with navigating documentation and eligibility

Remember, not all areas offer C-SNPs, so always check plan availability by ZIP code.

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Special Enrollment Periods for Chronic Special Needs Plans offer a vital lifeline to beneficiaries who need enhanced care and support for their chronic conditions. Understanding how and when these SEPs apply ensures that eligible individuals don’t miss out on essential benefits tailored to their health needs.

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Medicare Advantage Enrollment: When and How to Join a Plan

Medicare Advantage (also known as Medicare Part C) is a popular alternative to Original Medicare, offering coverage through private insurance companies approved by CMS. These plans often include additional benefits like dental, vision, hearing, and prescription drugs. For anyone considering Medicare Advantage enrollment, it’s essential to understand the different enrollment periods and special situations that may qualify you for coverage; including the Medicare Advantage Trial Right.

Enroll in Medicare Advantage

There are a few windows when beneficiaries can sign up for a Medicare Advantage plan:

1. Initial Enrollment Period (IEP)

When an individual first becomes eligible for Medicare, they have a 7-month window to enroll:

• Begins 3 months before the month they turn 65
• Includes their birthday month
• Ends 3 months after their birthday month

When an individual qualifies for Medicare due to a disability, their IEP will begin three months before the 25th month of disability benefits and end three months after that month.

2. Annual Enrollment Period (AEP): October 15 – December 7

During AEP, anyone with Medicare can:

• Join a Medicare Advantage Plan
• Switch from one plan to another
• Drop their Medicare Advantage Plan and return to Original Medicare

Changes made during AEP take effect on January 1 of the following year.

Watch a YouTube Video on Medicare AEP Marketing Rules

3. Medicare Advantage Open Enrollment Period (MA OEP): January 1 – March 31

This period is for individuals who are already enrolled in a Medicare Advantage Plan. During MA OEP, you can:

• Switch to a different Medicare Advantage Plan
• Drop your plan and return to Original Medicare (with or without a Part D plan)

Click here to learn more about MA OEP

Special Enrollment Periods (SEPs)

Life happens and Medicare understands that. That’s why certain life events qualify beneficiaries for a Special Enrollment Period (SEP), allowing you to make changes outside the usual windows.

You may qualify for an SEP if:

• You move to a new address that isn’t in your plan’s service area
• You lose other coverage, such as employer, union, or Medicaid coverage
• Your plan is no longer available
• You get coverage through Medicaid or a State Pharmaceutical Assistance Program (SPAP)
• You’re diagnosed with certain conditions, allowing you to enroll in a Special Needs Plan (SNP)
• You’re released from incarceration
• You live in, move into, or move out of a nursing home or other long-term care facility

Each SEP has its own rules and timeframe, typically lasting 2 to 3 months around the qualifying event.

Medicare Advantage Trial Right

The Medicare Advantage Trial Right is a special protection for those trying a Medicare Advantage Plan for the first time. Here’s how it works:

Who Qualifies:

You qualify if:

1. You joined a Medicare Advantage Plan when you were first eligible for Medicare at age 65, and
2. Within the first 12 months, you decide you want to go back to Original Medicare
3. You dropped a Medigap (Medicare Supplement) policy to try a Medicare Advantage Plan for the first time, and within 12 months you want to switch back.

What You Can Do:

• Return to Original Medicare
• Enroll in a Part D prescription drug plan if needed
• In most cases, buy the same Medigap policy you had before, even if the insurance company normally wouldn’t sell it to you

Note: The Trial Right is only available once in your lifetime. It’s designed to offer peace of mind for those unsure whether a Medicare Advantage Plan is the best choice.

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How to Enroll

Enroll in a Medicare Advantage Plan:

• Online at Medicare.gov
• Directly with a carrier – there are a couple ways to do this including: online or over the phone
• Through a licensed Medicare agent or broker, who can help compare options and guide you through the process. This is our favorite option and the service is free!

Be sure to have:

• Your Medicare number
• The effective dates for Parts A and B

Medicare Advantage Plans offer convenience, extra benefits, and sometimes lower costs, but it’s important to choose the plan that fits health needs and lifestyle. Knowing enrollment rights and timing windows helps avoid penalties, gaps in coverage, or being locked out of better options.

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Working While Collecting Social Security

Many Americans choose to continue working while collecting Social Security; whether to stay active, boost income, or ease into retirement. Although those who are not yet at full retirement age, need to understand how working can affect their benefits. The Social Security Administration (SSA) may withhold a portion of their payments if their earnings exceed certain limits.

Can You Work and Collect Social Security

Yes, In fact; you can collect Social Security benefits while working. However, depending on your age and income, benefits may be temporarily reduced.

What Is Full Retirement Age (FRA)

The full retirement age depends on the year an individual was born. For most people retiring today, the FRA ranges from 66 to 67. Earnings limits apply to those who collect Social Security before reaching FRA and continue to work.

2025 Social Security Income Limits & Penalties

In 2025, if an individual is under the full retirement age for the entire year, the SSA deducts $1 from their benefits for every $2 they earn over $22,320/year (approx. $1,860/month).

Example:
Individuals who earn $30,000 while receiving Social Security before FRA are $7,680 over the limit. This means; SSA would withhold $3,840 of their benefits.

For those who reach full retirement age in 2025, the limit is higher:
You can earn up to $59,520 in the months before your birthday, with only $1 withheld for every $3 earned over the limit.

Once you reach full retirement age, there are no penalties; you can work and earn as much as you want without a reduction in benefits.

Learn about Medicare penalties

What Happens to Withheld Benefits

The good news: the money isn’t gone forever. When you reach full retirement age, the SSA will recalculate your benefit amount and increase it to account for the months when benefits were withheld due to excess earnings.

Are There Tax Implications

The answer is; yes, Social Security benefits may be taxable depending on total income (including wages, investments, and other retirement income).

If combined income (defined as adjusted gross income + nontaxable interest + half of your Social Security benefits) is:

• Between $25,000–$34,000 (individual) or $32,000–$44,000 (married), up to 50% of benefits may be taxed.
• Above $34,000 (individual) or $44,000 (married), up to 85% of benefits may be taxable. 

Impact on Medicare premiums

• If you receive Social Security benefits, your Medicare Part B premiums can be automatically deducted from your monthly payment.
• The standard Part B premium for 2025 is $185, but it can be higher based on your income from two years prior. 

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

Other considerations

• You will continue to pay Social Security and Medicare taxes on your earnings while working, regardless of age.
• Working might increase your future Social Security benefits, especially if your current earnings are higher than those in some previous years used to calculate your benefit.
• Some states also tax Social Security benefits. 

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When Working Makes Sense

Even with temporary benefit reductions or taxes, working while collecting Social Security may be worth it. Additional income can help:

• Cover rising expenses
• Delay tapping into savings
• Boost your Social Security by increasing your lifetime earnings record

Key Takeaways

• You can work and collect Social Security
• Earnings limits apply before full retirement age
• Benefits may be withheld, but are recalculated later
• Your benefits may be taxable depending on total income

Before deciding to work while on Social Security, consider speaking with a financial advisor or using the Social Security Earnings Test Calculator at SSA.gov. It’s a smart move to understand how your job may affect your benefits so you can make the most of your income now and in the future.

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Prior Authorization For Original Medicare

Starting January 1, 2026, those on Original Medicare who reside in New Jersey, Ohio, Oklahoma, Texas, Arizona, or Washington, will be required to get a prior authorization for Original Medicare before you receive some covered services. This will cause a major shift in how some beneficiaries use their Medicare benefits.

Medicare is launching a pilot program called the WISeR Model; short for Wasteful and Inappropriate Services Reduction and with it comes something traditionally associated with Medicare Advantage plans: prior authorization.

What Is Prior Authorization

Think of prior authorization as an ok from Medicare. Before your doctor can move forward with certain procedures such as; back surgery, an epidural, or a knee replacement, they have to get Medicare’s approval first. If Medicare doesn’t approve the service, the beneficiary will be on the hook for the entire cost.

This step is designed to prevent beneficiaries undergoing unnecessary or risky treatments, but it also means more paperwork, potential delays, and a new layer of bureaucracy for Original Medicare beneficiaries.

Why Is Medicare Doing This

According to CMS, the WISeR model has three main goals:

• Cutting down on fraud and wasteful spending
• Protecting patients from unnecessary or potentially harmful care
• Using technology and expert review teams to promote high-quality, cost-effective treatment

Medicare emphasizes that the goal is not to deny care, but to ensure the care being provided is truly necessary.

Which Services Will Require Prior Authorization

The WISeR pilot affects 17 outpatient services Medicare has identified as potentially overused or subject to misuse. These include:

• Back and neck surgeries
• Knee and joint surgeries
• Epidural injections and other pain treatments
• Skin grafts
• Nerve stimulators

What You Need to Know if You Have a Medigap Plan

Even if you have a Medicare Supplement plan (Medigap) like Plan G or Plan N, this change still affects you:

Watch a quick video on High Deductible Plan G

• Medicare Must Approve First: Medigap only helps pay your portion after Medicare approves the service. If Medicare denies it, Medigap won’t cover anything.
• Longer Wait Times: Prior authorization can delay access to care while your provider waits for Medicare’s decision.
• Less Flexibility: Traditional Medicare has long been valued for its ease of access to services—this new layer limits that freedom for certain procedures.
• No Formal Appeals: Under the WISeR pilot, there’s no standard appeal process. If denied, your doctor can submit more info, but there’s no official right to appeal like there is in broader Medicare.

How Does This Compare to Medicare Advantage

If this sounds familiar, it’s because Medicare Advantage plans have used prior authorization for years. However, there are key differences:

• Traditional Medicare is administered by the federal government, while Medicare Advantage is offered by private insurers.
• The WISeR model only requires PA for 17 specific outpatient services, while Medicare Advantage may require approval for hundreds of services and medications.

What’s Next

Right now, this is a pilot program affecting just six states. But if it’s successful, Medicare could expand it nationwide or add more services to the list.

Even if you don’t live in one of the six pilot states, it’s wise to stay informed—these changes could affect you in the future.

What Medicare Beneficiaries Should Do

1. Talk to Your Doctor
   Ask if any upcoming procedures might require prior authorization.
2. Plan Ahead
   Build in extra time for possible delays when scheduling certain treatments.
3. Stay Informed
   Keep up with updates from CMS and talk to your Medicare agent, especially if you plan to travel or move to another state.

The WISeR model represents a big change for Traditional Medicare, especially for those who’ve enjoyed its simplicity and flexibility. While the goal is to protect patients and reduce waste, many worry it could delay care or add confusion.

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Stay up-to-date on agent events and information

For now, being proactive is your best defense. Know which services are affected, communicate clearly with your doctor, and keep up with Medicare updates. This pilot could be the first step in a broader transformation of how Original Medicare works.

Medicare Advantage Trial Right Rules: What You Need to Know

For beneficiaries who understand the Medicare Advantage Trial Right Rules, this SEP provides a second chance to find a plan to best fit their needs. Switching health plans is stressful; especially if you’re not sure whether your new Medicare Advantage (MA) plan will meet your needs. Fortunately, Medicare offers a special protection called the Trial Right. This provides MA plan enrollees a one-time opportunity to go back to Original Medicare and Medigap as well as a PDP plan if their MA plan isn’t a good fit.

In this blog, we explain Trial Rights, who qualifies, and how to use it so both Medicare agents and beneficiaries are well informed of all the options.

What is a Medicare Advantage Trial Right

The Trial Right is a federally protected enrollment right under Medicare. It allows certain individuals who try a Medicare Advantage plan for the first time to switch back to Original Medicare. When they switch to Original Medicare, in most cases, purchase a Medigap (Supplement) plan without medical underwriting.

This protection ensures that people aren’t stuck in a plan that doesn’t meet their healthcare needs, especially if they’re new to Medicare or trying out Medicare Advantage for the first time.

When Do Trial Rights Apply

There are the two situations when someone is entitled to a Medicare Advantage Trial Right:

Trial Right #1: First Time Joining a Medicare Advantage Plan

If a beneficiary joined a Medicare Advantage plan for the first time ever (at age 65 or older) and has been enrolled in that plan for less than 12 months, they can:

• Disenroll from the MA plan
• Return to Original Medicare (Part A & B)
• Purchase a Medigap plan (Medicare Supplement) with guaranteed issue rights; no medical underwriting
• Purchase a PDP plan to cover prescription drugs

Example:
Mary turned 65 and enrolled in a Medicare Advantage PPO instead of Original Medicare and Medigap. After 6 months, she realizes she prefers the flexibility of seeing any doctor and wants to switch. She has a trial right to go back to Original Medicare and buy a Medigap plan and PDP plan, even if she now has health issues.

Trial Right #2: Dropping a Medigap Plan to Try an MA Plan

If a beneficiary had a Medigap plan but switched to a Medicare Advantage plan for the first time, and it’s been less than 12 months, they can:

• Drop the MA plan
• Go back to Original Medicare
• Re-enroll in the same Medigap plan (if it’s still available) or buy a similar one from another company; with guaranteed issue rights

Example:
Joe had Plan G for two years, then switched to a Medicare Advantage HMO in January. By September, he misses his Medigap freedom. He can use his trial right to return to Original Medicare and get a Medigap plan without underwriting.

How to Use a Trial Right

Beneficiaries can typically switch during a valid election period such as:

• Annual Election Period (AEP) – Oct 15 to Dec 7
• Medicare Advantage Open Enrollment Period (MA OEP) – Jan 1 to Mar 31
• Special Enrollment Period (SEP) triggered by the trial right

Watch a YouTube video on Medicare OEP, SEPs and LEPs

Once the carrier process the disenrollment:

• Original Medicare (Parts A & B) coverage resumes
• The beneficiary can apply for a Medigap plan with guaranteed issue rights
• Beneficiaries must select Part D (drug coverage) separately, unless already built into the Medigap package

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Benefits of the Trial Right

• No medical underwriting for Medigap; even if you have pre-existing conditions
• A second chance to choose Original Medicare + Medigap coverage
• Ensures flexibility and peace of mind for new enrollees or first-time MA users

Important Rules and Limitations

• MA Plan enrollees must leave their current MA plan before the 12 months ends.
• It’s a one-time only right; once the beneficiary uses it, they cannot use it again.
• Your Medigap plan must still be available from the insurer, or you can choose another one. You must also apply for a Medigap plan as early as 60 days before the date your MA plan will end or no later than 63 day after your coverage ends.
• The beneficiary must consider prescription drug coverage:
  • If you return to Original Medicare, you’ll likely need to enroll in a standalone Part D plan.
• Not all agents are familiar with this rule; make sure your client knows their rights!

How Agents Can Use This in Sales

• Educate new-to-Medicare clients: They can try MA with confidence knowing they have a Trial Right.
• Use it as a consultative tool; not to push one product over another but to help the client choose what best fits their health and financial needs.
• Document Trial Right eligibility in your CRM or client file; especially if they switch from Medigap to MA.

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Medicare’s Trial Right protections give beneficiaries peace of mind when trying something new. As an agent, it’s your responsibility to educate clients on their rights and help them make informed decisions if their first choice doesn’t work out.

Helping a client use their Trial Right can be an important opportunity to show your value as a Medicare resource.

TRICARE and Medicare Coverage: How the Two Work Together

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

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

What Is TRICARE

TRICARE is the health care program for:

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

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

When a TRICARE Beneficiary Becomes Medicare-Eligible

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

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

What Is TRICARE For Life (TFL)

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

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

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

Agents, click here to see what you need to know before a Medicare sale

Coverage Details: Medicare TRICARE for Life

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

Can TFL Beneficiaries Enroll in Medicare Advantage

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

Agents should caution beneficiaries:

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

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

Do TFL Beneficiaries Need Medicare Part D

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

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

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

Key Points for Medicare Agents

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

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Key Takeaways for Beneficiaries

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

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

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

Prescription Discount Cards And Medicare

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

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

Prescription Discount Cards

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

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

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

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

When Medicare Beneficiaries Might Use a Discount Card

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

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

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

2. During the deductible phase

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

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

3. The plan copay is higher than the discount price

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

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

Important Considerations

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

How to Use a Discount Program

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

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

Medicare Agents

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

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

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

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

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Medicare vs. Employer Insurance: Which One Pays First

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

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

Primary Payer

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

Knowing which plan is primary ensures:

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

General Rule: Employment Size Determines Priority

If You’re 65 or Older and Still Working

If your employer has 20 or more employees:

• Employer insurance is primary
• Medicare is secondary

If your employer has fewer than 20 employees:

• Medicare is primary
• Employer insurance is secondary

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

Watch a video on how Medicare works with employer coverage

Under 65 and Have Medicare Due to Disability:

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

• Employer insurance is primary
• Medicare is secondary

If the employer has fewer than 100 employees

• Medicare is primary

Retiree Coverage or COBRA

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

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

What About Veterans Benefits or TRICARE

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

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

Beneficiaries

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

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