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The new SEPs for DNPs and LIS 2025 change when a dual eligible can leave or switch Medicare Advantage Plans. The Final Rule changed existing SEPs and put a new SEP for D-SNPs in place. Starting in 2025, dual eligible and LIS (Low-Income Subsidy) recipients can change their Medicare Advantage plan enrollment once per month. The rules vary according to the beneficiary’s level of help and include full-benefit dual eligibles, partial-benefit dual eligibles, and individuals enrolled in the LIS program but are not also enrolled in Medicaid (LIS-only).

Watch our recorded webinar on the changes to SEPs for DSNPS

SEP changes starting Jan 1, 2025:

1. The current SEP for Dual eligibles and LIS only individuals is available once per quarter. It lets individuals switch or disenroll from a Medicare Advantage plan. This SEP will be end as of Jan 1, 2025.
2. A new monthly SEP for all dual eligibles and LIS only individuals to disenroll from a MAPD plan and go back to Original Medicare and a stand-alone PDP plan.
3. There will be a new SEP for all Dual eligibles and LIS only individuals to switch PDP plan enrollment.
4. A new monthly SEP for full duals to enroll in an integrated and aligned D-SNP plan.

Monthly SEP for Dual Eligibles and LIS recipients

As of 2018, CMS put a quarterly SEP in place. This SEP allowed duals & LIS recipients to either enroll or disenroll in a MAPD or PDP plan. The enrollment or disenrollment goes into effect the first day of the following month after the enrollee makes a plan change during the first three quarters. If the change is made in the last quarter AEP from Oct 15 – Dec 7, the plan goes into effect as of January 1st of the following year.

CMS created a new SEP to replace the quarterly SEP. In 2025, dual eligible individuals and LIS-only individuals can change their MAPD and PDP enrollment one a month.  Those who qualify can switch to another standalone PDP plan or disenroll from a Medicare Advantage plan and go back to Original Medicare and a standalone PDP plan. Individuals cannot use this SEP to enroll in another Medicare Advantage plan.

Integrated SEP

The CMS Final Rule created an SEP that will help facilitate enrollment for Dual eligibles into integrated Medicare Advantage plans. Each month, Full-benefit dual eligibles have the option to enroll in, or switch between, integrated D-SNPs. This SEP is only available to full-benefit dual eligible individuals who wish to enroll in integrated plans. Doing this will align enrollment between their Medicare and Medicaid coverage.

Those eligible can use this SEP to enroll in either a FIDE SNP (Fully Integrated Dual Eligible Special Needs Plan); or a HIDE SNP (Highly Integrated Dually Eligible Special Needs Plan); or a D-SNP that is an AIP (Applicable Integrated Plan).

What you can’t do with the SEP

Individuals cannot use the SEP to enroll in a Coordination only D SNP that is not an AIP, or a standard Medicare Advantage plan. The goal CMS has with this AEP is to have dual eligible individuals enroll in aligned plans if they are available in their home state.

Who can use this SEP

This SEP is only available to full-benefit dual eligible individuals who have access to an integrated, aligned plan. The following individuals cannot use this SEP: partial-benefit dual eligible individuals, and Medicare-only individuals cannot use this SEP. Presently, partial-benefit dual eligible individuals and LIS-only individuals have a quarterly SEP they can use to switch Medicare Advantage Plans. Keep in mind, this SEP will end as of Jan 1. 2025.

What happens if a person uses both the monthly and integrated SEP in the same month?

If an individual attempts to use the monthly SEP and the integrated SEP the same month, the SEP used last in will be effective. For example, Ms. Smith uses the monthly SEP to go back to Original Medicare on March 10th and on March 16th, she uses the integrated SEP to enroll in an Integrated Plan A, the integrated SEP is last used, and Ms. Smith will be enrolled into Integrated Plan A on April 1st.

SEP Changes for DSNPS & LIS 2025

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When it comes to helping clients choose a Medicare plan, there are many types of plans to consider. Those clients leaning towards a Medicare Advantage plan need to understand Medicare PPO vs. Medicare HMO plans. Although both plan types provide comprehensive coverage, they differ in many ways including how the enrollee’s healthcare is managed, costs for care flexibility of providers used. In this blog, we’ll go over some benefits of PPO and HMO plans to help determine which option may suit your client’s needs best.

Medicare PPO Plans

Provider choice flexibility

Although Medicare PPO plans have a network of preferred providers, plan enrollees may opt to receive care from an out of network provider for a higher fee. PPOs give the enrollee the freedom to see any doctor or specialist they choose, without the need for a referral.

Costs

In general, PPO plans may have similar cost share amounts compared to HMO plans. These amounts vary by plan type, carrier and service area. However, PPO plans offer lower out-of-pocket costs if enrollees stay within the network. The flexibility to see out-of-network providers comes with the potential to pay higher out-of-pocket amounts for those services.

PCP (Primary Care Physician) requirement

Unlike HMO plans, PPO plan enrollees are not usually required to choose a primary care physician (PCP). They do not need to get a referral from a PCP before seeing a specialists or other healthcare provider.

Medicare HMO Plans

Restrictions

In general, the choice of providers in a Medicare HMO plan is more restrictive. Enrollees are required to use healthcare providers and facilities within the plan’s network, unless it is emergency situation. Those who opt to receive care from an out-of-network provider, may have to pay out-of-pocket for the full cost of services.

Lower Costs

HMO plans often have lower out-of-pocket costs compared to PPO plans. Although, the network of providers is limited, and enrollees must stay within the network to keep low costs.

PCP (Primary Care Physician) Requirement

HMO plans require enrollees to choose a primary care physician. Their PCP will manage their healthcare needs. If the enrollee wants to see a specialist, they must first obtain a referral from their PCP. This helps manage and coordinate care effectively but may be inconvenient for some people.

Agents watch a quick YouTube video on strategies to manage the 2025 AEP

How to choose

The best choice differs from one person to the next and is based on individual healthcare needs and preferences. Both plan types have advantages and disadvantages.

Consider a PPO Plan if:

1. The enrollee wants the flexibility to see any doctor or specialist without a referral.
2. Higher costs are less important than the ability to choose any provider
3. There may be a desire for out of network services, even at a higher rate.

Consider an HMO Plan if:

1. Enrollees are willing to use a specific network of providers.
2. They like the idea of a PCP managing and coordinating their healthcare needs.
3. The enrollee does not see the need to use out-of-network providers and does not mind network restrictions.

Agents must consider the clients’ needs, budget and service area in order to find the best fit for their client.

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This year has been very confusing to say the least; as far as Medicare commisions 2025 go. As a result of recent lawsuits regarding the 2025 Medicare Final Rule, CMS issued updates to 2025 Medicare Advantage and Part D broker commissions on July 18, 2024. The newest amounts supersede those originally reported by CMS for CY 2025.

What you need to know

Please note; additional amounts previously stated have been removed. The one-time administrative increases of $100 to initial enrollments and $50 to renewals no longer apply.

This means, the additional money will not be added into the commission amounts anytime in the near future. If the judge approves CMS Final rule at some point in 2025, the commission rates will increase by $100 for initial enrollments and $50 for renewals.

Even without the increases listed above, CMS has increased commissions for both MA and PDP plans. This is due to an increase in the Fair Market Value (FMV). The maximum broker compensation below reflects the increase.

Maximum commissions 2025

It is important to note: commission rates vary by state.

In both CA and NJ, initial commission rates have increased from $762 per member for 2025 to $780 per member for the year.  The renewal commissions for CA and NJ have gone up from $381 per member for the year to $390 per member for the year. 

The states of CT, DC and PA have had an increase in initial MA commissions from $689 per member for the first year to $705 per member for the first year.  Renewal commissions for CT, DC and PA have increased from $345 per member per year to $353 per member per year.

Both Puerto Rico and the U.S. Virgin Islands initial MA commissions have gone up from $418 per member for the year to $428 per member for the year.  The renewal commissions have increased from $209 a member for the year to $214 per member for the year.

In all states not listed above, the initial MA commission amounts have increased from $611 per member per year to $626 per member per year. Renewal commissions have increased from $306 per member for the year to $313 per member for the year.

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Maximum commissions for PDP plans 2024:

The commission rates for PDP plans are the same in all states.

Initial commission rates for PDP plans have risen from $100 per member per year to $109 per member per year.  Commissions for PDP plan renewals have also increased from $50 per member each year to $55 per member each year.

Medicare Advantage Commissions 2025

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Managing healthcare online is not only easy but in some cases, a necessity. In this post we answer the question: why create an online Medicare account. We discuss some of the ways this makes accessing information easier.

The online Medicare account is tailored to each individual and provides personal information about benefits and coverage. This ensures beneficiaries receive updates and reminders in a timely manner.

Create an Online Medicare Account

It is not difficult to set up an online Medicare account.

1. Go to the Medicare website; Medicare.gov
2. Scroll down until you see the linbk to log in or create an account.
3. Once you are in there, follow the prompts and enter your personal information. such as (Medicare number & birthdate).
4. Once the account is set up, you can access all the tools and inforamtion you need.

Why create an online Medicare account:

Save current prescriptions and pharmacies to help keep track of your medications as well as easily compare health and drug plans in your service area.

Click here to watch a YouTube video on the new prescription payment program

1. Enroll in digital information. This provides a quick and easy way to access materials without waiting for the mail to arrive.
2. The site uses encryption and other security measures to ensure the safety of personal data. This proivides peace of mind to Medicare beneficiaries.
3. In the event you can’t find your Medicare card, you can use this site to print out a copy of your card.
4. Access all your Medicare information in minutes.

Fast and Easy

An online Medicare account provides easy access to important information. It also allows Medicare beneficiaries a way to manage health information from home anytime they like. They can check coverage, review claims, or update personal information with just a few clicks. There is no need to waste time on hold or fill out paperwork. All the Medicare information is accessible whenever it’s needed.

Medicare Coverage

The online account provides an up-to-date look at Medicare benefits. Beneficiaries can find out what their plan covers and keep track of deductible payments. It is easy to check on recent cliams without waiting for mail to arrive.

Claims and Payments

Online Medicare accounts are an easy way to track claims and payments. In addition, this can help beneficiaries spot discrepancies or billing errors. Finding mistakes early is a great way to correct them quickly and avoid delays in payments and aggrevation.

Replace a lost Medicare card

Losing your Medicare card can be stressful, but with an online account, requesting a replacement is simple and straightforward. You can order a new card online and have it sent to you without the hassle of phone calls or office visits.

Tools and Resources

Medicare’s online portal provides many tools and resources to help beneficiaries make informed decisions about healthcare. By entering an updated list of medications, beneficiaries can compare drug prices. They can view Medicare plan information or estimate out-of-pocket costs for specific services. These tools help beneficiaries understand what’s available and lets them look at plans that best suit their needs.

Please note: It is always a good idea to enlist the help of a licensed insurance agent to discuss coverage need and sort out all the options.

Paperless

When an individual sets up an online Medicare account, they can choose to recieve paperless communications. In other words, they can avoid some of the paper mail cluttering their counter tops. This provides a way to view important documents in a timely manor and eliminates the need to file them and search for them later.

Additionally; an online Medicare account is useful for Medicare beneficiaries. It is an easy and secure way to access important health coverage information.

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CMS will begin their Medicare drug price negotiations 2026 with 10 popular high cost prescription medications. CMS has announced the first 10 drugs that will be subject to price negotiations.  The negotiations are part of the Inflation Reduction Act.  Until recently, Medicare was able to negotiate prices for the medical care beneficiaries receive; this did not include the costs of medications.  As of January 1, 2026, this will change and the negotiated drug prices begin to go into effect.

Watch a YouTube video on Medicare Part D changes 

Medicare will negotiate the cost for some of the more expensive prescrption medications with drugmakers. Please note; the negotiations do no tapply to drugs that have a generic equivalent.

The first 10 medications CMS will negotiate are:

1. Eliquis (a blood thinner)
2. Enbrel (for rheumatoid arthritis)
3. Entresto (for heart failure)
4. Farxiga (for diabetes, heart failure & chronic kidney disease)
5. Fiasp & Novalog (for diabetes)
6. Imbruvica (for blood cancers)
7. Januvia (for diabetes)
8. Jardiance (for diabetes)
9. Stelara (for psoriasis & Chron’s disease)
10. Xarelto (a blood thinner)

As per CMS, the 10 drugs listed above make up about 20% of the Medicare Part D spending from June 2022 through the end of May 2023.  Medicare Part D covers prescriptions beneficiaries take at home.  Part D does not cover medications administered by medical providers in medical facilities. When this is the case, Medicare Part B covers the necesary drugs. This applies to treatment of cancer or other health conditions. 

Take a look at the drug price negotiation fact sheet 

Medicare beneficiaries spend billions on prescription drugs

Due to the incredibly high cost of some essential medications, some beneficiaries have to either forgo basic needs or the drugs that maintain their quality of life. 

CMS has also put a prescrption payment program in pace to help spread out the cost of prescriptions for beneficiaries.

Learn about the Medicare prescription payment program.

The first 10 drugs are just the start

This list of 10 drugs is only the beginning of the price negotiations.  In 2027, Medicare plans to add 15 more drugs and more in the following years.  As long as the rug manufacturers continue to be unsuccessful in their attempts to stop price negtiations, the list will continue to expand each year.

Drug manufacturers

If the drug companies do not agree to the negotiations, they face possible tax penalties.  Drug manufacturers can avoid the tax penalty if they remove their drug from the Medicare market.  However, if they do that, they will take lifesaving drugs from Medicare beneficiaries as well as lose a large part of their market share.

Some large drug companies are seeking legal counsel to stop the drug price negotiations.  They argue that the loss in income will affect their ability to fund necessary research and development and that in turn will reduce their ability to produce new medical treatments.

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As of July 18 2024, CMS published an update on the Medicare Final Rule. The update states that all commission payments will stay as they were prior to the CMS Final Rule changes. Commissions payments for MA and PDP plans remain the same for the rest of 2024 and 2025 while the stay is in effect. This means, the addtional $50 and $100 payments to brokers and uplines is no longer an option. Uplines will continue to receive over ride payments as they do now.

At some point, in 2025, the will be a final decision on the CMS Final Rule. Once that happens, the commission payment structure is subject to change.

Click here to download commission chart for 2025

Due to the fact that; a lawsuit was filed against the validity of some provisions in the Medicare Final Rule. Many organizations feel that CMS and the Department of Health and Human Services does not have the authority to place restrictions on their income. The lawsuit also states parts of the rule are arbitrary and were put in place without following proper procedure.

A federal court in Texas put a stay on some provisions of the CMS contract rule 2025 Final Rule on July 3, 2024, to amend current broker compensation for Part D and Medicare Advantage plan sales.  Medicare Advantage insurers and marketers now have to wait and see what the final outcome will be for their businesses.

Once the judge makes his decision, all parties involved will have an opportunity to appeal the decision. If this happens, there is no way to predict when we will know the final outcome.

The 2025 AEP and the carriers

There are only a few short months before the start of AEP on October 15th. Because of this, each carrier seems to be making an independent decision on how to proceed with their 2025 benefits. The decision how to pay agents/brokers until the court makes a final ruling also seems to depend on the carrier.

Many carriers have already decided to reduce benefits and plan service areas due to the increased financial burden CMS has placed on them. Some carriers may exit the market altogether and a few will expand into new markets.

What all this means for Agents

As of today, agents are feeling very uncertain as to what their future business looks like. No matter what the outcome, this AEP will be interesting with all the plan changes and the uncertainty of the PDP market

CMS designed specific policies to stop incentivizing the sale of one Medicare product over another. They aimed to pull back MA/MAPD marketing money that carrieres were providing agents. There is a some speculation that smaller companies do not have the same budget to work with as the large competitiors. This gives the bigger companies an unfair advantage.

Click here to learn more about the proposed compensation changes

Because carriers are responsible for the actions of anyone marketing their plans, all advertisements must pass CMS guidelines before they are approved for use.

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In many cases, long-term care insurance is an important financial planning tool. LTC policies provide financial assistance for the cost of care for chronic illnesses, disabilities or injuries associated with aging. Policies cover; nursing home care, assisted living facility care, home health aides, adult daycare and more. Although many older adults require long term care, there are some who do not. We will discuss; what happens with unused LTC policies.

Approximately 70% of Americans will need long-term care at some point. Although the level of care and length of time needed varies by individual. The likelihood of a need for long-term care increases with age. The premium for a LTC policy can be difficult to afford for many people especially on a fixed income.

Agents, click here to learn why you should offer ancillary health products

What happens if you don’t use the policy

If you spend your hard-earned money on a plan and never need it, do you just lose all that money? Is there any value in a LTC policy if you never use it? The answer to that question depends on the type of LTC policy the beneficiary chooses.  

Traditional LTC policies

Beneficiaries who opt for a traditional LTC policy can expect payment of the contracted amount if they require long term care. With these policies, if the beneficiary does not require these services, the policy has no value and can end up costing quite a bit.

Those who purchase traditional policies may have a difficult time maintaining coverage due to the rising costs as their age increases. Policies do not usually have a guaranteed premium amount. When this happens, many seniors find themselves unable to afford the policy and end up dropping the coverage.

There are partnership policy options for those who wish to purchase a traditional LTC policy. Partnership policies are a way for policyholders to protect assets if they exhaust long-term care benefits and must apply for Medicaid.  Each state has specific requirements for partnership policies and provide protection against inflation.

Hybrid LTC policies

Hybrid LTC policies may be a good alternative to traditional policies. They provide value even if the beneficiary does not require long term care. Hybrid policies may be combined with either a life policy or an annuity. In other words, there is value in this option in different circumstances.

With a hybrid policy, beneficiaries who decide to discontinue coverage may be able to leave with some cash. Annuity based plans provide the annuity’s value less the surrender charges. Those who add a return of premium rider could leave with their entire plan cost back. In this scenario, the beneficiary does not lose. If the beneficiary dies without using the policy, their heirs may receive a tax-free death benefit similar to a life insurance policy.

What to consider when purchasing a LTC policy

The premiums for LTC coverage may be expensive, therefore think carefully about your budget when choosing a plan. Age, health, coverage amount, elimination period are a few things that contribute to the cost of coverage. Many plans offer optional features, like inflation protection or a non-forfeiture benefit, that may also be important to consider.

In some situations, there are discounts on coverage. Some examples include; if the enrollee is in good health or if the policy is purchased by a couple.

Information for Agents

We have a number of long term care products available to offer your clients. Options include: traditional as well as fixed annuity & long-term care rider, Life and long term care or chronic illness rider. We also have several, affordable short-term care plans available. To find out more about our products; contact our office at 203-796-5403 or email teal@croweandassociates.com.

Agents who want to join the Crowe team or add a carrier to your contract; click here

The bottom line

By comparing the different coverage options, elimination and benefit periods, as well as costs, beneficiaries can make informed decisions. A licensed insurance agent can also add valuable insights into benefit options and costs.

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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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