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AHIP Medicare

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  • Medicare is a health benefits program for U.S. citizens or permanent residents:
    • Age 65 or older
    • Under age 65 with certain disabilities
      • Includes citizens determined to be disabled with Amyotrophic Lateral Sclerosis (ALS), often referred to as Lou Gehrig’s Disease; or to be disabled based on exposure to environmental health hazards are entitled to Medicare the month they are deemed to be disabled.
    • For all ages with end-stage renal disease (ESRD)
  • History – Medicare was signed into law in 1965. A brief history of Medicare is available at http://www.cms.gov/History/
  • Medicare is administered by the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services
  • Medicare law is Title XVIII of the Social Security Act: "Health Insurance for the Aged and Disabled"
    • Part A – Hospital
    • Part B – Medical
    • Part C – Medicare health plans, which must cover Part A and Part B benefits
    • Part D – Prescription drug coverage
  • Different Ways to Get Medicare
    • Original Fee-for-Service (FFS) Medicare (has two Parts – Part A and Part B)
      • Part A – Hospital, skilled nursing facility, hospice, and home health services
      • Part B – Professional services such as those provided by a doctor or non-physician professional, outpatient care, and other medical services
      • Different Ways to Get Medicare, cont’d.
      • Part C - Medicare Health Plans (Medicare Advantage plans must include Part A and Part B)
        • Health Maintenance Organizations (HMOs) (some also include Part D)
        • Preferred Provider Organizations (PPOs) (some also include Part D)
        • Private Fee-for-Service Plans (PFFS) (some also include Part D)
        • Special Needs Plans (SNPs) (always include Part D)
        • Medical Savings Account Plans (MSAs) (do not include Part D)
        • Cost and PACE Plans (not Part C MA plans - different plan types, may include Part D)
        • Employer or Union Group Plans
      Different Ways to Get Medicare, cont’d.
    • Part D – Prescription Drug Coverage
      • Stand-alone Prescription Drug Plan (PDP) or
      • Coverage in a health plan
      • Part C Medicare Health Plans
        • All Medicare Advantage (MA) plans must:
          • Cover all Part A and Part B benefits;
          • Provide plan cost-sharing actuarially equivalent to cost sharing under Medicare Parts A and B, but may be different for specific services; and
          • Include an annual maximum out-of-pocket (MOOP) limit on total enrollee cost sharing (deductibles, coinsurance, and copayments) for Part A and Part B services.
        • Extra Benefits – Medicare health plans also may cover extra benefits not covered by Original Medicare, such as:
          • Lower Cost Sharing [Note: Some plans reduce the Part B premium.]
          • Vision Services
          • Hearing Services
          • Dental Services
          • Routine foot care services
          • Chiropractic Services
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      • Medigap insurance:
        • Is sold by private insurance companies to fill "gaps" in Original Medicare coverage;
        • Works only with Original Medicare;
        • Covers all of a portion of Part A and Part B cost sharing (coinsurance, copayments, or deductibles) for beneficiaries in Original Medicare.
          • Does not cover Medicare Benefits, but works in tandem with Original Medicare coverage.
      • Some Medigap policies cover benefits not covered by Part A or Part B of Original Medicare, such as extra days of coverage for inpatient hospital care of foreign travel emergency care.

      Note: See slides "Further Information on Medigap - Medigap Plans A through N" for more information on Medigap.

Medicare Entitlement - Part A

  • Most individuals automatically get Part A coverage without having to pay a monthly premium. This is because they or a spouse paid Medicare taxes while working.
  • These individuals receive Part A coverage without paying a Part A premium.
  • For those individuals who do not automatically qualify for Part A coverage, the Part A premium in 2013 is $243 or $441 a month depending on an individual's duration of Medicare-covered employment.
  • Individuals with disabilities who are under age 65 are automatically enrolled in Part A after they have received Social Security or Railroad Retirement disability benefits for 24 months.
  • At Age 65
    • Most individuals who file an application for Social Security or Railroad Retirement benefits 3 months before they turn age 65 or later are automatically enrolled in Part B unless they refuse Part B coverage.
  • Individuals with disabilities who are under age 65 are automatically enrolled in Part B the earlier of:
    • the month they turn 65 if they have received Social Security or Railroad Retirement benefits for at least 4 months before they turn age 65, without having to fill out any additional application for those benefits. They also are given an opportunity to refuse Part B coverage.
    • the month after they have received Social Security or Railroad Retirement disability benefits for 24 months. They also are given an opportunity to refuse Part B coverage. [Note: Exception for ALS disease or environmental exposure.]
      • Beneficiaries enrolled in Part B must pay a monthly premium.
        • The standard monthly premium for Part B is $104.90 in 2013.
        • Individuals with income over $85,000, or filing jointly with incomes over $170,000, pay more, up to $335.70 a month in 2013 based on the income related monthly adjustment (IRMA).
      • Part B premiums may be deducted from Social Security checks or Railroad Retirement checks.
        • The Office of Personnel Management may offer premium deduction in the future.
          • Individuals who do not enroll in Part B when first eligible (e.g., at age 65) can enroll during a General Enrollment Period, January 1 – March 31.
            • Part B coverage begins on July 1 of the year they enroll.
            • The Part B premium is increased 10% for each full 12-month period the beneficiary could have had Part B but, did not enroll.
          • Exception: Individuals who have group health plan coverage based on their own current employment or the employment of a spouse are not subject to the premium increase and may enroll in Part B anytime while covered under the group health plan or during a special enrollment period that occurs during the 8-month period immediately following the last month of the group coverage.
            • Part C Medicare Advantage Health Plan
              • Individuals who are entitled to benefits under Part A and enrolled under Part B are eligible to enroll in a Medicare Advantage plan.
            • Part D Prescription Drug Benefits
              • Individuals who are entitled to benefits under Part A and/or enrolled under Part B are eligible for Part D prescription drug benefits.

elp for Individuals with Limited Income/Resources - Apply to State Medicaid Office

  • Beneficiaries with limited income and resources should be encouraged to apply to their State Medicaid office to determine eligibility for various programs.
  • Beneficiaries may qualify for help from the State to pay the Medicare Part A (if any) and Part B premium, the Part A and Part B deductibles and cost sharing, and/or some Part D prescription drug costs.
  • Tell them to call 1-800-Medicare (1-800-633-4227) and just say "Medicaid" for the State Medicaid telephone number
    • Beneficiaries may qualify for help through these programs:
      • Medicaid: help with health care costs. Apply to State Medicaid office.
      • Medicare Savings Program: help paying Medicare Part A and/or Part B premiums and, in some cases, deductibles and coinsurance/copayments. Apply to State Medicaid office or Social Security Administration (SSA) at 1-800-772-1213 or apply online at http://www.socialsecurity.gov/prescriptionhelp.
      • Part D low-income subsidy: help paying for prescription drug coverage. Apply to State Medicaid office and the State will check for eligibility for this and other programs such as the Medicare Savings Program. Persons interested in Part D help only also may contact the SSA.
      • Supplemental Security Income (SSI) benefits: help with cash for basic needs. Apply to State Medicaid office or SSA.
        • Part A helps cover inpatient care in hospitals that is medically necessary. In 2013, for each benefit period (as defined by Medicare) in a year, beneficiaries pay:
          • $1,184 deductible and no coinsurance for a stay of up to 60 days
          • $296 per day for days 61-90 of a hospital stay
          • $592 per "lifetime reserve day" after day 90 each benefit period (up to 60 days over your lifetime)
          • All costs for each inpatient day beyond 150 days
            • Part A also helps cover:
              • Blood
              • Hospice care
              • Home health care
              • Skilled nursing and rehabilitative care only after a three day hospital stay, up to 100 days in a benefit period (as defined by Medicare). In 2013, beneficiaries pay $148 coinsurance for days 21-100 each benefit period.
              • Inpatient psychiatric care (up to 190 lifetime days)
            • Part A does not cover custodial or long-term care.
            • Cost-sharing may differ for enrollees of Medicare health plans.
            • Medicare Part B Benefits
              • Generally cover medically necessary physician and other health care professional services, outpatient hospital, clinical lab and diagnostic tests, therapies, mental health care, medical equipment, and medications and supplies provided incident to a physician service.
              • Beneficiaries pay a deductible each year ($147 in 2013), and after the deductible is satisfied, 20% coinsurance on most Part B covered services.
              • Cost-sharing may differ for enrollees of Medicare health plans.
                • Beneficiaries will have no cost-sharing for most preventative services.
                • Preventative Services Include:
                  • One-time "Welcome to Medicare" physical exam
                  • Annual wellness visit after 12 mos. enrolled in Part B
                  • Immunizations – pneumococcal, hepatitis B, annual flu shot, H1N1
                  • Abdominal aortic aneurysm screening – one time, with referral>
                  • Alcohol misuse screening - every 12 months for certain individuals
                  • Bone mass measurement – every 24 months for certain conditions
                  • Cardiovascular screening blood tests – every five years for all persons
                    • Colorectal cancer screening – four different tests, vary in frequency
                    • Depression Screening - every 12 months
                    • Diabetes screenings – up to two per year for those with risk factors
                    • Diabetes self-management training - for persons with diabetes
                    • Glaucoma testing - once per year for those at high risk
                    • HIV Screening
                    • Intensive Behavioral Therapy for Cardiovascular Disease -one face-to-face visit annually in a primary care setting
                    • Mammogram (Breast Cancer Screening) - annual screening for most women
                    • Medical nutrition therapy - for those with diabetes/kidney disease or kidney transplant
                    • Medicare Part B Benefits - Preventative Services and Screenings (3 of 3)
                      • Obesity Screening and counseling - for certain individuals
                      • Pap test and pelvic examination - every 24 mos. for all women; every 12 mos. for those at high risk
                      • Prostate cancer screening - every 12 mos. for men over age 50
                      • Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling to Prevent STIs - for certain individuals
                      • Smoking cessation counseling - for any illness related to tobacco use
                      • Other Part B Items and Services, Part 1 of 2
                        • Ambulance services

                        • Ambulatory surgical center fees

                        • Blood

                        • Cardiac rehabilitation–for certain situations

                        • Chiropractic services–for limited situations

                        • Clinical laboratory services

                        • Clinical research studies – some costs of certain care in approved studies

                        • Defibrillator (implantable automatic)

                        • Diabetic supplies

                        • Durable medical equipment – restricted to certain suppliers in some areas

                        • Emergency room services

                        • Eyeglasses after cataract surgery – limits apply
                        • her Part B Items and Services, Part 2 of 2
                          • Foot exams and treatment for certain diabetics
                          • Hearing and balance exams (no hearing aids)
                          • Home health services in certain situations
                          • Kidney dialysis and disease education – certain situations
                          • Mental health care (outpatient) – limits apply
                          • Occupational and physical therapy – limits apply
                          • Pulmonary rehabilitation for COPD
                          • Prosthetic/Orthotic items
                          • Second surgical opinions
                          • Speech-language pathology services
                          • Telehealth services in some rural areas
                          • Tests like X-rays, MRIs, CT scans
                          • Transplant physician services and drugs
                          • ot Covered by Medicare Part A & B
                            • Acupuncture

                            • Dental care/dentures

                            • Cosmetic surgery

                            • Custodial care

                            • Health care while traveling outside the US – exceptions apply

                            • Hearing aids

                            • Orthopedic shoes

                            • Outpatient prescription drugs (this is covered under Part D)
                            Medicare part a pays 180 days of phsyciatric care
                            • Routine foot care

                            • Routine eye care and eyeglasses

                            • Some screening tests and labs

                            • Vaccines, except as previously listed (those not covered under Part B are covered under Part D)

                            • Syringes and insulin unless inpatient psychiatric hospitalused with an insulin pump (this is covered under Part D)
  • A beneficiary in Original Medicare may receive Part D prescription drug coverage through a stand-alone prescription drug plan (PDP).

  • A beneficiary may also leave Original Medicare and receive drug coverage through a Medicare Advantage health plan (MA-PD) or sometimes through a Medicare Advantage (MA) plan and a separate PDP.

  • Generally, with the exception of those dually eligible for Medicare and Medicaid, Medicare beneficiaries must actively select a Part D plan.
  • Original Medicare and Part D Prescription Drug Coverage, cont’d.
    • Annual Enrollment Period - is October 15 to December 7
    • Cost - Beneficiaries who enroll in Part D typically pay a monthly premium, annual deductible and per-prescription cost-sharing.
      • Extra help is available for low-income beneficiaries.
      • In 2013, beneficiaries with income above $85,000 (individual) or $170,000 (couple) pay an income-related monthly adjustment (IRMA) amount in addition to the Part D premium.
    • Penalty for late enrollment:
      • There is a permanent premium penalty of 1% of the national standard premium for every month that a beneficiary could have had Part D coverage, or equivalent creditable coverage and chose not to enroll. There is no penalty for individuals who qualify for low-income assistance.
      • For More Information about Medicare

        Note: Original Fee-for-Service (FFS) Medicare is also referred to as Original Medicare or the Original Medicare Plan

        Skip Download Content Materials
        Download Content Materials

        Please note, downloadable materials are available as an offline resource and benefit to our users. Accessing and printing of these materials is not recognized by the system to administer a completion status.

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        Skip Further Information on Medigap (Medicare Supplement Insurance)
        Further Information on Medigap (Medicare Supplement Insurance)
        • Medigap is health insurance sold by private insurance companies to fill gaps in Original Medicare coverage.
        • Medigap helps pay all or a portion of Part A and Part B coinsurance, copayments, and/or deductibles when Original Medicare determines that a benefit is medically necessary. Some Medigap plans also cover benefits not covered by Original Medicare.
        • Medigap policies are available in standardized benefit plans, identified by the letters A - N (different plans are offered in Massachusetts, Minnesota, and Wisconsin).
        • Turning age 65 and signing up for Part B triggers a six-month Medigap open enrollment period when Medigap plans must be issued, regardless of any pre-existing conditions, called a guaranteed issue right. In limited circumstances, leaving a Medicare Advantage plan will trigger a guarantee issue opportunity. Some states have guarantee issue for Medicare beneficiaries under age 65.
        Medigap Coverage

        Most Medigap plans pay for some or all of the following costs:

        Part A

        Part B

        Other

        • < >Part A Coinsurance and Hospital BenefitsPart A DeductibleCoverage for 365 Additional Hospital Days when Medicare coverage endsHospice Care Coinsurance or CopaymentSkilled Nursing Facility Care CoinsurancePart B Coinsurance or CopaymentPart B DeductiblePart B Excess ChargesBlood (First 3 pints) (also under part A)Foreign Travel Emergency not covered by Medicare
        • Non-Medicare-covered Preventive Services
        • Beneficiaries in Original Medicare with Medigap Drug Coverage
          • Medigap plans H, I, and J with drug coverage could no longer be sold as of January 1, 2006.
          • Some beneficiaries may have decided to keep their H, I, or J policy with the drug coverage they had before January 1, 2006. Insurers are required to notify beneficiaries annually whether or not the prescription drug coverage they have is creditable (coverage that expects to pay, on average, at least as much as Medicare's standard Part D coverage expects to pay).
          • If these beneficiaries choose a Part D plan now, they must pay a Part D late enrollment penalty unless their Medigap coverage was creditable. To enroll in Part D these beneficiaries may:
            • Keep their Medigap coverage with the drug portion of the coverage removed and enroll in a Part D PDP plan; OR
            • Drop their Medigap coverage and enroll in a MA-PD or other health plan with a PDP.

          Note: See also Part 3, "Medicare Part D Prescription Drug Coverage."

          • Medigap is NOT a Medicare Advantage health plan or other Medicare health plan.

          • Medigap supplements Original Medicare benefits only.

          • In addition
            • A Medigap plan cannot be used with a Medicare Advantage health plan.
            • It is illegal to sell a Medigap plan to someone already in a Medicare Advantage health plan.
              • Types of coverage that are NOT Medigap policies
                • Medicare Part A or Part B
                • Medicare Advantage Plans (Part C), such as an HMO, PPO, PFFS, SNP, or MSA
                • Medicare Cost Plans
                • Medicare Prescription Drug Plans (Part D)
                • Medicaid
                • Employer or union plans
                • TRICARE
                • Veterans' Administration (VA) benefits
                • Long-term care insurance policies
                • Indian Health Service, Tribal and Urban plans
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              ecent Changes in Medigap
              • Plans E, H, I, and J are no longer sold after May 31, 2010, but beneficiaries with those plans may keep them.

              • Plans M and N are new choices.

              • New policies effective on or after June 1, 2010, will cover Hospice Part A coinsurance or copayment. Plan K will cover 50%, and Plan L will cover 75% of these costs.

              • Plans D and G bought on or after June 1, 2010 have different benefits than D or G plans bought before June 1, 2010, but benefits won't change for beneficiaries who had these policies before June 1, 2010.

Medicare Health Plans

  • Under the Medicare Advantage (MA) program, private companies offer health plans that cover all Medicare Part A and Part B benefits.
    • Many also cover Part D prescription drug benefits (MA-PD plans).
    • All MA plans offer a maximum out-of-pocket limit.
    • Many MA plans also offer extra benefits that Medicare does not cover.
  • The types of Medicare Advantage (MA) plans are:
    • Health Maintenance Organizations (HMOs), some have a point-of-service (POS) benefit;
    • Preferred Provider Organizations (PPOs), local and regional;
    • Private Fee-for-Service (PFFS) Plans;
    • Special Needs Plans (SNPs); and
    • Medical Savings Account (MSA) Plans.
  • Medicare Cost Plans, PACE plans, Demonstration and Pilot programs, and Employer/Union Group Plans are other types of Medicare health plans.
  • Eligibility
    • A beneficiary must be entitled to Part A and enrolled in Part B.
    • The beneficiary must live in the MA plan's service area.
    • MA plans must enroll any eligible beneficiary who applies regardless of health status, except that:
      • Generally, beneficiaries are not eligible if they have end-stage renal disease (ESRD) unless they were enrolled in a health plan offered by the same organization before becoming eligible for Medicare or their enrollment was terminated due to the plan's termination, non-renewal, or service area reduction.
      • Special Needs Plans (SNPs) must limit new enrollments to beneficiaries who meet specified plan eligibility criteria (e.g., beneficiaries who are dual eligible, have specified chronic conditions, or reside in institutions or live in the community, but require institutional level of care).
    • A beneficiary must continue to pay his/her Part B premium.
    • In addition, the beneficiary may need to pay an MA plan premium.
    • Help for Individuals with Limited Income/Resources - Apply to State Medicaid Office
      • Beneficiaries with limited income and resources should be encouraged to apply to their State Medicaid office to determine eligibility for various programs: Tell them to call 1-800-Medicare (1-800-633-4227) and say "Medicaid" for the State Medicaid telephone number.
      • Beneficiaries may qualify for help from the State or CMS to pay:
        • The Medicare Part A and Part B premiums;
        • The Part A and Part B deductibles and cost sharing;
        • Some Part D prescription drug costs; and/or
        • Some benefits not normally covered by Medicare, such as help with personal care and rides to doctor appointments.
        • Help for Individuals with Limited Income/Resources - Apply to State Medicaid Office
        • Beneficiaries may qualify through these programs by applying to the State Medicaid office.
          • Medicaid: help with health care costs.
          • Medicare Savings Program: help paying the Medicare Part B premium and, in some cases, deductibles and coinsurance.
          • Part D low-income subsidy: help paying for prescription drug coverage. The State Medicaid office will check eligibility for this and other programs such as the Medicare Savings Program. Persons interested in Part D help only may call the Social Security Administration (SSA) at 1-800-772-1213 or apply online at www.ssa.gov/prescriptionhelp.
          • Supplemental Security Income (SSI) benefits: help with cash for basic needs. You also may apply through SSA.
MA Plan Types: Coordinated Care Plans – HMOs
  • Generally, HMO enrollees must use plan network doctors and hospitals within the plan's service area to receive most covered services.
    • Emergency and urgently needed services received outside of the plan network are covered.
    • When the enrollee is temporarily absent from the plan's service area, dialysis services are covered.
    • In most other cases, if enrollees get care out-of-network without prior approval from the plan, they will have to pay for it themselves.
  • HMOs must have a maximum limit on member out-of-pocket costs of not greater than $6,700 per year and many plans have lower limits.
  • MA Plan Types: Coordinated Care Plans – HMOs, cont’d.
    • Some HMOs offer a Point of Service (POS) Option that allows enrollees to go to non-plan doctors and hospitals generally without receiving prior approval for certain services.
      • Cost sharing is generally higher than for services obtained from network providers.
    • Enrollees may need to select a primary care doctor and may need a referral for specialty care.

    • If an enrollee needs a type of specialist who is not in the plan's network, the plan will arrange for care outside of the network.
    • MA Plan Types: Coordinated Care Plans – PPOs
      • PPO enrollees generally may get care from any provider in the U.S. who accepts Medicare, but will pay less if they go to one of the "preferred" providers in the PPO's network.

      • Enrollees usually will pay higher cost-sharing if they get care from a non-preferred provider.

      • PPOs must have a maximum limit on member out-of-pocket costs for network providers of not greater than $6,700 per year and an aggregate limit on network and non-network costs of $10,000.

      • Enrollees do not need a referral to see a specialist or out-of-network provider, but may be encouraged to contact the plan to be sure the service is medically necessary and will be covered
      • MA Plan Types: Coordinated Care Plans – SNPs
        • Special Needs Plans must limit new enrollments to certain sub-populations of beneficiaries. SNPs are the only plan type that can limit enrollment to these populations. Types of SNPs include:
          • Dual Eligible SNPs – serve beneficiaries eligible for both Medicare and Medicaid (dual eligibles);
          • Chronic Care SNPs – serve beneficiaries with certain severe or disabling chronic conditions, such as diabetes; and
          • Institutional SNPs – serve beneficiaries in long-term care facilities within the plan's network as well as beneficiaries living in the community, but requiring an institutional level of care.
        • All SNPs provide Part D prescription drug coverage.
        • MA Plan Types: Private Fee-for-Service (PFFS) Plans
          • PFFS enrollees may receive covered services from any provider in the U.S. who participates in Medicare and agrees to accept the plan's terms and conditions of payment.

          • Some PFFS plans contract with network providers and if the PFFS plan has a network, enrollees usually pay more if they see out-of-network providers.

          • Except for emergencies, enrollees must inform providers before receiving services that they are PFFS plan members so the non-network providers can decide whether to accept the plan's terms and conditions.

          • Non-network providers may, on a patient-by-patient, and visit-by-visit basis decide whether to treat the beneficiary.

          • Non-network providers that accept Original Medicare may choose not to accept PFFS plan enrollees.
          • MA Plan Types: Private Fee-for-Service Plans, cont’d.
            • PFFS is not the same as the Original Medicare plan that is offered by the Federal Government.

            • PFFS is not a Medicare supplement, Medigap, Medicare Select policy, or stand-alone Prescription Drug Plan.
            • MA Plan Types: Private Fee-for-Service Plans, cont’d.
              • PFFS plan options available to beneficiaries may include:
                • PFFS plan offering only Medicare A/B benefits;
                • PFFS plan that combines Medicare A/B and Part D prescription drug benefits (MA-PD plan); or
                • PFFS plan offering Medicare A/B benefits and a stand-alone Part D prescription drug plan (PDP).
                • MA Plan Types: Private Fee-for-Service Plans, cont’d.
                  • PFFS plans generally pay non-network providers the same amount Original Medicare would pay them.
                    • The amount the plan pays is specified in the plan's terms and conditions of payment.
                  • Providers are not permitted to charge the enrollee more than the cost sharing specified in the PFFS plan's terms and conditions of payment.
                  • Cost sharing may include a deductible and copayment or coinsurance.
                  • Cost sharing may include balance billing up to 15% of the Medicare rate only if allowed in the plan's terms and conditions of payment.
                  • PFFS plans must have a maximum limit on member out-of-pocket costs for network and non-network providers of not greater than $6,700 per year.
                  • MA Plan Types: Medical Savings Account (MSA) Plans
                    • A Medicare Medical Savings Account is a high deductible health plan combined with a savings account for health care expenses. Medicare makes a contribution to the beneficiary's savings account.
                    • MSA enrollees pay for health care expenses from the savings account and then out-of-pocket until the annual deductible is met, after which the plan pays 100% for covered services.
                      • The maximum deductible for MSA plans in 2014 is $11,200.
                    • MSAs cover Part A and Part B benefits, but not Part D Medicare prescription drug benefits.
                    • Beneficiaries may enroll in a stand-alone PDP.
                    • Enrollees pay the Part B premium but no plan premium except for any premium for supplemental benefits.
    • MA Plan Types: MSA Plans, cont’d.
      • Enrollees may receive covered services from any Medicare approved provider in the U.S.

      • MSAs may not have a network or MSAs may have a network of providers who will provide services at lower costs.

      • All providers must accept the same amount that Original Medicare would pay them as payment in full.

      • MSA plans must offer coverage of preventive services before the enrollee has met the deductible.

      • Note: MSA demonstration plans may no longer be sold for enrollments effective as of January 1, 2012.
      • Other Medicare Health Plans
        • Medicare 1876 Cost Plans
          • Cost plan enrollees can choose to receive Medicare-covered services:
            • Under the plan's benefits by going to plan network providers
              • Plan cost sharing applies
            • Under Original Medicare by going to non-network providers
            • Original Medicare cost sharing applies
          • Cost plans may offer Part D prescription drug coverage as an optional benefit.
          • Cost plans may offer other optional supplemental benefits
            • Programs of All-Inclusive Care for the Elderly (PACE)
              • A Medicare plan for frail, elderly beneficiaries
              • Available in limited areas of the country
              • Include comprehensive medical and social service delivery systems using an interdisciplinary team approach in an adult day health center, supplemented by in-home and referral services
              • Other Medicare Health Plans, cont’d
                • Employer/Union Plans
                  • Employers and unions:
                    • May offer retirees Medicare Advantage individual or group plans sponsored by an MA HMO, PPO, or PFFS plan.
                    • May contract directly with CMS to offer an MA plan to its retirees.
                    • Usually cover Medicare-eligible spouses and dependents.
                  • Plan options vary depending on the employer or union.
                  • Beneficiaries should check with their employer or union group benefits administrator before changing plans to avoid losing coverage they want to keep.
                  • Some beneficiaries may be able to use their employer or union coverage along with a Medicare plan.
                    • Marketing representatives must:
                      • Market only health care related products during any MA or Part D sales activity or presentation.
                      • Prior to any marketing appointment, clearly identify the types of product(s) that will be discussed, obtain agreement from the beneficiary and document that agreement.
                        • Documentation for appointments resulting from a sales presentation must be in writing using a "Scope of Appointment" form.
                        • For appointments made over the phone, required documentation is a recording of the call. The call must be placed by the plan sponsor, NOT the marketing representative/agent/broker.
                      • During appointments scheduled in response to a reply card, only discuss the products included in the reply card in which the beneficiary has indicated interest.
                      • A plan sponsor or agent may not agree to the scope on behalf of the beneficiary.
                        • In order to discuss a health care line of business not covered in the pre-appointment documentation, the marketing representative must ask the beneficiary to complete a new scope of appointment form that includes the additional product(s) and must wait at least 48 hours after the initial visit before returning for the second appointment.
                          • Marketing representatives may leave plan brochures for the other lines of business but may not discuss or conduct marketing activities related to them.
                          • Enrollment applications for the additional lines of business may not be included in any materials provided during the initial appointment.
                        • Exception: If during an individual appointment a beneficiary specifically asks to discuss another product type, he or she must sign a new scope of appointment form that includes the new product type, and the marketing representative may then discuss the additional product during the same appointment.
                        • Required Practices: Scope of Appointment, cont'd
                          • Sales presentations open to the public do not require documentation of prior beneficiary agreement to the scope of the presentation, but event advertising materials must indicate what products will be discussed at that time.
                            • A beneficiary may sign a scope of appointment form at a marketing presentation for a follow-up appointment.
                          • When a beneficiary initiates contact, for example, by walking into a marketing representative's office, or attending a sales appointment properly set up for another individual, the marketing representative should document their agreement to the scope of the appointment, note that the beneficiary was a "walk-in," and may then present the appropriate information.
                          • Records of beneficiary agreement to the scope of an appointment must be retained for ten (10) years.
                            • Prohibited telephonic activities include:
                              • Bait-and-switch strategies such as making unsolicited outbound calls to beneficiaries about other business as a means of generating leads for Medicare plans. Examples of other lines of business include discount prescription drug card, Medigap plan, needs assessment, educational event, a review of Medicare coverage options, or any other service that is not an MA plan or PDP.
                              • Calls to beneficiaries based on referrals resulting in an unsolicited contact (e.g., referrals from friends, relatives, neighbors, or companies that collect, buy, or sell contact information). Marketing representatives may provide their contact information (e.g., business cards) to friends and others who wish to make referrals, so that the referred beneficiary can contact the agent directly.
                                • Prohibited telephonic activities include:
                                  • Calls for marketing purposes to former members who have disenrolled or are disenrolling;
                                  • Calls or visits to beneficiaries who attended a sales event, unless explicit permission was given by the beneficiary for the call or visit; and.
                                  • Calls to confirm receipt of mailed information
                                    • Outbound call scripts must
                                      • Be submitted for CMS review and approval;
                                      • Include a privacy statement clarifying the beneficiary is not required to provide any health-related information to the plan's representative unless it will be used to determine enrollment eligibility, such as for Special Needs Plans (SNPs); and
                                      • Clarify that failure to provide information will in no way affect the beneficiary's membership in the plan, but that Medicaid status or presence of a condition status will be needed to confirm eligibility for a dual eligible or chronic care SNP, respectively.
                                        • If during the course of an outbound call by a Medigap issuer, a beneficiary requests additional information on a MA or PDP product, the agent may have the discussion ONLY if the call is being recorded.
                                        • Third parties may not make unsolicited MA or PDP marketing calls to set up appointments with potential enrollees (other than to current plan members when contracted by the plan), for example:
                                          • Third parties may not make unsolicited calls to provide a "benefits compare" meeting and provide those contacts to plans for ultimate use as an MA or PDP appointment.
                                          • Third parties may not set up an appointment to discuss Medigap policies and use the appointment to discuss MA and PDP products unless the third party complies with CMS' scope of appointment guidance.
                                            • Outbound calls must NOT include:
                                              • Requests for beneficiary identification numbers including SSN, bank account, credit card, Health Insurance Claim Number (HICN) or birth date through pre-enrollment scripts.
                                              • Any statement that implies the plan is endorsed by Medicare, calling on behalf of Medicare, or calling for Medicare
                                              • Marketing to Establish a New Relationship vs. to Current Clients
                                                • CMS distinguishes between telephonic contact with a beneficiary to establish a new relationship and contact where a business relationship already exists with the marketing representative.
                                                • When contacting a beneficiary by telephone to establish a new relationship when the beneficiary has given permission for the contact (e.g., by filling out a business reply card), a consent for future contact must be limited in scope, short-term, and event-specific, not open-ended.
                                                • When contacting one's clients or for plan's contacting current plan members, consent for each specific contact is not required to discuss plan business.
                                                • General Audience Marketing
                                                  • General audience marketing includes direct mail, newspaper, magazines, television, radio, yellow papers, and the Internet
                                                  • Rules regarding unsolicited contacts do not apply to the marketing of these materials
                                                  • All these materials are subject to CMS approval and content requirements:
                                                    • Exception: Agents/Brokers may generate and use materials that are "generic in nature," without prior submission, but such materials must not discuss content specific to plan benefits; discuss plan cost-sharing; or include plan name.
                                                  • For rules with regard to prior announcements at sales events, see slides Medicare Marketing Rules: Marketing or Sales Events.
                                                    • Marketing representatives must NOT:
                                                      • Send e-mail to a beneficiary, unless the beneficiary agrees to receive e-mail from the plan and has provided his/her e-mail address to the plan.
                                                      • Rent or purchase an e-mail list to solicit or to distribute plan information.
                                                      • Acquire e-mail addresses through any type of directory.
                                                      • Send e-mail to prospective enrollees at an e-mail address obtained through friends or referrals.
                                                    • Note: Plan sponsors must provide an opt-out process for beneficiaries who no longer wish to receive e-mail communications.
                                                    • Required Practices: Marketing Activities, cont’d.
                                                      • Marketing representatives must:
                                                        • Provide to prospective enrollees only CMS-approved plan marketing materials or CMS marketing materials.

                                                          • Exception: Agents/Brokers may generate and use materials that are "generic in nature," without prior submission (for example business cards indicating types of products he/she is selling). Such materials must not discuss content specific to plan benefits; discuss plan cost-sharing; or include the plan name.
                                                        • Include with the marketing materials that include an agent's/broker's phone number a statment saying that calling the number will direct the individual to a licensed insurance agent/broker
                                                        • Use only CMS-approved plan marketing scripts and presentations.
                                                        • If gifts or prizes are offered, state clearly that there is no obligation to enroll. (Note: Gifts or prizes may not exceed $15 in retail value or in aggregate throughout the year, $50 or less )
                                                        • Prior to, or at the time of enrollment, inform the beneficiary in writing of their relationship with the plan they represent, including potential for compensation based on the beneficiary's enrollment.
                                                        • Required Practices: Required Materials with an Enrollment Form
                                                          • When a beneficiary is provided with enrollment instructions/form, he/she must also receive:
                                                            • Plan ratings information (See slides titled "Plan Ratings")
                                                            • Summary of Benefits; and
                                                            • Multi-language insert, which alerts beneficiaries that translated materials are available.
                                                          • When a beneficiary enrolls in a plan online, the plan sponsor must make these materials available electronically, (e.g., via website links) to the potential member prior to the completion and submission of the enrollment request
                                                          • Required Practices: Required Materials at the Time of Enrollment and Thereafter
                                                            • Plans mustprovide the following materials to new members at the time of enrollment and to renewing members annually:
                                                              • Annual Notice of Change/Evidence of Coverage (ANOC/EOC) or EOC as applicable
                                                              • Comprehensive or abridged formulary (Part D sponsors only)
                                                              • Pharmacy directory (Part D sponsors only)
                                                              • Provider directory (Part D sponsors excluded)
                                                              • Membership ID Card
                                                              • Part D low income subsidy (LIS) rider
                                                            • With the exception of the LIS rider, the materials must be provided within 10 days of confirmation of enrollment or by the last day of the month prior to the effective date, whichever is later
                                                            • Required Practices: Plan Ratings
                                                              • CMS releases plan ratings that allow beneficiaries to compare MA plans and Part D plans. These ratings include categories, such as detecting and preventing illness, member satisfaction, and customer service.
                                                              • Beneficiaries who have access to the Internet may obtain plan rating information at http://www.medicare.gov.
                                                                • Click the "Health & Drug Plans" button on the left.
                                                                • Required Practices: Plan Ratings, cont’d
                                                                  • Plan sponsors must provide the plan’s overall performance ratings to beneficiaries in the standard Plan Ratings information document.
                                                                    • The document must be provided with any enrollment form and/or Summary of Benefits and must also be available on plan sponsors’ websites.
                                                                    • CMS generally issues plan ratings in October of each year, and plan sponsors must update their ratings within 15 days of the release.
                                                                    • Plan sponsors with an overall 5-star rating have the option to include CMS’ gold star icon on marketing materials.
                                                                    • Plan sponsors must include the following statement on all materials referencing Plan Ratings information:
                                                                      • “Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next."
                                                                        • Plan sponsors and their marketing representatives may:
                                                                          • Reference a plan's ratings on an individual measure in conjunction with the plan's overall performance rating.
                                                                          • Use the plan's star ratings in a manner that does not mislead beneficiaries into enrolling in plans based on inaccurate information.
                                                                        • Plan sponsors with an overall 5-star rating may market year-round under a special election period (SEP).
                                                                        • If a plan sponsor with an overall 5-star rating is assessed a lower rating for the upcoming year, the sponsor must stop marketing under the SEP by November 30 of the current year.
                                                                        • CMS notifies enrollees in these plans that if they do not make a change during the Annual Election Period, they have a one-time chance to switch to a plan with 3 stars or more by calling 1-800-MEDICARE begin_of_the_skype_highlighting 1-800-MEDICARE FREE end_of_the_skype_highlighting. This does not create an opportunity for marketing.
                                                                        • Plan sponsors with a rating below 3 stars for three consecutive years receive a low performer icon (LPI)
                                                                        • CMS notifies enrollees in these plans that if they do not make a change during the Annual Election Period, they have a one-time chance to switch to a plan with 3 stars or more by calling 1-800-MEDICARE begin_of_the_skype_highlighting 1-800-MEDICARE FREE end_of_the_skype_highlighting. This does not create an opportunity for marketing
                                                                          • Plan sponsors and their marketing representatives may not:
                                                                            • Use a plan’s star rating in an individual category or measure to imply a higher overall plan rating than is actually the case.
                                                                              • For example, a plan which received a 5-star rating in customer service promotes itself as a “5-star plan,” when its overall plan rating is actually only 2-stars.
                                                                            • If it has received a low performer icon (LPI), mention its star rating without also mentioning its LPI.
                                                                            • Use references to the poor performance rating of a beneficiary’s plan in marketing. The option for beneficiaries in poor performing plans to request a special enrollment period does not create an opportunity for marketing.
                                                                            • Required Practices: PFFS Marketing Activities
                                                                              • PFFS materials for potential members, including presentations, must include the following disclaimer:
                                                                                • "A Private Fee-for-Service plan is not a Medicare supplement plan. Providers who do not contract with our plan are not required to see you except in an emergency."
                                                                              • PFFS marketing representatives should:
                                                                              • Explain that if a beneficiary obtains a service not covered under the PFFS plan benefits because it is not medically necessary, the beneficiary is responsible for the entire cost of the service.
                                                                              • Explain that an an enrollee (or his or her providers) may obtain a written advance coverage determination from the plan before obtaining a service to confirm if the service is medically necessary or will be covered by the plan.
                                                                              • Marketing representatives must NOT:
                                                                              • Market any non-health care related products (such as annuities and life insurance) during any MA or Part D sales activity or any other marketing activity for existing members as required under HIPAA Privacy Rules. This is considered cross-selling.

                                                                                • Dental coverage is considered medical/health related.
                                                                                • Plans may sell non-health related products on inbound calls only when a beneficiary requests information on other non-health products
                                                                                • Prohibited Practices: Marketing Activities, cont'd
                                                                                  • Marketing representatives must NOT:
                                                                                    • Return uninvited to an earlier “no show” appointment.
                                                                                    • Require potential enrollees to interact with a licensed agent in order to obtain plan materials or to enroll in a plan if the enrollee is not asking for advice or counseling.
                                                                                    • Require a face-to-face appointment to provide plan information or enroll the beneficiary.
                                                                                  • Plan sponsors must not pay agents unless they:
                                                                                    • Are appointed to sell in the State (if required),
                                                                                    • Have been annually trained,
                                                                                    • Have obtained a passing score on the training program selected by the Plan sponsor and
                                                                                    • Have not been terminated for cause by the Plan sponsor.
                                                                                    • EXCEPTION: when the Plan sponsor or the agent has elected to terminate the contract, the language in the contract will determine whether the agent will be entitled to renewal payments for existing business.
                                                                                      • Marketing representatives must NOT:
                                                                                        • Solicit enrollment applications prior to the start of the annual election period on October 15;
                                                                                        • Engage in marketing prior to October 1, including adding content to websites and use of social/electronic media.
                                                                                        • Create their own plan specific marketing materials;
                                                                                        • Charge beneficiaries marketing or administrative fees;
                                                                                        • Encourage individuals to enroll based on their health status unless the plan is a special needs plan that focuses on the beneficiary's particular condition;
                                                                                        • Conduct health screening or other activities that could give an impression of "cherry picking."
                                                                                          • Marketing representatives must NOT engage in agressive marketing, which includes prohibited marketing practices that have a high likelihood of misleading beneficiaries and causing harm, such as:
                                                                                            • High pressure sales tactics and scare tactics;
                                                                                            • Bait and switch strategies such as making unsolicited outbound calls to beneficiaries about other lines of business as a means of generating leads for Medicare plans
                                                                                            • Door-to-Door solicitation; and
                                                                                            • Engaging in activities that could mislead or confuse beneficiaries, such as claiming that a Medicare health plan is endorsed by Medicare or that Medicare recommends the beneficiary should enroll in the plan.
                                                                                              • Marketing representatives must NOT:
                                                                                                • Provide false or misleading information about the plan, including benefits, provider rules, and all other plan information.
                                                                                                • Claim that Medicare, CMS, or any government agency endorses or recommends the plan.
                                                                                                • Lead beneficiaries to believe that the broker or agent works for Medicare, CMS or any government agency.
                                                                                                  • PFFS marketing representatives must NOT:
                                                                                                    • Say that a PFFS plan is the same as Original Medicare or a Medigap plan.
                                                                                                    • Lead beneficiaries to believe they are purchasing a stand-alone PDP rather than a PFFS plan
                                                                                                    • Use any materials or make any presentations that imply PFFS plans function as Medicare supplement plans or use terms such as "Medicare Supplement replacement."
                                                                                                  • PFFS marketing representatives may:
                                                                                                  • Clarify that the PFFS plan does not pay after Medicare pays its share, but rather, it pays instead of Medicare and the beneficiary pays any applicable cost-share or co-pay.
                                                                                                  • Prohibited Practices: Marketing Activities, cont’d
                                                                                                    • Marketing representatives must NOT:
                                                                                                      • Assert that their plan is the "best" plan.
                                                                                                      • Make explicit comparisons between their plan benefits and those of other named plans, unless they have written concurrence from all plan sponsors being compared.
                                                                                                    • Marketing representatives may refer to the results of studies or statistical data in relation to customer satisfaction, quality, or cost as long as specific study details and information on the relationship with the entity that conducted the study are given.
                                                                                                      • Marketing representatives must NOT:
                                                                                                        • Offer gifts or prizes to potential enrollees during the marketing presentation that exceed $15 retail value.
                                                                                                        • Offer rebates or other cash or monetary inducements of any sort to entice beneficiary enrollment.
                                                                                                        • Offer post-enrollment promotional items that in any way compensate beneficiaries based on their utilization of services.
                                                                                                        • Provide any meal, or allow any other entity to provide or subsidize a meal at any event or meeting in which plan benefits are discussed or materials distributed, although light snacks are permitted. This prohibition on meals at marketing events applies to both existing enrollees and potential enrollees.
                                                                                                        • ]
                                                                                                          Light Snacks versus Prohibited Meals
                                                                                                          • Marketing representatives should contact their plan sponsor regarding the appropriateness of the food products provided and must ensure that items provided could not be reasonably considered a meal and/or that multiple items are not being "bundled" and provided as if a meal.
                                                                                                          • Examples of foods that may be considered "light snacks" include:
                                                                                                            • Fruit and raw vegetables
                                                                                                            • Pastries and muffins
                                                                                                            • Cookies or other small bite-size dessert items
                                                                                                            • Crackers
                                                                                                            • Cheese
                                                                                                            • Chips
                                                                                                            • Yogurt
                                                                                                            • Nuts
                                                                                                              • Marketing representatives cannot say:
                                                                                                                • The government wants you to join our plan because it helps them.
                                                                                                                • I am certified by Medicare to sell this plan.
                                                                                                                • If your doctor accepts Medicare, she accepts this plan.
                                                                                                                • There are no limits on services.
                                                                                                                • We cover all drugs and have no formulary restrictions.
                                                                                                                • If you don't like this plan, you can stop paying your premium and return to original Medicare anytime.
                                                                                                                • It is better to choose a different company if you are sick.
                                                                                                                • Promotional Activities: Nominal Gifts
                                                                                                                  • Marketing representatives may offer gifts to potential enrollees if they attend a marketing presentation as long as the gifts are of nominal value and are provided regardless of enrollment and without discrimination.
                                                                                                                    • Gifts are of nominal value if an individual item is worth $15 or less (based on retail purchase price of the item);
                                                                                                                    • When more than one gift is offered, the combined value of all items must not exceed $15;
                                                                                                                    • Gifts must not be in the form of cash or monetary reward, even if their worth is less than $15. Cash gifts include charitable contributions on behalf of an attendee, gift certificates, or gift cards that can be readily converted to cash.
                                                                                                                    • If the gift is one large one that is enjoyed by all attending an event, the total cost must be $15 or less when divided by the estimated attendance. Anticipated attendance may be used, but must be based on venue size, response rate, or advertisement circulation.
                                                                                                                    • Promotional Activities: Drawings, Prizes, Giveaways
                                                                                                                      • Plan sponsors must include a disclaimer on all marketing materials promoting a prize or drawing or any promise of a free gift that there is no obligation to enroll in the plan.
                                                                                                                      • Plan sponsors must track and document promotional activities and items during the year.
                                                                                                                      • Plan sponsors and their marketing representatives may not willfully structure pre-enrollment activities with the intent to give people more than $50 per year.
                                                                                                                      • Promotional Activities: Drawings, Prizes, Giveaways, cont'd
                                                                                                                        • Promotional items may not:
                                                                                                                          • consist of health benefits (e.g., free checkup),
                                                                                                                          • be tied directly or indirectly to the provision of any covered item or service,
                                                                                                                          • be structured to inappropriately influence the beneficiary’s selection of a provider, practitioner or suppliers of any item or service, or
                                                                                                                          • be used or included with the Summary of Benefits or Annual Notice of Change/Evidence of Coverage (ANOC/EOC).
                                                                                                                          • Promotional Activities: Rewards and Incentives
                                                                                                                            • Plan sponsors may provide rewards and incentives only to current members for Medicare covered preventive services that have a zero dollar cost-share.
                                                                                                                            • Plan sponsor rewards and incentives for current members must:
                                                                                                                              • Be offered in connection with the whole service
                                                                                                                              • Be offered to all eligible members without discrimination
                                                                                                                              • Have a monetary cap not to exceed $15 per reward item (based on the retail value of the item)
                                                                                                                              • Be tracked and documented during the contract year
                                                                                                                              • Comply with all relevant fraud and abuse laws, including, when applicable, the anti-kickback statute and civil monetary penalty prohibiting inducements to beneficiaries
                                                                                                                              • Promotional Activities: Rewards and Incentives, cont’d
                                                                                                                                • Plan sponsors rewards and incentives for current members must not:
                                                                                                                                  • Be items that are considered a health benefit, (e.g., a free checkup);
                                                                                                                                  • Be items that consist of lowering or waiving co-pays;
                                                                                                                                  • Be offered in the form of cash or other monetary rebates;
                                                                                                                                  • Be used to target potential enrollees
                                                                                                                                  • Be structured to steer enrollees to particular providers, practitioners, or suppliers
                                                                                                                                  • Be tied directly or indirectly to the provision of any other covered item or service
                                                                                                                                  • Promotional Activities: Referral Programs
                                                                                                                                    • A marketing representative may request referrals only from current members of an MA or Part D plan and requests may not be made during an individual marketing appointment
                                                                                                                                      • You may request names and addresses, but not phone numbers. Information can be used only for mail solicitation.
                                                                                                                                    • A letter sent from a marketing representative to members soliciting referrals cannot offer a gift in return for a lead.
                                                                                                                                    • Marketing representatives may NOT use cash promotions as part of a program through which current members of MA or Part D plans refer prospective enrollees to the marketing representative, but may offer thank you gifts valued at up to $15 each or up to $50 in the aggregate for the year based on retail purchase price for the item.
                                                                                                                                    • Thank you gifts must be available to all members that provide a referral, and cannot be conditioned on actual enrollment of the person being referred.

                                                                                                                                     

                                                                                                                                    • Plan sponsors may:
                                                                                                                                      • Market non-Medicare health-related products to current members as permitted by HIPAA Privacy Rules
                                                                                                                                      • Market health-related products, which may include, for example:
                                                                                                                                        • Long term care insurance
                                                                                                                                        • Dental or vision policies
                                                                                                                                    • Plan sponsors must:
                                                                                                                                      • Allow members and non-members to opt out of communications describing non-Medicare health-related products
                                                                                                                                    • Plan sponsors must NOT:
                                                                                                                                      • Market non-health related products to current members unless they have obtained opt in authorization from the members to as required by HIPAA Privacy Rules
                                                                                                                                      • Marketing Activities: Marketing in a Health Care Setting
                                                                                                                                        • Marketing representatives may:
                                                                                                                                          • Engage in marketing activities (i.e., conduct sales presentations and distribute and accept enrollment applications) in common areas of health care settings, for example:
                                                                                                                                            • At a hospital or nursing home, in a cafeteria, community or recreational room, or conference room;
                                                                                                                                            • At a retail pharmacy, in areas away from the pharmacy counter.

                                                                                                                                        • Marketing representatives must NOT:
                                                                                                                                        • Engage in marketing activities in areas where patients receive health care services, for example:
                                                                                                                                          • In the area where a beneficiary waits for health care or pharmacy services, exam rooms, dialysis center treatment areas, or hospital patient rooms.
                                                                                                                                          • Marketing that is prohibited in health care settings is prohibited during and outside of normal business hours.
                                                                                                                                          • Marketing Activities: Rules for Providers (Including those with Co-Branding Relationships with a Plan)
                                                                                                                                            • "Providers " include providers contracted with the plan and its subcontractors, such as pharmacists, pharmacies, physicians, hospitals, and long-term care facilities including providers with a co-branding relationship.
                                                                                                                                            • Providers may:
                                                                                                                                              • Provide the names of plan sponsors with which they contract/participate.
                                                                                                                                              • Provide information and assistance in applying for the LIS;
                                                                                                                                              • Make available marketing materials for a subset of contracted plans as long as the providers offer the same option to all plans with which they participate.
                                                                                                                                              • Refer patients to other sources of information such as SHIPs, marketing representatives, the state's Medicaid office, SSA, CMS's website, or 1-800-MEDICARE begin_of_the_skype_highlighting 1-800-MEDICARE FREE end_of_the_skype_highlighting;
                                                                                                                                              • Print out and share information from CMS's website, including the "Medicare and You" Handbook or "Medicare Options Compare" or other documents that were written by or previously approved by CMS; or
                                                                                                                                              • Feature SNPs in a mailing announcing an ongoing affiliation with the SNP, including information on special plan features, the population served, or specific benefits. The announcement must list all other SNPs with which the provider is affiliated.
                                                                                                                                              • Marketing Activities: Rules for Providers, cont’d. (Including those with Co-Branding Relationships with a Plan)
                                                                                                                                                • Providers must not
                                                                                                                                                  • Offer sales/appointment forms;
                                                                                                                                                  • Accept enrollment applications;
                                                                                                                                                  • Make phone calls or steer beneficiaries in any way, to a limited number of plans based on financial or any other interest of the provider;
                                                                                                                                                  • Mail marketing materials on behalf of plans;
                                                                                                                                                  • Offer anything of value to induce beneficiaries to select them as their provider or to enroll in a particular plan;
                                                                                                                                                  • Provide a health screening as a marketing activity;
                                                                                                                                                  • Accept compensation directly or indirectly from the plan for beneficiary enrollment activities;
                                                                                                                                                  • Distribute materials/applications within an exam room setting; or
                                                                                                                                                  • Have a party, dance or other event not related to the medical care of their patients if the intention of the event is to steer beneficiaries to a plan.
                                                                                                                                                  • Marketing Activities: Rules for Providers Marketing in a Long-term Care Facility
                                                                                                                                                    • Long-term care facilities include, for example, nursing homes, assisted living facilities, and board and care homes.
                                                                                                                                                    • Plan sponsors/marketing representatives may schedule an appointment with a beneficiary in a long-term care facility ONLY upon request of the beneficiary (or authorized representative).
                                                                                                                                                    • Providers may
                                                                                                                                                      • Make available/distribute plan marketing materials as long as all plans with which the provider participates are offered the same opportunity.
                                                                                                                                                      • Display posters or other materials in common areas and in admission packets announcing all plan contractual relationships.
                                                                                                                                                      • Provide residents that meet the I-SNP criteria an explanatory brochure, reply card, and phone number for additional information for each I-SNP with which the facility contracts to explain qualification criteria. (See Part 5 for enrollment information.)
                                                                                                                                                        • When marketing an employer/union group waiver plan, marketing representatives must follow all rules and guidelines except the following:
                                                                                                                                                          • the prohibition against unsolicited contacts;
                                                                                                                                                          • the prohibition against cross-selling other products;
                                                                                                                                                          • the requirement to obtain prior documentation of the scope of an appointment;
                                                                                                                                                          • the prohibition against providing meals;
                                                                                                                                                          • marketing representative compensation requirements; and
                                                                                                                                                          • the requirement that a marketing representative must pass an annual test, although the requirement for annual training does apply.
                                                                                                                                                        • All activities conducted by the employer/union, or its designees, to enroll employees in the plan are excluded from the marketing requirements.
                                                                                                                                                        • May not include any sales activities such as the distribution of marketing materials or the distribution or collection of plan applications;Must be advertised as "educational" otherwise they will be considered marketing events;
                                                                                                                                                        • Educational events:
                                                                                                                                                            • Are designed to inform Medicare beneficiaries about MA plans, PDPs, and/or other Medicare programs;
                                                                                                                                                            • Do not steer or attempt to steer potential enrollees toward a specific plan or limited set of plans;
                                                                                                                                                            • May not include any sales activities such as the distribution of marketing materials or the distribution or collection of plan applications;
                                                                                                                                                            • Must be advertised as "educational" otherwise they will be considered marketing events; and
                                                                                                                                                            • Are held in public venues and do not extend to in-home or one-on-one settings.
                                                .
                                    .

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Who is Eligible to Enroll in MA or Part D Plans?
  • An individual is eligible to enroll in an MA plan if the individual is entitled to Medicare benefits under Part A and enrolled in Part B.
    • Generally, beneficiaries are not eligible if they have end-stage renal disease when first enrolling in the plan.
  • An individual is eligible to enroll in a Part D plan if the individual is entitled to Medicare benefits under Part A and/or enrolled in Part B.

  • For MA and Part D plans the individual must
  • Reside in the service area of the plan.
  • Submit a complete enrollment request (a legal representative may complete the enrollment request for the individual)
  • Be fully informed of and agree to abide by the plan rules provided during the enrollment request
  • Enrollment Rules
    • Medicare beneficiaries may be enrolled in only one MA plan and only one Part D plan at a time.
    • If enrolled in a Medicare coordinated care plan (HMO/PPO) or a PFFS plan that includes Part D drug coverage, the beneficiary may not be enrolled in a stand-alone PDP.
      • Enrollment in a stand-alone PDP will result in automatic disenrollment from a Medicare coordinated care or PFFS plan that includes Part D coverage.
    • Enrollees may be enrolled in a stand-alone PDP only if they are enrolled in:
    • Original fee-for-service Medicare;
    • Private Fee-for-Service (PFFS) plan without Part D drug coverage;
    • Medical Savings Account (MSA) plan; or
    • 1876 Cost plan.
      • The Medicare prescription drug benefit of a MA-PD is only available to members of the MA-PD plan.

      • If a beneficiary is enrolled in a MA-PD plan, the enrollee must receive his/her Medicare prescription drug benefit through that plan.
        • Enrollees in certain Employer/Union retiree group plans may have different options.
      • An MA or Part D plan may not impose any additional eligibility requirements as a condition of enrollment other than those established by CMS.
      • 4. Yes. Mrs. Weiss must be entitled to Part A or enrolled in Part B to be eligible for coverage under the Medicare prescription drug program. tick_green_small.gif

 

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Please note, downloadable materials are available as an offline resource and benefit to our users. Accessing and printing of these materials is not recognized by the system to administer a completion status.

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Formats of Enrollment Requests - Paper
  • Plan sponsors must accept enrollment requests, regardless of whether they are received in a face-to-face interview, by mail, by facsimile, or through other mechanisms defined by CMS.

  • Paper:
    • All plans must make available and accept a CMS-approved paper enrollment form appropriate to the plan type (MA, PDP, MA-PDP, MSA, or PFFS).
  • Short forms:
  • A short enrollment form is available to allow for changes in plans offered by the same parent organization.

 

 

 

 

  • Enrollment via the internet:
    • CMS offers an on-line enrollment center through www.medicare.gov and 1-800-MEDICARE begin_of_the_skype_highlighting 1-800-MEDICARE FREE end_of_the_skype_highlighting.
      • CMS on-line enrollment is disabled for MA and Part D plans with a lower performer icon (LPI), which means the plan received less than 3 stars for three consecutive years.
    • MA and Part D plans may offer CMS-approved online enrollment on the plan sponsor's website.
    • The only online enrollment mechanism that third party entities (on behalf of the plan sponsor) may make available to potential enrollees is via the plan sponsor's website.
    • Online enrollment via an agent or broker website is NOT permitted.
  • Enrollment via telephone:
    • Plans may accept incoming calls only from a beneficiary or authorized representative to complete an enrollment request.
    • CMS offers telephone enrollment through 1-800-Medicare begin_of_the_skype_highlighting 1-800-Medicare FREE end_of_the_skype_highlighting.
    • A plan representative, agent or broker must not be present or on the phone.
    • Calls must be recorded.
    • Individuals must be advised that they are completing an enrollment request.
    • Collection of financial information is prohibited.
    • Who May Complete the Enrollment Form?
      • If a paper enrollment form is used, the beneficiary must sign it.

      • No other person can sign the enrollment form on behalf of the beneficiary without legal authority to do so.
        • For example, if both spouses cannot attend a sales presentation, the present spouse may make a decision to enroll and complete the enrollment form, but cannot enroll the absent spouse.
      • If an individual executes the enrollment request on behalf of the beneficiary, he/she must sign the attestation on the enrollment form that states:
      • he/she has authority to make health care decisions for the beneficiary under State law and
      • can provide documentation of this authority to the plan sponsor or CMS upon request.
      • Who May Complete the Enrollment Form?, cont’d.
        • As permitted under the law of the State where the beneficiary resides, CMS will allow a legal representative or other individual to execute an enrollment or disenrollment request on behalf of a beneficiary.
          • This may include court-appointed legal guardians, individuals with durable power of attorney for health care decisions, or individuals authorized to make health care decisions under state surrogate consent laws, provided they have authority to act for the beneficiary in this capacity.
            • The authority must pertain to health care decisions. Authority to make financial decisions or insurance purchases is not sufficient authority.
            • The authority may apply beginning on a specified date or may only apply when the beneficiary becomes incapacitated.
            • Who May Complete the Enrollment Form?, cont’d.
              • If a marketing representative helps to complete the enrollment form, he/she must clearly indicate his/her name on the form.
              • Exceptions -- The marketing representative does not need to include his/her name on the form:

                • If a beneficiary requests an enrollment form be mailed to him/her and the name and mailing address are pre-filled;
                • If he/she fills in the "office use only" block; and/or
                • If he/she corrects information on the enrollment form after verifying an individual's information and adding the representative's initials and date next to the correction.
              • If the marketing representative pre-fills any other information, including the beneficiary's phone number, he/she MUST include his/her name.
              • Marketing representatives must safeguard beneficiary information including enrollment forms.
              • What Information is Required to Complete the Enrollment Request?
                • CMS requires the following information for an enrollment request to be complete:
                  • MA or Part D plan name
                  • Beneficiary's:
                    • Name
                    • Date of Birth
                    • Sex
                    • Permanent Resident Address
                    • Medicare Number
                    • Response to ESRD Question
                    • Signature and/or authorized representative signature
                  • Authorized representative contact
                  • Employer or union name and group number (if applicable)
                  • Name of current MA plan (if applicable) and new plan
                  • Verification of SNP eligibility (if applicable)
                  • Acknowledgments (see next slide)
                  • Release of information
                • If enrollment is completed during a face-to-face interview, the plan representative should use the individual's Medicare card to verify the spelling of the name, sex, Medicare number; and Part A and Part B effective dates.
                • Beneficiary Acknowledgements when Enrolling
                  • The enrollment application form requires the beneficiary to acknowledge that he/she :
                    • Must keep Medicare Part A and Part B if enrolling into an MA plan and must keep Part A or Part B if enrolling into a Part D plan;
                    • Agrees to abide by the plan's membership rules as outlined in the member materials;
                    • Consents to the disclosure and exchange of information necessary for the operation of the MA or Part D program;
                    • Can be enrolled in only one MA and Part D or MA-PD plan and enrollment in the plan automatically disenrolls him/her from any other MA, Part D, or MA-PD plan; and
                    • Understands his/her right to appeal service and payment denials the plan makes.
                    • Beneficiary Acknowledgements when Enrolling
                      • The enrollment application form requires the beneficiary to acknowledge that he/she :
                        • Must keep Medicare Part A and Part B if enrolling into an MA plan and must keep Part A or Part B if enrolling into a Part D plan;
                        • Agrees to abide by the plan's membership rules as outlined in the member materials;
                        • Consents to the disclosure and exchange of information necessary for the operation of the MA or Part D program;
                        • Can be enrolled in only one MA and Part D or MA-PD plan and enrollment in the plan automatically disenrolls him/her from any other MA, Part D, or MA-PD plan; and
                        • Understands his/her right to appeal service and payment denials the plan makes.
                        • Marketing representatives may NOT

                          • Deny or discourage beneficiary enrollment based on:
                            • anticipated high need for health care services;
                            • race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or sexual orientation; or
                            • geographic location within the service area.
                          • Target marketing to beneficiaries from higher income areas.
                            • Note: Appointments must be scheduled without regard to the health or financial status of the beneficiary.
                          • State or imply that only seniors may enroll, rather than all Medicare beneficiaries.
                          • Enrollment Discrimination Prohibition and Exceptions
                            • Marketing representatives may NOT ask health questions unless they are necessary to determine eligibility to enroll [e.g., ESRD, chronic care SNPs, low income subsidy (LIS)].
                            • Certain plan products and services may only be available to enrollees with specific diagnoses (e.g., medication therapy management for those with chronic conditions).
                            • Only organizations offering SNPs may limit enrollment to individuals who:

                              • are dual eligible;
                              • are in an institution; or
                              • have a severe or disabling chronic condition.
                            • Marketing representatives may target items and services to beneficiaries that correspond to these categories of SNP plans.

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Roadmap to Enrollment Periods
  • Enrollment periods based on calendar:
    • Annual Election Period (October 15 - December 7)
    • Medicare Advantage Disenrollment Period (January 1 - February 14)
  • Enrollment periods based on special circumstances:
  • Initial election periods when beneficiary first eligible for Medicare
  • Special enrollment periods (SEPs) when special circumstances arise
  • Continuance open enrollment for institutionalized individuals

 

Enrollment Periods
  • Beneficiaries may only enroll in or change plans at certain fixed times each year or under certain limited special circumstances.
    • If the application does not include information supporting a permissible election period, plans must contact the beneficiary to decide if enrollment is permissible.
  • Enrollment periods are:
  • MA Initial Coverage Election Period (ICEP)
  • Part D Initial Enrollment Period (IEP)
  • MA and Part D Annual Election Period (AEP)
  • MA and Part D Special Enrollment Periods (SEP)
  • Open Enrollment Period for Institutionalized Individuals (OEPI)
  • MA 45-Day Disenrollment Period (MADP)
  • Cost plans may but are not required to open for enrollment during the MA Annual Election Period, but Cost plans that offer an optional supplemental Part D benefit must accept Part D enrollments during the AEP.
  • See "Cost Plan Enrollment Periods" section for more information on Cost Plan Enrollment Periods.
  • Cost Plan Enrollment
Enrollment Periods MA Initial Coverage Election Period (ICEP)
  • The MA ICEP and the Part D IEP occur together as one period when a newly Medicare eligible individual has enrolled in BOTH Part A and Part B at first eligibility.
  • Who is eligible for the MA ICEP?
    • The ICEP is available to individuals who are newly eligible for Medicare Advantage (MA).
  • When does the MA ICEP take place?
    • The ICEP begins three months immediately before the individual's first entitlement to both Medicare Part A and Part B and ends on the later of the last day of the month preceding entitlement to both Part A and Part B, or the last day of the third month after the month in which an individual meets the eligibility requirements for Part B.
  • What can individuals do during the MA ICEP?
    • During the ICEP, an eligible individual may enroll in an MA plan – or an MA-PD plan if the individual is eligible for Part A and enrolled in Part B
    • The individual can make one enrollment choice under the ICEP. Once enrollment is effective, the ICEP is used.

 

Enrollment Periods
  • The MA ICEP and the Part D IEP occur together as one period when a newly Medicare eligible individual has enrolled in BOTH Part A and B at first eligibility.
  • Who is eligible for the Part D IEP? < >The IEP is available to individuals who are newly eligible for Medicare Part D prescription drug coverage.The IEP begins 3 months before the month an individual meets the eligibility requirements for Part B, and ends 3 months after the month of eligibility.
  • Individuals eligible for Medicare prior to age 65 (such as for disability) will have another IEP when attaining age 65.
  • What can individuals do during the Part D IEP?
    • Beneficiaries may make one Part D enrollment choice, including enrollment in an MA-PD plan.
Enrollment Periods Annual Election Period
  • Who is eligible for the Annual Election Period?
    • The Annual Election Period is available to all MA and Part D eligible beneficiaries.
  • When does the Annual Election Period take place?
  • October 15 – December 7
  • No action is needed if the beneficiary chooses to keep his/her current plan. She/he should check for any benefit changes under the plan.
  • Beneficiaries may add or drop MA and/or drug coverage, or return to Original Medicare.
  • Beneficiaries may make more than one enrollment choice during the Annual Election Period, but the last one made prior to the end of the Annual Election Period, as determined by the date the plan or marketing representative receives the completed enrollment form, will be the election that takes effect.
  • What can beneficiaries do during the Annual Election Period?

 

Enrollment Periods Annual Election Period, cont’d.
  • Marketing representatives may not accept enrollment forms before October 15 for enrollments under the Annual Election Period.
  • If a beneficiary sends an enrollment form to the plan before the Annual Election Period begins, the plan will process the application beginning on the first day of the election period (October 15).
  • A beneficiary will receive an acknowledgment letter when the plan sponsor receives an early enrollment form.

 

Enrollment Periods MA Disenrollment Period (MADP)
  • As noted, the Affordable Care Act, passed in 2010, created the MADP and eliminated the "Open Enrollment Period." Exception: Institutionalized beneficiaries have a continuous open enrollment period.
  • Who is eligible for the MADP?

    • All MA or MA-PD enrollees
  • When does the MADP take place?

  • From January 1 – February 14 of each year.
  • What can beneficiaries do during the MADP?
    • MA and MA-PD enrollees may request disenrollment from their plan and return to Original Medicare and subsequently may enroll in a PDP or may simply request enrollment in a PDP, resulting in automatic disenrollment from the MA plan. (Exception: MA-only PFFS must request disenrollment first.)
Enrollment Periods Special Enrollment Periods (SEP)
  • Who is eligible for an SEP?
    • MA eligible and Part D eligible beneficiaries who experience certain qualifying events are allowed an SEP.

 

Enrollment Periods Special Enrollment Periods (SEP), cont’d.
  • When does the SEP take place?
    • Timeframes for SEPs are variable, however, most begin on the first day of the month in which the qualifying event occurs and last for a total of three months. The SEP ends when the individual utilizes their SEP to make an allowed change, or the time period expires, whichever comes first. Where appropriate, SEPs allowing changes to MA coverage are coordinated with those allowing changes in Part D coverage.
    • Some (but not all) situations resulting in an SEP include:
      • Change in residence
      • Involuntary loss of creditable drug coverage
      • Exceptional conditions such as
        • Gaining or losing Medicaid eligibility
        • Gaining or losing the Part D low-income subsidy
        • Changing employer/union group health plan coverage
        • Enrollment based on incorrect or misleading information

 

Enrollment Periods Special Enrollment Periods (SEP), cont’d.
  • What can beneficiaries do during an SEP? < >Under Part D SEPs, qualifying beneficiaries generally have one opportunity to drop, add or change their Part D coverage.Under MA SEPs, qualifying beneficiaries generally have one opportunity to change their MA coverage. (Except for MSA plan enrollees.)But, if a beneficiary disenrolls from his/her MA plan and returns to Original Medicare, he/she may subsequently select a new MA plan, as long as he/she does so before the SEP expires.

 

 

SEP - Contract Violations Marketing Misrepresentation
  • Who is eligible?
    • Beneficiaries who have enrolled in a MA or Part D plan based upon misleading information.
    • To take advantage of this SEP, beneficiaries must contact Medicare (e.g., call 1-800-MEDICARE begin_of_the_skype_highlighting 1-800-MEDICARE FREE end_of_the_skype_highlighting).
  • When does the SEP take place?
  • Begins when a determination is made by CMS that the beneficiary qualifies for the SEP.
  • Ends once a new enrollment decision is made.
  • CMS will help all qualifying beneficiaries select a new Medicare plan option, which may include a different MA or Part D plan or Original Medicare.
  • Requests for retroactive enrollments will be handled by CMS Regional Office caseworkers who will discuss with beneficiaries the possible ramifications.
  • What can beneficiaries do during the SEP?

 

Typical SEPs Change of Residence
  • Who is eligible?
    • MA and Part D enrollees who move out of their existing plan's service area, or who have new options available to them as a result of a permanent move.
    • Beneficiaries who have moved into a plan service area from a location where there was no Part D plan available (e.g. overseas) qualify for an SEP just for Part D election purposes.
  • When does the SEP take place?
  • Begins either the month before the permanent move if the plan is notified in advance or the month the beneficiary provides notice of the move.
  • Continues for two months following the month it begins or the month of the move, whichever is later.
    • Example: A beneficiary resides in Florida and is currently in Original Medicare and not enrolled in an MA plan. The individual intends to move to Maryland on August 3. An SEP exists for this beneficiary from July 1 through October 31.
  • The individual may choose an effective date of up to 3 months after the month in which the enrollment form is received by the plan, but it may not be earlier than the date of the permanent move.
  • Qualifying beneficiaries have one opportunity to enroll into a new MA or Part D plan.
  • What can beneficiaries do during the SEP?

 

 

Typical SEPs - Involuntary Loss of Creditable Drug Coverage
  • Who is eligible?
    • Beneficiaries eligible for Part D who involuntarily lose creditable prescription drug coverage including a reduction in coverage so it is no longer creditable.
  • When does the SEP take place?
  • Begins with the month in which the beneficiary is advised of loss of creditable coverage.
  • Ends 2 months after loss of creditable coverage or the date the individual received the notice, whichever is later.
  • One opportunity to select a PDP or MA-PD plan.
  • What can beneficiaries do during the SEP?

 

Typical SEPs - Exceptional Conditions Gaining or Losing Medicaid Eligibility
  • Who is eligible?

    • Beneficiaries who are entitled to Medicare Part A and/or Part B and receive any type of assistance from Medicaid (full or partial benefits).
  • When does the SEP take place?
  • Begins the month the beneficiary gains or loses dual eligibility.
  • If gaining eligibility: continues as long as the beneficiary receives Medicaid benefits. Note: dual eligible beneficiaries have a continuous special election period as long as they retain dual eligible status.
  • If losing eligibility: begins the month that Medicaid eligibility is lost and continues for two additional months.
  • What can beneficiaries do during the SEP?
    • Beneficiaries entitled to Part A and Part B can enroll in or disenroll from an MA and/or Part D plan at any time. Those entitled only to Part B can only do so for PDPs.

 

Typical SEPs - Exceptional Conditions Gaining Eligibility for Part D LIS
  • Who is eligible?
    • Non-dual beneficiaries who qualify for LIS but do not receive Medicaid benefits
  • When does the SEP take place?
  • Begins on the month the individual becomes eligible for LIS.
  • Continues as long as he or she is eligible for LIS.
  • What can beneficiaries do during the SEP?
  • Enroll in or disenroll from a PDP or MA-PD plan at any time.

 

Typical SEPs - Exceptional Conditions Losing Eligibility for Part D LIS
  • Who is eligible?
    1. Beneficiaries who lose their LIS eligibility because they are no longer deemed eligible for the following calendar year.
    2. Beneficiaries who lose their LIS eligibility during the year outside of the annual redetermination process.
  • When does the SEP take place?
    • Group 1: January 1 – March 31
    • Group 2: Begins the month beneficiaries are notified and continues for two months.
  • What can be done during the SEP?
  • Enroll in or disenroll from a PDP or MA-PD plan

 

 

Typical SEPs - Exceptional Conditions Employer/Union Group Coverage
  • Who is eligible?
    • Beneficiaries who elect into or out of employer-sponsored MA plans.
    • Beneficiaries disenrolling from an MA plan to enroll in employer/union sponsored coverage that includes medical and/or drug coverage.
    • Beneficiaries disenrolling from employer sponsored coverage (including COBRA coverage) to elect an MA plan.
  • When does the SEP take place?
  • Begins when the employer/union plan would otherwise allow the individual to make changes to his/her coverage.
  • Ends 2 months after the month the employer or union-sponsored coverage ends.
  • Qualifying beneficiaries have one opportunity to
    • Enroll in an employer group/union-sponsored MA or Part D plan;
    • Disenroll from an MA or Part D plan to take employer/union-sponsored coverage of any kind; or
    • Disenroll from employer/union-sponsored coverage to enroll in an MA or Part D plan.
  • What can be done during the SEP?

 

Typical SEPs - Exceptional Conditions 5-Star Plans
  • Who is eligible?
    • Beneficiaries who live in the service area of a 5-star plan and are enrolled in an MA or PDP plan, or beginning in 2013, a Cost plan
    • Beneficiaries who live in the service area of a 5-star plan, are enrolled in Original Medicare, and meet the eligibility requirements for Medicare Advantage or Part D plans.
  • When does the SEP take place?
  • The annual SEP will be available beginning on December 8 and may be used once through November 30 of the following year. For example, the SEP for calendar year 2014 can be used from December 8, 2013 through November 30, 2014.
  • Disenroll from a MA plan or PDP or Cost plan or leave Original Medicare.
  • Enroll in a 5-star MA plan or PDP or Cost plan.
  • Eligible individuals may enroll in a 5-star plan through 1-800-MEDICARE begin_of_the_skype_highlighting 1-800-MEDICARE FREE end_of_the_skype_highlighting, Medicare.gov, or directly through the 5-star plan.
  • What can be done during the SEP?

 

Typical SEPs - Exceptional Conditions 5-Star Plans
  • Who is eligible?
    • Beneficiaries who live in the service area of a 5-star plan and are enrolled in an MA or PDP plan, or beginning in 2013, a Cost plan
    • Beneficiaries who live in the service area of a 5-star plan, are enrolled in Original Medicare, and meet the eligibility requirements for Medicare Advantage or Part D plans.
  • When does the SEP take place?
  • The annual SEP will be available beginning on December 8 and may be used once through November 30 of the following year. For example, the SEP for calendar year 2014 can be used from December 8, 2013 through November 30, 2014.
  • Disenroll from a MA plan or PDP or Cost plan or leave Original Medicare.
  • Enroll in a 5-star MA plan or PDP or Cost plan.
  • Eligible individuals may enroll in a 5-star plan through 1-800-MEDICARE begin_of_the_skype_highlighting 1-800-MEDICARE FREE end_of_the_skype_highlighting, Medicare.gov, or directly through the 5-star plan.
  • What can be done during the SEP?
MA Open Enrollment Period for Institutionalized Individuals/Part D SEP for Institutionalized Individuals
  • Who is eligible?
    • Institutionalized individuals who move into, reside in, or move out of an institution including, for example, a skilled nursing facility, nursing facility, rehabilitation hospital, or hospital.
    • In addition, the OEPI is available for individuals who meet the definition of "institutionalized" to enroll in or disenroll from an MA SNP for institutionalized individuals.
  • When does the OEPI take place?
  • The OEPI is continuous for eligible individuals. The OEPI ends two months after the month the individual moves out of the institution.
  • MA beneficiaries can make an unlimited number of MA enrollment requests and may disenroll from their MA plan.
  • Individuals may enroll in or disenroll from a Part D plan
  • Beneficiaries in an MA plan may return to Original Medicare during the OEPI.
  • What can be done during the SEP?

 

Cost Plan Enrollment Periods
  • Cost plans must establish an annual open enrollment period of at least 30 days and may permit beneficiaries to enroll continuously throughout the year except in the following circumstance:

    • An organization with a Cost plan and a MA plan in the same service area may not enroll new individuals in the Cost plan.
  • If a Cost Plan is not continuously open for enrollment, it must publicize its enrollment period in the appropriate media throughout its service area.

  • Cost plans may close enrollment during the year and must notify CMS and the general public 30 days before doing so. Cost plans may also re-open enrollment but public notice is not required.

 

Cost Plan Enrollment Periods, cont'd
  • For Cost plans that offer an optional supplemental Part D benefit, beneficiaries may select this benefit only during enrollment periods available under the Part D program, and Cost plans must accept Part D enrollments during these periods.
  • A beneficiary who is enrolled in an MA plan must have a valid MA disenrollment period in order to switch to a Cost plan.

 

Post-Enrollment: Outbound Verification Calls
  • For enrollments where an agent or broker (independent or employed) was involved, plan sponsors must call new applicants to confirm they wish to enroll and understand the features/rules of the plan. Marketing representatives must not make the call and must not be present with the applicant during the call.
  • Marketing representatives must:
    • Provide the beneficiary with a description of the enrollment verification process and
    • Obtain a phone number from the beneficiary for the plan sponsor to use to make the enrollment verification call.
  • Exceptions: Plan sponsors are not required to conduct outbound verification calls for switches from one plan to another plan of the same type (e.g., PFFS to PFFS, or PDP to PDP) offered by the same MA or PDP organization or for enrollments into employer or union sponsored plans.

 

 

Post-Enrollment: Materials for the Beneficiary
  • After the plan receives the enrollment form and prior to the effective date of coverage all plans must provide the member with:
    • A notice acknowledging receipt of the complete enrollment request;
    • A copy of the completed paper enrollment form unless the individual already received a copy when completing the form;
    • The plan rules;
    • The member's rights and responsibilities;
    • Evidence of plan membership and the effective date of coverage so that he/she may begin using the plan services as of the effective date; and
    • Information for how to obtain services prior to the receipt of an ID card (if the sponsor has not yet provided the ID card).
Post-Enrollment: Premium Payment
  • At a minimum, plans must offer beneficiaries the option to pay the monthly premium through
    • Direct billing by the plan;
    • Premium withholding from their Social Security check; and
    • Automatic withdrawal from a bank, credit card, or debit card.
  • Plans also may offer other payment options such as a coupon book.

 

-Enrollment: When does coverage begin?
  • If a beneficiary joins during the Annual Election Period, (October 15 – December 7), coverage begins January 1 of the following year.
  • At other times, coverage generally begins on the first day of the month following the month in which the beneficiary joins a plan.
  • Because a beneficiary may have more than one election period when completing the enrollment application, the marketing representative should know which election period the beneficiary is using.

 

Enrollee Protections

Members of a plan have a right to:

  • Be treated with dignity and respect at all times;
  • Be protected from discrimination;
  • Select and/or change their personal primary care network provider without interference from the plan;
  • Learn about all of their treatment choices and participate in treatment decisions;
  • Have their questions about Medicare answered in a way they can understand;
  • Have access to doctors, specialists, and hospitals:
    • Enrollees in HMOs, PPOs, and SNPs must have access to provider networks that include enough doctors, specialists, and hospitals to provide all covered services necessary to meet enrollee needs. Enrollees throughout the plan's service area must have access to network providers within resonable travel time.
    • Exception - In limited circumstances, PPOs that serve regions established by CMS (Regional PPOs) may offer specified services only through non-network providers with CMS approval.
Enrollee Protections, cont’d.

Members of a plan have a right to:

  • Have access to covered Part D drugs through network pharmacies:
    • Have access to plan networks that include retail, specialty, and home infusion pharmacies to provide convenient access to covered drugs.
      • Exception: PFFS plans may provide access to covered drugs through a network or by covering the drugs at any pharmacy.
    • Have convenient access to network long term care pharmacies, if the enrollee resides in a long term care facility.
    • Have convenient access to Indian Health Service, Tribal, and urban Indian organization (I/T/U) pharmacies, if enrollees are American Indians or Alaska Natives (AI/AN).
  • Get emergency care when and where they need it;
  • Know how doctors are paid;
  • Have personal and health information kept private;
  • Obtain a treatment plan from their Medicare Advantage organization;

 

Enrollee Protections, cont’d.

Members of a plan have a right to:

  • File complaints (sometimes called grievances), including complaints about the quality of their care;
  • Get a decision about health care payment or services, or prescription drug coverage; and
  • Get a review (appeal) of certain decisions about health care payment, coverage of services, or prescription drug covearage.

 

Enrollee Protections: Complaints, Grievances, Coverage Decisions, Appeals
  • Medicare health plan and prescription drug plan members have two main processes to deal with problems they have with their plan.
    • The grievance process is used for complaints about the operations of a plan.
    • The appeals process is used to ask for a review of coverage decisions on plan benefits and coverage or payment.
      • Members or their representatives may file a grievance if they experience problems with their health care services such as timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item.
      • Grievance issues also may include complaints that a covered health service, procedure, or item furnished during a course of treatment did not meet accepted standards for delivery of health care.
      • An enrollee or their representative may make the complaint orally, in writing, or via a CMS website at: https://www.medicare.gov/MedicareComplaintForm/home.aspx.
      • Plans must provide a link to the medicare.gov website where the member can enter a complaint.
      Enrollee Protections: Coverage Decisions
      • Coverage decisions are determinations made by a Medicare health plan or prescription drug plan with respect to whether medical care or prescription drugs are covered, the way in which they are covered, and problems related to payment.
      • Examples of times when a member may need a coverage decision include:
        • To obtain payment for certain services, such as the type or level of services the enrollee thinks should be furnished;
        • To obtain payment for services when the member is temporarily out of the area;
        • To continue a service that the enrollee believes is medically necessary; or
        • To obtain payment for a prescription drug.
      Enrollee Protections: Appeals of Coverage Decisions
      • If a member is not satisfied with the coverage decision, he/she or in some cases his/her physician can appeal the decision.

      • An appeal is a formal way to ask the plan to review or change a coverage decision.

      • An appeal can be filed if :
        • A member believes a Medicare health plan does not pay for or allow, or ends a service that should be covered; or
        • A member believes a Medicare prescription drug plan has not allowed or paid for a Part D prescription drug that should be covered.

       

       

       

       

       

       

 

 

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nrollee Protections: Appeals of Coverage Decisions
  • Medicare health plans and prescription drug plans must provide members with a written description of the appeal process.
  • To file an appeal members should look at their plan materials, call their plan.
  • As noted in Part 3, "Medicare Part D Prescription Drug Coverage," Part D plans:

    • Provide access via a secure website or secure e-mail address on the website for enrollees to quickly request a coverage determination or appeal a decision; and
    • Require network pharmacies to provide enrollees with a printed notice with the plan's toll-free number and website for requesting a coverage determination.
  • Marketing representatives can learn about plan specific appeal processes in their product specific training.

 

  • There are two types of disenrollment:
    • Voluntary disenrollment:
      • A member chooses to leave a plan because he/she wants to leave.
      • Members can only voluntarily disenroll during a valid enrollment or disenrollment period.
      • When a member changes plan coverage, he/she will be disenrolled automatically from the previous plan.
    • Involuntary disenrollment:
    • In certain situations, the plan may be required or may have the option to end a member's membership.

 

Disenrollment from MA or Part D Plans
  • Plan sponsors or their marketing representatives may not either orally or in writing or by any action or inaction request or encourage any plan member to disenroll from the plan except in specific situations authorized by CMS.
  • Plan sponsors may contact members to determine the reason for a voluntary disenrollment, but must not discourage a member from disenrolling after he or she indicates a desire to do so.
  • Plan sponsors must apply disenrollment policies in a consistent manner for similar members in similar circumstances.

 

 

 

Voluntary Disenrollment from MA or Part D Plans
  • During a valid enrollment/disenrollment period a member may request disenrollment from an MA or prescription drug plan by:
    • Enrolling in another plan;
    • Sending or faxing a signed written notice to the plan sponsor (or employer/union group, if applicable);
    • Submitting a request via the internet to the plan sponsor (if the plan offers this option); or
    • Calling 1-800-MEDICARE begin_of_the_skype_highlighting 1-800-MEDICARE FREE end_of_the_skype_highlighting or for TTY users call 1-877-486-2048 begin_of_the_skype_highlighting 1-877-486-2048 FREE end_of_the_skype_highlighting.
  • Members making verbal requests must be instructed to make the request via one of the above methods.

 

Voluntary Disenrollment from MA or Part D Plans, cont’d
  • Exceptions:
    • At the discretion of the plan sponsor, employer or union group sponsored plans may accept verbal disenrollment requests from members and need not require written requests.
    • Employer or union sponsored plans may also permit disenrollment through a group disenrollment process.
    • To disenroll from an MSA plan members must write to the plan. The enrollee cannot disenroll via 1-800-MEDICARE begin_of_the_skype_highlighting 1-800-MEDICARE FREE end_of_the_skype_highlighting.
    • To disenroll from PFFS and not enroll in another plan, members should contact the plan or Medicare.
    • To ensure disenrollment from a PDP, members should submit a written request or call Medicare in the following situations:
      • Joining an MA PFFS plan without drug coverage;
      • Joining an MSA plan; and
      • When NOT joining any other health or prescription drug plan.
Voluntary Disenrollment from Cost Plans
  • Medicare Cost plan members may end their membership at any time during the year and enroll in Original Medicare.
    • The member must submit a written request and cannot disenroll by calling Medicare.
  • A beneficiary who disenrolls from a Cost plan may join a MA plan or a PDP during the Annual Election Period or other MA or Part D election period.

 

Involuntary Disenrollment from MA, Part D, or Cost Plans
  • There are two types of involuntary disenrollments by plans.
    • Required involuntary disenrollments by plans: CMS requires a plan sponsor to disenroll the individual.
    • Optional involuntary disenrollments: CMS provides an option for plan sponsors to disenroll individuals under certain circumstances.
  • CMS will disenroll beneficiaries who fail to pay the additional Part D premium based on income, i.e., the "Part D income related monthly adjustment amount" (Part D-IRMAA).

 

Involuntary Disenrollment from MA or Part D Plans, cont’d
  • Plan sponsors must disenroll a member from the plan in the following situations:
    • A permanent change in residence (including incarceration) makes the member ineligible to be enrolled (see slide titled "Enrollee Protections: Coverage Decisions" for rules regarding temporary change in residence);
    • The member does not stay enrolled in Part A and Part B for MA and MA/PD plans or does not stay enrolled in Part A or Part B for PDP plans;
    • A SNP member loses special needs status;
    • The member dies; or
    • The plan sponsor's contract is terminated, withdrawn, or the service area is reduced and excludes the member (Exceptions apply).
Temporary Exception to Involuntary Disenrollment When a Member Moves from the Service Area
  • Requirements for members who change residence
    • MA Organizations:
      • May offer an extended visitor/traveler (V/T) benefit of up to 12 months.
      • Do not need to disenroll members in these programs who remain temporarily out of the area for up to 12 months.
      • Must disenroll members who are not in these (V/T) programs who have been out of the area more than 6 months
      • Individuals have an SEP to enroll in a MA, MA-PD, or PDP.
    • Part D Plan Sponsors:
    • Must disenroll a member 12 months after identifying that the individual has moved outside of the service area if the plan has been unable to confirm the move with the member.
    • Exceptions may apply for members who have low income subsidy.
Involuntary Disenrollment Cost and MSA Plans
  • Medicare cost plans must disenroll a member:
    • Who does not stay continuously enrolled in Part B
    • Moves out of the service area for more than 90 days (up to 12 months for some plans)
  • MSA Plans must disenroll a member:
  • Who no longer meets MSA eligibility requirements except the MSA Plan may not disenroll:
    • Beneficiaries who develop end stage renal disease (ESRD) while enrolled in the MSA Plan or
    • Beneficiaries who elect the Medicare hospice benefit while enrolled in the MSA Plan.
Involuntary Disenrollment from MA, Part D or Cost Plans – At Plan Option
  • Plan sponsors may involuntarily disenroll a member from the plan if the member:
    • Does not pay premiums on a timely basis;
    • Engages in disruptive behavior;
    • Provides fraudulent information on an enrollment request;
    • Knowingly falsifies or withholds information about third party reimbursement for prescription drugs; or
    • Allows another individual to use his or her enrollment card.
  • Plan sponsors must take action consistently among all members of each discrete plan.

 

Involuntary Disenrollment from MA, Part D or Cost Plans – At Plan Option, cont’d
  • Enrollee's Rights:
    • For failure to pay plan premiums the plan sponsor must:
      • Notify the member in writing and
      • Provide members with a grace period of not less than 2 months.
      • Exceptions apply for payment of premiums for dual eligible individuals and those who qualify for the Part D low income subsidy.
      • CMS may extend the grace period for good cause and reinstate enrollment if the beneficiary pays the overdue premiums within 3 calendar months of disenrollment.
    • Cost plans may disenroll a member for failure to pay plan premiums and/or cost-sharing and must:
    • Notify the member in writing before the member is required to leave the plan.
Involuntary Disenrollment from MA, Part D or Cost Plans – At Plan Option, cont’d

Enrollee's Rights, cont'd:

  • A plan sponsor may not end a member's enrollment for any reason related to the member's health.
    • Exception for SNPs because a member must be involuntarily disenrolled if he/she loses special needs status, which m ay be health-related
    • If the member believes they are being encouraged to leave the plan because of his/her health, the member should contact Medicare.
      • 1-800-MEDICARE begin_of_the_skype_highlighting 1-800-MEDICARE FREE end_of_the_skype_highlighting
      • TTY Users should call 1-877-486-2048 begin_of_the_skype_highlighting 1-877-486-2048 FREE end_of_the_skype_highlighting
  • Members have the right to make a complaint if the plan ends their membership.
  • If a plan ends an enrollee's membership, the plan must tell the member the reason in writing and explain how the member may file a complaint against the plan.
  • Under specified circumstances, a member may be reinstated in his/her former plan (e.g., error or demonstration of "good cause" for failure to pay premiums)

 

Additional information

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