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Medicare Advantage Compensation Loss – State Regulators Push Back

The tension between state insurance regulators and Medicare Advantage (MA) carriers is reaching a new level. As insurers continue tightening their budgets and limiting new enrollment; often by cutting commissions to brokers and restricting access to online applications. Some state officials are challenging what they view as unfair and potentially unlawful practices when it comes to Medicare advantage compensation loss.

With the 2026 Medicare Annual Enrollment Period (AEP) already underway, this conflict could shape the future of how MA plans are marketed, sold, and regulated.

Why Carriers Are Reducing Broker Compensation

Financial pressures have been building within Medicare Advantage for several years. Rising utilization costs, increased regulatory scrutiny, and shrinking federal reimbursement have pushed Medicare insurers to prioritize profit stability over rapid membership growth.

As part of this shift, some carriers have:

• Eliminated or reduced commissions on specific plans
• Limited access to agent-facing online enrollment platforms
• Discouraged new enrollments that could attract higher-cost members

The carriers intend to use these measures to control risk and protect margins. Although for brokers and agents, the fallout is immediate; lost income, lowered client expectations, and fewer ways to serve Medicare beneficiaries effectively.

Watch a YouTube video on SEPs for discontinued Medicare advantage plans

States Begin to Challenge Commission Cuts

Insurance commissioners in Delaware, Idaho, Montana, Oklahoma, New Hampshire, and North Dakota have taken a firm stance: cutting or withholding commissions to reduce Medicare Advantage enrollment crosses the line into unfair trade practices.

Some regulators have directly warned carriers to stop using marketing tactics that restrict enrollment or disadvantage third-party marketers. Others have gone further:

• Idaho issued cease-and-desist orders against UnitedHealthcare and PacificSource for allegedly violating state insurance standards.
• Additional states have threatened penalties, sanctions, or legal action if insurers refuse to restore fair broker compensation.

State officials argue that if MA plans are sold within their borders, insurers must comply with state marketing and sales laws regardless of the program’s federal oversight.

The Stakes Are High for Both Sides

This conflict puts both insurers and brokers; and ultimately beneficiaries, in a difficult position.

For insurers, compliance with state demands could trigger:

• Tighter pricing
• Fewer $0 premium plans
• Potential consideration of market exits

As one industry expert noted, when carriers feel they cannot adjust compensation or enrollment strategy to manage risk, they may be more likely to scale back or leave smaller markets.

However, carriers also have strong incentives not to leave states completely. If an insurer exits a Medicare Advantage market, it is barred from re-entering for years. This could present a long-term setback few companies want to face.

For brokers, reduced compensation means:

• Inconsistent or unpredictable payment
• Competing against carriers that restrict access to enrollment platforms
• Difficulty supporting clients when carriers remove commissions after applications are already submitted

Marketing groups emphasized that commissions are built into plan pricing and actuarial calculations. In other words; carriers planned for these costs long before selling the product.

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Legal and Regulatory Questions

A key unresolved issue is whether state regulators have the authority to intervene in the sales and marketing of a federal healthcare program like Medicare Advantage.

Many legal experts believe states have more power than carriers acknowledge. They regulate:

• Agent licensing
• Marketing conduct
• Fair business practices within state borders

Some policy analysts argue that states may actually hold more leverage than CMS in enforcing sales and marketing standards; especially when unfair business practices affect consumers or licensed agents.

Idaho’s insurance director has signaled that the state expects legal challenges and is prepared to defend its position. This includes efforts to force insurers to retroactively pay withheld commissions.

On the other hand, insurers may counter-sue states, arguing that Medicare’s federal structure preempts state authority.

Where This Leaves Brokers and Beneficiaries

As this dispute unfolds, brokers remain stuck in the middle. They must comply with evolving state rules while navigating restrictive carrier policies. At the same time, beneficiaries risk losing access to the knowledgeable agents they rely on to explain coverage options, especially in rural or underserved markets.

Let’s Sum it all up

• Medicare Advantage carriers are reducing or eliminating broker commissions to limit new enrollment and protect margins.
• Insurance regulators in at least six states are challenging these tactics and threatening enforcement actions.
• If insurers restore full commissions, they risk enrolling higher-cost or unprofitable members, creating financial strain.
• The question of whether states can regulate MA sales and marketing remains unresolved, setting up likely court battles.

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Why Medicare Supplement Rates Are Increasing

Many Medicare beneficiaries have recently noticed that their Medicare Supplement (Medigap) premiums are climbing; sometimes more than expected. The Medicare supplement rate increases can be frustrating, especially for retirees on fixed incomes. However, there are several factors driving these adjustments that help explain why costs are rising across the board.

Rising Healthcare Costs Nationwide

Healthcare costs in the United States continue to rise each year, driven by inflation in hospital charges, doctor fees, prescription drug prices, and medical technology. Medicare Supplement insurance companies base their premiums on the cost of paying future claims. As healthcare services become more expensive, insurers must collect more in premiums to keep up with the cost of covering beneficiaries’ care.

An Aging Policyholder Population

As people age, they typically require more frequent and costly medical care. Medicare Supplement plans, particularly those with long-standing enrollees, experience higher claim volumes as the average age of their members increases. When claims outpace the amount collected in premiums, insurers must adjust rates to remain financially stable.

Inflation and Administrative Expenses

General economic inflation affects almost every industry; including insurance. Administrative expenses such as employee wages, technology costs, and compliance requirements have all increased in recent years. Insurers incorporate these higher operating costs into their premium calculations, which contributes to annual rate increases.

Medical Advancements and Utilization

Medical advancements help seniors live longer and healthier lives, but they also come with higher price tags. New treatments, diagnostic tools, and specialized therapies often cost more than older alternatives. At the same time, people are using more healthcare services overall, from preventive screenings to outpatient procedures, raising total claim costs and, ultimately, premiums.

Plan Type and Rating Method

The way a Medicare Supplement plan is priced also affects future rate increases. There are three main rating methods:

• Community-rated: Everyone pays the same rate regardless of age. Increases are usually due to inflation or claim experience.
• Issue-age-rated: Rates are based on the age when you enroll; increases come from inflation and claims, not your age.
• Attained-age-rated: Rates start lower but increase as you age, plus inflation and claim adjustments.

Those enrolled in attained-age plans often experience the steepest long-term increases.

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Smaller Risk Pools and Market Shifts

As Medicare Advantage enrollment continues to grow, fewer people are buying new Medicare Supplement plans. A smaller pool of members means less spread of risk, which can cause rates to rise faster for remaining policyholders. Additionally, some carriers exit certain states or discontinue specific plans, leaving fewer options and less competition.

Watch a video on the special enrollment periods for discontinued Medicare advantage plans

Managing Future Increases

While rising premiums are often unavoidable, beneficiaries can take steps to manage their costs. Reviewing your plan annually, comparing rates from other carriers, or switching to a different Medigap plan type may help reduce expenses. Working with a licensed Medicare agent ensures you understand your options and can make informed decisions based on your health needs and budget.

Medicare Supplement rate increases reflect broader trends in healthcare spending, demographics, and the insurance market. While the numbers may fluctuate, understanding the reasons behind them helps seniors plan ahead and make the most of their Medicare coverage.

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Deductibles and Other Medical Costs: What They Mean for Your Healthcare Budget

Healthcare terms can feel confusing, especially when it comes to how much you’ll actually pay for medical services. One of the most important pieces to understand when choosing insurance, or reviewing your current coverage, are deductibles and other medical costs.

These costs directly impact what you spend before your insurance steps in and how much you’re responsible for throughout the year. Understanding them helps you plan better, compare plans accurately, and avoid unexpected medical bills.

What Is a Deductible

A deductible is the amount you must pay for covered healthcare services before your insurance begins to share the costs.

For example, if your deductible is $2,500, you pay the first $2,500 of covered medical expenses yourself. After you meet your deductible, your insurance typically starts paying a portion of costs (often through coinsurance).

Think of the deductible as your first layer of financial responsibility in your insurance plan.

What Are Out-of-Pocket Costs

Out-of-pocket costs are expenses you’re responsible for when receiving care. They may include:

• Deductibles
• Copayments (fixed dollar amounts per service)
• Coinsurance (a percentage of the cost of services)
• Non-covered services

When comparing plans, look not only at the deductible but also the overall cost-sharing structure. A low-deductible plan may have higher premiums but lower out-of-pocket expenses when you receive care and vice versa.

Understanding the Out-of-Pocket Maximum

Most health insurance plans also include an out-of-pocket maximum (OOPM). This is the most you’ll pay in a policy year for covered services. Once you reach that limit, your insurance covers 100% of eligible expenses for the remainder of the year.

This limit is an important financial safeguard, especially for individuals with chronic conditions or unexpected medical events.

Watch a Video on Medicare IRMAA & Part B SEP Rules

Why Your Deductible and OOP Spending Matter

Knowing your deductible and out-of-pocket maximum helps you:

• Budget healthcare expenses
• Select a plan that fits your needs
• Avoid surprises when receiving care
• Plan ahead for prescriptions, specialists, or procedures
• Understand how preventive services are covered (This is key; many preventive services are covered before deductible!)

Tips for Choosing the Right Plan

When evaluating health plans, consider:

• How often you visit doctors
• Whether you take ongoing prescriptions
• Expected medical needs (e.g., planned surgery, therapies)
• Monthly premium cost versus potential annual expenses
• Your comfort level with risk and unexpected bills

People who expect regular medical care may benefit from lower deductibles and higher premiums. Those who rarely seek care may prefer a lower-premium, higher-deductible option.

Deductibles and out-of-pocket costs aren’t just insurance jargon; they are vital components of your financial health plan. Understanding them helps you to make smarter decisions and choose coverage that protects both your health and your wallet.

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If you ever feel uncertain about comparing plans or estimating potential costs, don’t hesitate to ask questions. Being informed is the first step to confident healthcare decisions. That is why working with a licensed insurance agent is so important.

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The Value of Medicare Agents and the Service They Provide

When individuals approach Medicare eligibility, they often discover just how complex healthcare decision-making can be. With dozens of plan types, varying costs, evolving coverage rules, and aggressive advertising from every direction, choosing the right Medicare coverage can feel overwhelming. That’s where licensed Medicare agents bring tremendous value.

Medicare agents act as trusted advisors, providing clarity, guidance, and personal advocacy. Their goal isn’t just to help someone enroll in a plan; it’s to ensure clients understand their benefits and feel confident in their healthcare choices year after year.

Simplifying a Complicated System

While Medicare is an essential program, it isn’t always easy to navigate. Beneficiaries have questions such as:

• Original Medicare or Medicare Advantage?
• What’s the difference between a Medigap plan and a Medicare Advantage plan?
• Do I need a Part D prescription drug plan?
• What are my costs? What doctors can I see? Will this plan cover my prescriptions?

A Medicare agent breaks this information down into clear, understandable terms. They help clients compare plan options side-by-side, explain key terms like premiums, deductibles, and maximum out-of-pocket costs, and ensure beneficiaries avoid costly mistakes such as missing enrollment deadlines or choosing plans that don’t fit their needs.

Personalized Guidance

Every Medicare beneficiary has unique needs; health conditions, prescription needs, doctor preferences, budget considerations, and lifestyle factors. Independent Medicare agents take the time to understand these factors and recommend plans that offer the best fit, not just the best marketing.

Many agents represent multiple carriers, allowing them to provide unbiased comparisons and advocate for the plan that truly serves the client best.

Watch a quick YouTube video comparing Medicare Advantage vs. Medicare Supplements

Year-Round Support and Advocacy

Medicare decisions don’t end at enrollment. Plans can change their provider networks, drug formularies, premiums, and benefits from year to year. Agents ensure beneficiaries stay informed and help them:

• Review plans annually during the Annual Enrollment Period
• Understand billing and claims issues
• Navigate carrier customer service challenges
• Access additional benefits and programs that can reduce healthcare costs

This ongoing support is one of the most valuable services agents provide and it’s often at no cost to the beneficiary, since agents are typically compensated by the insurance carriers.

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Protection Against Misinformation

Medicare marketing is everywhere, and not all of it is accurate. Agents serve as a reliable source of truth, cutting through misleading ads and high-pressure sales tactics. They are licensed, trained, and required to follow strict compliance rules designed to protect Medicare beneficiaries.

A Partner in Your Healthcare Journey

Medicare agents don’t just enroll people in plans, they build long-term relationships. They offer peace of mind, help clients understand their benefits, and stand by their side when questions or challenges arise.

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For many seniors, working with a Medicare agent means having a trusted professional who knows their needs, understands the system, and is committed to helping them access the best possible care.

HMO POS Medicare Plans: Flexibility Within a Network

There are many types of Medicare advantage plans to choose from; including HMO POS Medicare plans mentioned. HMO POS stands for Health Maintenance Organization–Point of Service. While it sounds complicated, the carriers designed these plans to provide a balance between affordability and flexibility.

Let’s break down what that means and how it might benefit Medicare beneficiaries.

What Is an HMO-POS Plan

An HMO-POS Medicare Advantage plan is a type of Medicare Advantage (Part C) plan that combines the cost-saving structure of a traditional HMO with some of the flexibility of a PPO (Preferred Provider Organization).

Like a standard HMO, members typically have a primary care physician (PCP) who coordinates their care. They also provides referrals for specialists within the plan’s network. However, the “POS” or Point of Service, feature lets members seek care outside the network in certain situations, though often at a higher cost.

How It Works

Here’s how an HMO-POS plan typically operates:

• In-Network Care: You’ll get the highest level of coverage when you use doctors, hospitals, and specialists within the plan’s network.
• Out-of-Network Care: You may be able to see an out-of-network provider, but you’ll usually pay more for those services.
• Referrals: In most cases, beneficiaries need a referral from their primary care doctor for specialist visits; even if they’re going out-of-network.
• Cost-Sharing: Costs for out-of-network care are higher and may include additional copays or coinsurance, depending on the service.

This design gives members the ability to stay within a coordinated network for predictable costs while maintaining the option to go outside the network if they need extra flexibility.

Watch a video on the Discontinued Medicare Advantage Plan Special Enrollment Period

Benefits of an HMO-POS Plan

• Lower Premiums: Many HMO-POS plans offer competitive premiums compared to PPO plans.
• Coordinated Care: Having a primary care provider manage your overall care helps ensure treatments and prescriptions work together effectively.
• Flexibility for Travel or Specialists: Members who occasionally need to see an out-of-network specialist or receive care while traveling appreciate the added flexibility.

Things to Consider

While HMO-POS plans offer more freedom than a traditional HMO, it’s still important to review the plan’s rules and costs:

• Out-of-network care is not always covered for every type of service.
• You’ll need to confirm what types of care the POS option allows outside the network.
• Costs can add up if you frequently go out-of-network. These plans are best for those who primarily stay within one area but want a flexibility.

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Is an HMO-POS Medicare Plan Right for You?

If you value affordable premiums and coordinated care but want the option to seek care outside your plan’s network, an HMO-POS Medicare Advantage plan may be a great fit. It offers the best of both worlds — structure when you want it, and flexibility when you need it.

Before enrolling, compare the provider networks, out-of-network rules, and total costs to make sure the plan meets your healthcare needs and lifestyle.

Agents, stay up-to-date on the our latest webinars an agent events.

HMO-POS Medicare Advantage plans give beneficiaries a smart blend of structure and freedom; ideal for those who want reliable care coordination with the occasional option to step outside the network.

Medicare Drug Cost Cap 2026

Beginning in 2025, Medicare introduced one of the most significant changes to prescription coverage in years: a yearly limit on out-of-pocket costs for medications under Medicare Part D. This change continues in 2026, with a slightly higher limit on the Medicare drug cap 2026 designed to help beneficiaries manage rising prescription expenses.

What Is the 2026 Medicare Drug Cap?

In 2026, the Medicare Part D out-of-pocket cap will be $2,100. Once a beneficiary pays $2,100 in out-of-pocket costs for covered prescription drugs in a calendar year, they will owe nothing more for those medications for the rest of the year.

This cap includes deductibles, copays, and coinsurance for covered Part D drugs, but it does not include:

• Monthly Part D premiums
• The cost of drugs covered under Medicare Part B (such as infusions administered in a doctor’s office)
• Medications not on the plan’s formulary

Whether someone has a stand-alone Part D plan or a Medicare Advantage plan with drug coverage, the cap applies to all covered prescriptions.

Why This Change Matters

Before this new system, Medicare beneficiaries had no upper limit on out-of-pocket drug costs. This meant that those with chronic illnesses or expensive specialty medications could spend thousands each year with no relief.

The new $2,100 cap gives beneficiaries greater financial protection and predictability. Once the limit is reached, cost-sharing ends, offering peace of mind for those managing ongoing or high-cost prescriptions.

The increase from $2,000 in 2025 to $2,100 in 2026 accounts for inflation and rising drug prices. This cap is part of the Inflation Reduction Act (IRA), which aims to make medications more affordable and includes additional measures like insulin cost caps and Medicare drug price negotiations.

How the Cap Works

Here’s an example:
Suppose Mary, a Medicare beneficiary, pays copays and coinsurance for her medications throughout 2026. Once her total out-of-pocket spending for covered Part D prescriptions reaches $2,100, she won’t have to pay anything else for those drugs for the rest of the year.

However, it’s important to note that costs for non-covered or Part B drugs won’t count toward the cap. Also, her monthly plan premiums remain separate and will continue.

Watch a YouTube video explaining the drug cap

What Beneficiaries Should Do

Even with this welcome protection, it’s crucial to review your plan each year during the Medicare Annual Enrollment Period (October 15 – December 7). Here’s what to consider:

• Check your plan’s formulary: Make sure all your prescriptions are covered.
• Compare plan costs: Premiums, deductibles, and copays can vary widely between plans.
• Track your spending: Plans will monitor your progress toward the cap, but keeping your own records is wise.
• Explore payment options: The new Medicare Prescription Payment Plan allows beneficiaries to spread out their drug expenses evenly throughout the year instead of paying large costs upfront.

A Step Toward Affordability

The 2026 Medicare drug cost cap is a milestone for millions of Americans who depend on prescription medications. While it doesn’t eliminate all costs, it offers much-needed relief and certainty for those facing high drug expenses.

By understanding how the cap works and reviewing coverage carefully, Medicare beneficiaries can make informed decisions and take full advantage of this new protection.

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Wellcare Spendables Card 2026

The Wellcare Spendables Card continues to be a popular feature of many Wellcare Medicare Advantage (MA) and Dual Eligible Special Needs (D-SNP) plans. The Wellcare Spendables Card 2026 has expanded how and where members can use the card, making it even more valuable for managing everyday health expenses.

What Is the Spendables Card

The Spendables Card is a preloaded debit-style card given to eligible Wellcare members. It includes a monthly or quarterly allowance that can be used for approved health-related purchases. Depending on your plan, the card can pay for:

• Over-the-counter (OTC) health items like pain relievers, cold medicine, or vitamins
• Dental, vision, and hearing costs such as exams, eyeglasses, or dentures
• Healthy groceries and nutritional drinks
• Home safety items like grab bars or bathroom supports
• In some plans, gas, rent, or utility assistance for qualifying members

The allowance amount and eligible categories vary by plan and state, so it’s important to review your plan’s 2026 Summary of Benefits.

What’s New for 2026

1. Expanded coverage: More plans now let members use their Spendables balance on dental, vision, and hearing expenses, not just OTC items.

2. Broader retail network: Members can use their cards at more than 66,000 national retailers, including major pharmacies and grocery stores.

3. Integrated rewards platform: The Spendables Card now connects with the Wellcare Rewards program, so eligible members can manage both benefits through one system.

4. Added flexibility for chronic conditions: Members qualifying under Special Supplemental Benefits for the Chronically Ill (SSBCI) may use their allowance for gas, home safety, rent, pest control, or utility assistance.

Watch a YouTube video about the drug cap

How to Use the Card

After activation (via the member portal, app, or phone), you can use the card like a debit card at approved stores or providers. Common uses include:

• In-store or online OTC purchases at participating retailers
• Paying providers directly for covered dental, vision, or hearing costs
• Purchasing groceries or home items if your plan allows healthy food or safety benefits

If your total purchase exceeds your allowance, you’ll need to pay the difference. Unused balances may roll over month to month but generally expire at year’s end.

Why It Matters

The Spendables Card helps reduce out-of-pocket costs for everyday health needs while giving members flexibility and convenience. It also supports social determinants of health, recognizing that access to food, transportation, and home safety are vital to well-being. For dual-eligible and chronically ill members, the expanded benefits can provide meaningful support beyond medical care.

Key Questions to Ask

Before using your card, confirm:

• How much is my monthly or quarterly allowance?
• What items and services are eligible under my plan?
• Does my plan include healthy food, utilities, or rent benefits?
• Will unused funds roll over?
• Which stores and providers accept the card?

Example in Action

Mary, a Wellcare D-SNP member, receives a $100 monthly allowance. She buys OTC cold medicine and uses the remaining balance toward her dental copay. The next month, she uses part of the card to purchase fresh produce from an approved grocery retailer. Any leftover funds roll into the following month, helping her stretch her allowance through the year.

Final Thoughts

The Wellcare Spendables Card is a strategic benefit that can help Medicare Advantage and D-SNP beneficiaries pay for a wider range of health-supporting purchases in 2026. Going beyond traditional medical care, it reflects a broader view of wellness and takes into account social needs like home safety, food, housing and utilities (for eligible members).

If you or someone you’re helping is enrolling in a Wellcare plan for 2026 or already a member, it’s well worth taking the time to understand exactly how the Spendables card works under their specific plan, what the dollar amount is, what it covers, how to use it; and make a plan to use its allowance wisely.

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Medicare Agents as TPMOs: Compliance and Best Practices for Medicare Agents

As a Medicare agent, you are more than just a licensed professional helping beneficiaries find the right coverage; you are officially recognized by CMS as a Third-Party Marketing Organization (TPMO). Understanding Medicare agents as TPMOs is crucial to protecting your business and staying compliant.

What Is a TPMO

CMS defines a TPMO as any organization or individual compensated to perform lead generation, marketing, or enrollment activities for Medicare Advantage (MA) or Part D plans. That means independent agents and brokers fall under the TPMO umbrella whenever they market or sell these plans.

Why It Matters

The TPMO designation exists to ensure transparency, accountability, and consumer protection. CMS tightened these rules in response to misleading advertisements and beneficiary confusion. As a result, every agent who sells MA or Part D plans must meet strict communication and documentation requirements.

Watch a video on the FCC one to one consent rule

Key Compliance Requirements

Here are the most important rules every TPMO must follow:

• Mandatory Disclaimer: Every piece of marketing material, website, or verbal outreach must include the approved CMS disclaimer: “We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all your options.”
• Call Recording: Any phone call that discusses MA or Part D benefits; even informational calls must be recorded and securely stored for at least 10 years.
• Scope of Appointment (SOA): Always obtain an SOA before discussing plan details. Electronic and paper SOAs are acceptable but must be saved for recordkeeping.
• Avoid Misleading Language: Never imply government affiliation or say you offer “every plan” unless that is true. Be careful with phrasing on social media, websites, and mailers.

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Best Practices for Sales and Marketing

To remain compliant and build trust with clients:

• Lead with education, not sales. Help beneficiaries understand their options before recommending a plan.
• Use CMS-approved materials. Avoid customizing carrier pieces unless approved for agent use.
• Document everything. Keep records of calls, SOAs, and marketing pieces.
• Stay current on CMS updates. Rules can change annually; follow your FMO and carrier training closely.

Stay updated on agent events and information

Being classified as a TPMO isn’t just a compliance label; it’s a reminder that agents play a critical role in maintaining Medicare integrity. By following CMS rules, staying transparent, and putting client education first, you protect both your license and your reputation in the Medicare marketplace.

Why Medicare Star Ratings Matter – Understanding Their Importance

When comparing Medicare Advantage or Part D prescription drug plans, you’ll see a “star rating” next to each one. These ratings aren’t just numbers; they reflect the overall quality and performance of a plan. Knowing why Medicare star ratings matter can help beneficiaries make a more confident, informed choice.

What Are Medicare Star Ratings

Each year, the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) and Part D plans on a 1-to-5-star scale, with 5 stars being excellent and 1 star being poor.

CMS evaluates plans based on key measures such as:

• Preventive care and managing chronic conditions
• Member satisfaction and customer service
• Medication safety and accuracy of drug pricing
• Handling of complaints and appeals

These ratings help beneficiaries compare plan quality; not just costs.

Why Star Ratings Matter to Beneficiaries

1. Quality Over Cost
   A low monthly premium might look appealing, but a lower-rated plan could have poorer customer service or fewer care management programs. Star Ratings help you see the bigger picture.
2. Better Health Outcomes
   High-rated plans generally perform better in preventive care, chronic condition management, and prescription safety leading to improved member health.
3. Special Enrollment Advantage
   If a 5-star plan is available in your area, you can use the 5-Star Special Enrollment Period to switch once a year, even outside regular enrollment periods.

Watch a YouTube video on special enrollment periods

Why Star Ratings Matter to Carriers

For insurance carriers, these ratings are more than just feedback — they directly affect their business.

• Financial Rewards: CMS provides quality bonus payments to plans with ratings of 4 stars or higher. These bonuses can help carriers enhance benefits, reduce premiums, and remain competitive.
• Reputation and Market Growth: A higher-rated plan attracts more enrollees. Consumers often view Star Ratings as a trusted indicator of quality and satisfaction.
• Compliance and Accountability: Consistently low ratings can lead to penalties or even removal from the Medicare program. This motivates carriers to continuously improve service, communication, and care coordination.

In short, the Star Rating system drives both accountability and quality improvement for carriers and members alike.

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The Bottom Line

Medicare Star Ratings serve an important purpose for everyone involved. They help beneficiaries choose better plans, encourage carriers to maintain high standards, and ensure that Medicare funds support quality care.

When reviewing plans, remember; the stars tell a story about value, performance, and member experience. Taking time to understand them can make an important difference in satisfaction with healthcare coverage.

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Medicare Sales Compliance Rules – What Not to Say During a Medicare Sale

When you with meet with Medicare beneficiaries, the words you choose matter. CMS has strict marketing guidelines, and violating them can lead to serious issues, this includes fines or even loss of contracts. To protect your clients and your business; we will go over some Medicare Sales Compliance Rules regarding things Medicare agents cannot say or do during a sales appointment.

“We offer every Medicare plan available”

This statement is misleading. Not all plans contract with independent agents, and no agent can truly offer every plan. You may represent several excellent plans, but accuracy is essential. Always choose wording carefully on printed materials and in conversations.

Remember: CMS requires TPMOs (Third-Party Marketing Organizations) to include a disclaimer on all marketing materials, communications, and even phone calls with prospective clients.

“This plan is free”

CMS marketing guidelines prohibit agents from using the word free to describe any plan.

• A $0 premium does not mean the plan has no costs.
• Enrollees are still responsible for deductibles, co-pays, and coinsurance.
• Network restrictions often apply.

The word free is misleading and should never be used when describing Medicare plans, premiums, deductibles, or cost-sharing.

Watch a YouTube video on CMS final rule 2026

“This plan covers everything you need”

There is no Medicare plan that covers all of someone’s health needs. The agent’s role is to help clients compare options and choose what best fits their personal situation. Present the pros and cons, but never promise that a plan will meet 100% of their needs.

“This is the best plan”

Superlatives like “best” are not allowed unless supported by verifiable, CMS-approved data. What’s best for one client may not be best for another. Always focus on what meets that client’s needs, not a blanket claim.

“Medicare approves this plan’s benefits”

You cannot say or imply that Medicare endorses, approves, or recommends a plan. While Medicare Advantage and Part D plans must meet CMS standards, they are offered by private companies; not by Medicare itself.

Talking about non-Medicare products during an SOA

Stick to the Scope of Appointment (SOA). If the SOA only covers Medicare Advantage, you cannot bring up Medigap, Part D, or life insurance. If a client asks about other products, suggest scheduling another appointment.

Asking for friends’ or family contact info

You cannot request phone numbers or addresses of potential referrals. What you can do is hand clients extra business cards so they can share your information with others who may be interested.

Offering gifts or money for enrollment

Agents cannot provide financial incentives or high-value gifts in exchange for signing up. CMS allows small promotional items (worth $15 or less per item, up to $75 per year per person).

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Scare tactics or misinformation

Do not tell clients their current coverage will change just to push a new plan. You may compare benefits factually but avoid scare tactics. Clients must feel educated, not pressured.

Medicare compliance is about accuracy, transparency, and respect. Stick to CMS-approved language, avoid misleading claims, and always tailor your advice to the individual client. Doing so not only keeps you compliant; it builds lasting trust.

Stay up-to-date on Medicare agent events and information.