Comprehensive New Jersey Medicare Plan Comparison & Commission Schedule
MA/MAPD Plans (NJ): $864.00 Initial & $432.00 Renewal. PDP Plans (Nationwide): $114.00 Initial & $57.00 Renewal.
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Expected Availability: November 2025
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NIPR
Use the National Insurance Producer Registry for license applications and renewals.
Go to NIPR ↗Carrier Portals & Resources 📋
| Carrier | Agent Portal(s) | Provider Search |
|---|---|---|
| Aetna | Find a Doctor ↗ | |
| AmeriHealth | Portal Login ↗ | Find a Doctor ↗ |
| Braven Health | Broker Portal ↗ | Find a Doctor ↗ |
| Clover Health | Broker Portal ↗ | Find a Doctor ↗ |
| Healthspring (Cigna) | Find a Doctor ↗ | |
| Horizon BCBSNJ | Broker Portal ↗ | Find a Doctor ↗ |
| Humana | Agent Portal ↗ | Find a Doctor ↗ |
| Jefferson Health Plans | Agent Portal ↗ | Find a Doctor ↗ |
| Physicians Mutual | Agent Portal ↗ | Find a Dentist ↗ |
| UnitedHealthcare | Jarvis Portal ↗ | Find a Doctor ↗ |
| Wellcare | Workbench ↗ | Find a Doctor ↗ |
| Wellpoint | Broker Portal ↗ | Find a Doctor ↗ |
Official U.S. Government Guide: Medicare & You 2026
This is a summary of the official U.S. government Medicare handbook. It provides a comprehensive overview of benefits, coverage options, and costs for 2026.
What's New & Important for 2026?
- Prescription Drug Cost Cap: If you have Medicare Part D, your annual out-of-pocket costs for covered drugs will be capped at $2,100 in 2026. Once you hit this cap, you will not have a copayment or coinsurance for covered drugs for the rest of the year.
- Drug Price Negotiation: Prices for the first 10 drugs negotiated by Medicare will take effect on January 1, 2026.
- New Covered Services: Medicare now covers Advanced Primary Care Management services, where a provider coordinates your care with 24/7 access to your care team. CT colonography is also now a covered colorectal cancer screening option.
- Go Digital with Medicare: You are encouraged to create a secure Medicare.gov account to manage prescriptions, get notices electronically (eMSNs), and access the handbook digitally.
For more details on Advanced Primary Care, review this official guide from Medicare.
Medicare Advanced Primary Care Guide ↗Your Two Main Coverage Options
You can choose to receive your Medicare benefits in one of two ways:
Original Medicare
- Includes Part A (Hospital Insurance) and Part B (Medical Insurance).
- Allows you to use any doctor or hospital in the U.S. that takes Medicare.
- You can add a separate Part D plan for drug coverage and a Medigap policy for supplemental coverage.
- In most cases, you don't need a referral to see a specialist.
Medicare Advantage (Part C)
- An alternative from private companies that bundles Part A, Part B, and usually Part D.
- Often requires using doctors and hospitals in the plan's network.
- Plans have a yearly limit on what you pay out-of-pocket for covered services.
- Most plans offer extra benefits not covered by Original Medicare, like vision, hearing, and dental.
Download the Official Guide
Download the complete, official "Medicare & You 2026" handbook directly from the U.S. government website.
Download "Medicare & You 2026" PDF ↗PPO to HMO Agent Playbook
The Invisible Barriers: Why Seniors Resist Change
A senior's decision isn't a simple cost analysis; it's an emotional process governed by powerful cognitive biases. Resistance is rarely a logical rejection of an HMO's features. Instead, it's a manifestation of deep-seated needs for comfort, familiarity, and avoiding loss.
Key Insight: The conversation is won by positioning the HMO's value *before* objections occur. You must first address and neutralize the client's powerful, underlying fear of loss before any discussion of gain can be effective.
- Status Quo Bias: The client's current PPO is their baseline. Any change is psychologically framed as a potential loss, triggering resistance. This is amplified by the "frustration echo"—the negative memory of their initial, overwhelming Medicare enrollment. Clinging to their current plan is a defense mechanism to avoid that stress again.
- Loss Aversion: The psychological pain of a loss is about twice as powerful as the pleasure of an equivalent gain. The fear of losing a doctor or "freedom" feels immediate and threatening, while potential gains like lower copays feel abstract and distant.
- Decision Fatigue & Low Self-Efficacy: Making thousands of decisions daily depletes mental energy, leading to procrastination and avoidance. While seniors want to make their own choices, a majority feel unqualified and fear making the wrong one. Your role is not to give them more data, but to give them more **confidence**.
Phase 1: Empathetic Discovery (Asking the Right Questions)
The goal is to uncover the client's specific pain points and anxieties with their current PPO. Use open-ended questions to encourage storytelling and diagnose their primary psychological drivers.
Questions to Uncover Care Coordination Pain:
"Tell me about a time you had to see a specialist. How did you handle coordinating that appointment and sharing information with your primary doctor?"
"Have you ever felt like you were the one responsible for making sure all your different doctors were on the same page about your health?"
Questions to Uncover Financial Anxiety:
"When you think about healthcare costs for the future, what worries you the most? Is it the predictable monthly premium, or is it the 'what if' costs of a major health event?"
"Have you or any of your friends ever received a medical bill that was much higher than you expected, even though you thought you were covered?"
Questions to Uncover Decision Fatigue:
"A lot of my clients tell me that just trying to keep track of which doctors are in-network and what the rules are can be a full-time job. How has that experience been for you?"
Phase 2: Strategic Reframing (Connecting Pain to Solution)
Connect the client's articulated challenges directly to the reframed HMO solutions. This is a tailored presentation, not a generic feature list.
Framework 1: The "Concierge Care" Model
Reframe the PCP from a "gatekeeper" to a "Personal Healthcare Quarterback" who coordinates the patient's entire healthcare journey.
Client says: "It was such a hassle getting my records to the cardiologist."
Your Transition:
"It sounds like you've really felt the stress of having to be your own care coordinator. That's a heavy burden. What if you had a personal healthcare quarterback, someone whose entire job was to manage all of that for you, at no extra cost to your plan?"
Framework 2: The "Financial Fortress" Model
Position the HMO's closed network not as a limitation, but as the ultimate protection against catastrophic "surprise medical bills." It's a "curated network" of vetted doctors, not a restricted one.
Client says: "I worry about what a hospital stay would really cost."
Your Transition:
"That 'what if' worry is what keeps so many people up at night. That's precisely why our plan is designed like a financial fortress. We build the walls of our curated network so that you are 100% protected from those unexpected, out-of-network costs. It’s about giving you financial peace of mind."
Phase 3: Handling Common Objections with Empathy
Objections are not roadblocks; they are expressions of loss aversion. First, validate the emotion behind the objection, then reframe the benefit to address that core fear.
Objection: "I don't want to lose my doctor."
1. Acknowledge the Loss:
"I completely understand. You have a trusted relationship with Dr. Smith, and the thought of losing that is a real concern. That kind of relationship is incredibly valuable."
2. Check the Network & Reframe the Gain:
"The goal here isn't to take something valuable away, but to add a whole team of support around you. With our plan, you gain a dedicated primary doctor who acts as your personal advocate... Let's do this right now: let's look up Dr. Smith in our directory. Very often, the doctors our clients love are already part of our curated network."
Objection: "I don't want to be told where to go. I want freedom."
1. Acknowledge the Value:
"That sense of control over your own healthcare is absolutely important. It's your health, and you should be in the driver's seat."
2. Reframe "Freedom":
"Let's talk about two different kinds of freedom. There's the 'freedom to choose,' which sometimes comes with the hidden risk of huge surprise bills and the burden of coordinating everything yourself. Then there's a different kind of freedom: the freedom from worry. The freedom from ever fearing a bill that could bankrupt you. Our plan is designed to deliver that second, more meaningful kind of freedom: total peace of mind."
Quick-Reference Agent Cheat Sheet
A summary of psychological barriers and the counter-strategies to deploy.
| Psychological Barrier | Client's Internal Monologue | Agent's Counter-Strategy |
|---|---|---|
| Status Quo Bias | "Changing is risky and too much work. My current plan is fine." | Acknowledge Past Effort & Introduce "Upgrade" Frame. Validate their previous work and position the new choice not as a "switch" but as a simple "upgrade." |
| Loss Aversion | "I'll lose my doctor! I'll lose my freedom!" | Minimize Perceived Loss & Amplify Security Gain. Acknowledge what they have, then pivot to the security and support they will gain (e.g., protection from surprise bills). |
| Decision Fatigue | "This is too complicated. I can't deal with this right now." | Simplify & Coach. Reduce the cognitive load. Act as a trusted guide who makes the process easy. Your job is to make it simple for them. |
The Definitive Guide to Medicare in NJ (2024-2026)
The 2024-2026 Medicare Transformation
This period represents a rapid reshaping of the Medicare landscape, driven by the Inflation Reduction Act (IRA) and persistent medical inflation.
The Great Financial Divergence
A central theme is the widening financial gap within Medicare. Original Medicare (Parts A & B) costs are projected to rise substantially, while private plans (Parts C & D) are seeing profound structural reforms that provide new protections and premium stability.
Strategic Insight: The Pivot to HMOs
The 2026 market is defined by a significant, carrier-driven shift away from PPO plans toward more cost-effective HMOs. This is a direct response to financial pressures. For agents, this requires reframing the HMO not as a limitation, but as a high-value service providing care coordination ("Concierge Care") and financial security ("Financial Fortress").
Impact of 2026 Changes on Beneficiaries
Key reforms, particularly from the Inflation Reduction Act, are set to significantly benefit Medicare recipients starting in 2026:
- $2,100 Annual Cap on Part D Costs: Beneficiaries enrolled in a Medicare Part D plan will pay no more than $2,100 out-of-pocket for covered prescription drugs for the year. Once this cap is reached, they will have $0 cost-sharing for Part D drugs for the remainder of the calendar year.
- Drug Price Negotiation: Prices for the first 10 drugs negotiated by Medicare will take effect on January 1, 2026, potentially lowering costs for these specific high-expenditure medications.
- Increased Predictability: The elimination of the Part D coverage gap and the implementation of the out-of-pocket cap create a more predictable and manageable cost structure for prescription drugs.
Understanding Star Ratings (2026 Data)
Medicare uses a Star Rating system (1 to 5 stars) to measure the quality of health and drug services received by consumers enrolled in Medicare Advantage and Part D plans. A 5-star rating is considered excellent.
- What They Measure: Ratings are based on member experience surveys, medical records, and information from doctors and Medicare. They cover aspects like managing chronic conditions, member satisfaction, customer service, and drug safety.
- Why They Matter: Star ratings help beneficiaries compare plans based on quality and performance. High-performing plans (4 stars or higher) may receive quality bonus payments from CMS. Beneficiaries can use a special enrollment period once per year to switch to a 5-star plan if one is available in their area.
- 2026 National Averages: Approximately 72% of MA-PD enrollees are projected to be in contracts rated 4 stars or higher for 2026.
Medicare Cost & Benefit Trends (2021-2026)
A multi-year comparison of key financials for Original Medicare and private plans.
Original Medicare (Part A & B) Costs
| Cost Metric | 2021 | 2022 | 2023 | 2024 | 2025 | 2026 (Final) |
|---|---|---|---|---|---|---|
| Part B Standard Premium | $148.50 | $170.10 | $164.90 | $174.70 | $185.00 | $202.90 |
| Part B Annual Deductible | $203 | $233 | $226 | $240 | $257 | $283 |
| Part A Inpatient Deductible | $1,484 | $1,556 | $1,600 | $1,632 | $1,676 | $1,736 |
| Part A Daily Coinsurance (61-90) | - | - | - | - | $419 | $434 |
| SNF Daily Coinsurance (21-100) | - | - | - | - | $209.50 | $217 |
Medicare Advantage (Part C) Financials
| Cost Metric | 2021 | 2022 | 2023 | 2024 | 2025 | 2026 |
|---|---|---|---|---|---|---|
| Statutory In-Network MOOP | $7,550 | $8,300 | $8,850 | $8,850 | $9,350 | $9,250 |
| National Average MA-PD Premium | $21.22 | $19.52 | $18.50 | $15.09 | $13.32 | $11.50 |
| NJ Average MA Premium | - | - | - | $19.58 | $22.50 | $25.23 |
Medicare Part D Benefit Evolution (IRA Reforms)
| Benefit Parameter | 2021 | 2022 | 2023 | 2024 | 2025 | 2026 |
|---|---|---|---|---|---|---|
| Max Deductible | $445 | $480 | $505 | $545 | $590 | $615 |
| Initial Coverage Limit | $4,130 | $4,430 | $4,660 | $5,030 | N/A | N/A |
| Out-of-Pocket Threshold (TrOOP) | $6,550 | $7,050 | $7,400 | $8,000 | $2,000 Cap | $2,100 Cap |
| Catastrophic Coverage Copay | 5% | 5% | 5% | $0 | $0 | $0 |
2026 New Jersey Market Snapshot (CMS Data)
Note: CMS counts reflect total distinct plan options available anywhere in the state, which may differ from the curated list in this tool.
Total MA Plan Options
85
Total PDP Options
12
Avg. MA Premium
$25.23
% Access to $0 MA Plan
100%
Number of D-SNPs
6*
LIS Benchmark (PDP)
$43.43
Source: CMS State-by-State Fact Sheets, Sept 26, 2025. *D-SNP count from secondary CMS fact sheet.
2026 Plan Non-Renewals & Service Area Reductions (SARs)
A summary of major plan and service area discontinuations announced by carriers for the 2026 plan year in New Jersey.
Understanding Key Terms
Plan Non-Renewal
A plan non-renewal occurs when an insurance carrier decides to discontinue a specific plan and does not renew its contract with CMS for the upcoming year. Essentially, the plan is being retired and will no longer be offered anywhere in 2026.
Real-World Example
For 2026, all of Cigna's 2025 Medicare Advantage plans are being discontinued in New Jersey. A member in the `Cigna Preferred Medicare (HMO) (H3949-032-000)` plan, for instance, will find that this plan no longer exists anywhere in the state.
Helpful Tips for Agents
- Proactive Outreach is Key: Members must actively enroll in a new plan to avoid being defaulted to Original Medicare, which could create a gap in their prescription drug coverage.
- Check for AOR Protection: Carriers often have policies to protect your Agent of Record status. For example, if you enroll an affected Cigna client into a new 2026 HealthSpring plan, you will be retained as the AOR.
- Leverage the SEP: Your clients have a Special Enrollment Period (SEP) that extends beyond AEP, running from December 8, 2025, to February 28, 2026, giving you extra time to find the right solution.
Service Area Reduction (SAR)
A Service Area Reduction happens when a carrier continues to offer a specific plan but withdraws its availability from specific counties. The plan itself isn’t canceled, but its geographic footprint shrinks.
Real-World Example
In Missouri, the `Cigna True Choice Medicare (PPO)` plan is being discontinued in Caldwell county for 2026, but it continues to be offered in other parts of the state. A member in Caldwell county must find a new plan, but a member in a neighboring county may be able to keep it.
Helpful Tips for Agents
- Confirm the County: The impact of a SAR is county-specific. Always verify your client's county of residence to confirm if they are affected.
- Identical Consequences: For a member living in an exited county, the consequences are the same as a full non-renewal. They must choose a new plan or they will revert to Original Medicare.
- Look for the Letter: Clients will receive an official notification letter from their plan by October 2, 2025. This letter is your cue to schedule a review and discuss their options for 2026.
Aetna
Plan Crosswalk: The `Aetna Medicare Elite 2 NJ South (PPO) (H5521-511)` plan is being discontinued. Members will be automatically enrolled (crosswalked) into the `Aetna Medicare Elite (PPO) (H5521-123)` plan for 2026.
AmeriHealth
No major plan non-renewals or service area reductions have been announced for New Jersey in 2026.
Braven Health
Service Area Reduction: For 2026, the `Braven Medicare Choice Plus (PPO)` plan is being discontinued and will no longer be offered in the following 9 counties:
- Bergen
- Camden
- Hunterdon
- Middlesex
- Morris
- Passaic
- Somerset
- Sussex
- Warren
Clover Health
No major plan non-renewals or service area reductions have been announced for New Jersey in 2026.
HealthSpring (Cigna)
Major Market Exit: As part of its integration with Health Care Service Corporation (HCSC), all 2025 Cigna Medicare Advantage plans in New Jersey are being discontinued for 2026. Members will NOT be automatically crosswalked; every Cigna MA member in NJ must actively enroll in a new plan for 2026 coverage.
Discontinued 2025 MA Plans in New Jersey
| Discontinued 2025 Plan Name | 2025 Contract ID | Suggested 2026 Alternate Plan |
|---|---|---|
| Cigna Preferred Medicare (HMO) | H3949-032-000 | HealthSpring Preferred (HMO) (H3949-054-000) |
| Cigna Courage Medicare (HMO) | H3949-051-000 | None Provided |
| Cigna True Choice Medicare (PPO) | H7849-033-000 | HealthSpring Preferred (HMO) (H3949-054-000) |
| Cigna True Choice Savings Medicare (PPO) | H7849-110-000 | HealthSpring Preferred (HMO) (H3949-054-000) |
| Cigna True Choice Medicare (PPO) | H7849-129-000 | None Provided |
| Cigna True Choice Plus Medicare (PPO) | H7849-130-000 | None Provided |
| Cigna True Choice Plus Medicare (PPO) | H7849-131-000 | HealthSpring Preferred (HMO) (H3949-054-000) |
Horizon
No major plan non-renewals or service area reductions have been announced for New Jersey in 2026.
Humana
No major plan non-renewals or service area reductions have been announced for New Jersey in 2026.
Jefferson Health Plans
No major plan non-renewals or service area reductions have been announced for New Jersey in 2026.
UnitedHealthcare
No major plan non-renewals or service area reductions have been announced for New Jersey in 2026.
Wellcare
No major plan non-renewals or service area reductions have been announced for New Jersey in 2026.
Wellpoint
No major plan non-renewals or service area reductions have been announced for New Jersey in 2026.
NJ Market Deep Dive: The PPO vs. HMO Crossroads
The 2026 market is defined by a tension between past consumer preference for PPOs and future carrier strategies prioritizing HMOs.
While enrollment in PPOs has more than doubled in recent years, financial pressures are causing major insurers to eliminate PPO plans for 2026, shifting focus to more cost-effective HMOs. This makes understanding the trade-offs more critical than ever.
The "Next Generation" HMO: More Flexibility, Less Restriction
The traditional perception of an HMO requiring referrals for all specialist care has evolved significantly for 2026. For example, some Aetna HMO-POS plans don’t require a referral from a PCP to see a specialist, though some providers may still require a recommendation. Similarly, Clover Health notes that while members don’t need a referral, the PCP can help coordinate care, and prior authorization may be needed for certain services.
Major Change for 2026: UnitedHealthcare Referral Requirements
Starting January 1, 2026, most members in UnitedHealthcare Medicare Advantage HMO and HMO-POS plans will be required to get a referral from their PCP before seeing certain specialists. However, many common services—such as mental health, OB/GYN, oncology, physical therapy, telehealth, and preventive exams—will NOT require a referral.
Grace Period: UHC will not deny claims for lack of a referral for services through April 30, 2026, but will begin denying claims on May 1, 2026.
For full details, agents should consult UHC's official resources:
HMO vs. HMO-POS: Understanding the Difference
While both are types of managed care, the fundamental difference lies in the flexibility to receive care outside of the plan's network. In short, an HMO-POS plan offers more flexibility than a traditional HMO.
- HMO (Health Maintenance Organization): Generally requires you to use doctors and hospitals within the plan's network, except in emergencies. You usually need to choose a Primary Care Physician (PCP) who provides referrals to see specialists. This model typically offers lower premiums and out-of-pocket costs.
- HMO-POS (HMO with a Point-of-Service option): This is a hybrid plan. Like an HMO, you have a network and a PCP. However, it allows you to receive care out-of-network, though you'll pay a larger portion of the cost. This provides a safety valve for seeing specific out-of-network doctors while retaining the structure of an HMO.
HMO vs. PPO: A Head-to-Head Comparison
| Feature | HMO (Health Maintenance Organization) | PPO (Preferred Provider Organization) |
|---|---|---|
| Monthly Premium | Generally Lower | Generally Higher |
| Primary Care Physician (PCP) | Usually required to coordinate care. | Not Required |
| Referrals to Specialists | Varies by plan; many modern HMOs no longer require them, but some major carriers like UnitedHealthcare are reintroducing referral requirements for 2026. | Not Required |
| Out-of-Network Coverage | Not covered, except for emergencies (unless it's an HMO-POS plan). | Covered, but at a higher cost-share for the member. |
| Best For | Beneficiaries who prioritize lower costs and are comfortable with a coordinated care model within a specific network. | Beneficiaries who prioritize provider choice and flexibility, and are willing to pay more for the freedom to see out-of-network doctors. |
Agent Commissions & Policies
A detailed breakdown of 2026 commission structures and carrier-specific rules for New Jersey.
Core Commission Principles
CMS sets the maximum possible commission each year. Individual carriers then decide what they will actually pay, which can vary by plan, enrollment type, and the member's history.
- Standard (High/Low) Model: Characterized by a high initial payment for the first year, followed by a renewal rate of 50% for all subsequent years. This is the most common model (e.g., UnitedHealthcare's primary model).
- Levelized Model: A consistent, flat payment is made for all years, including the initial year. This provides predictable revenue but a lower first-year payment compared to the Standard model (e.g., Clover's model).
2026 Commission Structures (New Jersey)
1. CMS Maximum Allowable Commission (The Benchmark)
| Year | MA/MAPD Initial | MA/MAPD Renewal | PDP Initial | PDP Renewal |
|---|---|---|---|---|
| 2025 | $780 | $390 | $109 | $55 |
| 2026 | $864 | $432 | $114 | $57 |
2. UnitedHealthcare
UHC's compensation is highly dependent on the specific plan and member history.
- On Most Standard MA Plans: UHC pays the full CMS maximum. A new 2026 enrollment pays an initial $864.
- On Specific Non-Commissionable PPOs: For applications signed on or after October 1, 2025, two NJ PPO plans will pay no initial commission: `AARP Medicare Advantage from UHC NJ-0004 (H8768-022-000)` and `AARP Medicare Advantage from UHC NJ-6 (H8768-058-000)`.
- Note: For these two plans, agents will only receive a renewal commission of $390 for members who were enrolled prior to 2026.
AARP Medicare Supplement (A Note on Underwriters)
For 2026, it is critical to distinguish between the two companies that underwrite AARP-branded Medicare Supplement plans, as their commission structures are different.
- United Healthcare Insurance Company (UHIC): Plans underwritten by the primary company, UHIC, pay the standard Med Supp commission schedule, which is a tiered, flat-dollar amount that varies by plan letter. This is considered the normal commission.
- United Healthcare Insurance Company of America (UHICA): Plans underwritten by UHICA feature a significantly reduced, non-standard commission. For example, a new Plan G underwritten by this company pays only a $100 initial commission and $50 for renewals in years 2-6, and Plan A pays no commission at all.
3. Clover Health (Levelized Model)
CRITICAL 01/01/2026 UPDATE: For applications written on or after January 1, 2026, Clover has temporarily paused new business commissions for the majority of their portfolio to focus on member experience and clinical support.
- Commissionable Plans: Only three New Jersey plans remain active for new business commissions written in 2026:
H8010-003,H5141-007, andH5141-042. - Written in 2025: All new 2026 business written before January 1, 2026, will be paid as scheduled.
- Renewals: Commissions for existing business (written before 2026) are unaffected and continue to pay the scheduled $390 renewal rate.
- GTKY Admin Payments: A $50 payment remains available for "Getting to Know You" (GTKY) form submissions on ALL plans if submitted within 3 days of the application.
4. Aetna
- Medicare Advantage: Based on the provided site data, all listed Aetna HMO, D-SNP, and most PPO plans pay the full standard FMV commission for new sales.
- Medicare Supplement Plans: For plans underwritten by Aetna-affiliated companies (Accendo, ACI, CLI, etc.), the commission in NJ is based on the plan type.
- Plan N: Pays a 26% commission for the first 6 policy years, and 2.5% for years 7+.
- All Other Plans (G, F, etc.): Pay a 22% commission for the first 6 policy years, and 2.5% for years 7+.
- Stand-Alone PDPs: All new 2026 Aetna and SilverScript stand-alone PDPs are non-commissionable.
5. Humana (Multi-Tiered Model)
- Standard FMV: Humana pays full FMV for the majority of new-to-Humana sales.
- Non-Commissionable MA Plans: New sales for all `H5216` contract plans are non-commissionable to encourage member stability. This also applies to `H6622-100-002` in Morris County.
- Modified Commission on Plan H7617-045: Moving an existing Humana member to this plan results in a reduced, levelized commission of $165 for both initial and renewal years. A new-to-Humana member on this plan pays full FMV.
- Stand-Alone PDPs: Effective November 9, 2025, agents can no longer sell new stand-alone PDPs. The `Humana Basic Rx Plan (S5884-131)` is explicitly non-commissionable for 2026.
- HRA Payment: A $35 payment is available for completing a Health Risk Assessment (HRA) for new SNP members.
6. Other Carriers (Paying Full FMV)
- AmeriHealth: Confirmed to pay full FMV commissions for all MA/MAPD plans.
- Braven Health / Horizon: For 2026 effective dates, Braven Health will not pay new sales commissions for `Braven Medicare Choice (PPO)`, `Choice Plus (PPO)`, and `Freedom (PPO)`. New sales commissions will continue for `Braven Medicare Salute (PPO)` products. Horizon PDPs are also non-commissionable for new sales.
- HealthSpring (Cigna): The new PPO plan, `HealthSpring True Choice (H7849-149-000)`, is non-commissionable for new sales.
- Wellcare: Confirmed to pay full FMV commissions for all MA/MAPD plans.
- Wellpoint: All listed Wellpoint Special Needs Plans are non-commissionable for both initial and renewal payments.
2026 NJ Medicare Supplement (Medigap) Guide
Unlike Medicare Advantage, Medicare Supplement (Medigap) plans are standardized by the government. This means the core medical benefits of a plan with the same letter (e.g., Plan G) are identical regardless of the insurance company. Carriers compete on premium, customer service, ancillary benefits, and agent commissions.
Strategic Considerations for Under-65 Med Supp Enrollments in NJ
Critical Commission Alert: While a state like Pennsylvania may offer more comprehensive options such as a Plan G for under-65 individuals on disability, New Jersey's market is typically more restricted to plans like Plan D. From a business perspective, the most critical factor is compensation. For under-65 applicants in New Jersey, the Year 1 commission is 0% for Aetna, Cigna, Humana, and UnitedHealthcare. This positions these enrollments as service-oriented opportunities, as they do not provide immediate commission. However, these clients will receive a second, 6-month Medigap Open Enrollment Period when they turn 65, creating a future opportunity to place them in a standard, commissionable plan.
Carrier Discounts & Ancillary Benefits
| Carrier | Household Discount (HHD) | Other Discounts | Ancillary Benefits |
|---|---|---|---|
| Humana | 12% on "Achieve" plans | $2/month for autopay | SilverSneakers® Fitness Program |
| Cigna | 7% for living with a spouse or adult 60+ | None mentioned | Cigna Healthy Rewards® program |
| UHC (AARP) | 7% multi-insured discount if two members under the same AARP number are enrolled. Applies when living with a spouse or another person aged 50 or over. | Two options are available (cannot be combined): • EFT Discount: $2.00 per month. • Annual Payer Discount: $24.00 per year ($2/mo) for paying the entire 12-month premium (August through July) by August 31. |
Renew Active® fitness program, plus AARP® vision and hearing discounts. |
| Aetna | Available for applicants who have resided with a spouse or partner for the last 12 months. | None mentioned | Gym membership, plus vision and hearing discounts. |
2026 Commission Schedule Comparison
| Carrier | Standard Rate (Year 1, OE/UW) | Guaranteed Issue (GI) Rate | Payment Method |
|---|---|---|---|
| Aetna | 26% for Plan N; 22% for all others (Yrs 1-6) | 0.8% (Years 1-6) | Choice of 6, 9, or 12-month advance, or as-earned |
| Humana | 22% of premium (Yrs 1-6, Ages 65-80) | 3% of premium (Yrs 1-6) | 12-month advance |
| UHC (AARP) | $510 for Plan G; $408 for Plan N (flat-dollar) | 5% of standard rate (e.g., $25.50 for Plan G) | 9-month advance |
| Cigna | 25% for Plan N; 21% for Plans F & G (Ages 65-79) | 0% | Choice of 6, 9, or 12-month advance, or as-earned |
Note on UHC: A secondary underwriter (UHICA) pays a significantly reduced flat-dollar amount, such as $100 for Plan G.
Guaranteed Issue (GI) Commission Ranking
For GI sales, the compensation hierarchy is clear.
| Carrier (Ranked) | Guaranteed Issue Commission (Year 1) | Payment Method |
|---|---|---|
| 1. Humana | 3% of Premium | 12-Month Advance |
| 2. United Healthcare (UHIC) | $25.50 for Plan G (5% of standard rate) | 9-Month Advance |
| 3. Aetna | 0.8% of Premium | 12-Month Advance |
| 4. Cigna | 0% | N/A |
Special Commission Rules
- Internal Replacements: Moving a member within the same carrier family may result in a modified or zero commission. For instance, UHC pays 90% of the Year 2 rate with no advance for certain switches between its two underwriters.
- Replacing Competitors: When replacing another carrier's Med Supp plan, UHC pays a modified Year 1 commission equivalent to the Year 2 renewal amount.
Anniversary & Birthday Rules
Several states have "anniversary" or "birthday" rules that create a recurring Guaranteed Issue or Open Enrollment window for individuals who already have a Medicare Supplement plan. This allows them to switch plans, typically to one of equal or lesser benefit, without medical underwriting.
- Anniversary Rule (Missouri): Individuals can switch to the same plan (e.g., Plan G to Plan G) with a different carrier. The window is 30 days before and after the policy anniversary date.
- Birthday Rule (e.g., California, Oregon): Individuals can switch to a plan of equal or lesser value. The window is typically 30-60 days around their birthday.
Note: New Jersey does not currently have an Anniversary or Birthday rule for Medigap switching.
Agent's Guide to Medicare Enrollment Periods
Understanding the different enrollment periods is critical for compliant and effective client support.
Key Enrollment Periods
Review this official Aetna guide to understand the key enrollment periods and their rules.
Aetna Enrollment Guide ↗- Initial Enrollment Period (IEP): A 7-month window for individuals to sign up for Medicare when they first become eligible (typically around their 65th birthday).
- Annual Election Period (AEP): Occurs from October 15 to December 7 each year. During this time, all beneficiaries can join, switch, or drop a Medicare Advantage (Part C) or Prescription Drug (Part D) plan.
- Medicare Advantage Open Enrollment Period (MA-OEP): Runs from January 1 to March 31 annually. This period is only for individuals who are *already enrolled* in a Medicare Advantage plan. They can make a single change to another MA plan or switch back to Original Medicare.
Common Special Election Periods (SEPs)
SEPs allow individuals to change their coverage outside of the standard periods due to specific life events. Below are some of the most common triggers.
| SEP Trigger | Description & Duration |
|---|---|
| Change in Residence | For those who move out of their current plan's service area. This SEP typically allows for a plan change a month before the move and for 2 months after. |
| Loss of Other Coverage | For those losing coverage from an employer, union, COBRA, or Medicaid. This generally provides a 2-month window to enroll in a new plan after the other coverage ends. |
| Change in Dual/LIS Status | For those who gain, lose, or have a change in their Medicaid or Low-Income Subsidy (LIS) status. Update: Since 2025, this SEP allows one plan change per *month* for standalone Part D plans only, not MA plans. |
| Plan Non-Renewal or Termination | If a member's current plan is not being renewed by the carrier or is leaving their service area, they are granted an SEP to choose a new plan, typically from December 8th to the end of February. |
| 5-Star Plan Enrollment | A one-time opportunity per year (from December 8th to November 30th) to switch to a 5-star rated Medicare Advantage or Part D plan available in their area. |
Interactive Enrollment Period Qualifier
Still unsure? Use this tool to walk through a client's situation and identify potential enrollment periods.
High-Income Surcharges (IRMAA) for 2024-2026
A multi-year comparison of TOTAL monthly costs.
Brackets are based on MAGI from two years prior (e.g., 2026 rates use 2024 tax returns).
| MAGI (Individual) | MAGI (Joint) | 2024 (2022 Tax Return) | 2025 (2023 Tax Return) | 2026 (2024 Tax Return) | |||
|---|---|---|---|---|---|---|---|
| Part B Total | Part D Adj. | Part B Total | Part D Adj. | Part B Total (Total Cost) |
Part D Total (Plan Prem + Adj) |
||
| ≤ $109,000 | ≤ $218,000 | $174.70 | $0.00 | $185.00 | $0.00 |
$202.90 Standard Rate |
Plan Premium |
| > $109k - $137k | > $218k - $274k | $244.60 | +$12.90 | $259.00 | +$13.70 |
$284.10 + $81.20 IRMAA |
Plan Prem + $14.50 |
| > $137k - $171k | > $274k - $342k | $349.40 | +$33.30 | $370.00 | +$35.30 |
$405.80 + $202.90 IRMAA |
Plan Prem + $37.50 |
| > $171k - $205k | > $342k - $410k | $454.20 | +$53.80 | $481.00 | +$57.00 |
$527.50 + $324.60 IRMAA |
Plan Prem + $60.40 |
| > $205k - < $500k | > $410k - < $750k | $559.00 | +$74.20 | $592.00 | +$78.60 |
$649.20 + $446.30 IRMAA |
Plan Prem + $83.30 |
| ≥ $500,000 | ≥ $750,000 | $594.00 | +$81.00 | $629.00 | +$85.70 |
$689.90 + $487.00 IRMAA |
Plan Prem + $91.00 |
* 2024/2025 brackets shown for historical reference. 2026 brackets (Green Columns) are finalized.
Note: Married Filing Separately has different brackets (only two tiers: >$109k and >$391k).
Official Source: View the official CMS Fact Sheet for 2026.
CMS 2026 Premiums & Deductibles ↗NJ Prior Auth Pilot: The 'WISER' Model - Overview
Effective January 1, 2026, CMS is launching the Wasteful and Inappropriate Service Reduction (WISER) Model. New Jersey is one of only six pilot states for this six-year program, which introduces a mandatory structural change to Original Medicare oversight in the state.
CMS Rationale: Why This Affects NJ
The program is a national experiment designed to curtail fraud, waste, and abuse (FWA). WISER specifically targets services deemed low-value, costing Medicare billions annually.
The model is framed as a critical clinical quality initiative to shield NJ beneficiaries from unnecessary, low-value, and potentially harmful procedures.
WISER's Goal: It is designed to steer patients away from unnecessary, potentially harmful procedures and promote evidence-based care.
Pilot Program Details for New Jersey
- Duration: January 1, 2026 – December 31, 2031.
- Services Affected: A narrow, targeted list of *specific outpatient items and services* (approx. 15) historically associated with high costs and questionable utilization.
- NJ MAC: New Jersey is in Medicare Administrative Contractor (MAC) Jurisdiction L (JL), served by Novitas Solutions.
- Scope: Applies *only* to services provided to Original Medicare beneficiaries in New Jersey. It does not affect Medicare Advantage (MA) plans.
WISER Model: How It Works in New Jersey - The New Gatekeeper
CMS will contract with a single private technology company ("Model Participant") to manage the review process for all targeted services provided to NJ Original Medicare beneficiaries.
Vendor Compensation and AI Technology
- Vendor Compensation: The NJ vendor is paid a percentage of the Medicare spending successfully "averted" (denied claims or prevented services).
- Conflict of Interest: This compensation model has drawn intense criticism from the American Hospital Association (AHA) and lawmakers as a "perverse incentive" that prioritizes profit over clinical need.
- AI/ML Use: Technology is used to pre-screen requests, aiming to expedite approvals for clearly compliant cases.
- Human Safeguard: A final decision to *deny* care ("non-affirmation") must be made by a licensed human clinician; AI cannot deny a claim.
Controversial Payment Structure: The vendor assigned to New Jersey will be paid a percentage of Medicare savings from services it denies. CMS states vendors face financial penalties for inaccurate denials found in audits.
Provider Pathways (Functionally Mandatory)
For services on the WISER list provided to NJ Original Medicare beneficiaries, NJ providers *must* use one of these two options:
- Pathway 1: Pre-Service Prior Authorization Request (PAR): Provider submits full clinical documentation *before* the service. An "affirmation" provides a high degree of payment assurance. This is the path of minimal financial risk.
- Pathway 2: Pre-Payment Medical Review: Provider performs the service, submits the claim to Novitas, which then stops the claim and triggers review by the NJ vendor *before* payment. This carries substantial financial risk and payment delays.
Submission and Review Timelines
The timeframes set by CMS ensure efficient service for New Jersey providers:
- Standard PAR Review: Determination within 3 business days.
- Expedited PAR Review: Determination within 2 business days (for cases risking patient life/health).
- Affirmation Validity: Approvals are valid for 120 calendar days.
- Resubmissions: Providers have unlimited opportunities to resubmit a non-affirmed PAR. They can also request a peer-to-peer clinical review with the vendor.
WISER Model: Initial Services List for New Jersey
This is the initial, targeted list of outpatient services requiring prior authorization or pre-payment review for Original Medicare beneficiaries residing in New Jersey, effective Jan 1, 2026. This list focuses on areas prone to overutilization.
Documentation and Delay Notes
- Documentation: The review enforces existing National Coverage Determinations (NCDs) and the NJ-specific Local Coverage Determinations (LCDs) issued by Novitas Solutions.
- DBS Delayed: Deep Brain Stimulation (DBS - NCD 160.24) is delayed statewide and will *not* start on Jan 1, 2026.
- Settings: Applies to services provided in Office, Home, ASC, and Hospital Outpatient settings.
Initial List of Services for WISER Review (NJ - Effective Jan 2026)
| Category | Specific Service/Procedure | Governing Policy (NCD or NJ LCD) |
|---|---|---|
| Wound Care | Application of Skin Substitutes / CTPs (for Lower Extremity Chronic Wounds) | NJ LCD (L35041/L36690) |
| Pain Management | Epidural Steroid Injections (ESI) (Excludes facet joint injections) | NJ LCD (L39015, L39240, L36920) |
| Spine/Orthopedics | Percutaneous Vertebral Augmentation (PVA) (Vertebroplasty/Kyphoplasty) | NJ LCD (L34106, L38201, L35130) |
| Musculoskeletal | Knee Arthroscopy (Lavage / Debridement for Osteoarthritis) | NCD 150.9 |
| Urology | Sacral Nerve Stimulation (SNS) (Permanent Implant) | NCD 230.18 |
| Neurology | Electrical Nerve Stimulators (Spinal Cord Stimulator Implantation via Laminectomy) | NCD 160.7 |
| Sleep Medicine | Hypoglossal Nerve Stimulation (HGNS) for OSA | NJ LCD (L38307, L38312, L38385) |
| Spine Surgery | Cervical Fusion (Codes 22554, 22585 only) | NJ LCD (L39741, L39758, L39793) |
| Urology | Diagnosis and Treatment of Impotence (Penile Prosthesis Insertion) | NCD 230.4 |
| Pain/Neurology | Induced Lesions of Nerve Tracts (e.g., Trigeminal Rhizotomy) | NCD 160.1 |
| Respiratory | Phrenic Nerve Stimulator | NCD 160.19 |
| Urology | Incontinence Control Devices (Mechanical/Hydraulic) | NCD 230.10 |
| Spinal Stenosis | Percutaneous Image-Guided Lumbar Decompression (PILD) | NCD 150.13 |
| Neurology | Vagus Nerve Stimulation (VNS) (for listed indications) | NCD 160.18 |
WISER Model: What It Means for Your New Jersey Clients
The primary impact is the introduction of a new administrative hurdle for NJ residents seeking specific elective procedures under Original Medicare.
Core Rights That Do Not Change
Reassure your New Jersey clients of these protections:
- Original Medicare Coverage Rules: WISER is a review process; it does not change what Medicare covers if the service is medically necessary.
- Financial Liability: The client’s Part B deductible/20% coinsurance are unchanged for *approved* services.
- Freedom of Choice: The client keeps their right to see any provider that accepts Original Medicare, in any state.
- MA Plans Are Exempt: If your client is in a Medicare Advantage plan, this pilot does not affect them.
New Hurdles & Potential Risks in NJ
- Potential Delays: The mandatory PAR process, even when efficient, adds time before a procedure can be scheduled, potentially increasing delays in care.
- Risk of Denial: A client’s NJ doctor's recommended procedure may be denied coverage if the third-party vendor determines it lacks medical necessity per CMS rules.
- Travel Rule: The PA requirement is tied to the beneficiary’s NJ residence. If they seek a WISER service out-of-state (e.g., Florida), the NJ vendor still performs the review.
- ABN Warning: If a PA is denied, the NJ provider must issue an Advance Beneficiary Notice (ABN) if they plan to perform the service and hold the client financially responsible.
If Care is Denied: The Appeals Process
A denied *claim* (after pre-payment review) is an initial determination and grants the beneficiary full appeal rights.
- Level 1: Redetermination (Filed with Novitas Solutions within 120 days of denial).
- Level 2: Reconsideration (Filed with QIC within 180 days).
- Levels 3-5: Subsequent appeal rights to an ALJ, the Medicare Appeals Council, and Federal Court.
Critical Free Resource in NJ: The New Jersey State Health Insurance Assistance Program (SHIP) offers free, expert, and unbiased counseling to beneficiaries on all Medicare issues, including navigating the appeals process.
NJ SHIP Contact: 1-800-792-8820
WISER Model: NJ Agent Insights & Industry Context
This information is crucial for counseling your New Jersey clients and understanding the strategic implications of the pilot.
The Core Controversy & Agent Talking Points
WISER's payment model, based on a percentage of savings from denials, has led to near-unanimous opposition from medical groups (AHA, AMA, SIR, APMA).
- Financial Conflict: The model's compensation structure creates a perverse incentive for the vendor to deny care, posing a direct threat to clinical judgment.
- Care Delay Risk: Groups like the Society of Interventional Radiology warn that delays for time-sensitive procedures like Percutaneous Vertebral Augmentation "could result in dozens of avoidable deaths per 1,000 patients".
- Administrative Burden on NJ Providers: WISER adds significant, uncompensated workload, especially for smaller practices, potentially impacting access.
Strategic Implications for NJ Providers & Medicare
- Gold Carding: CMS is exploring an exemption ("gold card") for NJ providers with a proven 90% PA affirmation rate, incentivizing strong internal documentation from the outset.
- Long-Term "MA-ification": WISER explicitly imports MA tenets (PA, third-party vendors, AI) into Original Medicare. If the NJ pilot is deemed successful, it sets a powerful precedent for national expansion of PA in Original Medicare.
- Counseling Shift: While the gap is smaller, Original Medicare still offers significantly less PA than most MA plans. This distinction is vital for counseling clients prioritizing access and autonomy.
Financial Assistance Programs
Key federal and state programs to help clients with limited income and resources.
Federal Low-Income Subsidy (LIS / "Extra Help")
LIS helps pay for Part D premiums, deductibles, and copayments. Since 2024, all who qualify receive the full subsidy.
| Parameter | 2021 | 2022 | 2023 | 2024 | 2025 | 2026 (Projected) |
|---|---|---|---|---|---|---|
| Annual Income Limit (Ind.) | $19,140 | $20,385 | $21,870 | $22,950 | $23,475 | Modest Increase |
| Resource Limit (Ind.) | $14,790 | $15,510 | $16,660 | $17,220 | $17,600 | Modest Increase |
| Generic Drug Copay | $3.70 | $3.95 | $4.15 | $4.50 | $4.90 | $5.10 |
| Brand-Name Drug Copay | $9.20 | $9.85 | $10.35 | $11.20 | $12.15 | $12.65 |
Understanding LIS Premiums for 2026
While Extra Help covers Part D premiums up to a certain amount (the regional Low-Income Subsidy benchmark), beneficiaries enrolled in plans with premiums *above* this benchmark will still have to pay the difference.
- The 2026 LIS Benchmark Premium for New Jersey is $43.43.
- If a full LIS beneficiary chooses a PDP with a monthly premium of $50.00, they will be responsible for paying the $6.57 difference ($50.00 - $43.43).
- Beneficiaries can avoid paying a premium by choosing a plan at or below the benchmark amount. CMS provides notices to affected individuals and allows a Special Enrollment Period to switch plans.
For more detailed information on Medicare Savings Programs, review this guide from Humana.
Humana Medicare Savings Programs Guide ↗New Jersey PAAD Program
The Pharmaceutical Assistance to the Aged and Disabled (PAAD) program is a state-funded initiative that provides substantial relief from prescription drug costs. It works in coordination with Medicare Part D to ensure medications are affordable for eligible New Jersey residents by reducing copays to just $5 for generic drugs and $7 for brand-name drugs. For many beneficiaries, PAAD will also pay the entire monthly premium for a basic Medicare Part D plan.
2025 PAAD Eligibility Requirements
| Filing Status | 2025 Annual Income Limit |
|---|---|
| Single Individual | Less than $53,446 |
| Married Couple | Less than $60,690 |
- Applicant must be a New Jersey resident.
- Must be age 65 or older, OR between 18-64 and receiving Social Security Disability benefits.
- Important Note for Agents: The official PAAD income limits for the 2026 calendar year are determined by the Social Security cost-of-living adjustment (COLA) and are typically announced in late October 2025.
Essential Enrollment Resources
A directory of official websites and phone numbers for Medicare and NJ state programs.
| Resource / Action | Description | Official Link / Contact |
|---|---|---|
| Apply for Medicare (A&B) | The official SSA portal to sign up for Original Medicare. | SSA Website ↗ |
| Compare Plans (C&D) | The official Medicare tool to compare and enroll in MA and Part D plans. | Medicare.gov ↗ |
| Apply for Extra Help (LIS) | The official SSA online application for the Low-Income Subsidy program. | SSA Website ↗ |
| NJ SAVE Application | The single NJ SAVE application for multiple state/federal aid programs (PAAD, MSPs, etc.). | NJ SAVE Website ↗ |
| NJ FamilyCare (Medicaid) | New Jersey's application portal for Medicaid and CHIP health coverage. | NJ FamilyCare Website ↗ |
| NJ SHIP: 2026 MA Plan Chart | Official NJ SHIP chart of all 2026 Medicare Advantage plans. | nj.gov PDF ↗ |
| NJ SHIP: 2026 PDP Chart | Official NJ SHIP chart of all 2026 stand-alone Part D plans. | nj.gov PDF ↗ |
| NJ SHIP Counseling | Free, unbiased one-on-one Medicare counseling for New Jersey residents. | 1-800-792-8820 |
| 1-800-MEDICARE | Official CMS helpline for general Medicare questions. | 1-800-633-4227 |
Official CMS WISER Model Resources
Key Links
CMS Press Release (Full Text)
CMS Launches New Model to Target Wasteful, Inappropriate Services in Original Medicare
Model will leverage enhanced technologies to protect Medicare beneficiaries, federal taxpayers from unnecessary services, fraud, waste, and abuse
The Centers for Medicare & Medicaid Services (CMS) is announcing a new Innovation Center model aimed at helping ensure people with Original Medicare receive safe, effective, and necessary care. Through the Wasteful and Inappropriate Service Reduction (WISeR) Model, CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process relative to Original Medicare’s existing processes, helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars. This model builds on other changes being made to prior authorization as announced by the U.S. Department of Health and Human Services and CMS on Monday.
“CMS is committed to crushing fraud, waste, and abuse, and the WISeR Model will help root out waste in Original Medicare,” said CMS Administrator Dr. Mehmet Oz. “Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures.”
Wasteful care, including services that provide little to no clinical benefit, not only increase costs, but also put patients at risk. Waste in healthcare represents up to 25% of healthcare spending in the United States. The Medicare Payment Advisory Commission estimates that up to $5.8 billion in Medicare spending in 2022 alone was spent on services with minimal benefit.
“Low-value services, such as those of focus in WISeR, offer patients minimal benefit and, in some cases, can result in physical harm and psychological stress,” said Abe Sutton, Director of the CMS Innovation Center. “They also increase patient costs, while inflating health care spending.”
The WISeR Model will test a new process on whether enhanced technologies, including artificial intelligence (AI), can expedite the prior authorization processes for select items and services that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use. These items and services include, but are not limited to, skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis. The model excludes inpatient-only services, emergency services, and services that would pose a substantial risk to patients if significantly delayed.
Companies selected to participate in the model will operate in assigned geographic regions and must have clinicians with appropriate expertise to conduct medical reviews and validate coverage determinations. Importantly, while technology will support the review process, final decisions that a request for one of the selected services does not meet Medicare coverage requirements will be made by licensed clinicians, not machines.
Model participants will receive payments based on their ability to reduce unnecessary or non- covered services (inappropriate utilization) and lower spending in Original Medicare. Participants’ payments will be adjusted based on their performance against established quality and process measures that measure the model participants’ ability to support faster decision- making for providers and suppliers and improve provider, supplier and beneficiary experience with the prior authorization process.
The WISeR Model will not change Medicare coverage or payment criteria. Health care coverage for Original Medicare beneficiaries remains the same, and beneficiaries retain the freedom to seek care from their provider or supplier of choice. Under the model, providers and suppliers in the assigned regions will have the choice of submitting prior authorization requests for selected items and services or their claim will be subject to pre-payment medical review. Those providers and suppliers that choose to submit a prior authorization may either submit their request directly to model participants or to their Medicare Administrative Contractor that will forward the request to the model participant. CMS may include a pathway in the future that would allow providers and suppliers with strong compliance records to qualify for exemptions from WISeR review, which would further reduce administrative burden and allow greater focus on high-risk areas. The WISeR Model does not impact people enrolled in Medicare Advantage.
CMS has issued a Request for Applications for companies interested in participating in the WISeR Model.
To view the Model Overview fact sheet, visit: https://www.cms.gov/files/document/wiser-fact-sheet.pdf.
For more information on the WISeR Model, visit: https://www.cms.gov/priorities/innovation/innovation-models/wiser.
The WISeR Model can be seen on the Federal Register at: https://www.federalregister.gov/.
Version History
- v45.7 (Current)
• Commission Update: Integrated the 01/01/2026 Clover Health new business commission pause across the data engine and financial guides.
• Data Correction: Updated the "Clover Health Value (HMO)" contract code fromH5141-003to the correctH8010-003.
• UI Update: Added high-visibility warning notes to Clover plans in the main table to notify agents of the new business pause.
• Filter Fix: Corrected an issue where "C-SNP" and "D-SNP" filter buttons were not functioning. They now correctly filter the plan list. - v45.5
• Universal Search Engine: The search bar now scans deep within all Guide Modals (Objections, Carrier Hub, Financial Guide) and displays matching text snippets at the top of the results.
• Smart Highlighting: Search terms are now highlighted in the plan table and inside modals. Highlights adapt to the selected color theme (e.g., Neon Green for High Vis, Hot Pink for Color Mode).
• Print Overhaul: Completely rewrote the print engine. Now defaults to Portrait mode with a "Spreadsheet" layout, fitting 8-10 plans per page by hiding line breaks and maximizing density.
• Data Update: Updated plan names for Jefferson Health Plans to "Jefferson Health Plans Choice" and "Jefferson Health Plans Choice Plus".
• Content Cleanup: Removed the outdated "Government Shutdown" guide to streamline the tool.
NJ Medicare Plan Comparison & Commission Tool
1. Introduction
Welcome to the Comprehensive New Jersey Medicare Plan Comparison & Commission Schedule! This powerful tool is designed exclusively for insurance agents to provide an at-a-glance analysis of the 2026 Medicare landscape in New Jersey. It allows you to quickly find, filter, analyze, and compare hundreds of plan options to effectively serve your clients.
2. First Steps: Adjusting Your View
The tool defaults to a modern "Color Mode" for optimal viewing. If you prefer a traditional black-on-white display, you can change it immediately.
How to Change Themes: Click the 🎨 Theme Mode button located in the top header. Each click cycles through the different visual themes: Color Mode, Light Mode, Dark Mode, and High Visibility.
To switch to the standard light theme, simply click the button until it displays "☀️ Light Mode".
3. Getting Started: Accessing the Tool
The tool is password-protected for agent use only.
- Enter Access Code: When you first visit the page, you'll be greeted by a login screen. Enter the provided access code into the input field.
- Unlock: Click the "Unlock Tool" button. If the code is correct, the main application will load.
The session will remain active as long as your browser tab is open.
4. Understanding the Main Interface
The tool is divided into two main sections:
- Filter Panel (Left): This is your command center. It contains all the controls to narrow down the plan list to your exact specifications.
- Plan Display (Right): This area shows the results of your filters. Plans are automatically grouped and sorted for easy viewing.
5. The Filter Panel: Your Control Center
This panel contains numerous options to refine your search.
Saved Searches & Session Status
- Saved Searches: Save a complex set of filters for later use. Select a saved search from the dropdown to instantly re-apply those filters. Use the 💾 Save and 🗑️ Delete buttons to manage your saved searches.
- Session Status: Tracks how long you've been using the tool and the number of filter queries you've run in the current session.
Core Filtering Functions
- Global Text Search: The most flexible filter. Type any keyword here—a plan name, a contract code, a specific benefit like "flex card," or a city—to search all plan data.
- Favorites: Check the "⭐ Show My Favorites" box to display only the plans you have previously marked as a favorite.
- Filter by Location:
- ZIP Code: Enter a client's ZIP code and click "Search ZIP" for the most accurate results. If a ZIP code spans multiple counties, you'll be prompted to select the correct one.
- County: Alternatively, select a county directly from the dropdown menu.
- Clear Location: Use this button to remove any active ZIP or county filters.
- Show Only Commissionable Plans: This filter is on by default. It hides plans that do not offer a commission for new enrollments (e.g., renewal-only plans). Uncheck it to see all plans regardless of commission status.
- Checkbox Filters: Use the checkboxes to narrow down plans by:
- Carrier: (e.g., UnitedHealthcare, Aetna)
- Plan Type: (e.g., PPO, HMO, SNP)
- Plan Category: (e.g., MAPD, MA-Only)
- Key Benefits: ($0 Premium, Giveback, OTC, etc.)
- Leader Status: (Market Leaders, Carrier Leaders)
6. The Plan Display: Analyzing the Results
The plans that match your filters are displayed in this section, organized for clarity.
Reading the Plan Table
- Grouping: Plans are first grouped by Category (MAPD, MA-Only, etc.), then by Commission Type, and finally by Carrier.
- Sorting: Click on any column header with an arrow indicator (e.g., "Premium & Giveback") to sort the currently visible plans by that data point. Click again to reverse the order.
- Plan Row Details:
- Plan Name: Click the plan name to open a detailed pop-up with all benefits.
- Pills/Badges: Quick visual cues like PPO, $0 Premium, and Market Leader highlight key features.
- Icons:
- ☆ / ★ (Favorite): Click the star to add or remove a plan from your personal favorites list.
- 📄 (Plan Documents): Click this icon to view the plan's official Summary of Coverage & Benefits (SCB) in a pop-up.
- Comparison Checkbox: The checkbox on the far left adds the plan to the comparison tool.
7. Core Features in Detail
The Plan Comparison Tool
- Select Plans: Check the box on the left of any plan row you wish to compare.
- Comparison Bar: A bar will appear at the bottom of the screen showing how many plans you have selected.
- Compare: Click the "📊 Compare" button on the bar to open a detailed, side-by-side table of your selected plans.
- Export & Print: From the comparison modal, you can print the comparison or export it to a CSV spreadsheet.
The Main Pop-Up Guides
Located above the plan results, these three buttons open powerful informational modals:
- GUIDE: The Definitive Guide to Medicare in NJ: A comprehensive, multi-tab guide covering market trends, key 2026 costs, IRMAA, financial aid (PAAD), commissions, prior authorization pilot, enrollment periods, and more.
- 🏢 Carrier Hub: Your one-stop shop for links to agent portals, provider directories, and other essential resources for all major carriers.
- 🤝 PPO to HMO Playbook: A sales and objection-handling guide with scripts and strategies for navigating client conversations about the shift from PPO to HMO plans.
8. Header Actions
The buttons at the very top of the page provide additional functionality:
- 🗜️ Condensed View: Reduces the spacing in the plan table to fit more information on the screen.
- 🔗 Share: Copies a unique URL to your clipboard that contains your current filter settings. You can send this link to a colleague or save it to recreate your exact search.
- 📊 Export to Spreadsheet: Exports all currently filtered plans into a CSV file.
- 📄 Print / PDF: Creates a printer-friendly version of the current view.
We hope this guide helps you make the most of this powerful tool!