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As an agent, helping clients navigate Medicare Supplement (Medigap) insurance can be both rewarding and challenging. One key aspect agents must understand and be able to explain to clients is what is Medicare supplement underwriting. Although Medigap plans offer standardized benefits, getting approved for coverage; especially outside of guaranteed issue periods, often depends on the underwriting process. Here’s what you need to know to guide your clients effectively.

Medicare Supplement Underwriting

Underwriting for Medicare Supplement plans refers to the process insurers use to evaluate an applicant’s health history before they issue a policy. This process determines whether an applicant qualifies for coverage and, in some cases, what premium they’ll pay. It typically includes a health questionnaire and a review of the applicant’s prescrption medications and medical history.

When Underwriting Is Required

Underwriting is generally required when a client applies for a Medigap plan outside of their open enrollment period or a guaranteed issue period. Here’s a breakdown:

Medigap Open Enrollment Period (OEP): This is a six-month window that starts the first month a client is 65 or older and enrolled in Medicare Part B. During this time, carriers must accept the applicant regardless of health status; CMS does not permit underwriting.

Guaranteed Issue Rights: These occur in specific situations (such as losing employer coverage or moving out of a Medicare Advantage plan’s service area). During this time, the client can enroll in certain Medigap plans without having to go through medical underwriting.

Learn more about Guaranteed Issue Rights

Unfortunately, outside of these periods, applicants are typically subject to underwriting and can be denied coverage based on pre-existing conditions.

Common Health Conditions That Affect Underwriting

While each carrier has it’s own underwriting criteria, common disqualifying conditions include:

• Congestive heart failure
• Insulin-dependent diabetes with complications
• Chronic obstructive pulmonary disease (COPD)
• Cancer within the past two years
• Alzheimer’s or dementia
• End-stage renal disease (ESRD)

In addition; some carriers may impose a waiting period for pre-existing conditions or adjust premiums based on health history.

Watch a quick YouTube video on Medicare Supplement underwriting

Navigating Medicare Supplement Underwriting

• Timing is everything: Try and encourage clients to apply during their OEP or another guaranteed issue window to avoid underwriting altogether.
• Pre-Qualify Applicants: Ask clients key health questions before submitting applications to avoid the disappointment of unnecessary declines.
• Know the Carriers: Different insurers have different underwriting guidelines. It is a good idea to familiarize yourself with each carrier you represent’s underwriting grids and health questions.
• Explore Alternatives: In the event the plan declines a client, they can opt for a plan that does not require underwriting, such as Medicare Advantage or other coverage options.

Understanding Medicare Supplement underwriting is essential to provide viable options to your clients. By staying informed about carrier guidelines and knowing how to time applications correctly, you can help clients get the coverage they need with fewer issues.

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Because there are so many regulations for Medicare sales, agents need to constantly be learning. That is why we will discuss Medigap Guaranteed Issue Rights in this post. This is a subject that is crucial to understand but often misunderstood.

Medigap Guaranteed Issue Rights

Guaranteed Issue (GI) Rights are protections under federal law that provide beneficiaries the right to purchase certain Medigap (Medicare Supplement) policies without having to go through medical underwriting. That means insurance companies can’t:

• Deny the beneficiary enrollment in a policy
• Charge enrollees more based on health
• Impose waiting periods for pre-existing conditions (in most cases)

These rights kick in during specific situations, often tied to changes in your health coverage or life circumstances.

When Guaranteed Issue Rights Apply

Here are some common scenarios that trigger GI rights:

Turning 65

Anyone who turns 65 has a 6 month period where they can enroll in a Medigap plan without having to go through underwriting.

Loss of Employer or Union Coverage

Individuals that have health coverage through an employer or union (including COBRA) that ends have 63 days from the end of that coverage to buy a Medigap policy using GI rights.

Medicare Advantage Plan Leaves a service Area

If a Medicare Advantage (MA) plan no longer provides service the enrollee’s area, is terminated, or they move out of the plan’s service area, they can return to Original Medicare and buy a Medigap policy under GI protections.

Beneficiary Tries a Medicare Advantage Plan for the First Time

Those who joined an MA plan when they were first eligible for Medicare at 65 and switch back to Original Medicare within the first 12 months can buy any Medigap policy offered in their state.

Medigap Insurance Company Goes Bankrupt or Misleads You

If the Medigap insurer goes out of business or the beneficiary is misled into buying a policy, they have GI rights to purchase another policy.

Trial Rights

In some cases, beneficiaries have “trial rights” that allow them to try out an MA plan and return to a Medigap plan under GI protections. This typically applies if they dropped a Medigap policy for an MA plan and want to switch back within 12 months.

Rules and Timelines

• Typically individuals have a 63-day window from the date previous coverage ends to use their GI rights.
• The plans that are guaranteed issue depend on eligibility and location. The standard Medigap plans are Plans A, B, C, F, K, or L.
• The federal government mandates guaranteed issue rights, although some states offer broader protections. It is important to check the rules for each state.

Watch a YouTube video on Medicare Supplement Underwriting GI & non-GI states

Why Guaranteed Issue Rights Matter

Without GI rights, applying for Medigap outside the initial enrollment period often means going through medical underwriting. Those who have pre-existing conditions could be denied coverage or charged more.

GI rights are a safeguard. They ensure that when life throws a curveball like; losing coverage, moving, or simply changing your mind, beneficiaries can access supplemental coverage without penalty.

Birthday Rule

There are 6 states that allow beneficiaries to change Medigap plans without underwriting during a specific period before/after their birthday each year on a GI basis. The states that have this rule are: CA, ID, IL,KY, LA, MD, NV, OK & OR. Each of these states has it’s own specific rules for this.

Important:

Some states allow beneficiaries to change Medigap plans any time or at specific times without undergoing medical underwriting. These states are: CT, NY, MA & ME.

In CT & NY enrollees change Medigap plans anytime of the year without underwriting. Massachusetts offers an annual open enrollment where beneficiaries do not have to go through underwriting. In Maine there is an open enrollment in June where Medicare Supplement enrollees can switch to a similar or lower benefit plan without underwriting.

Anyone applying under GI rights; insurance companies may request documentation (like letters from the former insurer). Keeping all notices and paperwork handy makes the application process smoother.

Medigap Guaranteed Issue Rights are an important part of the Medicare landscape, especially for those navigating transitions. Understanding when and how they apply allows you to help clients make informed choices and avoid gaps in healthcare coverage.

Physicians Mutual Preventive Benefits are part of their Medicare Supplement plans designed to enhance Original Medicare by covering additional healthcare expenses. Notably, certain plans include coverage for preventive health care services and may offer access to fitness programs like Silver&Fit.​

Preventive Health Care

Preventive health care is essential for early detection and management of health conditions. Because of this, Physicians Mutual provides benefits for preventive services in most of their Medicare Supplement plans, excluding Plan A. These benefits are not subject to high deductibles, ensuring that policyholders can access necessary preventive services without significant out-of-pocket costs.

The Preventive Benefits Rider

This Medicare Supplement portfolio is unique to the market. It offers a Preventive Benefits Rider that not only covers preventive care but adds the Silver & Fit program as well.
This wellness combination is not available from any other insurance carrier.

The rider offers extra benefits for physical exams, health screenings and routine blood work not covered by Orignal Medicare.

The Silver & Fit Program

This program provides useful benefits such as; memberships at one of thousands of participating fitness centers as well as discounts at premium fitness centers. Additionally they provide each member with a choice of one home fitness kit per year and assces to thousands of on-demand workout videos.

Watch our YouTube video for all the details

Silver&Fit Fitness Program

Staying active is vital for overall health, especially for seniors. The Silver&Fit program offers access to a network of fitness centers and resources to help seniors stay fit. While Original Medicare does not cover Silver&Fit, some Medicare Supplement and Medicare Advantage plans include similar programs. Physicians Mutual offers Silver&Fit benefits in specific states, often as part of their preventive benefits rider. Availability and terms can vary, so it’s important to review plan materials or consult with a licensed agent to determine if Silver&Fit is included in your area.

Considerations For Choosing a Plan

When selecting a Medicare Supplement plan with Physicians Mutual, consider the following:

• Plan Availability: Physicians Mutual offers various plans, including Plan A and Plan G. They also offer Innovative Plan G options which feature lower premiums with a deductible for the initial years.
• Preventive Benefits: Confirm whether the plan includes preventive health care services and understand any associated costs or limitations.​
• Fitness Programs: If access to fitness programs like Silver&Fit is important to you, verify the availability within your chosen plan and state.​Medicare Plan Finder
• Discounts: Physicians Mutual may offer discounts for non-tobacco users, automatic bank withdrawals, or household discounts when another adult aged 60 or older resides with you.

For personalized information and to explore plan options that best suit your healthcare needs and lifestyle, consider contacting a licensed Medicare agent.

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Unfortunately, as people age, the risk for chronic conditions like heart disease, diabetes, and cancer increases. Although with the right preventive measures in place, many of these conditions can be delayed, managed effectively, or even avoided. That is why we will go over the importance of preventative services for Medicare beneficiaries.

Preventive Healthcare

The objective of Preventive healthcare is to maintain wellness and discover health issues before they become serious. It includes regular checkups, screenings, immunizations, counseling, and lifestyle intervention. These services are all designed to detect potential health problems early or prevent them from happening.

Why Preventative Service for Medicare Beneficiaries Matters

Early Detection

Some serious conditions, such as colorectal cancer or high blood pressure, may not show symptoms until they’ve progressed. That is why routine screenings are important. They can catch these conidtions early, when they’re easier to treat. This helps the beneficiary have a better qualityof life and save money on treatments.

Managing Chronic Conditions

Due to the fact that, over two-thirds of Medicare beneficiaries suffer from multiple chronic conditions, preventative care is essential. Preventive care helps manage these illnesses more effectively, avoiding emergency visits, hospitalizations, and complications. Annual wellness visits give beneficiaries an opportunity to review medications, coordinate care, and update personalized prevention plans.

Immunizations

Keep in mind; Flu shots, shingles vaccines, and COVID-19 boosters can be life-saving for older adults whose immune systems may not be as strong as younger individuals. Medicare Part B covers many of these vaccines. Staying up-to-date with immunizations can help prevent avoidable illness and hospital stays.

Mental and Cognitive Health

Preventive care also includes screenings for depression and cognitive impairment that are critical as people age. These services allow early interventions that can improve quality of life and help individuals maintain independence.

Health Education and Lifestyle Support

Through programs like smoking cessation counseling and diabetes self-management training, Medicare supports healthier living. Lifestyle changes such as, eating healthier foods, excercising or quitting smoking can dramatically reduce the risk of future health problems.

Overcoming Barriers to Access

Despite the clear benefits, many beneficiaries don’t fully utilize preventive services. Reasons include lack of awareness, confusion about coverage, transportation challenges, or simply not knowing what’s available to them. That’s why education and outreach; especially from healthcare providers, caregivers, and community organization are so crucial.

In the event a client wants to have better coverage for an illness, agents should understand the benefitof ancillary products to avoid gaps in coverage.

Agents: Watch a quick YouTube video on why and how to sell ancillary products

Preventive healthcare isn’t just about avoiding illness. It’s about living better, longer, and keeping your independence. For Medicare beneficiaries, taking advantage of all the preventive services Mediare covers is one of the smartest health decisions they can make.

Medicare provides essential health coverage for seniors and certain disabled individuals, but it doesn’t cover everything. That’s where Medicare Supplement plan (Medigap) come in. These policies help cover out-of-pocket costs like copays, coinsurance, and deductibles. Is a Medicare Supplement enrollment right for you? We will discuss who might be a good fit for one.

Medicare Supplements

Medicare Supplement policies are insurance plans provided by private insurance companies, designed to work with Original Medicare. They help cover the “gaps” in Medicare coverage, making healthcare costs manageable. However, beneficiaries cannot have a Medicare Advantage with a Supplement. Individuals must have Original Medicare to enroll in a supplement plan.

Who should consider a Medicare Supplement

Medicare Supplement plans are a great option for individuals who want more comprehensive coverage and predictable healthcare costs. Here are some reasons individuals may benefit from enrolling in a Medicare Supplement plan:

Lower Out-of-Pocket Costs

Original Medicare beneficiaries pay coinsurance, copays, and deductibles for medical services, which can add up. For those who prefer to minimize these expenses, a Medicare Supplement plan can significantly reduce out-of-pocket costs, providing greater financial security and predictable expenses.

Frequent Healthcare Users

For individuals with chronic conditions who require frequent doctor visits, or need ongoing medical treatments, Medicare Supplement can be an cost saving option. It covers costs that would otherwise be paid out-of-pocket, making medical expenses more manageable.

Travelers and Snowbirds

Unlike the network restrictions of Medicare Advantage plans, Supplement plans provide nationwide coverage. Some plans even offer foreign travel emergency coverage, making them ideal for those who travel frequently or live in multiple states throughout the year.

Flexibility in provider choice

Medicare Supplement plans allow enrollees to see any doctor or specialist who accepts Medicare assignment. There is no need for referrals or network restrictions. This is very attractive to those who want more freedom in their healthcare options.

Individuals who can afford the premiums

While Medicare Supplement plans reduce out-of-pocket costs, they come with monthly premiums in addition to the Medicare Part B premium. For individuals who can comfortably afford the premiums, a Supplement plan can provide peace of mind and financial protection against unexpected medical expenses.

New Medicare Enrollees

For most beneficiaries, the best time to enroll in a Medicare Supplement plan is during the six-month Medicare Supplement Open Enrollment Period, which begins when beneficiaries first enroll in Medicare Part B. During this time, beneficiaries have guaranteed issue rights. This means they can enroll in any Medicare Supplement policy available in their state without medical underwriting. Those who apply outside this period, may be subject to higher premiums or even denial based on health conditions. Please note; underwriting does not apply to those who live in one of the 4 guarantee issue states.

Who might not want a Medicare Supplement

Although Medicare Supplements are beneficial for many, they may not be a good choice for everyone. Those who might not benefit from a Medicare Supplement are:

• Enrolled in a Medicare Advantage Plan: Medicare Supplement cannot be used with Medicare Advantage.
• Individuals with employer or retiree coverage: Some employer-sponsored plans provide secondary coverage to Original Medicare, making a Medicare Supplement unnecessary.
• Those who rarely use medical services: Healthy individuals who don’t visit the doctor often may find the cost of a Medicare Supplement premium outweighs the benefit.

Watch a quick YouTube video Medicare Advantage vs Medicare Supplement

Beneficiaries should seek the advice of a licensed Medicare agent before enrolling in a plan. They can help compare plan option to ensure they make the best choice for the individual situation. Understanding healthcare needs and financial situation can help determine if a Medicare Supplement is the best plan choice.

As a Medicare insurance agent, maintaining a strong reputation and ensuring client satisfaction is essential for success. While providing the best possible service, agents must also be proactive in preventing client complaints that could damage their credibility, lead to compliance issues, or impact their business. We will explain how to avoid client complaints and build better client relationships.

Explain plan details and costs clearly

Many complaints arise from misunderstandings about plan coverage, costs, or network restrictions. To avoid this, agents should take the time to explain plan details, including premiums, deductible and co-pays. Do not forget to include out-of-pocket plan limits.

Remember to emphasize any network restrictions as well as provider availablity. This is extremely important for Medicare Advantage plans. It is helpful to provide a summary of benfits so clients can review them before enrolling in a plan.

Ensure clients enroll in the correct plan

Sometimes complaints occur if the client feels they were enrolled in a plan that does not fit their needs. The best ways to avoid this are; conduct a thourough needs assessment. Be sure you consider all medications, docotors and expected healthcare useage. Comparing mulitple plans and explaining the pros and cons of each helps the client make an informed decision.

Learn about rapid disenrollments

Be transparent coverage changes

Because Medicare plans can change every year, clients may be unhappy if they experience unexpected costs or coverage changes. To prevent this; be sure you procactively inform them of any modifications to their current plan, Remind them to take a look at their annual notice of change (ANOC). Offer an annual review during AEP to ensure thye are still in the best plan for their coverage needs.

Follow CMS compliance guidelines

The CMS has strict marketing and sales guidelines. Agents must avoid misleading or high-pressure sales tactics, use only approved marketing materials and be sure to obtain consent before discussing any pans. It is also important to never make unverified claims about coverage, benefits or plan costs.

Provide ongoing support

Clients appreciate agents who are accessible and responsive. To maintain trust; return calls and emails promptly. Offer assistance after enrollment, such as claims questions and benefit explanations. It is always a good idea to follow up to make sure clietns are happy and understand hw to use their plan benefits.

Handle issues and complaints professionally

Even with the best practices, complaints may still come up. When they do; be sure you listen attentively to the client’s concerns without interruption. It is important to acknowledge their frustration and provide a solution oriented repsonse. If it is necessary, escalate issues to the appropriate carrier rep or Medicare support services.

Document interactions

Keeping records of client communications, plan discussions, and enrollments helps protect agents and clients in case of disputes. Maintain notes from meetings, make note of any special concerns. Keep written enrollment confiramtions and copies of signed documents, authorizations especially the SOA.

Stay updated on Medicare rules and plans

Medicare regulations, plan offerings, and compliance rules change regularly. Stay informed by attending carrier training and webinars. Complete all annual certifications including AHIP. Join industry groups and network with other agents to stay updated on all industry and CMS rules.

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Medicare agents play an important role helping clients navigate complex healthcare decisions. By being transparent, compliant, and client-focused, agents can minimize complaints, enhance client satisfaction, and build a strong reputation in the industry. Providing top-notch service not only leads to long-term client relationships but also increases referrals and business growth.

In a memo dated March 20, 2025, CMS withdrawals DST SEP change. CMS announced the withdrawal of the changes to the enrollment process that were set to take place on April 1,2025. In other words, there will be no changes to the DST SEP policy that is currently in place.

Why this is good news

The reversal of this decision is great news for both agents and their clients. Because it takes the burden off of already stressed clients who have had to deal with a weather related or other FEMA declared area emergency.  This means, the current SEP will not change. Beneficiaries do not have to self-enroll using 1-800-Medicare to use this SEP.

As per the CMS memo of March 20, 2025, insurance carriers will accept enrollment applications submitted by licensed agents. This helps Medicare beneficiaries avoid both stress and confusion. It also allows agents to ensure the process is completed correctly and in a timely manor.

Medicare DST SEP

The DST SEP is an enrollment election period for qualified Medicare beneficiaries . CMS provides this SEP to those who miss a valid election period due to weather-related emergencies or FEMA declared disasters.

Only areas where state or local government officials declare an emergency or disaster can use this SEP. This SEP starts the date the incident occurs and continues for two months after it starts or the extension period begins. It can be in place for up to a year after the incident.   

Please note: Beneficiaries can either enroll in or disenroll from a Medicare plan using the DST SEP. New coverage goes into effect the first day of the month following the submission of the application.

Eligibility for the DST SEP

To qualify for this SEP, the beneficiary must live in the area the disaster occurred in. In addition, they must have missed a valid election period (AEP, IEP or OEP, or an SEP) because of the emergency.

In some cases, individuals use the SEP if they require help from a family member or caregiver who is impacted by a disaster. This can prevent them receiving the assistance they need during an enrollment period.

Watch a quick YouTube video on the changes to DSNP SEPs

A couple more reasons to use the DST SEP: When a disaster causes the inability to access Medicare plan information or submit an application. Another example is; when a disaster impacts a healthcare facility or provider. This can hinder the beneficiary’s access to information necessary to make an informed enrollment decision.  

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Choosing the right Medicare Supplement (Medigap) plan is an important decision for individuals managing healthcare costs. In this post, we will answer the question; why enroll in a Plan N.

Medicare Supplement Plan N can be a great plan option due to its balance of affordability and comprehensive coverage. Individuals considering their Medicare Supplement options may find the Plan N is the perfect fit for their healthcare needs.

Lower monthly premiums

One of the biggest advantages of Plan N is its cost-effectiveness. Although Plan N provides many of the same benefits as other Medigap plans, its premiums are generally lower than Plan G. This makes it a good option for individuals who want solid coverage without paying a high premium for benefits they may not use too often.

Comprehensive coverage

Plan N covers many out-of-pocket costs that Original Medicare does not, including:

• Medicare Part A hospital coinsurance and hospital costs for up to 365 days after Medicare benefits are exhausted
• Medicare Part B coinsurance (except for small copays)once the annual Part B deductible is paid
• First three pints of blood
• Part A hospice care coinsurance
• Skilled nursing facility (SNF) care coinsurance
• Limited foreign travel emergency coverage (80% up to plan limits)

Out-of-Pocket costs

Plan N offers lower premiums in exchange for reasonable cost-sharing amounts. This includes:

• Up to a $20 copay for doctors visits
• Up to a $50 copay for emergency room visits (this copay is waived if the enrollee is admitted)

These low out of pocket amounts costs are predictable and manageable.

Please note: Unlike Plan G, Plan N does not cover Medicare Part B excess charges. Although, this is usually not an issue for beneficiaries who visit doctors that accept Medicare assignment, as they agree to charge only the Medicare-approved amount.

Plan N is a great choice for individuals who:

• Want the freedom to use any provider that accepts Medicare assignment
• Want to save on monthly premiums and still have great coverage
• Do not mind paying a nominal copay for medical services

Freedom to choose any provider that accepts Medicare assignment

Unlike Medicare Advantage plans, which have network restrictions, Medigap Plan N allows beneficiaries to see any doctor who accepts Medicare assignment. This is beneficial for individuals who seek care in more than 1 state and want greater flexibility in choosing healthcare providers. This is especially helpful if the individual uses several providers to treat medical conditions or illnesses.

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Protection from high hospital costs

Hospital stays can be expensive, but Plan N covers Part A coinsurance and hospital costs beyond Medicare’s limits. This ensures that beneficiaries do not face excessive out-of-pocket costs for extended hospital stays allowing beneficiaries to focus on recovery.

Alternative to more expensive Medigap plans

For those who want comprehensive coverage without the higher Plan G premiums, Plan N provides a good balance between affordability and comprehensive coverage.

Why enroll in Plan N

Medicare Plan N is a good choice for:

• Individuals who want lower monthly premiums
• Those who are comfortable with small copays for doctor and ER visits
• Beneficiaries who may use more than one Medicare-approved provider
• People looking for nationwide coverage without restrictive networks

Medicare Supplement Plan N is a great choice for those who want a balance of affordability and comprehensive coverage. With lower premiums, predictable cost-sharing, and strong hospital coverage, it offers a practical solution for many Medicare beneficiaries. Beneficiaries should consult with a licensed Medicare agent before enrolling in any Medicare Plan to ensure the plan aligns with healthcare and financial needs.

Because diabetes affects millions of Americans, understanding Medicare diabetes coverage is extremely important to both agents and those affected by diabetes. For diabetics, proper management and access to supplies is essential to maintaining health and quality of life. Fortunately, Medicare provides comprehensive coverage for diabetes-related services and supplies. It’s important to understand what Medicare covers and how to maximize benefits.

Medicare Part B

Medicare Part B covers a variety of diabetes-related supplies and services, including:

Blood Sugar Testing Supplies – This includes blood glucose monitors, test strips, lancets, and control solutions. Medicare generally covers up to 300 test strips and lancets every three months for insulin-dependent beneficiaries and up to 100 for non-insulin users.

Continuous Glucose Monitors (CGMs) – Medicare covers therapeutic CGMs and related supplies for qualifying individuals who meet specific criteria.

Insulin Pumps and Insulin for Pumps – Medicare covers insulin pumps as durable medical equipment (DME) and the insulin used in these pumps.

Medical Nutrition Therapy (MNT) – Beneficiaries with diabetes may receive MNT services, including nutritional assessment and counseling.

Diabetes Screenings – Medicare covers two diabetes screenings per year for beneficiaries at risk of developing diabetes.

Diabetes Self-Management Training (DSMT) – A critical education service that helps patients learn how to manage their diabetes effectively.

Medicare Part D: Prescription Drug Coverage

While Medicare Part B covers insulin used in pumps, Medicare Part D (Prescription Drug Plans) covers most other types of insulin, as well as oral diabetes medications, needles, syringes, and certain related supplies. Coverage may vary based on the specific Part D plan, so it’s important to review formulary lists and copayment amounts before enrolling in a plan.

Medicare Advantage (Part C) and Supplemental Coverage

Medicare Advantage (MA) plans must cover everything Original Medicare (Part A and Part B) covers but often include additional benefits, such as expanded prescription drug coverage, wellness programs, and cost-sharing assistance for diabetes management. Some plans may also offer broad access to CGMs and other advanced diabetes care.

How to get Medicare covered diabetes supplies

It is important to always use suppliers and pharmacies that are part of your Medicare plan’s network. Check with the plan provider for specific requirements and preferred providers. Beneficiaries must obtain a prescription from their doctor for blood sugar testing supplies.

Click here to download Medicare coverage of diabetes supplies, services & prevention programs

Medicare provides extensive support for individuals with diabetes, but navigating coverage details can be complex. Understanding what’s included under Medicare Part B, Part D, and Medicare Advantage plans helps beneficiaries make informed decisions and access necessary supplies for effective diabetes management.

Because some agents are unsure of the PAP ACC and MCD SEPs, we will go over them and try and clear up any confusion.  It is important to know; both CMS and the carriers monitor the use of these SEPs. They are reporting any inappropriate use of these SEPs. We hope this post provides information that makes is easier to use these SEPs properly. This will help prevent delays with your client’s application processing.

What is a PAP SEP

A PAP (Pharmaceutical Assistance Program) SEP is an enrollment period for individuals who qualify to enroll in the state’s pharmaceutical assistance program (SPAP). To qualify for the SPAP program, beneficiaries must meet specific income and asset requirements.

Click here to see a list of states where the SPAP is available

Who can use a PAP SEP

The PAP SEP begins when the individual enrolls in the SPAP. If an individual enrolls in the SPAP program, they receive one oppportunity annually to use this SEP. They can use it to enroll in or change their Medicare Advantage or PDP plan. Anyone automatically enrolled in a PDP plan by their SPAP cannot use this SEP.

If an individual receives notice that they no longer qualify for SPAP benefits, they can use the PAP SEP. The SEP begins the month they lose the SPAP and continues for two months after they are notified of the loss (whichever comes later).

What is an ACC SEP

The ACC SEP is a Medicare Advantage Special Enrollment Period for those who request plan information in an accessible format.  Beneficiaries cannot use the ACC SEP as an election period on it’s own. The beneficiary must have been eligible for another valid election period before they can use this SEP.  The ACC SEP ensures beneficiaries who requested information in an accessible format receive additional time to submit an application for a vailid election period. This helps them get enrollment requests processed by extending the deadlines for application submissions.

Accessible format is a way of receiving health coverage information in a way that can be understood by individuals with disabilities. This format includes large print, Braille, audio recordings, or digital text that can be read by screen readers. This allows beneficiaries to access and understand important medical inforamtion and make appropriate plan choices.

Find out about the CT MSP income limits 2025

Who can use an ACC SEP

The ACC SEP is available to any Medicare beneficiary who did not recieve the materials they needed to make an informed enrollment decision in an accessible format at the same time standard material is provided.

Important: This is not a “stand-alone” election period. Indviduals must have been eligible of another valid election period but didn’t have the information they needed in an accessible format to make an informed decision in time. This SEP starts at the end of an election period in which the beneficiary submits a request for accessible formatted materials. The SEP is ineffect for at least as long it takes for the beneficiary to recieve the materials.

Watch a YouTube video on new rules for Dual and Drug help in 2025

What is an MCD SEP

The code MCD is for Medicaid and can only be used by individuals who have a change in Medicaid status of some type. Individuals who are newly eligible for Medicaid, lose eligibility Medicaid, or who’s Medicaid status changes can use the MCD SEP. Qualified individuals can use this SEP once within 3 months of the qualifying event or notification of change (whichever is later).

Who can use the MCD SEP

The MCD SEP applies to Medicare beneficiaires who:

Become eligible for any type of assistance through the Title XIX program. This includes partial duals who receive cost sharing assistance under Medicaid.

Those who lose eligibility for assistance or have a change in the level of assistance they qualify for. This applies even if they stop receiving Medicaid benefits or still qualify for LIS (Low Income Subsidy).

This SEP gives individuals one chance to make a change within 3 months of a qualifying event or when they receive a notice of the changes, whichever is later.  The effective date for enrollments is the first day of the month after the carrier recieves the enrollment request.

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Please remember: Agents must use the correct SEP code to ensure carriers can process enrollments in a timely manner. Using an incorrect code could cause a delay or denial by the carrier. In some instances, it can result in the agent receiving corrective action from carriers and/or CMS.