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Medicare Advantage Trial Right Rules: What You Need to Know

For beneficiaries who understand the Medicare Advantage Trial Right Rules, this SEP provides a second chance to find a plan to best fit their needs. Switching health plans is stressful; especially if you’re not sure whether your new Medicare Advantage (MA) plan will meet your needs. Fortunately, Medicare offers a special protection called the Trial Right. This provides MA plan enrollees a one-time opportunity to go back to Original Medicare and Medigap as well as a PDP plan if their MA plan isn’t a good fit.

In this blog, we explain Trial Rights, who qualifies, and how to use it so both Medicare agents and beneficiaries are well informed of all the options.

What is a Medicare Advantage Trial Right

The Trial Right is a federally protected enrollment right under Medicare. It allows certain individuals who try a Medicare Advantage plan for the first time to switch back to Original Medicare. When they switch to Original Medicare, in most cases, purchase a Medigap (Supplement) plan without medical underwriting.

This protection ensures that people aren’t stuck in a plan that doesn’t meet their healthcare needs, especially if they’re new to Medicare or trying out Medicare Advantage for the first time.

When Do Trial Rights Apply

There are the two situations when someone is entitled to a Medicare Advantage Trial Right:

Trial Right #1: First Time Joining a Medicare Advantage Plan

If a beneficiary joined a Medicare Advantage plan for the first time ever (at age 65 or older) and has been enrolled in that plan for less than 12 months, they can:

• Disenroll from the MA plan
• Return to Original Medicare (Part A & B)
• Purchase a Medigap plan (Medicare Supplement) with guaranteed issue rights; no medical underwriting
• Purchase a PDP plan to cover prescription drugs

Example:
Mary turned 65 and enrolled in a Medicare Advantage PPO instead of Original Medicare and Medigap. After 6 months, she realizes she prefers the flexibility of seeing any doctor and wants to switch. She has a trial right to go back to Original Medicare and buy a Medigap plan and PDP plan, even if she now has health issues.

Trial Right #2: Dropping a Medigap Plan to Try an MA Plan

If a beneficiary had a Medigap plan but switched to a Medicare Advantage plan for the first time, and it’s been less than 12 months, they can:

• Drop the MA plan
• Go back to Original Medicare
• Re-enroll in the same Medigap plan (if it’s still available) or buy a similar one from another company; with guaranteed issue rights

Example:
Joe had Plan G for two years, then switched to a Medicare Advantage HMO in January. By September, he misses his Medigap freedom. He can use his trial right to return to Original Medicare and get a Medigap plan without underwriting.

How to Use a Trial Right

Beneficiaries can typically switch during a valid election period such as:

• Annual Election Period (AEP) – Oct 15 to Dec 7
• Medicare Advantage Open Enrollment Period (MA OEP) – Jan 1 to Mar 31
• Special Enrollment Period (SEP) triggered by the trial right

Watch a YouTube video on Medicare OEP, SEPs and LEPs

Once the carrier process the disenrollment:

• Original Medicare (Parts A & B) coverage resumes
• The beneficiary can apply for a Medigap plan with guaranteed issue rights
• Beneficiaries must select Part D (drug coverage) separately, unless already built into the Medigap package

Agents, if you are ready to join the team at Crowe; click here for online contracting

Benefits of the Trial Right

• No medical underwriting for Medigap; even if you have pre-existing conditions
• A second chance to choose Original Medicare + Medigap coverage
• Ensures flexibility and peace of mind for new enrollees or first-time MA users

Important Rules and Limitations

• MA Plan enrollees must leave their current MA plan before the 12 months ends.
• It’s a one-time only right; once the beneficiary uses it, they cannot use it again.
• Your Medigap plan must still be available from the insurer, or you can choose another one. You must also apply for a Medigap plan as early as 60 days before the date your MA plan will end or no later than 63 day after your coverage ends.
• The beneficiary must consider prescription drug coverage:
  • If you return to Original Medicare, you’ll likely need to enroll in a standalone Part D plan.
• Not all agents are familiar with this rule; make sure your client knows their rights!

How Agents Can Use This in Sales

• Educate new-to-Medicare clients: They can try MA with confidence knowing they have a Trial Right.
• Use it as a consultative tool; not to push one product over another but to help the client choose what best fits their health and financial needs.
• Document Trial Right eligibility in your CRM or client file; especially if they switch from Medigap to MA.

Stay up-to-date on agent events and information – click here.

Medicare’s Trial Right protections give beneficiaries peace of mind when trying something new. As an agent, it’s your responsibility to educate clients on their rights and help them make informed decisions if their first choice doesn’t work out.

Helping a client use their Trial Right can be an important opportunity to show your value as a Medicare resource.

The 2026 Final Rule, released by CMS in April 2025, brings meaningful changes to Medicare Advantage (MA), Part D, and Special Needs Plans (SNPs). These updates aim to improve transparency, enhance care for high-needs populations, and modernize how payments are made to insurers. As a Medicare agent, staying informed helps you guide clients accurately and position your sales strategy for success

Key Changes Agents Should Know

1. Medicare Advantage Plan Payment Increase

CMS approved a 5.06% increase in average plan payments for 2026. This is expected to give insurers more room to offer richer benefits, reduce premiums, or expand supplemental services. Once the carriers release the 2026 plan designs, we will see if they have added enhancements.

2. Prescription Drug Reforms (Part D)

• Insulin Copays Capped: $35/month or 25% of the negotiated price; whichever is less.
• Vaccines: ACIP-recommended vaccines remain free (no deductible or cost-sharing).
• Prescription Payment Plan: Beneficiaries can spread out drug cost payments over the year.
  • New guidelines clarify enrollment, pharmacy coordination, and billing practices.

Agents; educate clients on enrolling in the payment plan; especially those with high drug costs.

3. Risk Adjustment Overhaul – Accuracy Takes Priority

CMS is completing its transition to the 2024 CMS-HCC risk adjustment model, which will be 100% in effect for 2026 MA plan payments. This model better reflects today’s healthcare needs by using updated diagnosis groupings and more current data.

Why It Matters:

• Plans with more chronically ill members (diabetes, COPD, heart failure) get higher CMS payments.
• Plans with healthier enrollees receive less.

Impact on Agents:

• Some plans may adjust benefits or premiums in response to expected payment changes.
• You may see enhanced offerings from plans that excel in care coordination and documentation.
• SNPs and plans serving dual-eligibles may experience meaningful shifts; pay attention to service area changes or new plan launches.

Bottom Line: This makes the system more fair, but you should monitor plan benefit designs closely in your key markets

Agents if you are ready to join the Crowe team, click here for online contracting.

4. D-SNP Simplification (Effective 2027)

CMS is improving integration for dual-eligible members with:

• One Medicare-Medicaid ID card
• Unified Health Risk Assessment (HRA)
• Faster HRA and care plan timelines

These changes make D-SNPs easier to explain and more attractive to clients. Prepare now by understanding how your D-SNP partners are adapting.

5. Inpatient Coverage Notification Rules

Plans must now notify both providers and beneficiaries at the same time about inpatient coverage decisions—helping ensure clear, real-time communication during hospital stays.

Watch a quick YouTube video on the Medicare 2026 Final Rule Proposal

6. What Didn’t Make the Cut

CMS did not finalize several proposed changes:

• No Part D coverage for anti-obesity drugs
• No new broker commission rules
• No restrictions on agent marketing or AI guardrails (yet)

Important: CMS has hinted that more agent-related changes may be proposed in the near future. Stay vigilant!

Updated 2026 Agent Commission Rates

CMS has announced significant increases in maximum allowable broker commissions for Medicare Advantage and Part D for Contract Year 2026 representing the largest MA commission bump in years

Click here for all the details

Action Steps for Agents

1. Study how your top plans may adjust benefits due to new risk adjustment payments.
2. Help clients understand the Prescription Payment Plan and insulin savings.
3. Stay tuned for more changes, especially around marketing, commissions, and AI regulations.
4. Start preparing D-SNP marketing materials ahead of the 2027 simplification rollout.

Find out about all the latest events and information for agents

Summary: CMS Final Rule 2026

TRICARE and Medicare Coverage: How the Two Work Together

Both agents and military retirees need to understand how TRICARE and Medicare coverage works in tandem. While both programs provide robust healthcare coverage, the rules around enrollment, coordination of benefits, and plan options may be confusing.

In this post, we’ll break down what TRICARE is, how it works with Medicare, key eligibility requirements, and what agents and beneficiaries need to know to ensure continuous and cost-effective coverage.

What Is TRICARE

TRICARE is the health care program for:

• Uniformed service members (active duty and retired)
• Their families
• National Guard/Reserve members
• Survivors and some former spouses

Administered by the Defense Health Agency (DHA), TRICARE provides coverage similar to private insurance plans and includes prescription drug benefits.

When a TRICARE Beneficiary Becomes Medicare-Eligible

When a TRICARE beneficiary turns 65 (or qualifies for Medicare earlier due to disability), they typically must enroll in Medicare Part A and Part B to maintain their TRICARE coverage.

Once they enroll in Medicare, TRICARE becomes TRICARE for Life (TFL).

What Is TRICARE For Life (TFL)

TRICARE for Life is the coverage that kicks in after a beneficiary becomes eligible for Medicare and enrolls in both Part A and Part B. TFL acts as a secondary payer to Medicare. Here’s how it works:

• Medicare pays first (as the primary insurance)
• TFL pays second, covering most or all of the remaining costs
• Out-of-pocket costs are minimal or nonexistent for covered services

Important: If a TRICARE beneficiary does not enroll in Medicare Part B, they will lose TRICARE coverage, unless they are an active-duty service member or family member of one.

Agents, click here to see what you need to know before a Medicare sale

Coverage Details: Medicare TRICARE for Life

Service	Medicare Pays	TFL Pays	Beneficiary Pays
Doctor visits	80%	Remaining 20%	$0 (in most cases)
Hospital stay	Medicare-approved	TFL covers deductible	$0
Prescription drugs	N/A	TFL (through Express Scripts)	Varies (copays)
Services not covered by Medicare (e.g., overseas)	N/A	TFL may pay	May vary

Can TFL Beneficiaries Enroll in Medicare Advantage

Technically, yes; TFL beneficiaries can enroll in a Medicare Advantage (MA) plan, but this often creates coverage conflicts and doesn’t offer cost savings.

Agents should caution beneficiaries:

• TFL does not coordinate well with MA plans.
• Some services covered by TFL may be denied if the MA plan doesn’t approve them.
• MA plans may interfere with how TFL pays claims.

Most beneficiaries are better off staying with Original Medicare + TRICARE for Life.

Do TFL Beneficiaries Need Medicare Part D

No, TFL includes a robust pharmacy benefit through Express Scripts. Enrolling in a separate Medicare Part D plan may result in:

• Loss of TRICARE pharmacy coverage
• Unnecessary monthly premiums
• Coordination issues

Agents: When working with TRICARE beneficiaries, always ask if they use the Express Scripts program before discussing Part D options.

Key Points for Medicare Agents

• Do not sell Medicare Advantage or Part D plans to TFL beneficiaries without reviewing the consequences.
• Always verify TRICARE status before recommending plan changes.
• Turning 65 is a triggering event that requires Medicare Part A & B enrollment to keep TRICARE.
• TFL works best with Original Medicare not Advantage plans.
• Help clients plan for premium costs; Medicare Part B still has a monthly premium, even with TFL.

Agents; if you are ready to join the team at Crowe, click here for online contracting

Key Takeaways for Beneficiaries

• Enroll in Medicare Part A and B when eligible to keep your TRICARE benefits.
• TRICARE for Life + Medicare offers comprehensive, low-cost healthcare.
• Avoid Medicare Advantage or Part D unless you understand the impact on your TRICARE benefits.
• You do not need Medigap; TFL acts as your Medicare supplement.

For military retirees and their families, TRICARE for Life is a valuable benefit that pairs seamlessly with Medicare; when used correctly. As an agent, your role is to educate and protect beneficiaries from making decisions that could disrupt their healthcare.

Click here for agent events and information

Whether you’re a veteran trying to understand your coverage or an agent assisting a retired service member, remember: when in doubt, stick with Original Medicare + TRICARE for Life.

Permission to Contact for Medicare Sales: What Agents Need to Know

As a Medicare agent, staying compliant with CMS marketing guidelines is critical. One of the most important aspects of compliance is obtaining Permission to Contact for Medicare sales (PTC) from potential beneficiaries before initiating sales calls or marketing activities. Failing to do so can result in regulatory violations, fines, and loss of certification with carriers.

In this blog, we’ll break down what Permission to Contact is, how to obtain it,and CMS rules that apply.

What Is Permission to Contact (PTC)

PTC is a CMS-required process that ensures beneficiaries give express consent before a Medicare agent can reach out to discuss plan options, answer questions, or schedule appointments. This rule protects Medicare beneficiaries from unsolicited contact and promotes ethical sales practices.

Crowe/Pinnacle agents can access online tools that help agents gather important client information including PTC with RetireFlo for Connecture or Sunfire’s BlazeSnyc:

Watch a video on RetireFlo for Medicare producers: Obtain client scopes, PTC, drug & doctor lists

Take a look at how the Sunfire BlazeSync customer intake form works

CMS Guidelines for Permission to Contact

According to CMS Medicare Communications and Marketing Guidelines (MCMG), agents may not:

• Cold call beneficiaries.
• Leave marketing materials in common areas (e.g., lobbies or libraries) to collect leads.
• Approach beneficiaries in healthcare settings or parking lots.

Agents must have documented permission from the beneficiary prior to outreach, unless the beneficiary initiates the contact.

Important: The PTC Permission to Contact form expires after 12 months or once it’s purpose has been fulfilled. If you need to contact the beneficiary after the original PTC expires, you must obtain a new one.

Acceptable Ways to Obtain Permission:

1. Permission to Contact (PTC) Form
2. Scope of Appointment (SOA) form
3. Inbound phone call from the beneficiary
4. Online request form (such as a lead form on your website)
5. Text or email initiated by the beneficiary
6. Business reply cards (BRCs)
7. Event sign-in sheets (when clearly marked as giving permission to be contacted)

Once permission is granted, it only applies to the scope and method defined. For example, if a beneficiary gives you permission to call about Medicare Advantage plans, you can’t use that to market life insurance or annuities.

Ready to join the Crowe team; click here for online contracting

What Must Be Included in a PTC Form

A compliant Permission to Contact form should include:

• Beneficiary name
• Date
• Type of contact permitted (e.g., phone, email)
• Reason for contact (e.g., Medicare Advantage plan information)
• Statement that the individual is not obligated to enroll
• Signature or consent checkbox (if digital)

The form must also make it clear that responding is optional and not a condition of enrollment.

Permission to Contact Form

First Name: ____________________
Last Name: ____________________
Phone Number: ____________________
Email (optional): ____________________
Preferred Contact Method: ☐ Phone ☐ Email
Reason for Contact:
☐ I would like to be contacted by a licensed insurance agent to discuss Medicare Advantage and/or Prescription Drug Plans.

By completing this form, you agree that a licensed sales agent may contact you about Medicare plan options. You are under no obligation to enroll. This is a solicitation for insurance.

Signature: ____________________
Date: ____________________

Note: Agents should keep a copy of all PYTC forms for 10 years as art of their CMS compliance record.

When you Do Not Need a PTC

Although there are strict rules regarding client communication, there are exceptions when the contact is for ongoing client communications. Agents can contact existing clients about other products as long as the have an active business relationship. You can also contact plan enrollees with information on their coverage as long as you are listed as AOR.

Digital Lead Forms and Compliance

If you use online marketing to generate leads, your form must:

• Clearly indicate that a licensed agent will be contacting the user
• Include disclaimers like: “By submitting this form, you agree to be contacted by a licensed sales agent by phone, email, or text message about Medicare plan options. You are not obligated to enroll.”
• Ensure proper data encryption and opt-out procedures

Click here to stay updated on agent events and information

Getting Permission to Contact is not just a CMS requirement; it’s a trust-building opportunity. It shows respect for your client’s privacy and helps you build a compliant, professional reputation.

Always follow the most current CMS guidelines (as they can update annually), and never cut corners when it comes to consent. Remember, ethical practices protect both your business and your clients.

2026 AHIP Certification Guide for Medicare Agents

Each year, Medicare agents must complete a series of certifications before they’re ready to sell to Medicare Advantage (MA/MAPD) or Prescription Drug Plans (PDPs) to their clients. One of the most important is the AHIP. Our AHIP 2026 certification guide should help you check this off your list.

The 2026 AHIP training is available on June 23, 2025, and it will cover any business written for the remainder of 2025 and all of 2026.

If you’re looking to stay compliant, contract with carriers, and be “Ready to Sell,” here’s everything you need to know to get started; including test tips, module breakdowns, discount info, and what happens if you do not pass.

What Is the AHIP and Why It’s Important

The AHIP (America’s Health Insurance Plans) certification is a CMS-compliant annual training course designed to ensure Medicare agents understand:

• The structure of Original Medicare
• How Medicare Advantage and Part D plans work
• Compliance and marketing rules
• Enrollment periods
• Fraud, waste, and abuse (FWA) prevention

Most MA/MAPD and PDP carriers, with a few exceptions (such as UnitedHealthcare, which has its own certification) require agents to pass AHIP. Completing it is often the first step toward certification with each carrier for the Annual Enrollment Period (AEP).

2026 AHIP Launch Date

• Course Available: June 23, 2025
• Covers: Remainder of 2025 and all of 2026
• Cost: $175 (discounts often available through major carriers)

Crowe/Pinnacle Financial Agents can receive a $50 discount by taking the course through PFSinsurance.com. Just log in, go to the Certifications tab, and scroll to the AEP Toolkit for the Pinnacle AHIP discount link.

2026 AHIP Test Tips

• The test includes 50 multiple choice questions
• Agents have 2 hours and 3 attempts
• Passing Score: 90%
• If you fail all three attempts, you must repurchase and retake the course
• Warning: Some carriers will not allow you to sell their plans for the year if you fail three times

Watch our AHIP Test Tips 2025 on YouTube

What’s in the AHIP Modules

The AHIP course is split into two main parts:

Part 1: Medicare Overview (5 Modules)

1. Module 1 – Overview of Medicare Program Basics: Choices, Eligibility and Benefits
2. Module 2 – Medicare Health Plans
3. Module 3 – Medicare PArt D: Prescription Drug Coverage
4. Module 4 – Marketing Medicare Advantage and Part D Pans
5. Module 5 – Enrollment Guidance Medicare Advantage and Part D Plans

Tip: Download the slides for all Modules. If you took the 2025 course, you do not have to complete all 5 modules, you can skip 1-3 (just do the review). You may only need to complete modules 4 & 5.

Because each module includes a 20-question practice test, it may not be a bad idea to go over all modules. The final exam questions are pulled directly from these quizzes. Pay close attention to any you got wrong to be sure you answer them correctly when it counts.

Part 2: Fraud, Waste & Abuse (FWA)

Part 2 of the AHIP certifications FWA consists of 3 Modules

1. Non-Discrimination Training; what qualifies as discrimination and what does not.
2. Medicare Fraud, Waste and Abuse; how to identify and report FWA, financial and ethical consequences and the impact of FWA.
3. General Compliance; legal tools and compliance requirements and who they apply to.

Each of these modules has a practice test and a final test when those are completed. You only need a score of 70 to pass this portion.

After You Pass: What’s Next

1. Download your AHIP certificate
2. Transmit your results to participating carriers through AHIP, or manually upload it to the carriers you are contracted with dashboards
3. Complete carrier-specific certifications for each MA or PDP product line

Helpful Reminders

• UnitedHealthcare (UHC) doesn’t require AHIP but does have its own certification
• AHIP 2026 is similar to 2025, but includes updates for new CMS rules, including changes related to Part D redesign and marketing compliance
• You must complete AHIP before you receive a RTS from most carriers even if you complete their certifications.

If you’re a new agent looking to join a supportive upline or an existing agent who wants to add a carrier to your existing contract:
Click here for online contracting

Getting AHIP-certified early is a smart move. It opens doors to carrier contracts, helps avoid delays, and gives you the confidence to serve your Medicare clients accurately and compliantly.

Click here to stay up-to-date on agent events and information.

Don’t wait until the last minute; take advantage of our AHIP 2026 tips, download the modules, and use the practice tests. Remember, three tries is all you get before you have to start over; so make your first try count!

Medicare OEP Open Enrollment Period

The Medicare Open Enrollment Period (OEP) runs annually from January 1 to March 31. It is specifically for individuals already enrolled in a Medicare Advantage (Part C) plan as of January 1.

This period does not apply to those with Original Medicare (Part A and B) only; it’s strictly for Medicare Advantage plan members who may want to make a one-time change.

What Changes Can You Make During OEP

Those enrolled in a Medicare Advantage plan, can make one change during the OEP. The options include:

• Switching to a different Medicare Advantage plan, with or without drug coverage
• Dropping your Medicare Advantage plan and returning to Original Medicare, with the option to add a Part D prescription drug plan

Changes You Cannot Make:

• Switch from Original Medicare to a Medicare Advantage plan
• Enroll in Part D drug coverage if you’re on Original Medicare and missed your IEP or AEP
• Make multiple changes; OEP only allows one switch

Watch a video on Medicare enrollment periods

Why Use the OEP

Here are a few common reasons beneficiaries take advantage of the Medicare OEP:

• Their current Medicare Advantage plan doesn’t cover a needed medication or provider
• They discovered higher costs or restrictions after using the plan in January
• They had a change in health and want a different plan with better specialist coverage
• They were unaware of better plan options during the Annual Enrollment Period (AEP), which runs from October 15 to December 7

How Is OEP Different from AEP

Important Considerations

• If you switch to Original Medicare during OEP, you may not be guaranteed Medigap (Medicare Supplement) coverage; unless you’re in a trial right or qualify for a Special Enrollment Period.
• Any changes made during the OEP become effective the first day of the month after the change is made (e.g., a change in February takes effect March 1).
• It’s important to review coverage early in the year to determine if your current plan still meets your needs.

Work with a Licensed Agent

The Medicare OEP is a valuable but limited opportunity to make corrections or improvements to your coverage. If you’re unsure whether your plan fits your health needs or budget, speak with a licensed Medicare agent. They can help you compare options, check provider networks and drug formularies, and make confident decisions about your healthcare.

Agents; if you are ready to join a winning team, click here for Crowe contracting!

Stay updated on agent information and events, click here

Understanding Medicare Coverage of Physical Therapy

Physical therapy can play a vital role in recovery from injury or illness, helping individuals regain strength, mobility, and independence. However, it can also be a time-consuming and costly process. If you’re a Medicare beneficiary, it’s important to understand Medicare coverage of physical therapy.

When Physical Therapy May Be Necessary

Physical therapy (PT) is designed to evaluate and treat conditions that limit the ability to function in daily life. The goals of PT may include:

• Restoring lost mobility or strength
• Slowing physical decline
• Managing chronic conditions
• Preventing further injury

Medicare Coverage of Physical Therapy

Most outpatient physical therapy services are covered under Medicare Part B, which includes:

• Medically necessary physical therapy
• Occupational therapy (OT)
• Speech-language pathology (SLP)

If you receive physical therapy during an inpatient stay (such as in a hospital or skilled nursing facility), Medicare Part A may cover those services as part of your inpatient benefits.

Medicare Advantage (Part C) members should refer to their plan’s Evidence of Coverage or contact the plan’s member services for specific benefits, as coverage may vary by plan.

Eligibility & Medical Necessity

For Medicare to cover physical therapy:

• The services must be medically necessary
• A doctor or healthcare provider must prescribe and supervise the treatment
• The patient must receive care at a facility that accepts Medicare assignment

Services must target a diagnosed condition and be part of a treatment plan with documented goals and progress reviews.

Agents if you are ready to join the team at Crowe; click here for contracting

Therapy Thresholds and the KX Modifier Rule (2025 Limits)

In 2018, Medicare eliminated the hard cap on therapy services, replacing it with a “soft cap” or threshold. This allows continued access to necessary care while tracking usage and ensuring services are medically necessary.

In 2025, the therapy thresholds are:

• $2,330 for combined Physical Therapy (PT) and Speech-Language Pathology (SLP) services
• $2,330 for Occupational Therapy (OT) services

Once a patient exceeds these thresholds, the provider must apply a KX modifier on Medicare claims to confirm that services continue to be medically necessary.

Important: These thresholds are not a hard limit. As long as therapy is medically necessary and properly documented, Medicare will continue to cover services beyond the threshold.

Stay updated on the latest agents events and information

What Will You Pay?

Under Medicare Part B:

• You pay the annual Part B deductible (which is $240 in 2025)

• After meeting the deductible, you’re responsible for 20% coinsurance of the Medicare-approved amount

If you have a Medicare Supplement (Medigap) plan, it may cover the 20% coinsurance. Be sure to confirm your provider accepts Medicare assignment, which ensures you’re not billed more than Medicare’s approved rates.

Agents watch a quick video on AEP Planning

Who Can Provide Covered Therapy Services?

To be covered by Medicare, therapy must be delivered by:

• A licensed Physical Therapist (PT)

• A licensed Occupational Therapist (OT)

• A licensed Speech-Language Pathologist (SLP)

These professionals must meet Medicare’s credentialing and billing requirements.

Documentation and Progress Tracking

For continued Medicare coverage, your therapy provider must:

• Track and document your progress

• Demonstrate ongoing medical necessity

• Review and update your care plan as needed

Active participation in your therapy plan and attending all scheduled sessions are key to both recovery and continued coverage.

With understanding and guidance, accessing the necessary physical therapy services is easy and comes without added financial stress. 

Beneficiaries enrolled in a Medicare Advantage plan should review plan-specific benefits or contact their Medicare agent or your plan’s customer service for details. 

Understanding the Different Types of Medicare Advantage Plans

Medicare Advantage (Part C) plans offer an all-in-one alternative to Original Medicare, often including additional benefits like dental, vision, hearing, and even prescription drug coverage. These plans are offered by private insurance companies approved by Medicare. Whether you’re a Medicare beneficiary or an agent helping clients make informed decisions, understanding the different types of Medicare Advantage plans is essential.

There are many types of Medicare advantage plans to consider when choosing coverage that best fits your needs. Here’s a breakdown of the main types of MA plans available:

HMO (Health Maintenance Organization) Plans

Key Features:

• Requires members to use a network of doctors and hospitals.
• Members must choose a Primary Care Physician (PCP).
• Referrals are usually needed to see a specialist.
• Most HMO plans include prescription drug coverage (Part D).

Best for: People who are comfortable with a coordinated care approach and staying within a specific provider network to keep costs low.

PPO (Preferred Provider Organization) Plans

Key Features:

• Offers more flexibility in choosing healthcare providers.
• You can see out-of-network providers, usually at a higher cost.
• No need to choose a PCP or get referrals for specialists.
• Often includes Part D prescription drug coverage.

Best for: Those who want the freedom to see any doctor or specialist without a referral and are willing to possibly pay a bit more for that flexibility.

SNPs (Special Needs Plans)

Key Features:

• Tailored for individuals with specific diseases, health conditions, or financial needs.
• Types include:
  • C-SNPs: For people with chronic conditions (e.g., diabetes, heart disease).
  • D-SNPs: For dual-eligible individuals (Medicare and Medicaid).
  • I-SNPs: For people in institutional care (like nursing homes).
• Always includes prescription drug coverage.
• Offers care coordination and case management.

Best for: Individuals with specific medical, financial, or living circumstances who need a personalized care approach.

PFFS (Private Fee-for-Service) Plans

Key Features:

• Allows you to see any Medicare-approved provider who agrees to the plan’s payment terms.
• No need to choose a PCP or get referrals.
• Some PFFS plans include drug coverage; others don’t.

Best for: People who want flexibility and are comfortable checking whether their provider will accept the plan’s terms.

POS (Point of Service) Plans

Key Features:

• A hybrid of HMO and PPO.
• You can go out-of-network for certain services, often with higher copays or coinsurance.
• Requires a PCP and referrals for specialists (when in-network).
• May include drug coverage.

Best for: Beneficiaries who like the care coordination of an HMO but want some out-of-network flexibility.

If you are ready to join Crowe team; click here for online contracting

MSA (Medical Savings Account) Plans

Key Features:

• Combines a high-deductible health plan with a savings account that Medicare deposits money into.
• Funds can be used to pay for qualified medical expenses.
• Does not include Part D coverage; must be purchased separately.

Best for: Those who prefer managing their own health savings and expenses and are comfortable with high deductibles.

Watch a quick YouTube video on why agents should include ancillary products with MA sales

Choosing the Right Medicare Advantage Plan

When evaluating which type of plan is best for you or your client, consider:

• Provider access: Do you want to stay in-network or have more flexibility?
• Prescription needs: Is Part D coverage important?
• Cost preferences: Would you rather pay higher premiums for lower out-of-pocket costs or vice versa?
• Health conditions: Are there chronic conditions or Medicaid eligibility that might qualify for an SNP?

Each Medicare Advantage plan type offers different benefits, restrictions, and costs. Understanding these differences is the key to selecting the most suitable coverage.

Agents, stay up-to-date on the our latest webinars an agent events.

CMS 2026 Part D Redesign & the Executive Order on Drug Prices

Starting January 1, 2026, CMS will implement Medicare Part D redesign 2026 updates that were put in place by the Inflation Reduction Act. They will also enact the new Most-Favored-Nation (MFN) Executive Order issued May 12, 2025. The goal of these actions is to better align U.S. drug prices with those paid by other high-income nations.

CMS 2026 Part D Redesign: Key Cost Updates

• $615 deductible before coverage kicks in.
• Initial Coverage Phase: beneficiary pays 25% coinsurance; 65% is plan-covered, and manufacturers cover 10% (plus CMS provides a 10% subsidy on select negotiated drugs)
• Out-of-Pocket Cap: annual TrOOP limit rises to $2,100 in 2026
• Catastrophic Phase: beneficiaries pay $0; plans cover 60%, manufacturers 20%, CMS 20–40%

Watch a video on the CMS Medicare Final Rule Proposal

Selected Drug Subsidy Program & Negotiated Prices

The Direct price negotiations initiated under the IRA (Inflation Reduction Act) for the first 10 high-cost Part D drugs begins in 2026. These selected drugs also qualify for a 10% subidy, provided by CMS during the initial coverage phase.

Additionally; the expected savings for medicare is estimated at about $6 billion with an estimate of $1.5 billion in savings on beneficiary out-of-pocket costs.

Executive Order: Most-Favored-Nation Pricing (May 12, 2025)

• Directs agencies (HHS, CMS, Commerce, USTR) to benchmark U.S. drug prices against the lowest prices in OECD nations
• Encourages direct-to-consumer drug purchasing programs at these international prices
• Includes authority to impose tariffs or regulatory action if manufacturers don’t comply within 30 days
• Targets anti-competitive practices, middlemen reforms, accelerated generic and biosimilar availability, and simplified importation
• Reform measures also extend to Medicaid and facilitate value-based pricing and site-neutrality
• Implementation faces legal uncertainties, with pharmaceutical leaders raising concerns over future innovation and practicality

Medicare Prescription Payment Plan (MPPP) Updates

• Auto re-enrollment with a 3-day opt-out window for returning participants
• No extra fees and pharmacy reimbursement within 14 days (e-claims) or 30 days (paper)
• All plans must include smoothed monthly billing as an alternative to per-fill copays

What Agents Can Do

Emphasize cost cap increases: deductible ($615) and TrOOP ($2,100), and detail catastrophic phase structure.

Promote savings with negotiated drug program: mention the overall savings after the TrOOP is reached.

Educate clients about MPPP; how monthly smoothing can reduce sticker shock and how to opt out.

Highlight executive order impacts; both MFN implications and ongoing drug price negotiations that can give them additional price drops or new purchasing options.

Address drug import possibility from Canada, pending MFN implementation.

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What This Means for Agents & Clients

• Lower costs for select medications due to CMS negotiations and MFN pricing policies
• Enhanced predictability and affordability via MPPP
• Opportunities in marketing: position these changes as saving tools during Open Enrollment
• Stay alert to implementation updates and legal progress on MFN rules

Get updated agent information and event details

Exploring Alternatives to LTC Plans

Long-Term Care (LTC) insurance is designed to help cover the cost of services such as home care, assisted living, and nursing home care. However, traditional LTC insurance isn’t always the right fit for everyone. Whether it’s due to affordability, underwriting requirements, or changing needs, many people are looking for alternatives to LTC plans to prepare for future care costs.

Here’s a look at some viable alternatives to traditional LTC insurance agents can suggest to clients as an affordable option.

Hybrid Life Insurance with LTC Riders

What it is: A life insurance policy (usually whole or universal life) that includes a rider allowing policyholders to use part of the death benefit to pay for long-term care expenses.

Pros:

• If the policy holder never needs care, beneficiaries still receive the death benefit.
• Premiums are often guaranteed and cannot increase.
• Easier to qualify for than standalone LTC insurance.

This is a good choice for Individuals who want both life insurance and LTC protection in one plan and are concerned about “use-it-or-lose-it” LTC premiums.

Annuities with Long-Term Care Benefits

What it is: Some annuities offer enhanced payouts if the owner needs long-term care, effectively doubling or tripling the monthly income benefit for a specific period of time.

Pros:

• Guaranteed income stream.
• Fewer underwriting requirements.
• Can use qualified or non-qualified funds.

These annuities are an option for people with savings they want to protect or grow, who worry about future care expenses but don’t want traditional insurance.

Watch a quick video on Annuity basics

Short-Term Care Insurance

What it is: Short-term care policies cover care needs for a limited time; typically not more than 360 days. They are easier to qualify for and are more affordable when compared to traditional LTC policies.

Pros:

• Lower cost.
• Often no medical exam required.
• Quick benefit payout.

Clients who may not qualify for traditional LTC insurance or those seeking a more budget-friendly option to cover a temporary care gap should consider short-term insurance coverage.

Self-Funding with Investments

What it is: Creating a personal plan to save and invest funds specifically designated for possible long-term care expenses.

Pros:

• Complete control over assets.
• No underwriting or monthly premiums.

Cons:

• Requires discipline and adequate income.
• May be insufficient if care is needed sooner than expected or costs exceed projections.

Best for: High-net-worth individuals or financially savvy clients who prefer autonomy over their funds.

Medicaid Planning

What it is: Strategic financial planning to qualify for Medicaid coverage of long-term care. This might include asset protection strategies such as irrevocable trusts and gifting.

Pros:

• Medicaid is the largest payer of long-term care in the U.S.
• Can help preserve some assets for heirs.

Cons:

• Requires strict adherence to look-back periods and asset limits.
• Planning must be done well in advance.

This may be an option for those with limited assets or those with time to plan ahead using an experienced elder law attorney or Medicaid planner.

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Start the Conversation Early

The key to successful long-term care planning is starting early. Many of these alternatives become less viable with age or declining health. For agents, it’s important to offer a well-rounded view of options so clients can make informed decisions based on personal needs, health, and finances.

Remember: LTC planning isn’t one-size-fits-all. By exploring these alternatives, clients can have peace of mind; even if traditional long-term care insurance isn’t a viable option.

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Agent looking to expand your portfolio with LTC alternatives should consider contracting with carriers that offer hybrid products. It also helps to work with financial planners to create a comprehensive care funding strategy for your clients.