Medicare Advantage, from the ground up.
You already know insurance. This course teaches you Medicare: how the program is built, when people can actually enroll, and the CMS rules that keep your contracts safe. Thirteen chapters, about two hours, at your pace.
Chapter 1
The Medicare 101 index
Every fact in this course on one page. The 2026 numbers, all the election periods, the compliance rules. Built to search during an appointment.
The modules
Work them in order. Each chapter ends with the line that keeps you compliant.
Chapter complete
Where you stand
Progress is saved to your account. Finish the course before you take your first Medicare appointment.
Run the course
Control what agents can see, add accounts, and watch the team's progress.
Module visibility
A hidden module disappears from agents' Home, Course, and Progress views until you show it again. You always see everything.
Add an agent
Account
Modules for this agent
A choice here beats the course wide setting. Course setting hands the module back to the Module visibility card.
Medicare Advantage 101
Everything the course covers, on one page, in the order you would look it up. All dollar figures are the published CMS amounts for calendar year 2026.
The architecture of Medicare
Everything below is the course in lookup order. Medicare is a federal program with a fixed structure, and Medicare Advantage is one of two ways a person can receive it.
What Medicare actually is
Medicare is federal health insurance run by the Centers for Medicare and Medicaid Services, known as CMS. It is not a state program and it is not means tested. If a person qualifies, they qualify regardless of income or health.
That last point changes how you sell. In Medicare Advantage there is no underwriting. A member with stage four cancer and a member who runs marathons pay the same premium for the same plan in the same county. Your job is fit, not qualification.
The four parts
People say Part C and Medicare Advantage interchangeably. They are the same thing.
Inpatient care
Hospital stays, skilled nursing after a qualifying stay, hospice, and some home health. Premium free for most people because they or a spouse paid Medicare taxes for at least 40 quarters, which is ten years of work.
Outpatient care
Doctor visits, labs, imaging, durable medical equipment, preventive care, and drugs given in a clinical setting such as infusions. Part B always carries a monthly premium, and it is usually taken straight out of the Social Security check.
Parts A and B together are called Original Medicare. That is the government paying providers directly.
Medicare Advantage
A private plan, approved by CMS, that takes over administering the member's Part A and Part B benefits. The member stays in Medicare. They have chosen to receive it through a carrier instead of directly from the government.
By law an MA plan must cover everything Original Medicare covers. Most also bundle Part D and add benefits Original Medicare never had, such as dental, vision, hearing, fitness, and over the counter allowances.
Prescription drugs
Retail prescription coverage, delivered only by private plans. It comes either bundled inside an MA plan, which is an MAPD, or as a standalone drug plan, a PDP, sitting alongside Original Medicare.
There is no Part E, and there is no such thing as a Medicare Advantage plan that replaces Medicare. If a prospect tells you an agent said they would be getting off Medicare, that agent either misspoke or misled them. Correct it gently and move on.
Two ways to take your Medicare
Every Medicare beneficiary in the country sits on one of two paths. Understanding the tradeoff is the core of the appointment.
| Original Medicare (A and B) | Medicare Advantage (Part C) | |
|---|---|---|
| Provider access | Any provider nationwide who accepts Medicare, which is most of them. No network. | Plan network, usually county based. Out of network costs more or is not covered. |
| Out of pocket cap | None. Unlimited exposure without a supplement. | Required annual cap on Part A and B services. The biggest structural advantage. |
| Drug coverage | Must add a standalone PDP separately. | Usually built in. That is an MAPD. |
| Extra benefits | None. Medicare does not cover routine dental, vision, or hearing. | Commonly included, and the main reason members switch. |
| Referrals and approvals | No referrals. Little prior authorization. | HMOs often require referrals. Prior authorization is common. |
| Monthly premium | Part B premium, plus a PDP, plus a supplement if they buy one. | Part B premium, plus the plan premium, which is frequently zero dollars. |
| Predictability | Stable year to year. | Benefits, networks, and formularies can change every January. |
Neither path is universally better, and telling a member otherwise is both bad advice and a compliance problem. A snowbird who spends five months out of state is a poor HMO candidate. A member on a fixed income with no dental coverage and four maintenance drugs may be very well served by an MAPD.
How MA plans get paid, and why it shapes the product
CMS pays the carrier a fixed amount per member per month to take on that member's full Part A and B risk. The payment is risk adjusted, so the plan receives more for a member with documented chronic conditions and less for a healthy one.
- Zero dollar premiums are real. The plan is already funded by CMS, so it can offer a zero premium and still operate. Members are suspicious of this. Explain the funding, not the giveaway.
- Plans push annual wellness visits and in home assessments. Accurate diagnosis coding drives their payment. This is legitimate, and it is also why members get so many calls.
Plan types and networks
- HMO. In network only, except for emergencies, urgent care, and dialysis. Usually requires a primary care physician and referrals. Lowest cost, tightest control.
- HMO POS. An HMO with a limited point of service allowance for certain out of network services at a higher cost share.
- PPO. Covers out of network care at a higher cost share, so it carries both an in network cap and a higher combined cap. Better for travelers.
- PFFS. Private fee for service. Rare now. The provider decides at each visit whether to accept the plan's terms.
- SNP. Special Needs Plans, restricted to a defined population: dual eligibles, people in an institution, or people with a qualifying chronic condition. Its own training topic.
Verify the member's doctors in the plan directory and their drugs against the formulary during the appointment, not after. A network or formulary miss is the number one cause of a member disenrolling and of a rapid disenrollment chargeback against your commission.
What it costs in 2026
These are the federal numbers for calendar year 2026. Know the Part B premium and deductible cold. You will be asked in nearly every appointment.
| Item | 2026 amount | Notes |
|---|---|---|
| Part B standard premium | $202.90 / mo | Up from $185.00. Higher earners pay an IRMAA surcharge on top. |
| Part B annual deductible | $283 | Up from $257. |
| Part A hospital deductible | $1,736 | Per benefit period, not per year. A member can pay it more than once in a year. |
| Part A coinsurance, days 61 to 90 | $434 / day | Lifetime reserve days are $868 per day. |
| Skilled nursing, days 21 to 100 | $217 / day | Days 1 to 20 are covered in full after a qualifying stay. |
| Part A premium if not premium free | $565 / mo | For people with fewer than 30 quarters of coverage. |
| Part D maximum deductible | $615 | Plans may set a lower deductible or none at all. |
| Part D out of pocket cap | $2,100 | Hard annual cap on covered Part D drugs. Up from $2,000. |
| MA out of pocket max, in network | $9,250 | CMS ceiling. Most plans set theirs well below this. |
| MA out of pocket max, combined | $13,900 | PPO plans, in and out of network combined. |
| IRMAA first tier begins above | $109,000 | Single filer, double for joint. Based on the tax return from two years back, so 2026 uses the 2024 return. |
Two clarifications that trip up new agents. First, the MA out of pocket maximum counts only Part A and Part B services. Drug costs run on the separate Part D cap of $2,100. Second, joining an MA plan does not excuse anyone from the Part B premium. They pay the Part B premium plus whatever the plan charges. Some plans return part of the Part B premium, which is called a giveback, but the obligation never disappears.
Star ratings and the ANOC
CMS rates every MA contract from one to five stars on quality and member experience. Ratings drive bonus payments to the carrier, so plan richness and star performance tend to move together. A five star plan also carries its own special enrollment period.
Every September, plans must mail members an Annual Notice of Change, the ANOC, spelling out what changes on January 1. Build your AEP around it. A member whose ANOC shows a formulary change or a specialist copay jump is the member who needs a review.
Eligibility and election periods
This is where new agents make their most expensive mistakes. An enrollment submitted without a valid election period gets rejected, and the member can be left uncovered.
Who is eligible
A person qualifies for Medicare through one of three doors:
- Age. Turning 65, with the work history to qualify, or eligibility through a spouse.
- Disability. After 24 months of Social Security Disability Insurance payments. Medicare starts automatically in month 25.
- Diagnosis. ALS qualifies immediately upon SSDI entitlement. End stage renal disease qualifies under its own rules.
To enroll in a Medicare Advantage plan specifically, three things must all be true:
- The person has both Part A and Part B, and keeps paying the Part B premium.
- They permanently reside in the plan service area, usually defined by county.
- A valid election period is open for them right now.
End stage renal disease no longer blocks MA enrollment. That changed in 2021, and experienced agents still get it wrong.
Working past 65 with real employer group coverage is the most common reason to delay Part B without penalty. Do not talk that member into dropping group coverage before you understand what they have. If the employer has fewer than 20 employees, Medicare usually becomes primary, and delaying can hurt them.
The seven month window
The Initial Enrollment Period runs seven months: the three months before the month a person turns 65, their birthday month, and the three months after. The Initial Coverage Election Period, or ICEP, is the parallel window for choosing an MA plan.
Enrolling early is strictly better. A member who waits until month plus three has a coverage gap they did not need. Build your birthday outreach around the month minus three mark.
Every election period you will use
Initial Enrollment and Initial Coverage Election
The window around turning 65 or otherwise becoming entitled. Used once. This is your new to Medicare business.
Annual Election Period
The big one. Anyone can join, switch, or drop an MA or Part D plan. Coverage begins January 1. If a member submits more than one application, the last one on record wins.
Medicare Advantage Open Enrollment
Only for people already enrolled in an MA plan on January 1. They get one change: switch to a different MA plan, or drop to Original Medicare and add a PDP. It cannot be used to move from Original Medicare into an MA plan, and it cannot be used to switch standalone PDPs.
New to Medicare open enrollment
Someone who joins an MA plan during their ICEP gets one additional change through the last day of their third month of entitlement.
General Enrollment Period
For people who missed their IEP and need to pick up Part B. Coverage starts the first of the month after they enroll. A late enrollment penalty usually applies.
Special Enrollment Periods
Triggered by a qualifying life event. The common ones: a permanent move out of the service area, involuntary loss of employer or union coverage, the plan leaving the county or losing its CMS contract, entering or leaving an institution, gaining or losing Medicaid or Extra Help, a qualifying chronic condition, and the five star SEP that lets someone move into a five star plan once between December 8 and November 30.
Every SEP has its own eligibility test and its own window, and several were narrowed in recent rule cycles. Never assume one applies. Confirm the specific SEP code and its current rules with the carrier before you submit, and document what qualified the member. Using an SEP a member does not have is the fastest way to lose an appointment.
Late enrollment penalties
Penalties are permanent, and members blame the agent who did not warn them.
- Part B. Ten percent added to the premium for each full twelve month period the person could have had Part B and did not. It lasts as long as they have Part B.
- Part D. One percent of the national base beneficiary premium for each full month without creditable drug coverage, added permanently. CMS resets the base amount every year, so the penalty drifts upward over time.
Creditable coverage means drug coverage at least as good as standard Part D. Employer plans and VA coverage usually qualify, and the plan must tell the member in writing each year. Ask for that letter and keep a copy.
Marketing and compliance
Medicare Advantage is one of the most heavily regulated sales environments in insurance. These are not carrier preferences. They are federal regulation, and violations reach the agent, the agency, and the carrier contract.
You are a TPMO
CMS defines a Third Party Marketing Organization as any entity compensated to perform lead generation, marketing, sales, or enrollment for MA and Part D plans. Independent agents and agencies are TPMOs. Every rule in this section applies to you personally, not only to the carrier.
Before you market or sell any MA or Part D product you must, every year: hold an active state health license, complete AHIP or an equivalent certification, complete each carrier's product certification, and be appointed by that carrier. No exceptions and no grace periods.
Scope of Appointment
A Scope of Appointment, or SOA, is the member's written or recorded permission for you to discuss specific product types. It is the foundational document of a compliant appointment.
- It must be obtained before any personal marketing appointment begins.
- It is limited to the product types listed on it. If the SOA says Medicare Advantage and the member asks about a hospital indemnity plan, you need a new SOA before discussing it.
- It is valid for twelve months from the date of signature.
- It must be retained and produced on request.
Right now, and through September 30, 2026, the SOA must be obtained at least 48 hours before the personal marketing appointment, with narrow exceptions for walk ins and for appointments in the last four days of a valid election period.
Under the CY2027 final rule, that 48 hour waiting period is eliminated effective October 1, 2026. From that date you may capture the SOA and market in the same call or the same meeting. The SOA itself is still required. Only the waiting period goes away.
Know both versions this year. You work under the 48 hour rule for the rest of the summer, and under the new rule the moment PY2027 marketing opens on October 1.
Separately from the SOA, you need permission to contact before reaching out to a prospect at all. The member must have asked to be contacted, the request has to specify the method, and it does not last forever. A lead form filled out nine months ago is not live consent.
Recording and the TPMO disclaimer
CMS requires TPMOs to record the entire chain of enrollment: every call and every web based meeting where MA or Part D benefits, costs, or enrollment are discussed, from the first hello through the completed application. Not just the enrollment call. All of it.
Retention is currently ten years. Under the CY2027 rule this shortens to six years, with full audio required for the first three and audio or transcript acceptable for years four through six.
You must also read the TPMO disclaimer, the standard language stating that you do not offer every plan available in the area and telling the member how to reach Medicare directly for a complete list. Today it must be delivered within the first sixty seconds of a call. Under the CY2027 rule the trigger moves to before you discuss plan benefits. If you represent every plan in a service area, a narrower version applies. Confirm which one MIG uses.
Educational events vs sales events
| Educational event | Marketing or sales event | |
|---|---|---|
| Purpose | Teach Medicare generally. | Steer toward a specific plan or carrier. |
| Discuss specific plan benefits | No. | Yes. |
| Collect an SOA or application | No. | Yes. |
| Distribute plan materials | No. Business cards on a table are fine. | Yes. |
| Set individual appointments | No. | Yes. |
| Provide meals | Light snacks only. | No meals, ever. |
Hard prohibitions
These get agents terminated. There is no gray area in any of them.
- No unsolicited contact. No door knocking, no cold calls, no unsolicited texts or emails, no approaching people in common areas of a building. Permission to contact comes first.
- No meals at sales events. Snacks are fine. A meal is a prohibited inducement.
- No misleading use of the Medicare name, logo, or card image, and nothing suggesting you are calling from Medicare, Social Security, or a government agency.
- No unsubstantiated superlatives. The best plan, the highest rated plan, and the only plan that covers this all require documented proof.
- No cross selling non health products during a Medicare sales appointment. Annuities and life insurance need a separate appointment.
- No collecting applications or SOAs at an educational event.
- No enrollment from someone without a valid election period, and no completing an application on a member's behalf without them present and participating.
CMS revises MA marketing regulation every cycle. This page reflects the rules in effect as of August 2026 plus the changes landing October 1, 2026. Treat it as training, not as your compliance manual. Before every AEP, re run this section against the current CMS final rule and each carrier agent guide, which are sometimes stricter than CMS requires.
Eight things to never get wrong
- Medicare Advantage is Medicare. The member never leaves the program.
- The member keeps paying the Part B premium, $202.90 a month in 2026, no matter which plan they choose.
- An MA plan must cover everything Original Medicare covers, and must cap annual out of pocket spending on Part A and B services.
- No enrollment happens without a valid election period. Identify it before you take an application, not after.
- The MA OEP from January to March is only for people already in an MA plan, and it allows exactly one change.
- Get the SOA before the appointment, keep it inside the product types listed, and retain it.
- Record every call in the chain of enrollment, start to finish.
- Check doctors and drugs in the appointment. A network or formulary miss undoes the sale and the commission.
Prepared for MIG agent training, August 2026. All dollar figures are the published CMS amounts for calendar year 2026 and change annually. This course is carrier neutral and does not describe any specific plan benefits. It is training material, not compliance advice or legal advice. Verify all marketing and enrollment rules against the current CMS final rule and each carrier agent guide before every selling season.
Protecting your tomorrows, today.