Medicare Advantage (Part C)
Replaces Original Medicare. Bundled coverage through private insurers — often $0 premium. Best for healthy clients who want low cost.
Key fact: MA replaces Original Medicare — the client leaves traditional Medicare and joins a private plan approved by CMS.
📋 How It Works
- Combines Part A (hospital), Part B (medical), and usually Part D (drugs) in one plan
- Offered by private insurers — funded by Medicare paying the insurer a monthly amount per enrollee
- Most plans have $0 premium — client still pays their Part B premium ($174.70/mo in 2024)
- HMO: must use network providers, need referrals for specialists
- PPO: more flexibility, can see out-of-network providers at higher cost
- Has an annual out-of-pocket maximum — Original Medicare does not
- Many plans include extra benefits: dental, vision, hearing, OTC allowance, gym membership
✅ Best For
- Clients who want $0 or low premium coverage
- Healthy clients who rarely use healthcare
- Clients who want extra benefits (dental, vision, OTC)
- Clients who are comfortable with a network of providers
⚠️ Watch Out For
- Clients with chronic conditions or frequent specialist visits — network restrictions can be frustrating
- Clients who travel frequently — HMO networks don't cover out-of-area (emergency only)
- Copays add up for heavy users — may cost more than a Supplement long-term
🎙️ Opening Script
- "Are you turning 65 soon or are you already on Medicare? I want to make sure you're on the right plan for your situation."
- "Most of my Medicare clients are paying $0/month for their health coverage — let me show you what's available in your zip code."
- "With Medicare Advantage, you get everything Original Medicare covers, PLUS dental, vision, and often a quarterly allowance for OTC items — all bundled into one plan."
💬 Key Questions to Ask
- "Do you have any doctors you want to make sure stay in-network?"
- "Do you take any regular prescriptions? I want to make sure those are covered."
- "Do you travel outside the state much? That affects which plan type works best."
- "Are you currently on any employer or retiree coverage that would end when you enroll?"
🛡️ Objection Handlers
- "I already have Medicare" → "Original Medicare alone has no out-of-pocket maximum — if you're hospitalized, costs can pile up fast. An Advantage plan caps that and adds extra benefits."
- "I don't want to change my doctor" → "Let's check — I can look up your doctor in the network right now on SunFire. Most major providers accept multiple plans."
- "I heard Advantage plans are bad" → "That depends on the plan and the client. For healthy clients who want low premiums and extra benefits, they're often the best choice. Let me walk you through the difference."
This is the most common Medicare question you'll get. Know this comparison cold.
📊 Medicare Advantage vs Medicare Supplement
- MA Premium: Usually $0/month (client pays Part B ~$174.70/mo)
- Supplement Premium: $100–$350+/month depending on plan and age
- MA Networks: HMO/PPO — limited to network providers
- Supplement Networks: Any provider that accepts Medicare — nationwide
- MA Out-of-Pocket: Has an annual maximum ($3,000–$8,000 depending on plan)
- Supplement Out-of-Pocket: Plans F and G cover nearly all costs — very predictable
- MA Extra Benefits: Dental, vision, hearing, OTC, gym — included in most plans
- Supplement Extra Benefits: None — covers medical costs only
- Best MA Client: Healthy, budget-conscious, comfortable with network
- Best Supplement Client: Has chronic conditions, travels, wants predictable costs
📅 Enrollment Periods
- Initial Enrollment Period (IEP): 7-month window — 3 months before, the month of, and 3 months after turning 65
- Annual Enrollment Period (AEP): Oct 15 – Dec 7 every year — change plans, effective Jan 1
- Open Enrollment Period (OEP): Jan 1 – Mar 31 — switch MA plans or return to Original Medicare
- Special Enrollment Period (SEP): Triggered by qualifying events — losing employer coverage, moving out of plan area, dual eligibility changes
⚠️ Critical Enrollment Rules
- Client MUST have Medicare Part A and Part B before enrolling in MA
- Enrolling late in Part B triggers a permanent 10% premium penalty per year late
- If client has employer coverage, they may delay Part B without penalty — verify with employer HR first
- DSNP (Dual Special Needs Plans) require both Medicare AND Medicaid — verify eligibility before quoting
Medicare Supplement (Medigap)
Works alongside Original Medicare. Covers most or all out-of-pocket costs. Best for clients who want predictability and no network restrictions.
Supplement plans are standardized by CMS — a Plan G from Carrier A covers the exact same things as Plan G from Carrier B. The only difference is price and customer service.
📋 How It Works
- Client keeps Original Medicare (Part A + B) as primary — Supplement pays after Medicare pays
- No networks — client can see ANY provider that accepts Medicare, anywhere in the US
- Monthly premium varies by plan type, age, gender, tobacco use, and zip code
- Renewable for life as long as premiums are paid — carrier cannot cancel for health reasons
- Does NOT include Part D (drugs) — client needs a separate PDP
✅ Best For
- Clients with chronic conditions or frequent healthcare use
- Clients who travel frequently or have doctors in multiple states
- Clients who want to know exactly what they'll pay each month
- Higher-income clients who can afford the premium
📊 Most Common Plan Types
- Plan G (most popular for new enrollees): Covers everything except the Part B deductible (~$240/yr). Best balance of coverage and price.
- Plan N: Covers most costs but client pays up to $20 office visit copay and $50 ER copay. Lower premium than G.
- Plan F (no longer available to new enrollees after 2020): Covered everything including Part B deductible. Existing enrollees can keep it.
- High-Deductible Plan G: Lower premium, client pays first ~$2,800 out of pocket before Supplement kicks in. Good for very healthy clients.
💡 Plan G vs Plan N — Quick Guide
- Plan G: Higher premium, zero copays after Part B deductible paid. Best for frequent doctor visits.
- Plan N: Lower premium, small copays at office/ER. Best for healthy clients who want lower monthly cost.
- Rule of thumb: if client visits the doctor more than 6–8 times/year, Plan G usually wins on total cost.
🎙️ Opening Script
- "Original Medicare pays about 80% of your costs — a Supplement covers that other 20% so you're never hit with a surprise bill."
- "With a Supplement, you can see any doctor in the country that accepts Medicare — no networks, no referrals, no surprises."
- "The premium is higher than Advantage, but for clients who use their insurance, it almost always pays for itself."
🛡️ Objection Handlers
- "It's too expensive" → "Let's compare the total annual cost — premium vs. what you'd pay in copays and deductibles on an Advantage plan. For someone who uses their insurance, the Supplement usually comes out ahead."
- "My friend has Advantage and loves it" → "That's great for your friend — it's a fantastic product for the right person. Let me ask you a few questions to see which one fits YOUR situation better."
📋 Underwriting Rules
- Open Enrollment (guaranteed issue): First 6 months after enrolling in Part B at age 65 — no health questions, cannot be denied
- After Open Enrollment: Carrier can underwrite — health questions required, can be declined or rated up
- Key conditions that cause declines: Heart disease, COPD, diabetes with complications, recent cancer, kidney disease
- Guaranteed Issue (GI) events: Losing employer coverage, MA plan leaving area, moving out of plan area — client gets GI rights regardless of health
- Always quote Supplement during the client's IEP when possible — guaranteed issue = no health risk
Part D — Prescription Drug Plans
Standalone prescription drug coverage for clients on Original Medicare + Supplement. Always needed — late enrollment penalty is permanent.
Clients on Medicare Advantage usually have Part D built in. Part D standalone is only for clients on Original Medicare + Supplement.
📋 How It Works
- Private plans approved by Medicare — each has a formulary (list of covered drugs)
- Premiums vary by plan, zip code, and drugs needed — typically $10–$80/month
- Four coverage stages: Deductible → Initial Coverage → Coverage Gap (donut hole) → Catastrophic
- Always compare plans based on the client's specific drug list — formularies vary widely
- Use SunFire or MyHealthPlan to compare Part D plans by drug list
⚠️ Late Enrollment Penalty
- If client goes more than 63 days without creditable drug coverage, they get a permanent penalty
- Penalty = 1% of the national base premium for every month without coverage — adds up fast
- Penalty is added to their Part D premium FOR LIFE — never goes away
- Employer coverage, TRICARE, VA, and some other plans count as creditable — always ask
- Always enroll clients in Part D even if they take no medications — it's cheap insurance against the penalty
💡 Agent Tips
- Always get the client's full drug list before quoting — name, dosage, frequency
- Run Part D comparison on SunFire or MyHealthPlan every AEP — formularies change annually
- "Even if you don't take any medications, enroll in a low-cost Part D plan to avoid the lifetime penalty."
- Check preferred pharmacy — some plans have $0 copays at specific pharmacies (Walgreens, CVS, etc.)
- AEP (Oct 15 – Dec 7) is your annual touchpoint — review every client's Part D every year
Enrollment Periods & Key Rules
Know these cold — wrong enrollment timing costs clients money and locks them out of coverage.
📅 All Enrollment Periods
- IEP (Initial Enrollment Period): 7 months around 65th birthday — 3 before, birthday month, 3 after. Best time to enroll.
- AEP (Annual Enrollment Period): Oct 15 – Dec 7. Change MA or Part D plans. Effective Jan 1.
- OEP (Open Enrollment Period): Jan 1 – Mar 31. Switch MA plans or go back to Original Medicare. One change only.
- SEP (Special Enrollment Period): Triggered by qualifying events — losing employer coverage, moving, dual eligibility changes, plan termination.
- GEP (General Enrollment Period): Jan 1 – Mar 31 for Part A/B if missed IEP. Effective July 1. Penalty may apply.
🎂 Turning 65 — Step by Step
- Step 1: Confirm Part A and Part B enrollment — client should receive Medicare card about 3 months before birthday
- Step 2: Determine if client has employer/retiree coverage that would end — may affect timing
- Step 3: Decide: Medicare Advantage OR Original Medicare + Supplement + Part D
- Step 4: Quote on SunFire — compare MA plans by zip, drugs, doctors
- Step 5: Enroll before IEP ends to avoid gaps in coverage
- If client is still working and has employer coverage: they MAY delay Part B without penalty — confirm with employer HR before advising
⚡ Common SEP Triggers
- Losing employer or union coverage
- Moving out of plan service area
- MA plan leaving the area or losing contract
- Becoming newly eligible for Medicaid (DSNP opportunity)
- Leaving incarceration
- Returning from living abroad
- SEPs are typically 2 months from the triggering event — act quickly when a client calls about a life change
Special Needs Plans (SNP)
D-SNPs and C-SNPs offer richer benefits than standard MA plans. Knowing how to quickly identify candidates is one of the highest-value skills you can have.
🔵 D-SNP — Dual Special Needs Plan
For clients who have both Medicare AND Medicaid. Eligibility is income-based — they must qualify for Medicaid in their state.
Key benefits: $0 or very low premiums, extra dental/vision/OTC/food benefits, care coordination, often covers Medicaid cost-sharing
🟢 C-SNP — Chronic Special Needs Plan
For clients with specific chronic conditions (diabetes, CHF, COPD, CKD, etc.). No income requirement — condition alone qualifies them.
Why they're easier: You don't need to verify Medicaid. If they have the condition, they're likely eligible — just confirm the plan covers their condition.
🔵 How to Quickly Identify a D-SNP Candidate
⚠️ D-SNP requires active Medicaid. Always verify before quoting — if they don't have Medicaid, they cannot enroll in a D-SNP.
📋 Intake Questions — Ask These First:
"Do you currently have Medicaid or Medicaid health insurance?"
If yes → D-SNP candidate. Ask which state Medicaid plan.
"Do you receive any help paying for your Medicare premiums or copays from the state?"
This catches LIS/Extra Help recipients who may also have full Medicaid.
"What is your household income roughly per month?"
If at or near Medicaid income limits, they may qualify but not know it. 2025 individual limit is typically ~$1,255/mo (138% FPL) but varies by state.
"Do you have a Medicare Savings Program card or a QMB/SLMB/QI card?"
QMB = Qualified Medicare Beneficiary. Having this almost always means D-SNP eligible.
💡 Quick shortcut: If they're on Medicare AND their income is under ~$1,500/month (individual), always ask about Medicaid — many people have it and don't realize it counts.
🟢 How to Identify a C-SNP Candidate
✅ C-SNPs are condition-based, not income-based — making them easier to identify. No Medicaid verification needed. If the client has one of the qualifying conditions, they're likely eligible.
Common C-SNP Qualifying Conditions:
🩺 Diabetes (Type 1 or 2)
❤️ Congestive Heart Failure (CHF)
🫁 COPD / Chronic Lung Disease
🫘 Chronic Kidney Disease (CKD)
🧠 Cardiovascular Disorders
🩸 HIV / AIDS
🦴 Autoimmune Disorders
🧪 End-Stage Renal Disease
📋 Intake Questions for C-SNP:
"Do you have any ongoing chronic conditions your doctor is managing — like diabetes, heart failure, COPD, or kidney disease?"
If yes → check for C-SNP availability in their zip code on SunFire.
"Are you currently seeing a specialist regularly for any condition?"
Specialists = chronic condition. Opens the door to C-SNP conversation.
📊 D-SNP vs C-SNP Quick Reference
| Factor | D-SNP | C-SNP |
|---|---|---|
| Qualifier | Medicaid (income-based) | Chronic condition (no income test) |
| Easier to find? | Harder — must verify Medicaid | ✅ Easier — condition is the qualifier |
| Income required? | Yes — must meet Medicaid limits | No |
| Key benefit | $0 premium, OTC/food allowance, care coordination | Condition-specific care coordination & benefits |
| Verify with | State Medicaid card or MBI lookup | Doctor diagnosis / medical records |
💡 Pro Tip — Always Ask Both
A client can qualify for both a D-SNP AND have a chronic condition — but a single plan can only be one type. If they're dual-eligible, the D-SNP usually wins because the benefits are more comprehensive. Always check D-SNP first if income/Medicaid is in play, then consider C-SNP for clients who earn too much for Medicaid but have qualifying conditions.
Quoting Tools
SunFire and MyHealthPlan are your primary Medicare quoting platforms. Know both.
🔥 SunFire
- Primary quoting and enrollment platform for Medicare Advantage (110+ carriers)
- Enter client's zip code, birth date, and drug list to see all available MA plans ranked by total cost
- Check doctor network in-tool — search by provider name to confirm they're in-network
- Can enroll clients directly in SunFire — electronic scope of appointment required first
- Use during AEP to review all existing clients and flag anyone who should switch
SunFire
Medicare Advantage quoting & enrollment — 110+ carriers
sunfireinc.com ↗
sunfireinc.com ↗
💻 MyHealthPlan
- Side-by-side comparison tool for MA, Medicare Supplement, and Part D plans
- Great for showing clients a clear visual comparison during the sales call
- Useful for Part D drug plan comparison — enter drug list and find lowest total cost plan
- Use alongside SunFire when clients want a simple visual to review
MyHealthPlan
MA, Supplement & Part D comparison tool
myhealthplan.net ↗
myhealthplan.net ↗
📋 Standard Medicare Quoting Workflow
- Step 1: Get client's zip code, date of birth, Medicare number (Part A/B dates)
- Step 2: Get full drug list — name, dosage, frequency, preferred pharmacy
- Step 3: Get list of current doctors they want to keep
- Step 4: Open SunFire — run MA quote by zip, confirm doctors in-network, check drug coverage
- Step 5: If Supplement may be better fit, run Supplement + Part D comparison on MyHealthPlan
- Step 6: Present 2–3 options — explain trade-offs clearly
- Step 7: Complete Scope of Appointment before discussing plans (required)
- Step 8: Enroll in SunFire — confirm effective date and confirmation number
- Step 9: Log everything in The Atlas — note plan enrolled, effective date, drug list on file
Medicare Q&A
Real agent questions with detailed answers. Search by keyword or scroll through all topics.
Can people under 65 on Medicare through disability only get Medicare Advantage until they turn 65?
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What are the timeframes when someone over 65 loses employer coverage or retires?
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What are the important differences between Medigap plans?
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How do OTC cards work on Medicare Advantage? Are food cards only for dual Medicare/Medicaid members?
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Are all Part D drug plans the same? How do I shop for a PDP to pair with Medigap?
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What's the process for someone who delays Social Security but still wants Medicare at 65?
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