The “Big, Beautiful Bill” is going to the President for his signature to become law. This article updates our previous Medicare article by outlining the law, which KFF also discusses in depth.
Limiting Medicare Coverage of Certain Individuals
- Medicare is available to U.S. citizens, lawful permanent residents, certain immigrants from Cuba and Haiti, and individuals in the U.S. under the Compacts of Free Association.
- Individuals in the U.S. with Temporary Protected Status, refugee status, or asylee status are not eligible for Medicare.
- The individuals listed in the second bullet who are currently receiving Medicare benefits will lose their Medicare eligibility no later than 18 months after enactment of the legislation.
Opportunity for Agents
Inform any clients meeting the criteria listed above that they will lose Medicare eligibility in about 18 months from the enactment of this bill, letting them know they don’t need to act for now.
Eligibility and Enrollment Final Rule
Implementing the September 2023 CMS Final Rule on Enrollment of Medicare Beneficiaries in Medicare Savings Plans (MSPs) is delayed until October 1, 2034, except for provisions already in effect, including auto-enrollment of specific SSI recipients into the Qualified Medicare Beneficiary (QMB) group.
Opportunity for Agents
Find a reliable tool, such as the Benefits Checkup from the National Council on Aging (NCOA), that you can use to help low-income Medicare beneficiaries without MSPs or the low-income subsidy apply for these programs if they qualify.
Physician Fee Schedule Conversion Factor Adjustment (effective January 1, 2026)
Provides a temporary one-year increase of 2.5% to the Physician Fee Schedule conversion factor for all services furnished between January 1, 2026, and January 1, 2027
Opportunity for Agents
- Increase outreach to primary care physicians in your markets by identifying opportunities to partner with them on community outreach programs and patient education on Medicare.
- Emphasize your positive experience and thoughts about Medicare, letting physicians know that your partnership is positive and has the potential to benefit both of your needs.
Orphan drugs
- This amendment expands the orphan drug exclusion to include drugs designated for one or more rare diseases or conditions that have an approved indication or indications for those diseases or conditions.
- The period drugs on the market with only one or more orphan indications do not count toward the 7- or 11-year time frame for determining selection eligibility.
- This applies to the 2026 drug price selection for negotiated prices that take effect on or after January 1, 2028.
Opportunity for Agents
- Learn your clients’ high-priced drugs now to prepare.
- Lower prices for higher-cost drugs can be negotiated in 3 years (2028).
Nursing Home Staffing Final Rule (effective upon enactment)
Prohibits the HHS Secretary from implementing, administering, or enforcing the minimum staffing levels required by the final rule until October 1, 2034.
Opportunity for Agents
Long-term care and skilled nursing facility costs covered by Medicare may decrease, resulting in lower cost shares for your Medicare clients to pay.
Scott Meeks, our Medicare product specialist, is available to assist you with any questions about these changes and the opportunities they present for Medicare agents. Scott can also refer you to our Supplement product specialist, who will answer any questions specific to supplemental products.
Contact Agility Producer Support at (866) 590-9771 or email support@enrollinsurance.com to schedule a call or meeting with Scott or to answer any other insurance questions. Agility can also add you to our free, weekly email list for tips and vital information!
