For agent use only. This information is subject to change.
“Trying to do this by yourself is going to be an impossibility. We need each other. We’re all better together. Together, we’re better than we are apart.”
Ronnie James
Regional Sales Director, Tidewater Management Group
This quote perfectly explains why we host Tidewater Office Hours. The insurance industry is constantly changing, and no agent should feel like they’re navigating it alone. These monthly calls are designed to give you real-time industry insights, growth tips, and strategies to guide you towards success – backed by a team you can trust.
During our February Office Hours, Ronnie James and Kristi Bell covered updates impacting Medicare Advantage and Supplement, Social Security, compliance, and growth opportunities for this year and beyond.
Whether you joined us live or couldn’t make it, this recap has everything you need to catch up and guide your success this year.
Main Points Covered
The main topics covered during February’s call include:
- Social Security: Preparing Clients for What’s Ahead
- Medicare Advantage Updates
- Prior Authorizations
- Helping Clients Navigate Hospitalization & Appeals
- Medicare Supplement Highlights
- Additional Product News
- GLP-1 Medications: What’s Coming
- Compliance & Complaint Corner with Kristi Bell
Social Security: Preparing Clients for What’s Ahead
Social security is on track to deplete its trust fund by 2032, making reform almost unavoidable within the next seven years.
What this means for agents:
- Fewer workers are supporting people receiving benefits, creating sustainability issues and a need for reform
- If no action is taken, benefits will be cut
Social security was never designed to be a sole retirement income source. This is your opportunity to educate younger clients and explain why savings, annuities, and other coverage options are essential.
Medicare Advantage Updates
Proposed Pay Increase
The biggest story in January centered around Medicare Advantage and growing pressures on carriers, despite a 5% pay raise last year. Even with the increase, the cost of care remains very high, forcing carriers to make tough decisions. UnitedHealthcare used 2025 as a rest year, cutting back benefits, exiting markets, narrowing networks, and cutting marketing. For 2027, a propsed 0.09% pay increase for Medicare Advantage was announced. While this is not a final decision, its announcement led to the largest sell-off the insurance industry has ever seen. Stock prices dropped among carriers, including:
- UnitedHealthcare down nearly 20%
- Humana down 20%
- Aetna dropped approximatley 14%
- Elevance, Centene, and Molina declined between 5% to 13%
In total, the industry saw an estimated $80 billion loss in market capitalization. While there was a significant reaction, it’s important to remember this is only a proposed increase.
While waiting for a final decision on the pay increase, Ronnie reminded us that:
- Historically, insurance stocks tend to bounce, so agents are encouraged to invest in them.
- Most carriers will wait to make decisions about 2027 benefits and packages until a final amount is annouced.
Risk Adjustment, CMS Oversight, and Compliance Pressure
CMS and the Department of Health and Human Services (HHS) are increasing oversight around:
- Health Risk Assessments (HRAs) without supporting medical diagnoses
- Risk codes not tied to documented patient treatment
CMS is proposing to exclude certain risk scores from diagnoses and end payment for audio-only visits, changes that could save Medicare while costing the Medicare Advantage industry about $22.3 billion. As a result, carriers are tightening their standards and prioritizing quality over quantity – not only in membership growth but in the agents they choose to work with – making compliance more critical than ever.
Hospital-Owned Medicare Advantage Plans
We are seeing greater stability in markets with hospital-owned MA plans.
Why these plans stand out:
- Trusted, familiar hosptaiol systems
- Fewer network disruptions mid-year
- Lower denial rates for care within their own systems
Examples include Viva and HealthTeam Advantage – and it would not come as a surprise if more of these emerge.
These plans may not be the cheapest, but peace of mind and predictability sell.
Prior Authorizations
It is very important to make sure clients – especially those turning 65 – understand how prior authorizations work, as Medicare Advantage carriers made 53 million determinations in 2024 alone.
In January, Medicare also launched a new system called the WISeR model in six states, though implication has been challenging due to existing prior authorization processes. As Medicare continues to address waste, fraud, and abuse in the system, we are likely to see prior authorization requirements expand to other services.
Helping Clients Navigate Hospitalization & Appeals
Agents should have conversations with clients about hospitalization. Hospitals are often penalized by Medicare for high readmission rates and are looking to prevent patients from readmission. While hospitals recognize that post-acute care can reduce readmissions, Medicare Advantage plans often don’t view this care as necessary and may deny the claim. Helping clients understand and navigate the appeals process is critical because it clarifies the necessity of care and helps control costs for all parties involved.
Medicare Supplement Highlights
South Carolina Opportunity
From April 1 to August 15th, eligible SC residents enrolled in any Medicare Supplement plan with any carrier qualify for a guaranteed issue enrollment period, allowing them to switch to Blue Cross Blue Shield of South Carolina Medicare Supplement, without medical underwriting.
Benefits of the plan include:
- No health questions
- 12-month rate guarantee
- Upgrade or downgrade plans without underwriting
Enrollments are available through Connecture in IntegrityCONNECT and it pays commission for the life of the policy.
Birthday Rule Expansion
Six states are looking add birthday rule legislation this year. States where the birthday rule is active experience higher consumer premiums, lower agent commissions, and carriers leaving the market altogether. This was mentioned to say that Medicare Supplement remains valuable – but clients must understand that quality healthcare has a cost.
Additional Product News
Dental Insurance
By 2026, new legislation may require dental plans ot meet an 85% loss ratio in several states. As a result, we could see increased premiums, plans exiting markets, or lower broker compensation. So, sell dental now while the window is open.
Life and Annuities
Life and annuity sales are expected to remain solid throughout 2026. Now is the time to diversify your offerings and bring these products to clients.
New opportunity: We now have a new annuity product with a long-term care rider. There will be a webinar on February 12th at 10:00 AM EST if you are interested in learning more about this product. Register here.
ACA, Short-Term Plans, and Market Shifts
With enhanced ACA subsidies dissolving, many clients have experienced steep premium increases, while some dropped coverage altogether. As a result, Short-term Hospital Indemnity plans are gaining traction (due to their lower premiums) and will continue to do so if things don’t change in the coming years. Ronnie specifically highlighted Manhattan Life’s Affordable Choice Plan as an option worth reviewing.
GLP-1 Medications: What’s Coming
Currently, Medicare only covers GLP-1 drugs for diabetes and sleep apnea. However, in 2024, Medicare spent close to $27.5 billion on these drugs, making them a major budget item. To address costs and access, a temporary Medicare demonstration for GLP-1s is expected to begin in July 2026 in select states for the remainder of the year. This model aims to improve access to medications like Wegovy, Zepbound, and Ozempic at lower prices, with eligible beneficiaries estimated to pay around $50 per month. During this period, Part D plans will not carry the financial risk, and CMS is expected to release more details soon. Looking ahead, more carriers are anticipated to cover GLP-1 medications beginning in 2027.
Compliance & Compliant Corner with Kristi Bell
Kristi emphasized that compliance is a major focus across the industry, with some carriers pulling back from call centers, limiting enrollments, and closely monitoring agent activity.
Key reminder: Marketing materials must include the proper disclaimers. This includes websites, flyers, brochures, etc…
We’re here to help: Before launching any materials, send them to us for review. We also have compliant pre-built templates you can use in our resource hub.
Kristi also highlighted the importance of spending more time with DSNP and SSBCI clients due to recent member complaints.
DSNP clients have seen significant changes over the past two years, including the introduction of medication copays that clients must clearly understand. Agents should also educate clients on how to access their SSBCI benefits (food and utility cards) by completing HRAs and visiting their providers, because filed claims are the most effective way to receive benefits and reduce member complaints.
*You can read more about DSNP changes here.*
Final Thoughts: Your Not in This Alone
The industry is evolving quickly, but agents who stay informed, compliant, and supported by Tidewater Management Group will continue to thrive. Office Hours give you a monthly opportunity to ask questions, gain clarity, and stay ahead of what’s next – but the conversation doesn’t end when the call does. At TMG, discussions are constant and support is always within reach. Remember, we’re better together, and your growth doesn’t have to happen solo.
For agent use only. This information is subject to change.
