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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.

Navigating the world of Medicare can be overwhelming, especially when it comes to choosing the right supplemental coverage. That’s why it is important to understand what Medigap standardized benefits are and how they work.

Medigap is a type of private insurance that helps beneficiaries cover the “gaps” in Original Medicare (Parts A and B). Medigap plans cover things like; deductibles, coinsurance, and copays. What many people don’t realize is that Medigap policies are standardized, meaning the benefits for each plan type are the same, no matter which insurer you choose.

What “Standardized” Means

Starting in 1992, federal law requires all Medigap policies to adhere to standardized benefit structures, designated by letters: Plans A through N. The only real difference in plans is the premium each carrier charges for the plan. Although insurance companies charge different premiums, the benefits for each plan letter must be identical no matter who the provider is. In other words, every Plan N has to provide the exact same coverage for medical expenses no matter what company offers it.

Standardization makes it easy for beneficiaries to compare plans without worrying about differences in coverage. They can simply compare cost and company ratings to find the best options.

Examples of Medigap Plan options

• Plan A: This is the most basic plan option. It provides coverage for Medicare Part A coinsurance and hospital costs, Part B coinsurance, and the first three pints of blood.
• Plan G: The most comprehensive plan available to those who turned 65 after 1-1-2020. It covers all Medicare approved expsnes with the exception of the Part B deductible.
• Plan N: Offers lower premiums than Plan G and covers a portion of the copays for doctor visits and hospital visits. The enrollee will still have a small copay for Medical services. This plan does not cover the Part B deductible or excess charges.

Some States Have Different Medigsp Standards

Although most states follow the federal standardization model, Massachusetts, Minnesota, and Wisconsin have their own versions of standardized Medigap plans. These states use their own benefit structures however, they still follow the principle of offering consistent benefits across insurers within their states.

Please Note

• Plan C and Plan F are no longer available to beneficiaries who became eligible for Medicare on or after January 1, 2020. These plans provided coverage for the Medicare Part B deductible, which new legislation phased out to cut back on the overuse of services.
• Beneficiaries must have both Medicare Part A and Part B to enroll in a Medigap plan. There is a premium for Medigap plans in addition ot the Part B premium.
• Medigap works with Original Medicare, beneficiaires cannot use a Medigpa plan with a Medicare Advantage (Part C) plan.

Why Standardization is Important

Standardization simplifies decision-making for Medicare beneficiaries. It eleiminates the need to decipher insurnace benefits accross multiple insurance companies; instead, the focus is on price, company reputation, and rate increase history.

Watch a quick YouTube video on Medicare Supplement Underwriting

This helps foster competition between companies based on cost and service quality instead of confusing plan designs.

Choosing a Medigap plan doesn’t have to be a guessing game. With standardized benefits, benficiaries can make apples-to-apples comparisons between insurers and choose the coverage that meets both healthcare and financial needs.

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Because so many people confuse the terms Medicare and Medicaid, we will discuss Medicare vs Medicaid and explain the difference between the two terms. Although the terms are often mentioned in the same sentence, these programs serve different populations, have different eligibility rules, and provide different types of coverage.

Medicare

Medicare is a federal health insurance program. In general, beneficiaries of Medicare are:

• Individuals who are 65 and older
• Those under 65 with specific qualifying disabilites
• People who have beendiagnosed with either ESRD (End-Stage Renal Disease) or ALS

The Parts of Medicare

1. Part A – Hospital insurance (covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care)
2. Part B – Medical insurance (covers outpatient care, doctors’ visits, preventive services, and durable medical equipment)
3. Part C – Medicare Advantage Plans (offered by private insurers as an alternative to Original Medicare, often including vision, dental, and drug coverage)
4. Part D – Prescription drug coverage

Medicare Cost

Medicare is not entirely free. Most people get Part A premium-free, but they pay a monthly premium for Part B. They also may pay a premium for Part C and/or Part D. There are also optional Medicare Supplement plans available which also have a monthly premium. Medicare costs include things like deductibles, co-pays and coinsurance. The out-of-pocket amounts differ depending on the plan or plans chosen.

Medicaid

Medicaid is a program that is put in place by both federal and state governments. Individuals who receive this coverage are:

• People with low income who meet the income threshold amount (this varies by state)
• Certain pregnant women and children who meet the income level required
• People with disabilities with income that falls into the state requirement
• Some seniors, including those who also qualify for Medicare

Because Medicaid is administered by each state, the programs vary by state, including eligibility requirements and the services that the program provides.

Medicaid generally covers

• Hospital and doctor visits
• Long-term care (nursing home care)
• Home and community-based services
• Preventive care, mental health services, and more

In many cases, Medicaid covers services that Medicare does not; such as long-term custodial care.

Medicaid Cost

In most cases, Medicaid is either free or very low cost for eligible individuals. States may charge small copays for some medical services.

Medicare vs Medicaid – Key Differences

Can Individuals Have Both

The short answer is, yes! Some individuals qualify for both programs. These are called “dual eligibles.” For these people:

• Medicare typically pays first
• Medicaid may help cover Medicare premiums, deductibles, and services that Medicare does not cover (like long-term care)

Seniors with limited income or disabled individuals who qualify as dual-eligible receive comprehensive coverage at little to no cost.

Additionally; Medicare and Medicaid both play crucial roles in our healthcare system. They each serve a different purpose and population. Understanding who qualifies and what each program covers helps agents, individuals and families make informed healthcare decisions.

For assistance with eligibility or enrollment, consider contacting:

• Medicare.gov or 1-800-MEDICARE
• Click here for each state’s Medicaid office
• A local State Health Insurance Assistance Program (SHIP) for free counseling

When it comes to providing assistance to our clients, knowing all the services available to them is crucial. One important service we need to know about is the Medicare PACE program(Program of All-Inclusive Care for the Elderly).

Designed to help older adults meet their healthcare needs in the community instead of a nursing home or other facility, PACE is a unique and vital option for many Medicare and Medicaid beneficiaries. It provides a way to age with dignity and maintain independence.

In this post, we’ll break down what PACE is, who qualifies, what services it covers, and why it’s an important part of our healthcare system.

What Is the PACE Program

PACE is a program that provides comprehensive medical and social services to some elderly individuals living in the community who require assistance. A skilled team of healthcare professionals work with beneficiaries to coordinate their care. The bulk of the participants are dual eligible (on Medicare & Medicaid). The main objective of the program is simple: to help seniors stay in their homes and communities as long as possible while they receive high-quality, coordinated care.

Typically, PACE programs combine medical care, therapies, transportation, home care, and even meals; providing beneficiaries a full-service healthcare solution under one umbrella.

Who Is Eligible for PACE

To enroll in a PACE program, individuals must meet the following criteria:

• Be 55 years of age or older
• Live in a PACE service area (programs are not available everywhere)
• Be in need of nursing home level of care (the state of residence must certify this)
• Have the ability to live safely in the community with the help of PACE services

PACE is available to individuals who are eligible for Medicare, Medicaid, or who meet the criteria listed above. Some individuals pay nothing for PACE services, while others may have to pay a monthly premium.

Some Services PACE Covers

PACE offers a wide range of services, including but not limited to:

• Primary and specialty medical care
• Prescription drugs
• Nursing services
• Hospital and emergency care
• Home care and personal care
• Physical, occupational, and recreational therapies
• Social services and case management
• Adult day care
• Meals and nutritional counseling
• Transportation to medical appointments

In general, if a participant needs a service for their care and well-being, PACE either provides it or arranges for the beneficiary to receive it.

How PACE Works

Each participant in a PACE program has an team of health professionals who work together to coordinate care. This team includes doctors, nurses, social workers, physical therapists, and other specialists. Each individual has a plan tailored to thier needs. The team will adjust the care plan as needed.

PACE organizations receive a fixed monthly payment for services. If the beneficiary is on Medicare and Medicaid, the beenficiary pays nothing for this program. If the individual does not qualify for Medicaid, they are responsible to pay the monthly premium for long-term care portion of the program. They will also have to pay a premium for Part D drug coverage.

In general, beneficiaries receive all their healthcare services through the PACE organization. Many of the services are received at a PACE center, where participants see doctors, join therapy sessions, enjoy meals, and socialize.

Why PACE is Important

PACE programs offer an alternative to traditional nursing home care, promoting autonomy, better health outcomes, and a higher quality of life. The program may delay or even prevent the need for long-term nursing home placement. This benefits both individuals and healthcare systems focused on reducing the high cost of institutional care.

Because PACE focuses on preventive care and early intervention, participants often experience fewer hospitalizations and better management of chronic conditions.

How to Apply for PACE

For individuals who may be eligible for the PACE program; find out if there’s a program near you or contact Medicare or your state’slocal Medicaid office for more help.

For seniors who want to stay in their homes and communities, and for families looking for assistance with comprehensive care, PACE is a powerful option. Although it’s not available everywhere, the service area is growing. This is defintely worth considering for anyone who meets the criteria.