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In general, Medicare is an affordable way for qualified individuals to receive healthcare coverage. However, there are some Medicare costs both agents and beneficiaries need to understand.

Plan Premiums

Premiums are a monthly fee the beneficiary pays for Medicare coverage.

Part A premiums

Although most beneficiaries do not pay a premium for Part A as long as they have worked for a Medicare-taxed job for a period of at least 10 years (40 quarters). In 2024, the premium for those who do not qualify for free Part A are between $278 to $505 monthly. The amount is based on the number of quarters the beneficiary or their spouse worked and paid Medicare taxes.

Part B premiums

Unlike Part A, almost everyone pays a Part B premium with the exception of those who meet certain income and asset levels and qualify for extra help. In general, most beneficiaries pay a standard amount for Part B. In 2024, the Part B premium amount is $174.70, although this amount may be adjusted according to each beneficiary’s income level. Those who earn over a specific thresh hold will pay an additional amount (IRMAA).

Part C (Medicare Advantage)premiums

Part C plans offer a variety of premiums, although many provide coverage for $0. The premium amount is based on the beneficiary’s location and plan availability. Please note; an IRMAA can also apply to a Medicare advantage plan if it includes Part D coverage.

Part D premiums

Similar to Part C premiums, the cost for Part D coverage varies by plan and coverage area. The national base beneficiary premium for 2024 is $34.70 per month. This is just a general premium amount CMS uses to calculate LEP penalties and not an actual premium amount. Premiums actually vary from $0 up to over $100 per month. Similar to Part B, individuals may pay a higher rate if they qualify for an IRMAA.

Find out how ancillary health insurance can cover some of the gaps in coverage.

IRMAA (Income Related Monthly Adjustment Amount)

An IRMAA is an additional amount CMS adds to the beneficiary’s monthly premium amount for Part B and Part D if their income exceeds the threshold amounts set by Medicare each year. The IRMAA is based on the individuals tax return from 2 years prior.

Click here to learn more about the income brackets for IRMAA 2024

LEP (Late enrollment penalty)

There are specific times beneficiaries must enroll in Medicare coverage. These are enrollment periods. If the beneficiary misses their enrollment period, they may pay an LEP. Medicare will add the penalty to their monthly premium.

Watch a YouTube video on OEPs, SEPs and Late Enrollments

Part A LEP

The LEP only applies to those who do not qualify for premium free Part A. Those who do not enroll on time have to pay a 10% higher Part A premium. Medicare applies the penalty for twice the number of years the beneficiary was eligible but didn’t enroll in Medicare. This means, if the beneficiary was eligible for Medicare but didn’t sign up for 3 years, they would pay an additional 10% for their Part A premium for 6 years.

Part B LEP

This penalty adds 10% times the number of years the beneficiary did not enroll in Medicare to the monthly premium and applies as long as the beneficiary has Medicare. In other words, if the beneficiary signs up for Medicare 3 years late, they pay 30% more for their premium. However, if they are actively working or have coverage through a spouse who is working, they can delay Part B enrollment without an LEP. Once they stop working, they qualify for an SEP and are eligible to enroll in Part B.

Part D and Part C plans that include drug coverage LEP

The LEP for Part D or Part C plans that include prescription drug coverage is 1% of the national base premium (this premium changes annually), multiplied by the number of months the beneficiary was eligible and did not enroll. This penalty is similar to the Part B penalty, because it lasts as long as the individual is enrolled in Medicare Part D. The federal government uses the standard rate (national base premium) to calculate Part D penalties not the individual’s actual plan premium. If the beneficiary delays Part D enrollment because they have another creditable drug plan, the penalty doesn’t apply to them.

Deductibles

Enrollees pay a deductible each year before their plan pays it’s portion of covered medical expenses.

While other Medicare plans have annual deductible, the deductible for Medicare Part A is $1,632 for each inpatient hospital stay. An individual could pay this deductible more than once a year depending on how many times they are admitted to the hospital. Each hospital admission counts as a new benefit period, unless the beneficiary is readmitted before the end of the benefit period.  Each benefit period ends 60 days after the enrollee is discharged.

Both Part B and Part D plans have one annual deductible. The Part B deductible is $240 in 2024. Although Part D deductibles vary according to plan, Medicare puts an annual limit on the maximum deductible allowed; in 2024 the maximum deductible is $545.

Copays and coinsurance

Both copays and coinsurance are fixed amounts the beneficiary pays for covered services or medications. These amounts apply after the beneficiary pays the deductible.

Part A coinsurance and copays

Once the beneficiary is in the hospital for over 60 days, they pay a coinsurance amount of $408 per day in 2024 for days 61 to 90. If the beneficiary is in the hospital for over 90 days, they can use some or all of their 60 lifetime reserve days. In 2024, each of these days cost $816. Each beneficiary qualifies for 60 reserve days for their lifetime. Once the beneficiary uses them all, they pay the entire remaining cost of their hospital stay.

Part A pays the first 20 days in a skilled nursing facility, once the beneficiary goes over the 20 days, they pay $204 per day for days 21-100. After day 100, the beneficiary is responsible for all costs. Many beneficiaries apply for Medicaid if they qualify, once they exhaust the Medicare coverage.

Part B coinsurance and copays

Part B normally provides coverage for 80% of approved Medicare expenses. That leaves the beneficiary with the remaining 20%. However, Medicare fully covers most preventative visits. Beneficiaries pay a higher co-insurance amount if their provider does not accept Medicare assignment.

Supplemental insurance can cover the 20% co-insurance cost and some of the copays with original Medicare. Click here to learn more.

Part C coinsurance and copays

Because Medicare Advantage plans work differently than Original Medicare, the coinsurance and copays work in a very different way. Medicare advantage plans use a specific network of providers who agree to accept the terms of payment. Each plan has it’s own co-pay amounts for doctor and specialist visits. Some plans provide coverage for visit to out of network providers at a higher cost share amount.

Each plan also has an out of pocket maximum. Once the beneficiary reaches this amount, the plan pays 100% of their approved medical costs.

Part D coinsurance and copays

Part D copays and coinsurance can vary quite a bit from one plan to another. That is why it is important to check all medications and cost sharing amounts before choosing a plan. In general, the cost for a prescription is higher for brand-name medications especially if they are on a higher tier in the plans formulary. If the beneficiary uses medications that are not on the formulary, they may have to pay the full costs of the medication.

There are other factors that decide the cost of medications such as the deductible, tier, the coverage gap and the catastrophic phase of coverage. Although there are changes coming in 2025 that will alter some of those cost shares. Plan enrollees should check their plan every year to ensure they are on the best plan to meet their coverage and budgetary needs.

Click here to learn about the Part D changes for 2025

Providers who don’t participate in Medicare

It is important to note: Not all doctors participate with Medicare. In some instances (rarely, but some), a provider has opted out of Medicare and does not accept Medicare as payment. This means the patient is responsible for paying any fees for service out of pocket.

Find out what Medicare Advantage plans don’t cover

As you can see, there are many potential costs associated with Medicare plans. We have not listed all of them. It is important to check the summary of benefits or evidence of coverage each year to ensure enrollment in the best plan option for each individual situation. A licensed Medicare agent can provide invaluable insights into plan choices and coverage options.

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There are a few different terms people use for supplemental Medicare insurance such as; Medigap, Medicare Supplement or Med Supp. Private insurance companies offer these health insurance policies to individuals who are eligible for Medicare coverage. In general, Medicare covers about 80 % of approved medical charges. Medicare supplement plans are designed to cover the 20% of approved medical charges not covered by Original Medicare. Essentially, Medicare supplement policies help reduce out-of-pocket costs. This ensures healthcare costs are predictable and manageable.

Why choose a Medicare Supplement

Although Original Medicare provides substantial coverage, it doesn’t cover everything. Here are some reasons to consider a Medicare Supplement:

Out-of-Pocket Costs: Original Medicare requires beneficiaries to pay for a percentage of their approved medical expenses. Because these can add up quickly, especially if you have frequent medical needs, a Medicare supplement pays these costs and saves enrollees money.

Find out more about Medicare costs

Foreign Travel: In general, Original Medicare doesn’t cover healthcare services outside the U.S.. Although some Medicare supplement plans provide coverage for emergency medical care during foreign travel.

Predictable Expenses: With a Medicare supplement plan, enrollees have predictable medical expenses, making it easier to manage their healthcare budget.

No Network Restrictions: Medicare supplement plans do not have network restrictions, this allows individuals to see any doctor or specialist that accepts Medicare.

Supplemental Medicare insurance plans

There are ten standard Medicare supplement plans, labeled A through N. Each plan provides a different level of coverage. The plan benefits of each plan letter are standardized, meaning Plan A from one insurance carrier offers the same benefits as Plan A from any other insurance carrier. These benefits are universal and don’t change by location. Although, plan availability varies by location. Insurance carriers do not offer all plans in every state.

Here is a basic over view of plan benefits:

• Plan A: This plan provides basic benefits, covers coinsurance and hospital costs (up to 365 additional days after Medicare benefit is used).
• Plan B: Benefits Include all the Plan A benefits plus it covers the Medicare Part A deductible.
• Plan C: Covers all of Plan B as well as skilled nursing facility care coinsurance and foreign travel emergency and also covers the Part B deductible.
• Plan D: This plan is similar to Plan C , although it does not cover the Part B deductible.
• Plan F: Provides comprehensive coverage, including the Part B deductible. Please note; this plan is no longer available to anyone who is eligible for Medicare after January 1, 2020.
• Plan G: These plans provide coverage very similar to Plan F although, they do not cover the Part B deductible.
• Plan K and L: Both these plans offer lower premiums but higher out-of-pocket costs, with coverage limits.
• Plan M and N: Plans provide a good cost-sharing option for specific benefits and lower plan premiums.

Click here to view a comparison chart of Medigap plans

Choosing the Right Plan

Selecting the right Medicare supplement plan requires careful consideration of both health needs and finances. Things to consider when choosing a plan. Please consider using the services of a licensed Medicare agent when making important health coverage decisions. This will ensure you have all the information you need to make an informed choice.

Assess Your Health Needs: Consider your current health status and any anticipated medical needs. If you require frequent medical services, a plan with more comprehensive coverage might be beneficial.

Budget Considerations: Evaluate your budget for monthly premiums versus out-of-pocket costs. Higher premiums generally mean lower out-of-pocket expenses.

Compare Plans: It is a good idea to use the services of a licensed Medicare agent when making important health coverage decisions. In most cases, they can access tools that can provide a comparison of the plans available in your area. This ensures you have all the information you need to make an informed choice.

Watch a YouTube video comparison of our quoting tools Sunfire vs Connecture

Check for Special Benefits: Some plans offer additional benefits, such as foreign travel emergency coverage or even a fitness benefit.

If you want to learn some of the differences between a Medicare Supplement and an Advantage plan, click here.

Enrollment Periods

The best time to buy a Medicare supplement policy is during your Open Enrollment Period, which starts the first month you have Medicare Part B and are 65 or older. During this period, you have a guaranteed issue right, meaning insurers cannot deny you coverage or charge higher premiums due to pre-existing conditions.

Always remember to meet with your agent each year to review your options and adjust your plan as your healthcare needs change.

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Agents and beneficiaries need to understand the actual cost of any healthcare plan they are considering. That being said; we will explain deductibles vs out of pocket maximums and how they apply to your clients’ coverage.

Many health insurance plans have both a deductible as well as an out of pocket maximum. Both terms refer to a specific amount the beneficariy must pay each year before their insurance provides a specific level of coverage. Once the enrollee meets the dedcutible, the insurance plan pays the specified portion of eligible cost. On the other hand, once the enrollee meets the the out of pocket maximum, the insurance plan pays the entire cost for all covered services.

Deductibles

The amount an enrollee pays out of pocket for eligible services before the insurance plan covers their portion of the costs is a deductible. The amount of the deductible varies by plan and is specified in the summary of benefits or evidence of coverage for each plan.

Keep in mind, each type of coverage has it’s own deductible, for example; Medicare Part B, has one specific annual deductible for all enrollees. Medicare Part A has a hosptial deductible that the enrollee must meet each time they are admitted into the hospital (except in specific situations). Many Part D (prescrption drug plans) have an annual deductible that varies depending on the plan.

Find out about Medicare costs for 2024

Out of pocket maximums

An out-of-pocket maximum is the most a beneficiary pays out of pocket annually for covered healthcare expenses. Once the beneficiary reaches this limit, their insurance plan covers 100% of the costs of covered benefits. Deductibles, copays, and coinsurance are all included in this amount. It does not include expems premiums, balance-billed charges, or services that Medicare does not cover.

Learn more about out of pocket maximums

Additionally, several types of payments count towards the out of pocket maximum including; deductibles, copays and coinsurance. The plan’s monthly premium does not count toward the out of pocket maximum.

Please note; Original Medicare and supplements do not have an out of pocket maximum.

Additional information

Each year the deductible amount is subject to change. The deductible does not apply to many preventative services, such as annual check-ups, immunizations and vaccines. Most insurance plans cover these serices at 100%.

For those enrolled in a healthplan with a deductible and an out of pocket maximum, the amount paid toward the deductible applies to the maximum out of pocket cost. They continue to pay copays and coinsurance costs until they reach the out of pocket maximum.

Consider all costs before choosing a plan

There are many plans available with different deductibles and out of pocket maximums. That is why it is important for individuals to be aware of all costs associated with the plan they choose. A licensed insrance agent can help provide a comparison of plans that offer the coverage and costs each beneficiary is looking for. Each year during AEP, Medicare beneficiaries have an opportunity to meet with their agent to review their plan cost and coverage and make any changes necessary.

Understanding the Medicare out-of-pocket maximums is important for agents as well as clients. The amount changes each year; it is imperative to stay up to date on this information. This number may be a big factor for those who want to manage their healthcare expenses.

Out of pocket maximums

An out-of-pocket maximum is the most a beneficiary pays each year for covered healthcare expenses. Once they reach this limit, their insurance plan covers 100% of the costs of covered benefits. Deductibles, copays, and coinsurance are all included in this amount. It does not include premiums, balance-billed charges, or services that Medicare does not cover.

Medicare and out of pocket costs

Medicare is divided into different parts, each has its own rules for out-of-pocket costs.

Original Medicare (Part A and Part B)

Original Medicare does not have an out-of-pocket maximum. In other words, there is no cap on the amount beneficiaries can pay each year for healthcare services. This concern beneficiaries who require extensive medical care, as there is no financial limit to their liability.

Part A (Hospital Insurance): Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Although is no out-of-pocket maximum, enrollees are responsible for deductibles and coinsurance payments.

Part B (Medical Insurance): Part B covers outpatient care, preventive services and medical supplies. Part B is similar to Part A, there is no out-of-pocket maximum; beneficiaries pay the deductible and coinsurance.

Medicare Supplements

Medicare supplements also do not have an out of pocket maximum. This is due to the fact that it is not necessary because of the benefits these plansprovide. They cover most of the costs left behind by original Medicare; therefore, a maximum out of pocket amount is unnecessary.

Medicare Advantage (Part C)

Medicare Advantage plans, (Part C), are offered by private insurance companies approved by Medicare are an alternative to Original Medicare. One of the benefits of Medicare Advantage plans is they include an annual out-of-pocket maximum.

Although CMS sets a maximum each year that these plans cannot exceed, each plan sets its own annual limit. In 2024, the maximum out-of-pocket limit is $8,850 for in-network services and $13,300 for combined in-network and out-of-network services. Once enrollees reach this limit, the plan covers 100% of eligible healthcare costs for the rest of the year.

Medicare Prescription Drug Plans (Part D)

Medicare Part D provides prescription drug coverage and is available as a stand-alone plan or included in some Medicare Advantage plans. Most enrollees of part D plans have a deductible, co-pays and coinsurance. These costs apply to prescription medications on certain tiers of the plan formulary. Part D plans also have a coverage gap that can affect out-of-pocket costs.

Coverage Gap and Catastrophic Coverage: In 2024, once the benficiary and their plan have spent $4,660 on covered drugs, they enter the coverage gap. During this period, they pay no more than 25% of the cost for prescription drugs. Once out-of-pocket costs reach $8,000, they enter catastrophic coverage, and pay nothing for covered medications for the rest of the year.

Watch a video about the changes in drug coverage for 2025

Manage Out-of-Pocket Costs

Because of the potential for high out of pocket costs, it is a good idea to try and mange them ahead of time.

Choose a Medicare Advantage Plan: Consider a Medicare Advantage plan with a low out-of-pocket maximum to help control medical costs. These plans can provide financial protection and predictability.

Supplemental Coverage: Purchase a Medicare Supplement plan if you have Original Medicare. These plans help cover some out-of-pocket costs left over after Original Medicare pays its share.

Review plan coverage: Each year, enrollees should review the annual notice of change from their Medicare plan to understand changes in coverage, costs, or out-of-pocket maximums. It is also important to meet with a licensed Medicare agent and go over all your options to ensure you have a plan that best meets your healthcare and financial needs.

Prescription Drug Assistance Programs: Look into programs that offer assistance with prescription drug costs, especially if you are in the Part D coverage gap.

Learn about changes to the coverage gap (donut hole) for 2025

Preventive Care: It is best to use preventive services from an in-network provider. Staying on top of your health helps to avoid serious problems down the road.

Understanding and managing out-of-pocket maximums is essential for anyone on Medicare. While Original Medicare lacks an out-of-pocket maximum, Medicare Advantage plans provide a valuable safety net. By exploring supplemental coverage options and being proactive about healthcare decisions, beneficiaries can better manage their medical expenses and ensure they receive the necessary care without financial strain.

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Sometimes Medicare coverage is great and other times it is a challange. This is especially true when it comes to denials of coverage. If your client receives a denial, it’s essential to let them know they have the right to appeal. Understanding the Medicare appeals process can help your clients get the coverage they need. In this post, we provide a guide to help with this process.

Understand your coverage

One very important thing agents can do to help avoid denials of coverage; ensure clients understand their coverage. Discuss what each plan covers and what the beneficiary is responsible for such as copays, deductibles and coinsurance amounts. Licensed Medicare agents can help beneficiaries go over plan choices and ensure the beneficiary has the best coverage for their personal situation.

Agents can also discuss gaps in coverage and offer additional ways clients can cover themselves if anunexpected health problem comes up.

Learn the benefits of ancillary products sales; watch a quick YouTube video

Medicare Appeals

Medicare appeals are requests to review and reconsider decisions about healthcare coverage and payments. These appeals may be necessary when Medicare denies a beneficiarie’s request for a healthcare service, supply, or prescription drug, or refuses to pay for services they have received.

Click here to access appeals forms on CMS.gov

How to appeal a Medicare decision

Review the Notice of Denial

It is important to carefully read and understand the notice of denial before initiating an appeal. This document, often called either a EOB (explanation fo benefits) for Medicare advantage (Part C) or Part D plans or a MSN (Medicare summary notice) for Original Medicare, explains why coverage of the service or item was denied.

The plan must explain how to appeal the denial in writing. After the beneficiary files the appeal, the plan reviews its decision. If they do not agree with the appeal, an independent Medicare organization reviews the decision.

Understand Appeal Rights and Deadlines

There are very specific deadlines in place to file an appeal. The deadline varies by the type of Medicare coverage an beneficiary has.

Original Medicare (Part A and Part B)

The beneficiary has 120 days from the date they receive the MSN to file an appeal.

Medicare Advantage (Part C) and Prescription Drug Plans (Part D)

When a beneficiary of one of these plans wants to file an appeal, they have 60 days from the date they receive the EOB to file the appeal.

Collect Supporting documentation

Beneficiaries should gather any medical records, doctor’s notes, and any other evidence that supports their case. A healthcare provider is an invaluable resource to help provide documentation and expert opinions to help make the appeal successful.

If the beneficiary’s doctor agrees that they have are at serious risk, worsened by waiting, the plan must make a decision within 72 hours of receiving the request.

Click here to learn more about getting a fast appeal

Submit the appeal

The appeals process for Original Medicare and Medicare Advantage/Part D plans differs slightly.

For Original Medicare (Part A and Part B)

Fill out the redetermination request form included with the MSN or write a letter to the address listed on the MSN. It is important to include the beneficiaries’ name, Medicare number, the specific item or service in the appeal as well as any supporting documents. A Medicare contractor reviews the appeal.

For Medicare Advantage (Part C) and Part D (Prescription Drug Plans)

Appeals are submitted directly to the plan for reconsideration. The EOB has instructions on how to submit the appeals. If the initial appeal is denied, enrollees can request an independent review by a third-party organization.

Levels of Appeal

If the initial appeal is denied, there are many ways to escalate it.

1. Request reconsideration by an independent review entity.
2. If the amount in question reaches a specific threshold, you can request a hearing by an administrative law judge.
3. If the beneficiary is dissatisfied with the administrative law judge’s decision, enrollees can request a Medicare appeals council review.
4. If all else fails, the enrollee can file a lawsuit in federal district court.

Follow Up

Make sure beneficiaries keep copies correspondence or records related to the appeal. Always follow up on the status of the appeal and be sure to adhere to all deadlines.

Ensure a successful appeal

Be persistent; because appeals can take some time, it is important to be persistent. Don’t let initial denials discourage you.

Ask for assistance; use State Health Insurance Assistance Programs (SHIPs), which provide beneficiaries free assistance with Medicare appeals.

Organize all helpful information: it is essential to maintain a well-organized file of documents, correspondence, and any notes related to the appeal.

For help filing an appeal, contact the SHIP State Health Insurance Assistance Program.

Although Medicare denials and the appeals process may be discouraging, understanding the beneficiaries’ rights and the necessary steps makes the process manageable. Being thorough, organized, and persistent, improves the chance of a successful outcome for the appeal.

Understand your coverage

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In most cases, Medicare agents try to do their best to ensure their clients are in a plan that fits their medical as well as financial needs. However, there are times when a client may be unhappy with the service they receive for one reason or another. When this occurs, they may decide to file a grievance with either a carrier or the state. If this happens, agents need to know ho wto handle complaints properly to avoid making things worse.

Medicare agents understand that handling carrier complaints is part of our profession, as CMS continuously updates the rules to conduct business. Addressing the issue quickly and correctly is essential. Here are some suggestions for handling complaints and ensure compliance and avoid escalation.

Try to prevent complaints

The best way to handle a complaint is to try and avoid them as much as possible.

follow all CMS guidelines.

Make sure you know all the rules before you host an event whether it is educational or a sales event, there are definite rules to follow. Be sure you have all the updated regulations before you do anything that could lead to a complaint.

Watch our YouTube video for what you need to know before a Medicare sale

Collect Scopes

This is a big one! It is imperative that you collect a SOA and be sure you do it in the correct way. The Scope is an important tool that not only protects the Medicare beneficairy but the agent as well. Scopes prove that you had permission to talk to the beneficiary and what you had permission to discuss. There are a few different ways to collect a scope; in writing, electronically (by email) or with a voice recording.

Learn how Retireflo can help you maintain compliance

Check client information

Before you enroll a client in any plan, you must ensure they have the best choices available to them. Agents must check all their current providers to ensure they are in network with the plan the client chooses. It is also very important to check all medications and explain how the plans cover each medication.

See how our Sunfire quoting and enrollment system works

How to handle complaints

Watch for carrier communications

Check your emails regulary and be sure to pay attention to any carrier communcations you receive.
If there has been a complaint field agianst you, the carriers normally communicate it to you via email. This helps avoid delays in your response and gets allegations cleared up in a timely manor. Because complaints have a deadline for a response, not repsponding in a timely manor, could make things much more difficult.

Think before responding

If you receive a complaint or allegation, it is important to take time and read it carefully. Be sure to follow carrier instructions before you respond. In most cases, you will be asked to answer some questions in response to the allegation. Answer each question as accurately as you can.

Provide documentation

Make sure to provide any supporting documents you have. Documents may include; scopes, enrollment recordings or even a copy of the signed application. Be prepared to provide any evidence the carreir may request that can help support your actions.

Contact your upline

If you currently have an upline, it is a good idea to have them review your answers before the response deadline and provide any constructive feedback. They should suggest any needed revisions to help ensure the situation is resolved. Be sure to edit your answers if necessary.

If you would like to join our team, click here for online contract.

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Because there are a few different options when it comes to Medicare coverage, the question; does Medicare cover ER visits, has more than one answer. Each type of Medicare plan provides coverage for emergencies in a specific way.

In general, Medicare covers ER services when a beneficiary suffers from an injury or sudden illness that quickly worsens.

Original Medicare

If an individual enrolled in Original Medicare goes to the ER, they receive coverage for services from Medicare Part B. As long as they receive service from a either a hosptial or medical faciltiy that accepts Medicare. Additionally, Medicare Part B covers urgent care treatment for sudden illnesses or injuries that do not quailfy as a medical emergency.

Please note; emergency or urgent care a beneficiary receives is subject to a 20% copay as well as the annual Part B deductible. If an individual has a Medicare Supplement plan, it may cover the 20% copay.

When the beneficiary is admitted to the hosptial for a related condition within 3 days of the ER visit, they don’t pay the copay. Original Medicare processes the ER visit cost as part of the inpatient hospital stay.

Medicare Advantage

Although Medicare Advantage plans normally use provider networks for the enrollee’s care, the rules are very different during an emergency situation. When this is the case, Medicare Advantage plans must provie coverage for care even if the hospital or medical facility is out of the plan’s network. However, the copay amounts charged may differ from Original Medicare coverage. It is important to provide clients a complete picture of each plan they are considering. That includes emergency care copay amounts as well as all other coverage details and costs.

Medicare Advantage plans and the CMS consider an emergency, an untreated medical condition that could result in:

Serious jeopardy to the health of the individual. In the case of a pregnant woman, serious jeopardy to her health or the health of the unborn child. The definition also includes serious impairment or dysfunction of any organ or body part.

Some Medicare advantage plans don’t charge an ER copay if the enrollee is admitted to the hosptial within a 24 hours of the ER visit. When this happens, the MA/MAPD plan counts the ER visit as part of the hosptial stay. If the visit to the ER is later deemed not an actual emergency, MA plans cannot go back and require prior authorizatoion for the treatment.

Urgent care and Medicare Advantage plans

Instances where there is a non-emergent medical situation that requires immdiate attention, some MA/MAPD plans provide out-of-network coverage at urgent care facilities. This may happen if there is no in-network care available like on a weekend or if you are traveling outside the plan’s service area. Plan enrollees may have a copay similar to in-network urgent care.

Enrollees should check their plan’s summary of benefits or evidence of coverage for specific coverage provided by each plan. If you cannot locate these documents, enrollees can contact their insurance agent or call the member services number located on the back of their membership card.

Additional details

In general, Medicare provides coverage for ER visits that occur in the U.S.. It does not normally cover emergency medical care outside the U.S., although there are a few exeptions to this.

In some cases, Medicare supplements provide a lifetime limit of $50,000 for foreign travel emergencies. There are also Medicare Advantage plans that may provide a limited amount of coverage for foreign travel emergencies.

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Best Medicare Supplemental Insurance

Medicare Supplemental Insurance, also known as Medigap, plays an important role in filling the coverage gaps left by traditional Medicare coverage. Traditional Medicare covers about 80% of approved medical expenses, this leaves 20% for the beneficiary to pay. Because there are so many plans available, agents need to understand how to help clients choose the best Medicare supplemental insurance. In this blog, we discuss what Medicare supplements are, why they are essential, and how to find the best coverage for your client’s healthcare needs.

Understanding Medicare Supplemental Insurance

Medicare supplements are sold by private insurance companies and cover expenses that are not covered by Original Medicare.  These expenses include, copays, coinsurance, and deductibles. There are 10 plan choices available and each one offers a different level of coverage.  All the plans are standardized by CMS. This means, all plans with the same letter name must provide the same coverage.  The only difference between one plan of the same letter and another is the cost of the plan. This allows beneficiaries to choose the plan that best suits their individual healthcare needs and budget.

Find out about 2024 Medicare commissions – watch a YouTube video

Things to consider when comparing Medicare supplements

1. Different supplement plans offer varying levels of coverage. For example, Plan G provides comprehensive coverage, including all Medicare coinsurance, and copayments, while other plans may offer more limited coverage.
2. The premiums for supplement policies can vary significantly.  This depends on the plan type, location of client, and insurance company that is offering the plan. It’s essential to consider the monthly premium as well as potential out-of-pocket costs when comparing plans.
3. Unlike Medicare Advantage plans, which require enrollees to use a provider network, Medicare supplement plans allow beneficiaries to see any healthcare provider who accepts Medicare assignment. This flexibility benefits anyone who needs to see many different providers for one or more health conditions.
4. When a beneficiary chooses a Medicare supplement policy, it’s important to choose a reputable insurance company with a good financial rating. This gives the client peace of mind knowing they are dealing with a company that will pay their claims and provide reliable coverage.

Learn about Medicare supplement guaranteed issue rights

Top Medicare supplement Plans

Although the “best” Medicare supplement plan depends on individual healthcare needs and preferences, there are a few that are chosen most often by Medicare beneficiaries.

1. Supplement Plan F provides the most comprehensive coverage.  It pays all Medicare deductibles, coinsurance, and copayments.  Thus, providing beneficiaries with maximum financial protection. The premium for this plan is high, but that is based on the coverage it provides. Unfortunately, this plan is only available to those who turned 65 before January 1, 2020.
2. Plan G is the most similar to Plan F. This plan covers most Medicare expenses, except for the Part B deductible. It’s a great option for individuals who want comprehensive coverage at a slightly lower premium than Plan F.  It is available to anyone who turns 65 and is eligible for Medicare coverage.
3. Plan N is another great coverage option.  However, it requires beneficiaries to pay copays for some  services, such as some office visits and emergency room visits. Although, enrollees pay lower premiums than with Plans F or G.  To view a comparison chart of the all the supplements, click here.

Additional Information

In some states, there are high deductible options for Plans F & G.  These plans offer a low premium and full coverage once the deductible is met.

If you are a Medicare agents who wants to offer these plans; click here for online contracting

When shopping for a Medicare supplement plan, it’s important to:

1. Evaluate healthcare needs as well as budget.
2. Compare supplement plans offered by different insurance companies.
3. Consider coverage options, premiums, and company reputation.
4. Review the benefits and limitations of each plan carefully.

Medicare Supplemental Insurance provides Medicare beneficiaries a valuable coverage option. These plans offer peace of mind and financial protection against the high cost of healthcare. Consulting with a licensed insurance agent can provide valuable guidance to understand the complexities of Medicare supplement coverage and selecting the right policy.

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Medicare income limits 2024

The Medicare income limits 2024 effect about 7% of Medicare beneficiaries.  Each year, the Social Security Administration determines the income limit that the IRMAA is based on.  It’s crucial to stay up to date on the annual income limits weather you are an agent or a beneficiary. In this post, we go over Medicare income limits for 2024 and how they can impact beneficiaries.

Why Medicare income limits matter

Medicare donut hole 2025

There are some big changes coming to Medicare Part D (PDP) plans.  This includes the discontinuation of the Medicare donut hole 2025.  In January 2024, CMS released a draft of the Medicare Part D payment policies.

Starting next year, see what changes are being made to Part D (prescription drug) coverage.

The new design for prescription coverage will consist of three phases of coverage.

1. The first phase will be the “Annual Deductible Phase”.  In this phase the enrollee pays 100% of their prescription drug cost until they meet the deductible of $590.
2. The second phase is the initial coverage or “Standard Coverage Phase”.  This phase is the former initial coverage phase merged with the Donut Hole/Gap phase. During this phase.  Once the enrollee meets the spending threshold(OOP) of $2,000 for CY 2025, they complete this phase of overage and move into the catastrophic phase.
3. The third phase is the catastrophic phase. During this phase of coverage, the enrollee pays no cost sharing for covered Part D drugs.

As you can see, there is no donut hole (coverage gap) phase.  It is merged with the “Standard Coverage Phase”.

Find out about the 2025 Medicare Drug cap

The changes in payment liability

This new plan design includes changes in payment liability of enrollees, plan sponsors, drug manufacturers and CMS.

1. As stated above, in the first phase “Annual Deductible Phase”, the enrollee must pay 100% of the cost for prescription drugs until the deductible amount is met.
2. In the second phase initial coverage “Standard Coverage Phase” enrollees pay 25% coinsurance for covered drugs while the plan sponsor typically pays 65% for  applicable drugs and 75% for all other covered Part D drugs.  Manufacturers usually pay 10% of the cost through the discount program.
3. The third phase “Catastrophic Phase”, enrollees do not pay a cost share for covered Part D drugs.  Drug plan sponsors normally pay 60% of the cost on covered drugs.  Manufacturers pay a discount of about 20% and CMS pays a subsidy equal to 20% of the cost for applicable drugs.  CMS pays about 40% of drug costs for some other Part D drugs.

Click here to learn more about PDP plans

Key points

1. Removal of the Donut Hole/Gap phase – Merging together with the former initial coverage phase now the “Standard Coverage Phase”.
2. There are now only 3 coverage phases: Deductible, Standard & Catastrophic.
3.  The Out of Pocket (OOP) threshold is dropping to $2,000 annually.
4. The end of the Donut Hole/Gap discount program (CGDP) and the start of the Manufacturer Discount Program (Discount Program)changes what drugs get discounts and how they count towards the OOP.  This also changes who is responsible for the cost beyond a set amount.

Watch a YouTube video on Medicare Part D changes

The drug plans will pay similar amounts as in previous years, although a larger part of their responsibility starts much earlier than in previous years.  In other words, drug plans will pay more money on more enrollees overall.

Click here to learn all the details of the Medicare Part D redesign

It is expected that the added costs drug companies incur may result in either higher Part D plan premiums or possibly spread across other MAPD plan costs.

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