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

Preventive Healthcare

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

Why Preventative Service for Medicare Beneficiaries Matters

Early Detection

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

Managing Chronic Conditions

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

Immunizations

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

Mental and Cognitive Health

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

Health Education and Lifestyle Support

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

Overcoming Barriers to Access

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

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

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

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

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

Medicare Supplements

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

Who should consider a Medicare Supplement

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

Lower Out-of-Pocket Costs

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

Frequent Healthcare Users

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

Travelers and Snowbirds

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

Flexibility in provider choice

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

Individuals who can afford the premiums

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

New Medicare Enrollees

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

Who might not want a Medicare Supplement

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

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

Watch a quick YouTube video Medicare Advantage vs Medicare Supplement

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

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

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

Lower monthly premiums

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

Comprehensive coverage

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

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

Out-of-Pocket costs

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

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

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

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

Plan N is a great choice for individuals who:

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

Freedom to choose any provider that accepts Medicare assignment

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

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Protection from high hospital costs

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

Alternative to more expensive Medigap plans

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

Why enroll in Plan N

Medicare Plan N is a good choice for:

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

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

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

Medicare Part B

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

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

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

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

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

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

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

Medicare Part D: Prescription Drug Coverage

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

Medicare Advantage (Part C) and Supplemental Coverage

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

How to get Medicare covered diabetes supplies

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

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

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

To answer the question; what is the Medicare GEP; The Medicare GEP is an opportunity for individuals who missed their initial chance to sign up for Medicare Part A and/or Part B to enroll. It runs from January 1 to March 31 each year. This allows eligible individuals to enroll in Medicare coverage, though late penalties may apply.

Who needs the GEP

The GEP is for individuals who did not sign up for Medicare during their IEP (Initial Enrollment Period) and do not qualify for an SEP (Special Enrollment Period).

When does coverage begin

As of 2023, individuals who enroll in Medicare during the GEP will have their coverage begin the month after they enroll. Prior to 2023, coverage did not begin until July 1, which led to significant delays in accessing benefits.

Late enrollment penalties

Individuals who sign up during the GEP may have to pay an LEP (late enrollment penalty). This can increase monthly Medicare costs:

Part A penalty

For those who must pay a premium for Part A, the monthly premium could increase by 10%. This will be in place for twice the number of years they were eligible but didn’t sign up.

Part B Penalty

The monthly Part B premium will increase by 10% for each full 12-month period the beneficiary was eligible but didn’t enroll. This penalty is permanent and remains in place for as long as they have Part B.

Medicare Advantage, Part D and Supplement enrollment

If an individual enrolls in Medicare during the GEP, they can sign up for a Medicare Advantage (Part C) or a Medicare Part D prescription drug plan at this time. Coverage for these plans begins on the month following the enrollment. Although late enrollment in Part D or Medicare Advantage plans that include prescription drug coverage may include a lifelong penalty.

Medicare supplements can be a little more difficult to get after the individual’s Medigap open enrollment has passed. When this is the case, some states require enrollees to undergo underwriting which can lead to denial or higher premiums.

Avoiding the need for the GEP

Beneficiaries can avoid using the GEP (General Enrollment Period) and getting potential LEPs:

Sign up for Medicare during the Initial Enrollment Period, which starts three months before the 65th birthday and ends three months after.

Those who have employer-sponsored coverage should confirm whether they qualify for a Special Enrollment Period (SEP) when that coverage ends. If they do, be sure to enroll before the SEP ends.

The Medicare GEP is an important opportunity for those who miss their initial chance to enroll in Medicare. However, because of potential late penalties and delays in coverage, it’s best to sign up during the Initial Enrollment Period or a Special Enrollment Period when possible. Understanding enrollment deadlines helps ensure that beneficiaries get the healthcare coverage they need and avoid unnecessary costs.

Medicare Supplements, also called Medigap plans, are insurance policies private insurance companies offer to fill the “gaps” after Original Medicare pays it’s portion of approved medical expenses. Understanding what Medicare Supplements cover is essential for Medicare agents and anyone considering enrollment in a Medigap plan to reduce healthcare costs and enhance Medicare benefits.

Medicare Supplement plan overview

Medicare Supplement plans are standardized by the federal government, meaning the coverage provided by each plan of the same name (Ex. all Plan Ns) is the same across all insurance carriers. However, premiums vary based on provider and service area. There are 10 standard Medigap plans available in many states, labeled A, B, C, D, F, G, K, L, M, and N. Each plan letter provides a different level of coverage to meet varying healthcare needs and budgets.

Learn about Medicare premiums & deductibles

What Medicare Supplements cover

Medicare Supplement plans provide coverage once Original Medicare pays its portion of the cost for approved healthcare costs. See below for what Medicare supplements cover:

Medicare Part A coinsurance for hospital costs

All Medigap plans cover the coinsurance for hospital costs under Medicare Part A for up to an additional 365 days after Medicare benefits are exhausted.

Medicare Part B Coinsurance or Copays

Many Medigap plans cover the 20% coinsurance for outpatient services under Medicare Part B. Plan K and Plan L provide partial coverage, while Plan N may require a small copay.

Blood (First 3 Pints)

Original Medicare does not cover the first three pints of blood needed for some medical procedures. Medigap plans cover this expense.

Part A Hospice Care Coinsurance

Hospice care is covered by Medicare, but beneficiaries may have to pay coinsurance for certain medications and respite care. Medigap plans cover these costs.

Skilled Nursing Facility (SNF) Coinsurance

After 20 days in a skilled nursing facility, Medicare requires a daily coinsurance payment. Most Medigap plans cover this expense.

Medicare Part A Deductible

The Part A deductible for hospital stays can be substantial. Many Medigap plans, including Plans B, C, D, F, G, and N, cover this deductible.

Medicare Part B Deductible (Only for Plans C and F)

Plans C and F cover the Medicare Part B deductible; however, these plans are only available to beneficiaries who were eligible for Medicare before January 1, 2020.

Medicare Part B Excess Charges

If a healthcare provider does not accept Medicare’s approved amount as full payment, they may charge an additional amount of up to 15%. Plans F and G cover these excess charges.

Foreign Travel Emergency Care

Some Medigap plans (C, D, F, G, M, and N) provide coverage for emergency medical care during international travel, up to plan limits.

What Medicare Supplements don’t cover

Although Medigap plans cover many out-of-pocket expenses, there are some services they do not cover:

Prescription Drugs

Medigap plans do not include drug coverage. Beneficiaries must enroll in a Medicare Part D plan for prescription drugs.

Long-Term Care

Supplements do not cover services like custodial care in a nursing home or assisted living facility.

Dental, Vision, and Hearing

Routine dental, vision, and hearing services are not included in Medigap coverage.

Private-Duty Nursing

Typically, these services are not covered.

Watch a YouTube video on Medicare enrollment periods

What to consider when choosing a supplement

It is important to evaluate current healthcare needs and potential medical expenses to help determine the level of coverage needed. Budget is another big consideration before choosing a plan. One more important factor before enrollment is eligibility. Some plans require underwriting for anyone who is outside a guaranteed issue period. There are plans (C & F) that are no longer available to anyone who turned 65 after Jan 1, 2020.

Medicare Supplements provide invaluable financial protection by covering the out-of-pocket expenses left by Original Medicare. By understanding what these plans cover and how they work, you can make an informed decision that ensures peace of mind and comprehensive healthcare coverage. For those considering enrollment in a Medigap plan, a licensed Medicare agent can help provide guidance and compare options to find the plan that best meets coverage needs.

Why Switch from Medicare Supplement Plan F to Plan G

There are some good reasons to switch from Plan F to Plan G. We will compare Medicare supplement Plan F vs Plan G to help illustrate. For years, Medicare Supplement Plan F has been a popular choice for beneficiaries seeking comprehensive coverage. However, recent changes and market trends have led many to consider switching from Plan F to Plan G. While both plans offer great benefits, Plan G provides similar coverage at a lower premium cost.

Key Similarities Between Plan F and Plan G

Both Plan F and Plan G are Medigap plans designed to fill the gaps in Original Medicare (Part A and Part B). Both plans offer comprehensive coverage, including:

1. Medicare Part A deductible
2. Medicare Part A coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are exhausted)
3. Medicare Part B coinsurance or copayments
4. Part B excess charges (the amount a provider can charge above Medicare’s approved amount)
5. The first three pints of blood
6. Skilled nursing facility (SNF) care coinsurance
7. Foreign travel emergency coverage (80% up to plan limits)

The only difference is that Plan F covers the Medicare Part B deductible, while Plan G does not.

Why Switch to Plan G

Plan F Is No Longer Available to New Beneficiaries

As of January 1, 2020, Plan F is no longer available to individuals who became eligible for Medicare after that date. This change, part of the Medicare Access and CHIP Reauthorization Act (MACRA), was implemented to reduce overall healthcare costs.

Due to the fact that Plan F is closed to enrollees who turn 65 after Jan, 1, 2020, its risk pool is aging. This can lead to higher premiums over time as the pool becomes more expensive to insure.

Lower Premiums

Plan G often has significantly lower monthly premiums than Plan F does. While Plan G requires beneficiaries to pay the Medicare Part B deductible out-of-pocket ($257 for 2025), the savings in premiums can more than make up for this cost.

For example, if Plan F costs $50 more per month than Plan G, you’d save $600 each year by switching to Plan G. The savings would easily offset the $257 deductible.

Similar Comprehensive Coverage

Aside from the Part B deductible, Plan G provides identical coverage to Plan F. After meeting the deductible, Plan G covers all Medicare-approved expenses just like Plan F does.

Premium Stability

Because Plan G is open to new enrollees, its risk pool is younger and more diverse compared to Plan F. This dynamic helps keep premiums more stable over time.

In contrast, Plan F’s closed risk pool may lead to disproportionately higher premium increases as it’s enrollee population ages.

Making the switch sooner rather than later ensures you can take advantage of Plan G’s cost savings without disruption to your coverage.

Things to consider

Health Underwriting

Beneficiaries outside their initial enrollment period or guaranteed-issue period, may need to go through medical underwriting to switch plans. This means, insurers evaluate health status and may deny coverage or charge higher premiums based on pre-existing conditions.

Evaluate Your Healthcare Needs and budget

All potential enrollees should carefully calculate out-of-pocket costs, including the Part B deductible, to ensure Plan G is a cost-effective choice.

Enlist the help of a licensed agent

Because navigating Medigap plan changes can be complex, a licensed Medicare agent can help compare premiums, evaluate options, and explain the implications of switching plans. Agents can help submit the application to ensure it is done correctly as well as advise clients when to cancel their current coverage.

It is very important to confirm eligibility to enroll in or change plans and be aware if underwriting will apply.

Learn about Medicare enrollment periods – watch a quick YouTube video

More thoughts on Plan G

Switching from Medicare Supplement Plan F to Plan G is a practical choice for many beneficiaries seeking to reduce their healthcare costs without sacrificing coverage. With lower premiums, stable pricing, and nearly identical benefits, Plan G offers exceptional value especially for those who don’t mind paying the Part B deductible.

Those considering the switch should consult a licensed Medicare agent to ensure a seamless transition and take advantage of the savings and benefits Plan G has to offer. Making an informed decision now can lead to significant cost savings and peace of mind in the years to come.

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The question; why sell Medicare supplement HDG is easy to answer. As healthcare costs continue to rise, more Medicare beneficiaries are looking for affordable yet comprehensive medical coverage. High Deductible Plan G (HDG) has emerged as an attractive choice, combining the robust benefits of traditional Medicare Supplement Plan G with significantly lower premiums. For insurance agents, promoting HDG can be a win-win offering value to clients while providing a competitive edge in the Medicare market.

Understanding High Deductible Plan G

High Deductible Plan G works in a similar way to standard Plan G. Both plan options cover the same benefits once the beneficiary meets an annual deductible. For 2025, the deductible for HDG is set at $2,870. In other words, beneficiaries pay out-of-pocket for Medicare-covered expenses until they meet this threshold. Once the beneficiary reaches the deductible, the plan covers:

1. Medicare Part A coinsurance and hospital costs.
2. Medicare Part B coinsurance or copayments.
3. The first three pints of blood
4. Skilled nursing facility (SNF) care coinsurance.
5. Part A hospice care coinsurance/copays.
6. Foreign travel emergency coverage (up to plan limits).

The other difference between a standard Plan G and a HDG plan is the premium. HDG premiums are significantly lower than those for standard Plan G, making it an appealing option for cost-conscious beneficiaries.

Why agents should sell HDG

1. Appeal to cost-conscious clients: HDG is an excellent solution for beneficiaries who want comprehensive coverage and are willing to pay a higher deductible in exchange for lower monthly premiums. Many retirees on fixed incomes consider this a good option, especially those in good health who do not expect many healthcare expenses.
2. Growing market: With healthcare costs on the rise, there is a growing trend toward high-deductible health plans. Educating clients about HDG allows agents to tap into this expanding market of budget-conscious Medicare beneficiaries.
3. Competitive edge: Offering HDG plans show the agents ability to provide diverse options tailored to individual financial and healthcare needs. Agents who can explain the cost-benefit analysis of HDG effectively are more likely to earn trust and build long-term client relationships.
4. Cross-selling opportunities: Beneficiaries who choose HDG may still need assistance with other healthcare expenses. Agents can use this opportunity to cross-sell ancillary products such as dental, vision, and hearing plans, hospital indemnity or cancer heart attack and stroke coverage.
5. Client Retention: The affordability of HDGs are an excellent option for clients who might otherwise drop supplemental coverage due to cost concerns. By proactively offering HDG, agents can retain clients who might otherwise feel Medicare Supplements are unaffordable.

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How to Sell HDG Effectively

1. Be sure you educate potential clients. Clearly explain how HDG works. Be sure to emphasize the trade-off between lower premiums and the higher annual deductible. Use understandable examples to illustrate potential cost savings.
2. Explain the flexibility of the plans. Emphasize that HDG offers the same benefits as standard Plan G after the deductible is met. Clients can enjoy peace of mind knowing they’re protected against catastrophic expenses.
3. Put the focus on the plan’s affordability. Compare HDG premiums with standard Plan G and other Medicare Supplement plan premiums. Showcase how the premium savings can outweigh the deductible for clients who have minimal healthcare needs.
4. Use calculators or other tools to demonstrate potential savings with HDG, tailored to the client’s unique circumstances. This personalized approach can make the benefits of HDG more understandable.
5. Be prepared to address common objections, such as concerns about meeting the deductible. Highlight strategies for managing out-of-pocket costs and reassure clients about the plan’s comprehensive benefits.

Watch a quick YouTube video on selling ancillary products

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A few more things to consider

Medicare Supplement HDG Plans offer a winning combination of affordability and comprehensive coverage, making it a valuable option for many Medicare beneficiaries. For agents, HDG plans provide an opportunity to meet the needs of cost-conscious clients, differentiate themselves in a competitive market, and build lasting client relationships.

By focusing on education, affordability, and personalized service, agents can successfully position HDG plans as a smart choice for Medicare beneficiaries.

Because navigating Medicare enrollment period options can feel overwhelming, we will explain one specific enrollment opportunity. For beneficiaries seeking flexibility in healthcare coverage, Medicare supplements provide a good option. Because of this, the Medicare Supplement birthday rule is an important policy to understand. This rule, available in certain states, offers a window of opportunity to change Medicare Supplement (Medigap) plans without medical underwriting.

What Is the Medicare Supplement Birthday Rule

The Medicare Supplement birthday rule allows beneficiaries to switch Medigap plans annually around their birthday without undergoing medical underwriting. This means insurers cannot deny coverage or charge higher premiums based on health status during the designated timeframe.

Medicare supplement plans help cover out-of-pocket costs not paid by Original Medicare, such as copays, coinsurance, and deductibles. However, outside of the initial enrollment period, switching plans typically requires medical underwriting, which can be a barrier for those with pre-existing conditions. The birthday rule removes this obstacle during its specific enrollment window.

States That Have the Birthday Rule

As of now, the Medicare Supplement birthday rule is not a federal policy; it is enacted at the state level. Currently, 8 states including California, Idaho, Illinois, Kentucky, Louisiana, Maryland, Nevada and Oregon have implemented variations of this rule. Each state’s version differs slightly in terms of timing and eligible plans:

California

Beneficiaries have 60 days from the first day of their birth month to switch Medicare supplement plans to enroll in one with the same or a less benefits. They also have the option to switch insurance carriers during this period.

Idaho

Those who reside in ID have 63 days from their birthday to switch Medicare supplement plans with the either the same or less benefits. They can also switch to another insurance carrier if they like.

Illinois

Beneficiaries in IL have 45 days from their birthday to change Medicare supplement plans with either the same or less benefits. This rule only applies to plans with the existing insurance carrier or an affiliate of the current carrier. The affiliate carrier was added in 2024. In order to To qualify for the birthday rule in IL, beneficiaries must be between 65 and 75.

Kentucky

As of 1-1-24, KY allows Medicare supplement enrollees to switch to another supplement carrier that offers a plan with the same benefits as their current plan. They must switch within 60 days of their birthday.

Louisiana

In the state of LA, beneficiaries are given 63 days from their birthday to switch to another Medicare supplement plan with equal or lesser benefits. Enrollees are only permitted to enroll in a plan offered by either their current carrier or an affiliate of their current insurer.

Maryland 

As of July 1. 2023, beneficiaries have 30 days from their birthday to change Medicare supplement plans with either equal or less benefits than their current plan.

Nevada

In the sate of NV, the birthday rule allows beneficiaries 60 days form the first day of their birthday month to change supplement plans to one with the same or less benefits. It is also permitted to switch insurance carriers.

Oregon

Beneficiaries have 30 days from the first day of their birth month to switch Medicare supplement plans to another with the same or fewer benefits. They can also change insurance carriers.

Please note; beneficiaries and their agents must verify the state specific rules and timelines.

Watch a quick YouTube video on Medicare enrollment periods

How the Birthday Rule works

Each year plan enrollees should evaluate their current supplement coverage and decide if it still meets their needs. A licensed Medicare agent can help compare available plan options to find one that best suits the needs of the enrollee. They will also be able to advise of the applicable enrollment window using the appropriate birthday rule for each eligible state.

Beneficiaries must submit all applications before the enrollment period ends. Insurers cannot deny applications submitted during the birthday rule period. They are also prohibited from increasing premiums based on health conditions.

Benefits of the Birthday Rule

The birthday rule provides several advantages for beneficiaries. This includes the ability to adjust their coverage to better align with their healthcare needs and budget. It also allows enrollees an opportunity to change plans without fear of rejection.

Considerations for Beneficiaries

Although the birthday rule provides some significant benefits, there are a few important considerations:

State-Specific Rules: The availability and details of the birthday rule depend on where each beneficiary resides. It is not available in every state.

Plan Restrictions: In general, the rule applies only to plans that offer equal or lesser benefits, so beneficiaries cannot use it to upgrade coverage.

Timing: Those who miss the enrollment window must wait until next year’s birthday period to change plans.

Learn about Medigap guarantee issue rules; click here

The Medicare Supplement birthday rule is valuable for eligible beneficiaries. It provides an annual opportunity to change coverage without medical underwriting.

The 3 primary out-of-pocket costs to consider when you compare Medicare plans are; copays. coinsurance & deductibles. Medicare copays, coinsurance and deductibles all contribute to annual coverage costs for plan enrollees each year. These terms all describe the money beneficiaries pay towards health care services and prescription drugs when they have health insurance. 

Copays

A copay is a fixed amount of money beneficiaries pay for a specific service. They generally apply to: primary care provider visits, specialist visits, prescription drug refills (depending on the tier of the drug), and hospital services. Copays let the beneficiary know what they pay for each provider’s visit up front. Copays apply to most prescription drug plans, Medicare Advantage plans and some Medicare Supplement plans. Please keep in mind, sometimes there are other costs associated with a visit to a provider’s office.

Coinsurance

When a beneficiary and their health plan share the cost of approved medical services, that is coinsurance. Coinsurance payment amounts are based on a percentage of the cost. Beneficiaries enrolled in Original Medicare, will have to pay 20% of the cost for most services after they meet the annual deductible. After the enrollee meets the deductible, Original Medicare covers 80% of all approved costs.

Usually members of Medicare Advantage plans pay co-pays for medical visits instead of coinsurance. Although in many cases, MA/MAPD plan enrollees pay 20% coinsurance for Part B drugs (in-network).

Up until 2025, stand alone PDP plan enrollees could end up paying 25% coinsurance for drugs if they fell into the donut hole (coverage gap). The coverage gap was removed for 2025, therefore stand alone PDP enrollees do not pay coinsurance.

Click here to learn about the Part D prescription payment program

Deductibles

Deductibles are the amount plan enrollees pay out of pocket for most health care services before their plan starts to cover medical costs. The deductible does not apply to preventative services. Medicare plans cover preventative services at not cost to enrollees.

Once the deductible is met, enrollees are still required to pay copays and/or coinsurance costs.

There are 2 different deductibles for Original Medicare Part A & Part B, however many Medicare supplement plans cover the Part A deductible. There only 2 plans that cover the Part B deductible (Plan F & Plan C) neither plan is available to anyone who turns 65 after 1/1/2020.

Most MA/MAPD plans have separate deductibles; one for medical costs and one prescriptions. That means enrollees must meet their medical deductible before the plan pays for specific covered services. It also means enrollees must pay the deductible for prescriptions before the plan covers the cost of the medication. MA/MAPD enrollees still pay copays and coinsurance after they meet the deductible. Please note; each plan is different and deductible amounts are specified in a plan’s summary if benefits.

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

Copays, coinsurance, and deductibles

Copays, coinsurance & deductibles are all factors to consider when discussing Medicare options. All these things contribute to the total cost of each plan a beneficiary chooses.

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