How to Answer Medicare Questions During Open Enrollment
Medicare Open Enrollment runs from October 15 through December 7, 2026. During that window, people with Medicare can review and change their health and drug coverage, and changes take effect January 1. Families may revisit healthcare and financial decisions at the same time, so questions about Medicare coverage are likely to come up in conversations with prospects, residents, and their families.
Your team isn't expected to act as an insurance advisor, but clear, accurate answers build trust. Open Enrollment questions often come down to care planning, affordability, and timing.
What to know
A handful of facts answer many of the questions you’ll hear.
Assisted living and memory care: Medicare does not pay for room and board in assisted living or memory care. It may cover healthcare services residents receive there, but not the monthly cost of living in the community.
Skilled nursing and rehab: Families are often surprised by how limited Medicare’s skilled nursing coverage can be.
Part A may cover short-term skilled nursing care after an inpatient hospital stay of at least three consecutive days, and time under observation status or in the emergency department does not count. In 2026, days 1 through 20 cost $0 after the Part A deductible, and days 21 through 100 cost $217 a day. Medicare Advantage plans may charge copayments in the first 20 days, so families on those plans should check with their plan.
For hospital discharge referrals, one question helps families avoid a surprise bill: Was my loved one admitted as an inpatient, or placed under observation?
Medicaid has limits too. Like Medicare, Medicaid generally does not cover room and board costs in assisted living. Some states offer waiver programs that help with services, and the rules vary by state.
What to say
Listen first. A family asking about Medicare may be worried about cost, confused by a pile of plan mail, or hoping the answer is different from what they’ve heard. Ask what they’ve been told and what they’re hoping for before you answer.
Say the hard part plainly. If Medicare won’t cover the monthly cost, say so kindly and early. Families trust you more when you identify funding gaps early instead of letting them find out later.
Stay in your lane. Your team can explain what Medicare generally covers. It shouldn’t recommend a specific plan. Point families to the experts who can help: the State Health Insurance Assistance Program (SHIP), which offers free counseling, or 1-800-MEDICARE. Check with your compliance team on what your community’s counselors can and can’t say about plans and insurance.
Here’s language a counselor can use:
“Medicare doesn’t pay for room and board or day-to-day help in assisted living, so many families look at a mix of sources. I can’t advise on which Medicare plan to choose, but your State Health Insurance Assistance Program can, and it’s free. I’m glad to walk you through how families in our community typically cover the monthly cost. Would that be helpful?”
Move to a funding plan. Once you've answered the Medicare question, shift the conversation to the bigger issue: how the family plans to pay for care.
Depending on the situation, funding sources can include private funds, long-term care insurance, state Medicaid waiver programs, and, for veterans and surviving spouses, the VA Aid and Attendance benefit. Be clear that eligibility varies and that an elder law attorney or financial advisor can help with specifics.
Use Open Enrollment as a reason to follow up
Because Medicare questions are often care-funding questions, Open Enrollment can also be an opportunity to restart conversations that have stalled over cost.
A few ways to put that to work:
Reach out to prospects who stalled after a pricing conversation with a short, low-pressure check-in. Ask whether coverage questions came up and whether you can help answer them.
Log what you learn. Note the funding question on the prospect’s record, and update Expected Move Time if the family’s timeline shifted. AI Snapshot will then surface those details before your next call.
Schedule the next touchpoint with a date attached. December 8, the day after Open Enrollment closes, is a natural time to ask how the decision went. For families who say they need more time, set a January activity in the Activities Tab.
A note for home care teams
Home care agencies may see a different set of questions. The GUIDE model from CMS is a voluntary Medicare program that supports dementia care at home through care planning, caregiver training and support, and a 24/7 care navigator. It doesn’t reimburse custodial care hours directly, so families may still ask what else is available. We wrote a four-part series on GUIDE covering how agencies can work within the program.
The bottom line
Behind many Medicare questions is a simpler one: can we afford the next step? A counselor who answers plainly, points to the right free resources, and follows up on time is doing that family a service.
