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The Medicare Extra Help program is a federal assistance program that provides financial aid to Medicare beneficiaries who have limited income and resources. It helps pay for costs associated with Medicare Part D prescription drug plans, including premiums, deductibles, and co-pays.

The program is administered by both the SSA and the CMS. The goal of the program is to make needed medications accessible to those who need them.

Benefits of the Extra Help Program

For those who qualify, Extra Help provides savings on prescription drug costs. Some of the program benefits include:

Lower Monthly Premiums

Extra Help covers some or all of the monthly premiums for Medicare Part D prescription drug plans. The amount covered depends on the level of Extra Help an individual qualifies for and the specific Part D plan they select.

Reduced Deductibles

With Extra Help, enrollees pay lower or even zero deductibles on their prescription drug plans. This allows beneficiaries to access their medication benefits without needing to pay a high upfront cost.

Low Co-pays or Coinsurance

Extra Help reduces co-pays, or coinsurance amounts for prescription drugs. In most cases, beneficiaries pay no more than $4.50 for generic drugs and $11.20 for brand-name drugs in 2024. The cost for 2025 have not been announced yet.

No Late Enrollment Penalty

Medicare imposes a late enrollment penalty on those who delay Part D enrollment and did not have creditable coverage from another source. Those who qualify for Extra Help do not pay the penalty.

Elimination of the Coverage Gap

The Medicare Part D “donut hole” (coverage gap) can cause additional expenses for beneficiaries. Those who receive Extra Help don’t have to worry about this. They receive consistent coverage with reduced costs all year. Please keep in mind; in 2025 the coverage gap will be eliminated.

Watch a quick video explaining the $2,000 drug cap for 2025

Who’s Eligible for Extra Help

For an individual to be eligible for Extra Help, they need to have income and assets at or below the amount set by the SSA each year. In 2024, the approximate eligibility requirements are as follows:

Income Limit: In 2024 the income limit for Single individuals is $22,590, while the income limit for married couples is $30,660. These amounts do not apply to Alaska and Hawaii, those states have their own income parameters.

Asset Limit: for individuals is $17,220, while the limit for married couples is $34,360. Assets include things like cash, bank accounts, investments, and property that is not your primary place of residence.

Click here to view the Medicare.gov fact sheet for Extra Help

How to Apply for Extra Help

Online Application: The quickest way to apply is online through the Social Security Administration at ssa.gov.

Phone Application: Call the SSA at 1-800-772-1213 (TTY: 1-800-325-0778) and apply over the phone. An SSA representative will guide you through the application process and can answer any questions you may have.

Paper application: Those who wish to use a papaer application can do so, click here for application. Once the application is completed, mail it to: Social Security Administration, Wilkes-Barre Direct Operations Center, P.O. Box 1020, WIlkes-Barre, PA 18767-9910.

In-Person Application: Visit your local Social Security office to apply in person. You may also be able to get assistance through certain Medicare health plans or local state health programs.

After submitting your application, the SSA will determine your eligibility and send you a notice explaining your benefits. If you qualify, you’ll automatically start receiving assistance with your Medicare Part D costs.

Extra Help and Medicaid

Many people who qualify for Extra Help may also qualify for additional savings programs either through Medicaid or their state’s Medicare Savings Programs (MSP). Those who are eligible for both Medicaid and Extra Help, receive the maximum level of assistance possible, which can result in very low (or even zero) out-of-pocket costs for prescription drugs.

Those aready enrolled in Medicaid, Supplemental Security Income (SSI), or MSP Programs, may automatically qualify for Extra Help do not need to apply. If that is the case, the beneficiary receives a notice from Medicare confirming eligibility for Extra Help.

Agents watch a quick YouTube video on non-commisisonable PDP plans

Click here to join the team at Crowe or add a carrier to your current contract

Additional information

Anyone who may be eligible should apply. The application process is straightforward, and the savings can make a significant difference in Part D costs. This program can make a difference in the lives of those who require medications for a better quality of life and otherwise may not be able to afford it.

Understanding how to close a Medicare sale is essential. There are millions of people enrolling in Medicare every year. Agents who master the art of closing can build a large book of business while helping clients find the best coverage for their unique needs. We will provide a few ideas to help increase your chances of closing a Medicare sale.

Build Trust and a good rapport

Trust is essential in Medicare sales. Clients are trying to navigate complex health insurance options and avoid costly mistakes. They may feel overwhelmed or frustrated. Keep this in mind when you speak with a client. Here are some ways to help set your client at ease:

The most important thing you can do is listen actively. Provide clients an opportunity to express their concerns, preferences, and questions. This shows them that you understand their needs and wants and that you will try to find what the best plan for them.

Because Medicare choices are complicated, it is important to be transparent with clients. Break down the plan options and prepare to discuss the pros and cons of each one.

Stay educated on Medicare plan choices and regulations. Both of these things change every year. Understanding what is going on will help clients feel confident that they can trust that you are knowledgeable and capable. This will help put them at ease.

Understand the client’s needs

Keep in mind, every client has unique budget concerns and healthcare needs. it’s essential to understand each client’s personal situation completely before making any recommendations.

Asking questions about the client’s specific medications and providers is extremely important. Agents must make sure both doctors and medications are covered under each plan. How much can they afford to spend on out-of-pocket costs? Does your client have a low income where they may qualify for specific plans that offer additional benefits? You need to learn which benefits are most important to each client?

By listening to their answers, you can provide options that meet their needs. This helps narrow down the options and find a plan that they are happy with.

Be able to explain the parts of Medicare

Because Medicare has several parts, each with its own coverage and rules, you must understand each part and explain how they work so clients know what they are choosing. Providing a brief summary of each part will give clients a good understanding without overwhelming them.

Overcome Objections

Objections are a natural part of the sales process. Beneficiaries may have concerns about cost, network restrictions, or unfamiliarity with Medicare’s options. That is why agents need to be prepared to handle objections.

If the client is worried about costs, it is important to express empathy and find some affordable options or look for ways they can save on costs. You may need to help them apply for Extra Help or Medicare Savings Programs.

You will need to provide examples of how each option can work for them in specific situations. In many cases, you will need to do some calculations to help them decide which plan comes out better for their budget.

If they use several providers, look for plans that have a larger network and avoid network restrictions. When you have clients who travel, find a plan that gives them coverage wherever they go. Again, the answer to all these questions comes down to listening to the client.

Click here to learn the differences between PPOs and HMOs

Next Steps

Uncertainty causes clients to hesitate. Be sure you answer all their questions as best you can. The next thing you need to explain is the enrollment process. It will help to walk the potential client through the process.

The first step of enrollment is eligibility. It may help to explain Medicare enrollment periods, such as the Initial Enrollment Period (IEP) and Special Enrollment Periods (SEPs). This can ensure they understand when they should apply.

Next, explain what documents they will need and where they can apply. You may provide a paper application, a link to a carrier site or even a phone number. It all depends on the plan, the carrier and the tools you have available.

Watch our YouTube video on updates to Sunfire and Connecture quoting and enrollment tools

Make sure clients know that you are there if they have questions or concerns if any issues some up. You should let them know you will contact them regularly to check in and provide them with your contact information if they want to get in touch with you.

Closing Technique

Once you’ve addressed all questions and provided the necessary information, it’s time to close the sale and write the application. Here are a few closing techniques that can help with Medicare sales:

Assumptive Close: “This plan seems to be a good fit for your health needs, shall we go ahead and start the enrollment?

Choice Close: “Between the two plans we discussed, which do you feel is the best fit for you?”

Summary Close: “Just to recap, all your doctors participate with this plan it covers your prescriptions and also has a lower premium. Would you like to go ahead and enroll?”

These approaches to closing encourage commitment without pressuring the client. This encourages them to feel comfortable and confident in their decision.

Follow-Up

Following up after the sale is just as important as the initial sales process. Agents should contact the client to let them know their plan is approved. They also need to contact them to see how the plan is working for them. Making sure they are happy with their choice goes a long way to let them know you care about their satisfaction and are not there only for the sale. Let them know you’re available if any issues arise. A simple follow-up builds trust and can lead to referrals or renewal business. Both are invaluable in this industry.

Learn what Crowe has to offer agents – watch a quick video

Click here for online contracting

Closing a Medicare sale isn’t about hard selling; it’s about understanding your client’s needs, educating them on their options, and guiding them toward a solution that will benefit them most. We as agents are here to provide a service. Clients need Medicare coverage it is just a matter of sorting out the plan that best suits their needs. Helping clients make an educated choice is our goal.

By building rapport, being transparent, and confidently addressing any objections, you can create a closing experience that makes clients feel secure in their choice.

Many Medicare enrollees are wondering what the costs for Medicare Part B 2025 will be. Medicare Part B is a critical part of healthcare coverage for Medicare beneficiaries. It covers outpatient services, preventive care, doctor visits, and durable medical equipment. Knowing the expected premiums and deductible amounts can help beneficiaries plan their healthcare budgets effectively.

Medicare Part B Premiums in 2025

The Medicare Part B premium is the monthly amount that beneficiaries pay for medical coverage. In recent years, premium costs have steadily increased due to rising healthcare expenses, which include the cost of outpatient services and medical advancements.

For 2025, the CMS (Centers for Medicare and Medicaid Services) has projected an increase in the standard monthly premium for Medicare Part B to $185. This is up from $174.70 in 2024.

Please note; individuals who have an income over the specified threshold will pay an IRMAA and therefore the cost of their Part B coverage will be higher. For 2024, the high-income threshold was 103,000 for an individual and $206,000 for a couple. For 2025, it increases to $106,000 for an individual and $212,000 for couples.

Individuals who enroll in Part B coverage late may pay a penalty and therefore their monthly premiums are also higher.

Medicare Part B Deductible in 2025

In addition to the monthly premium, Medicare Part B enrollees must meet an annual deductible before Medicare starts covering most of the costs. For 2024, the Part B deductible was $240. For 2025 the deductible is predicted to be about $257.

Once the deductible is met, Medicare generally covers 80% of the Medicare approved costs leaving the beneficiary responsible for the remaining 20%. Factoring in the deductible as well as anticipated co-payments help with healthcare budgets.

Planning for Higher Costs

With the cost increases in 2025, there are a few ways beneficiaries can prepare:

Beneficiaries with a low income and limited assets may be able to apply for MSP. MSP may pay for Medicare Part B for those who qualify.

Those who are near the income threshold for IRMAA adjustments, consider strategies to manage your taxable income to potentially reduce your premium amount.

Consider a Medicare Advantage (Part C). These plans bundle Parts A and B and often Part D. They may also include additional benefits, like vision, dental, hearing and more. They sometimes offer lower out-of-pocket costs compared to traditional Medicare.

Look into a Medigap plan (Medicare Supplement). Medigap/supplemental policies help cover costs not paid by Medicare, such as co-pays and deductibles, which can help offset increases in Part B costs.

Navigating Medicare Costs

Medicare costs can be complicated, and even a small increase can have a significant impact on a fixed income. Resources like licensed Medicare agents and the State Health Insurance Assistance Program (SHIP) offer free advice for Medicare beneficiaries. This helps them understand their options and make the best possible choices.

Are you a licensed Medicare agent; join our team at Crowe – click here for online contract

Agents – Click here to watch a YouTube video of updates to Connecture and Sunfire for 2025

Knowing what to expect in terms of Medicare Part B costs helps enrollees make informed decisions about healthcare coverage.

Understanding Medicare Part D Costs in 2025

Medicare Part D, the part of Medicare that covers prescription drugs for millions of Americans, provides significant savings but comes with costs that beneficiaries need to plan for. Each year, adjustments are made to premiums, deductibles, and other costs associated with Part D. There will be some significant changes to the Medicare Part D costs 2025. We will discuss the Part D costs, what changes to expect, and tips to manage these expenses.

Watch a YouTube video on the Part D drug cap

Key Cost Components of Medicare Part D

Medicare Part D plans are offered by private insurance companies. Each plan has varying costs depending on the specific plan chosen. In 2025, the cost structure will include four main components:

Monthly Premiums

Medicare Part D premiums vary significantly, depending on plan and location. The average monthly premium for 2025 is around $40. Keep in mind, premiums for individual plans may be as high as $150 or as low as $0. Additionally, some beneficiaries qualify for the Medicare Extra Help program, which can help reduce premiums and other Part D costs.

Annual Deductible

In 2025, Medicare Part D’s standard annual deductible is capped at $590, though not all plans charge the maximum deductible. In general, plans use tiered pricing, meaning they might charge no deductible for lower-tiered drugs.

Initial Coverage Phase

Once the enrollee meets the deductible, they enter the initial coverage phase. During this phase, enrollees are responsible for a copayment or coinsurance for each prescription. In 2025, the initial coverage limit will be set at $2,000. This means that once the amount spent by the plan and the beneficiary reaches this threshold, enrollees transition to the catastrophic phase.

Catastrophic Coverage

In past years, after reaching the coverage gap or donut hole, beneficiaries would enter the catastrophic phase, with Medicare covering the bulk of prescription costs. A major shift in 2025 is the elimination of coverage gap/donut hole phase, meaning enrollees won’t have to pay coinsurance or copayments after reaching the catastrophic coverage limit of $2,000 in true out-of-pocket costs. This limit provides significant relief, especially for those needing high-cost medications.

Changes and Reforms Affecting Part D Costs in 2025

The Inflation Reduction Act (IRA) of 2022 brought changes to Medicare Part D in an effort to improve cost predictability and help enrollees manage high prescription drug expenses. Here’s a breakdown of the key IRA-related reforms that apply in 2025:

$2,000 Annual Out-of-Pocket Cap
Starting in 2025, Medicare Part D beneficiaries will have an out-of-pocket cap of $2,000 per year on prescription drugs. This landmark change helps beneficiaries with high drug costs avoid excessive spending and will particularly benefit those with high-cost prescriptions as long as they are on their plan’s formulary.

Monthly Payment Options
Medicare will introduce a “smoothing” option for beneficiaries with high prescription costs. This allows enrollees to spread out payments over the course of the year, rather than facing steep costs in any one month.

Managing Medicare Part D Costs in 2025

Compare Plans Carefully

Each Part D plan varies in terms of premiums, deductibles, and formulary (the list of covered drugs). Enrollees should review all available options carefully each year during the Medicare AEP (October 15 – December 7). A licensed Medicare agent can help to ensure beneficiaries choose a plan that best meets their needs and budget.

Use preferred pharmacies

Most Medicare Part D plans have preferred pharmacy networks where beneficiaries can get lower costs. Using these pharmacies can reduce copayments and coinsurance expenses. If enrollees use an out of network pharmacy, prescription drugs will usually cost more.

Ask your provider about lower-cost options

In some cases, when a beneficiary has a high-cost medication that is not on their plan’s formulary, they may want to ask their healthcare provider if there are generic or alternative medication that may be more affordable. Sometimes, a small change in medication can lead to considerable savings. If there is no generic available, their provider may need to ask for a formulary exception. When this is the case, the PDP plan provider agrees to pay for a non-formulary medication.

Evaluate Extra Help Options or patient assistance programs

Those who have a limited income and resources, may qualify for Medicare’s Extra Help program, which can help cover premiums, deductibles, and copayments. This program offers significant savings and could reduce costs drastically.
Additionally, many pharmaceutical companies offer assistance programs that provide discounts on high-cost drugs. Checking for available assistance can be a good strategy, especially for high-cost or specialty medications.

Preparing for 2025 and Beyond

The changes coming to Medicare Part D in 2025 are a step towards making prescription drugs more affordable for Medicare beneficiaries. The introduction of an annual out-of-pocket cap and the smoothing program can help provide Medicare enrollees better predictability of their prescription drug costs.

Anyone who relies on Medicare Part D, should review plan details and explore resources to manage these costs effectively. By understanding the structure of Part D and the recent changes, beneficiaries can maximize savings and access their medications without breaking the bank.

Each year CMS provides the costs for Medicare. the 2025 Medicare costs include some expected adjustments to premiums, deductibles, and out-of-pocket expenses. This year the changes are based on inflation, healthcare demand, and legislative impacts. Below, we go over the anticipated cost structure, reasons behind the adjustments, and what it means for beneficiaries.

Hospital Insurance – Medicare Part A

Premium

Itis important to note; most people qualify for premium-free Part A due to their work history. However, those who do not qualify will pay an estimated $281 monthly for those with at least 30 quarters of work history, and $510 monthly for those with less than 30 quarters of work history.

Deductible

The Part A deductible is projected to increase to approximately $1,684. The Part A deductible is the cost a beneficiary pays if admitted into either the hospital or a skilled nursing facility.

Coinsurance Costs

Medicare Part A also has daily coinsurance for longer hospital stays. For 2025, beneficiaries can expect coinsurance rates for extended stays to go up to about $421 per day. This reflects the overall rate of inflation in hospital service costs.

Medical Insurance – Medicare Part B

Standard Premiums:

The Part B standard premium, in 2024 is $174.70. This amount will increase to about $185 per month. This increase primarily reflects higher outpatient and physician service costs.

Income-Related Adjustments:

Beneficiaries with higher incomes pay an Income-Related Monthly Adjustment Amount (IRMAA), which will also see a slight increase. These adjustments are based on yearly income, with the highest earners potentially paying over $600 per month in premiums.

Deductible:

The Part B deductible is expected to rise to about $257. Once the beneficiary meets the annual deductible, Medicare usually covers 80% of Medicare approved Part B services. The beneficiary is responsible for the remaining 20%.

Medicare Advantage Plans – Medicare Part C

Medicare Advantage plans (Part C) offer an alternative to original Medicare and include Part A, Part B, and in most cases, Part D (prescription drug) coverage. Private insurance companies offer these plans, and the pricing varies from $0 and go up from there.

Medicare Advantage plan, costs vary based on the plan and insurer, enrollees will also see some increases in premiums and out-of-pocket maximums. CMS caps out-of-pocket maximums. In 2025, they are expected to reach roughly $8,500. This could mean higher costs for enrollees with extensive health needs. There are many plans that will reduce extra benefits such as OTC, vision and dental to name a few.

Prescription Drug Plans – Medicare Part D

Premiums

Part D premiums for standalone prescription drug plans have an average cost of about $40, although this amount varies from $0 up to $150 per month. Overall, there are fewer plan choices available for 2025. Some plans have left the market, and some plans have consolidated their options. The actual plan cost depends on the specific plan and region.

Watch a quick YouTube video on the $2,000 drug cap

Deductibles and Coverage Gap

The maximum allowable deductible for Part D has increased to $590 for 2025. Additionally, the “donut hole” or coverage gap, where beneficiaries pay a greater share of drug costs, has been removed for 2025. Additionally, out-of-pocket drug costs are capped at $2,000. This may significantly reduce expenses for high-cost medications as long as they are on the plan’s formulary.

Why costs are increasing

Medicare cost adjustments reflect a variety of economic and healthcare factors:

Rising Healthcare Costs

Inflation in healthcare affects everything from hospital services to drug prices, driving up Medicare costs.

An Aging Population

As more people enroll in Medicare, especially those with high health needs, the overall program costs increase.

Legislative Changes

Recent legislation, such as the Inflation Reduction Act, introduced caps on Part D costs, in an attempt to reduce prescription drug expenses for seniors. This is causing many changes in the industry while insurance carriers figure out how to pay the billions of dollars this program will cost them. Unfortunately, insurance agents will lose commission on many plans and various plan costs will go up for many enrollees to make up for these changes.

What Can Beneficiaries Do

Use the help of a licensed Medicare agent to compare coverage options each year. A licensed agent can help find the coverage you want as well as a cost that is within your budget. Comparing plans each year is crucial as benefits and plan formularies change each year.

The Medicare cost increases for 2025 underscore the need for beneficiaries to review their coverage options and consider their healthcare needs. Beneficiaries should take advantage of Medicare’s annual open enrollment period to reassess and choose the best coverage.

Be sure to look into financial assistance programs such as MSP and Extra Help. These programs can make a huge difference with Part B and D costs.

While the introduction of the Medicare drug cap in 2025 is a significant step towards making prescription medications more affordable, there are still some limitations and challenges to consider. Here are some key limitations of the Medicare drug cap:

The $2,000 Cap May Still Be Too High for Some Beneficiaries

• Although the $2,000 out-of-pocket cap is a substantial improvement, it might still be unaffordable for low-income beneficiaries who do not qualify for extra financial assistance. For individuals on a fixed income, $2,000 a year can still be a significant burden, particularly if they have other medical expenses.
• Some patients may still struggle with costs in the earlier part of the year, even if the cap limits their total annual expenses.

Only applies to Medicare Part D drugs

• The cap is specifically for Medicare Part D (stand-alone PDPs or MAPD plans) and does not cover drugs administered under Medicare Part B, such as certain cancer medications or infusion therapies. Beneficiaries who need these Part B drugs might still face high out-of-pocket expenses without the same cap protection.
• Many beneficiaries may not understand that the cap only applies to drugs that are on your plan’s formulary. If the client uses drugs that are not on their plan’s formulary, the cost of these drugs does not count towards the $2,000 cap. When the client uses a prescription drug that is off formulary, they should have their doctor request a formulary exception if possible.
• While the cap limits spending on prescriptions from a pharmacy, it doesn’t address the costs of drugs received during a hospital stay or in a doctor’s office, which can still be significant.

Potential for Premium Increases

• To offset the reduced out-of-pocket costs, some Part D plans might raise their monthly premiums. This means that, while beneficiaries may pay less at the pharmacy, they could see higher premiums throughout the year.
• Premium increases could make plans less affordable, especially for beneficiaries who use fewer medications and might not reach the $2,000 cap.

Does Not Impact Drug Prices Directly

• The $2,000 cap limits what beneficiaries pay out-of-pocket but does not control or reduce the actual prices of drugs set by pharmaceutical companies.
• Without addressing the root issue of high drug prices, there is still the potential for overall spending in Medicare Part D to rise, which could lead to higher premiums and other costs for beneficiaries over time.

Complex Smoothing Mechanism

• The smoothing mechanism introduced with the cap allows beneficiaries to spread out their out-of-pocket expenses throughout the year. While this can be helpful, it may also be complicated for some people to understand and use effectively.
• Beneficiaries might need assistance with opting into the smoothing mechanism and managing payments, and there could be administrative challenges that make it difficult for some to take full advantage of this feature.

Learn more about Medicare Smoothing

Watch a quick YouTube video on the Medicare prescription payment program

Limited Impact on Brand-Name and Specialty Drugs

• The cap does not change the formulary (list of covered drugs) or pricing tiers for plans that include Part D coverage. In other words, beneficiaries might still face high costs for certain brand-name and specialty drugs until they reach the $2,000 limit.
• Specialty drugs for conditions like cancer, multiple sclerosis, and rheumatoid arthritis are often very expensive, and while the cap limits total spending, beneficiaries may still need to pay large sums before they hit the cap, especially early in the year.

Variability Across Part D Plans

• All Part D plans vary in coverage, formularies, and cost-sharing structures. Beneficiaries may still face challenges finding a plan that covers all their medications at a reasonable cost, even with the new cap in place. Click her to learn why you should use a licensed Medicare agent
• Some plans may be better at managing costs than others, and beneficiaries will need to carefully compare their options during the Medicare AEP to ensure they get the best coverage for their needs.

Click here to learn why you should use a licensed Medicare agent.

Although the $2,000 out-of-pocket cap for Medicare Part D drugs is a step forward in making prescription drugs more affordable, it is not a perfect solution and does not address all the concerns associated with drug pricing and affordability.

When a client receives a denial for a Medicare claim, they may be frustrated. It is important to let them know they have options. If Medicare refuses to cover a service or item, or if there is a question about how much Medicare paid, clients need to understand the Medicare claim appeal process.

What Is a Medicare Appeal

A Medicare appeal is a formal request asking Medicare to review and reconsider a coverage or payment decision. You can appeal if:

• Medicare denies coverage for a service or item you think should be covered.
• You disagree with the amount Medicare paid for a service or item.
• Medicare decides to stop services you are currently receiving, like skilled nursing care or home health services.

Types of Medicare Appeals

The appeal process may differ depending on the type of Medicare you have. Here’s a breakdown:

1. Original Medicare (Part A and Part B) Appeals
2. Medicare Advantage (Part C) Appeals
3. Medicare Prescription Drug Plan (Part D) Appeals

Each type follows a specific set of rules, but the general steps remain similar across all parts.

Review the Medicare Summary Notice (MSN) or Explanation of Benefits (EOB)

Before beginning your appeal, review your Medicare Summary Notice (MSN) if you have Original Medicare or the Explanation of Benefits (EOB) if you have a Medicare Advantage or Part D plan. This document outlines what services Medicare paid for and what it denied. It will also tell you why the service was denied, which is critical information for your appeal.

Understand Your Appeal Rights

It’s important to understand your rights. Medicare guarantees that you can appeal their decisions, and there are five levels of appeals you can go through:

1. Redetermination by Medicare contractor
2. Reconsideration by a Qualified Independent Contractor (QIC)
3. Hearing before an Administrative Law Judge (ALJ)
4. Review by the Medicare Appeals Council
5. Judicial review in Federal District Court

You don’t have to go through all five levels, but it’s good to know that you have multiple opportunities to present your case if needed.

Filing a Level 1 Appeal

The first step in the appeal process is filing a request for redetermination. Here’s how to do it:

1. Fill Out the Medicare Redetermination Request Form (Form CMS-20027): You can download this form online, or you can write a letter that includes your name, Medicare number, the specific service or item you’re appealing, and the reason you disagree with the decision.
2. Attach Supporting Documents: Include any documents that support your claim. This might include doctor’s notes, medical records, or a letter from your provider explaining why the service is necessary.
3. Send Your Appeal: The address for sending your appeal is on your MSN or EOB. You must submit your request within 120 days of the date on your MSN or EOB.

Waiting for a Response

Medicare contractors are required to respond to your appeal within 60 days. If they approve your appeal, Medicare will cover the service or pay the amount you requested. If your appeal is denied, you can proceed to the next level.

Level 2 Appeal – Reconsideration by a Qualified Independent Contractor (QIC)

If your redetermination is denied, you can request a reconsideration from a Qualified Independent Contractor (QIC). This must be done within 180 days of receiving the redetermination notice.

1. File a Request for Reconsideration (Form CMS-20033): Similar to the first appeal, you can download this form or write a letter. Clearly state why you believe the initial decision was wrong and include any additional documentation to support your claim.
2. Send the Request to the QIC: The address is included in the denial notice from your redetermination.

The QIC must respond to your request within 60 days. If they uphold the denial, you can proceed to the next level.

Level 3 Appeal – Administrative Law Judge (ALJ) Hearing

If your reconsideration request is denied, you can appeal to an Administrative Law Judge (ALJ). This option is available if the amount in question meets a minimum threshold (in 2025, this amount is approximately $180).

1. Request a Hearing: You can request a hearing within 60 days of receiving the QIC decision. You can also request to participate in person, by video conference, or by phone.
2. Prepare for Your Hearing: This is your chance to present your case directly to an impartial judge. You may wish to have an attorney or advocate to help represent your interests.

The ALJ will issue a decision within 90 days of your hearing request.

Level 4 Appeal – Medicare Appeals Council Review

If the ALJ denies your appeal, you can request a review by the Medicare Appeals Council. This must be done within 60 days of receiving the ALJ’s decision. The Appeals Council can either make a decision or send your case back to the ALJ for another review.

Level 5 Appeal – Federal District Court

The final level of appeal is a judicial review in Federal District Court. This is typically reserved for cases where a significant amount of money is at stake (in 2025, the threshold is approximately $1,850). You must file your case within 60 days of the Appeals Council decision.

Tips for a Successful Appeal

1. File Your Appeal On Time: Always pay attention to deadlines to avoid missing your opportunity to appeal.
2. Provide Detailed Information: Include all relevant documents, medical records, and a clear explanation of why you disagree with the decision.
3. Get Help If You Need It: You have the right to get help from a Medicare advocate or attorney. You can also contact your State Health Insurance Assistance Program (SHIP) for free assistance.

Click here to join the team of licensed Medicare agents at Crowe and Associates

Filing a Medicare claim appeal may seem daunting, but understanding the steps can make the process more manageable. Whether you’re challenging a coverage denial or disputing the amount paid, following these guidelines can help you navigate the appeal process more effectively.

It is important to remember to always keep copies of all documents and correspondence, and don’t hesitate to seek assistance if you need it.

Medicare scope of appointment rules

The Medicare SOA rules 2025 are put in place by CMS.  The SOA (scope of appointment) is a form clients/potential clients as well as agents must complete before meeting to discuss Medicare plans. The SOA is mandatory when discussing either Medicare Advantage or PDP plans. It is always a good idea to collect a SOA before client meetings to protect both agents and clients.

Watch a quick video on the scope of appointment rules for 2024

Verbal scope of appointment

During the pandemic, agents did not host in-person meetings to discuss coverage options.  At that time, many appointments took place over the phone.  That led to the use of recorded, verbal SOAs. 

Watch a video on Connecture & Sunfire updates for 2025

Both Connecture and Sunfire offer easy ways to collect client intake forms and include SOAs.

View the RetireFlo intake demo for Connecture 

Take a look at the BlazeSync intake form on Sunfire

SOA information

• If the client calls the agent (inbound call), the 48-hour rule does not apply.
• The scope is good for 12 months from the date it is signed.  You must complete the appointment within that time or obtain a new scope. The scope is still good if the call drops and the same agent calls the client back.
• If additional benefits are added to the discussion, a new scope is necessary.

How long is an SOA good

A scope of appointment is good for 12 months from the signature date. During the appointment, it is important to discuss only products that were agreed to and included in the scope.  If additional products are added, the beneficiary needs to sign a new scope.

If the client needs to sign a new SOA,  this restarts the 48-hour waiting period and may move your meeting date further out.  This rule applies to any product regulated by CMS.

Click here for a generic SOA

CMS guidelines

In order to be complaint with CMS, agents need to have their clients complete a SOA form. The CMS final rule went into effect September 30. 2023 and added changes to how agents collect an SOA.

The SOA rules apply to agents and brokers who discuss Medicare coverage options and plans.  The 48-hour rule was put in place so beneficiaries could avoid the high-pressure sales tactics some agents use.  The 48-hour period provides beneficiaries time to consult friends, relatives or anyone they like to research their options. This time also provides agents time to prepare for the discussion.

Agents are able to contact the beneficiary once the SOA is completed for up to 12 months. It is essentially permission to contact until the meeting takes place.  The beneficiary has the option to opt out annually.

Please note, if the beneficiary does not select a coverage option on the SOA, Medicare requires the agent to avoid discussing that option without a new SOA where the option is clearly selected.

Exceptions to the 48-hour rule

If the beneficiary is in the last four days of a valid election period, agents may collect a same-day SOA.

When the beneficiary walks into your office and initiates a conversation about coverage options, agents can take a same-day SOA.  This same rule applies to inbound call initiated by the beneficiary to the agent requesting advice.

How long do you need to keep a SOA

Agents must be able to access the SOA form for ten years. Clients have the right to request a copy anytime within that time frame without any issues.  The SOA can provide help in the event that an issue or dispute occurs.  The Scope is in place to protect the consumer, but it can also protect the agent.

What qualifies as preventative under Medicare and how do you ensure you take full advantage of these benefits? Because preventive care is an essential part of staying healthy and managing potential health risks before they become serious, Medicare recognizes the importance of preventive care and offers a range of services to help beneficiaries maintain their health.

What Is Preventive Care

Preventive care refers to medical services that aim to prevent illness, detect conditions early, or promote overall good health. These services can include screenings, vaccines, counseling, and much more. By focusing on prevention, Medicare helps beneficiaries proactively manage their health and reduce the need for more costly treatments in the future.

Click here to download a copy of a comprehensive list or covered preventative services

Medicare Coverage for Preventive Services

Medicare provides a wide array of preventive services under Part B (Medical Insurance). Many of these services are available to beneficiaries at no cost. These services may help detect health problems early when treatment is sometimes more effective and less expensive.

Some common types of preventive care Medicare covers:

Wellness Visits

Within the first 12 months a beneficiary enrolls in Medicare Part B, they are entitled to a “Welcome to Medicare” preventive visit. This one-time visit includes a review of your medical and family history, as well as basic measurements like height, weight, and blood pressure.

After your initial visit, Medicare covers an annual wellness visit each year. This can help create or update a personalized prevention plan. This plan can help beneficiaries stay on top of their health by identifying risk factors and setting health goals.

Vaccinations and Immunizations

Medicare covers vaccines that help prevent serious illnesses, including:

1. Flu Shot (Influenza): Covered once per flu season, typically every fall or winter.

2. Pneumococcal Vaccines: Medicare covers two different pneumococcal shots. The initial shot as well as a second shot a year later if appropriate.

3. Hepatitis B Vaccine: Available to those at medium or high risk for Hepatitis B.

4. COVID-19 Vaccines and Boosters: Medicare covers COVID-19 vaccines and booster shots as recommended by health authorities.

5. The Shingles Vaccine: This vaccine is administered in two doses. The second dose is given two to six months after the first. Medicare covers the cost of both doses.

Read more about Medicare coverage of vaccines

Screenings and Tests

Medicare offers a variety of preventive screenings and tests to help detect health issues early, including:

1. Mammograms: Medicare covers mammograms for the purpose of screening once every 12 months for women aged 40 and older. Medicare may also cover diagnostic mammograms if medically necessary.

2. Colon Cancer Screenings: Medicare covers multiple types of colon cancer screenings, including fecal occult blood tests, multi-target stool DNA tests (like Cologuard), flexible sigmoidoscopy, and colonoscopy. The frequency of these tests depends on the specific test and risk factors.

3. Bone Density Tests: Covered once every two years (or more often if medically necessary) for individuals at risk for osteoporosis.

4. Diabetes Screenings: Medicare covers up to two diabetes screenings per year for individuals at risk. This includes those with a history of high blood pressure, high cholesterol, obesity, or a family history of diabetes.

5. Cardiovascular Screenings: Medicare covers a screening blood test every five years to check for conditions like high cholesterol and triglyceride levels.

Cancer Screenings

Because early detection of cancer can lead to better treatment outcomes. Medicare covers:

1. Cervical and Vaginal Cancer Screenings: Medicare covers pap tests and pelvic exams are once every two years, or every year for women at high risk

2. Prostate Cancer Screenings: Annual prostate-specific antigen (PSA) tests and digital rectal exams for men aged 50 and older.

3. Lung Cancer Screenings: Low-dose CT scans are covered annually for individuals at high risk, particularly heavy smokers or those who have quit smoking within the past 15 years.

Cardiovascular Health

Medicare covers several services to help maintain cardiovascular health, including:

1.Cardiovascular Behavioral Therapy: This includes counseling on diet and exercise to help reduce the risk of heart disease.

2. Blood Pressure Screenings: These are typically part of your annual wellness visit.

Diabetes Prevention Program

The Medicare Diabetes Prevention Program offers lifestyle coaching and resources to help beneficiaries at risk for diabetes prevent the onset of the disease. The program is designed to encourage weight loss, healthy eating, and regular physical activity.

Mental Health and Wellness

Medicare also covers preventive services aimed at mental health, including:

1. Depression Screenings: Medicare includes an annual screening for depression as part of the yearly wellness visit.

2. Alcohol Misuse Counseling: Medicare covers counseling for beneficiaries who are screened and found to have alcohol misuse issues.

3. Smoking Cessation Programs: Medicare covers up to eight counseling sessions per year to help beneficiaries quit smoking.

Obesity Screening and Counseling

For individuals with a body mass index (BMI) of 30 or higher, Medicare covers counseling sessions to help promote weight loss and healthy living. This coverage includes regular face-to-face meetings with a healthcare provider.

Screenings for Infectious Diseases

Medicare also offers coverage for screenings to detect infectious diseases, including:

1. HIV Screenings: Covered once every 12 months, or more frequently for individuals at higher risk.

2. Hepatitis C Screenings: Covered once if born between 1945 and 1965, or annually for those at high risk.

3. Sexually Transmitted Infections (STIs): Medicare covers both screenings and counseling sessions annually for individuals at risk.

Make the Most of Medicare Preventive Services

1. Schedule an annual wellness visit: This visit is a great opportunity to discuss overall health and get a personalized prevention plan. It’s also a good time to make sure you’re up to date on all the preventive services you’re eligible for.
2. Know What Medicare Covers: Familiarize yourself with the list of preventive services Medicare covers and discuss these options with your healthcare provider. They can help determine which screenings and vaccines are appropriate for you.
3. Keep Track of When You’re Eligible: Medicare covers some services once a year or every few years. Make a note of when you’re eligible for your next screening or vaccination.

Preventive care is an important part of Medicare coverage and can help you stay healthier, detect potential problems early, and avoid costly treatments. Whether it’s a simple flu shot, a cancer screening, or an annual wellness visit, Medicare makes it easy for beneficiaries to access a wide range of preventive services. Understanding what’s covered and taking advantage of these benefits can play a key role in maintaining health and well-being.

If you need help choosing a Medicare plan, click here to learn why you should use a licensed Medicare agent

When it comes to Medicare Advantage plans, HMOs (Health Maintenance Organizations) are a popular option. Many Medicare carriers offer HMOs as a coverage option. They offer comprehensive healthcare coverage and focus on coordination and preventive care, however they come with advantages and limitations. Before suggesting enrollment in an HMO plan, it’s important for beneficiaries to understand Medicare HMOs Pros and cons. There are both benefits and drawbacks for those enrolling in a Medicare HMO plan.

What is an HMO

A Medicare HMO is a kind of Medicare Advantage plan (Part C). It provides coverage through a specific network of doctors, hospitals, and healthcare providers. Plan enrollees generally must receive care from in-network providers, except in emergency situations. Medicare HMOs typically include coverage for:

• Medicare Part A (hospital insurance)
• Medicare Part B (medical insurance)
• Medicare Part D (prescription drug coverage), if included in the plan
• Many plans include additional benefits such as dental, vision, hearing, fitness programs and OTC benefits.

Now let’s take a closer look at the pros and cons of Medicare HMOs.

Medicare HMO Pros

Lower Out-of-Pocket Costs

In some cases, Medicare HMOs have lower monthly premiums and out-of-pocket costs compared to Original Medicare (Parts A & B) or other types of Medicare Advantage plans, like PPOs.

Medicare HMO plans also set a maximum limit on out-of-pocket spending for covered services. Once you reach this limit, the plan covers 100% of the costs for covered services for the remainder of the year.

Comprehensive Coverage

Medicare HMOs often include benefits beyond what Original Medicare offers, such as dental, vision, hearing, fitness programs, and even OTC benefits and in some cases, rides to and from medical appointments. They also may include wellness services like acupuncture or chiropractic care.

Many Medicare HMO plans also include Part D prescription drug coverage. This makes it easier to manage all healthcare needs with one plan.

Coordinated Care

With Medicare HMOs, healthcare is often more coordinated. The enrollee’s PCP (primary care physician) acts as the point of contact for all healthcare needs. The PCP coordinates care and refers enrollees to in-network specialists as needed.

This coordinated approach may lead to better preventive care and management of chronic conditions, as all healthcare providers are working together and have access to your health records.

Focus on preventative care

Many Medicare HMO plans emphasize preventive care services, such as regular check-ups, screenings, and vaccinations. By encouraging preventive care, HMOs aim to keep enrollees healthier and reduce the need for more expensive treatments down the road.

Medicare HMO Cons

Limited Provider Network

The most significant downside to Medicare HMOs is the restricted provider network. In general enrollees must use doctors and specialists within the plan’s network, except in emergencies. HMO plans do not provide coverage for healthcare administered by out of network providers for non-emergency situations. If the potential enrollee has doctors that are not part of the HMO network, they will need to change providers.

Those who receive care outside the network without a referral or in a non-emergency situation, may be responsible for the entire cost of service. This can be a major inconvenience for those who prefer the freedom to see any doctor or specialist.

Referrals Required for Specialist Visits

If a specialist is needed, the enrollee must get a referral from their primary care physician. Although this can improve care coordination, it also adds an extra step that can delay receiving needed care. This may be true, especially if the beneficiary has multiple health concerns that require a specialist.

Some people opt not to join an HMO based on the need for referrals alone. The referral requirement may be too restrictive. Some Medicare beneficiaries may prefer PPO plans, that allow direct access to specialists without needing a PCP referral.

Not All Services Are Covered

Although Medicare HMOs often provide additional benefits, not all services are covered. For example, certain treatments, procedures, or medications may not be included in the plan’s formulary or service list, even if they are covered by other Medicare Advantage plans.

Regional Coverage Limitations

Medicare HMO networks are typically regional, in other words, the plan’s network of providers is centered around a specific area. Those who travel frequently or spend part of the year in a different location, may find it challenging to access in-network care outside the plan’s primary service area.

Some plans offer a limited network for non-emergency care while traveling, but it’s important to check the specifics of each HMO plan to understand how it handles out-of-area coverage.

Higher Costs If Out-of-Network

While Medicare HMOs generally have lower out-of-pocket costs, these savings only apply if enrollees stick to in-network providers. If they receive care outside the network (non-emergency and without a referral), the costs can add up quickly, and they will most likely be responsible for the entire cost of their care.

This can be a big disadvantage for those that require specialized care that isn’t available within the network or when traveling and need non-emergency medical attention.

Is an HMO the right coverage choice

Deciding whether a Medicare HMO is the best choice of coverage depends on healthcare needs, preferences, and budget. Here are a few things beneficiaries need to consider:

• Are they comfortable having a primary care physician coordinate their care?
• Do they mind getting referrals for specialist visits?
• Are all their doctors and healthcare providers part of the plan’s HMO network?
• Do they travel often and need flexibility in accessing care outside their local area?
• Are the costs and benefits offered in line with what you are looking for in a healthcare plan?

Medicare HMOs offer a range of benefits, including lower costs, comprehensive coverage, and coordinated care. However, the restricted network and referral requirements can be drawbacks for those who prefer more flexibility. Carefully reviewing the pros and cons can help determine if a Medicare HMO is the best choice for your client’s healthcare needs.

If you are interested in helping people find the best coverage options and are ready to join the team at Crowe and Associates, click here for online contracting