Medicare Module 1 – Flashcards

The Part B deductible will no longer be covered for individuals newly eligible for Medicare starting January 1, 2020.The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will make changes to Medigap plans effective 2020. Specifically, for individuals newly eligible to Medicare, the Part B deductible cannot be covered. Therefore, Plans C and F will no longer be an option for newly eligible individuals starting January 1, 2020. However, individuals who already have Plans C and F will be able to keep their current versions of the plans and individuals eligible for Medicare prior to January 1, 2020, can purchase the current version of Plans C and F on or after January 1, 2020

Some cost plans transitioning to MA contracts will have "deemed" or facilitated enrollment. That is, unless a cost plan enrollee opts out, he/she will be automatically enrolled in an MA plan offered by the same organization.Individuals subject to deemed enrollment will be notified by CMS and the plan and given the opportunity to choose another option.

Medicaid: help with health care costs. Medicare Savings Program: help paying for 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.

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 2017, beneficiaries pay $164.50 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

Agent Armstrong is an independent agent under contract with MarketCo, a third party marketing organization. MarketCo has a contract with BestChoice health plan, a Medicare Advantage organization, to offer marketing services through its contracted agents and agencies. Agent Armstrong returns calls to individuals who call MarketCo in response to its mailers promoting BestChoice health plan. Agent Armstrong is a marketing representative of BestChoice. Thus, he is obligated to comply with all marketing requirements, including those regarding using only approved call scripts.

Plans/Part D Sponsors must submit to CMS social media (e.g.,Facebook, Twitter, YouTube, LinkedIn, Scan Code, or QR Code)posts that meet the definition of marketing materials, specifically those that contain plan-specific benefits, premiums, cost-sharing,or Star Ratings. Social media posts are subject to marketing requirements, such as those related to testimonials. Generally disclaimers are not required unless a communication written for social media has the potential to be disseminated via other mediums, such as youtube.Plans/Part D Sponsors must not include content on social/electronic media that discusses plan-specific benefits, premiums, cost-sharing, or Star Ratings for products offered in the next contract year prior to October 1.

Annual election period (October 15 - December 7) Medicare Advantage Disenrollment Period (January 1 - February 14) 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.MA and Part D 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)

Initial Coverage Election Period (ICEP) 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 individual's Part B initial enrollment period.The initial enrollment period for Part B is the seven (7)month period that begins 3 months before the month an individual meets the eligibility requirements for Part B, and ends 3 months after the month of eligibility.

Cover the following services even when provided by non-network providers: • emergency services; • out-of-area urgently needed services; and • out-of-area renal dialysis. Have access to doctors, specialists and hospitals: Get emergency care when and where they need it. CMS may offer services through non-network providers at the in-network enrollee cost-sharing level.

has QMB-Plus eligibility. She has decided to enroll in a Medicare Advantage plan. Ms. Jones can receive all Medicare covered services through her Medicare Advantage plan cost sharing. However, in order to receive coverage of services that are only covered under Medicaid, for example, dentures, she must go to a Medicaid provider or obtain the services through a Medicaid managed care plan if she is enrolled in one Categories of dual eligible beneficiaries and out-of pocket costs that must be paid by Medicaid: QMB Plus - Medicare Part A and Part B premiums; cost sharing for Part A & Part B benefits; Full Medicaid benefits.When a dual eligible individual enrolls in an MA plan, if the individual has coverage for Part A and B cost sharing, they will not have to pay more than the cost sharing that would apply under Medicaid. This rule applies to all types of Medicare Advantage plans, including dual eligible SNPs. Dual eligible beneficiaries may enroll in any type of MA plan except an MA MSA. Some MA plans, known as dual eligible Special Needs Plans, are tailored to dual eligible individuals, depending on the category (see prior slide) to which they belong.

Medicare Advantage HMO or PPO may only obtain Part D benefits through their plan. They may not enroll in a standalone PDP. (Employer group plan enrollees may have additional choices.)

He can give away more than one gift during a single event, but the aggregate retail value cannot exceed $15.

Preventive & screening services

Enrollment via the internet: CMS offers an on-line enrollment center through www.medicare.gov • Individuals can also enroll through: www.ssa.gov/medicare/apply.html • CMS on-line enrollment is disabled for MA and Part D plans with a low 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. MA organizations may develop and offer electronic enrollment mechanisms made available via an electronic device or secure internet website. A number of requirements apply to electronic enrollment mechanisms, including, but not limited to: Plan Sponsors must submit all materials, web pages, and images (e.g. screen shots) related to the electronic enrollment process for CMS approval.Individuals must be provided with all required pre-enrollment information (see module 4).The mechanism must comply with CMS' data security policies. Each individual must be advised at the beginning of the electronic enrollment process that he or she is completing an enrollment request.

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.

Part D enrollees have three options for paying their Part D premium. (1) Automatic electronic monthly mechanism, such as withdrawal from their checking or savings bank account or automatic deduction from their credit or debit card; (2) Direct monthly billing from the plan; or (3) Automatic deduction from their monthly Social Security Administration (SSA) benefit check. • Typically it takes 2-3 months for SSA withholding to begin or end. • When withholding begins, it will be for the 2-3 months of premiums owed. • If a beneficiary is considering this option, he/she should call the plan first. Generally the beneficiary must stay with the premium payment option for the entire year.

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.

An institutionalized beneficiary has a continuous open enrollment period (OEPI) for purposes of changing enrollment in Medicare Advantage plans; this period does not end until two months after the month the beneficiary moves out of the institution. Medicare-Medicaid beneficiaries have a continuous special enrollment period that permits them to enroll in a MA, MAPD, PDP, or MMP (in applicable states and subject to state-specific eligibility rules) during any month. As previously noted this enrollment is only valid when executed by the beneficiary/legal representative or as State law allows. The Medicare Managed Care Manual Chapter 2 has a full description of the relevant special enrollment periods

Medicare Advantage HMO or PPO may only obtain Part D benefits through their plan. They may not enroll in a standalone PDP. (Employer group plan enrollees may have additional choices.) MA MSA may only obtain Part D benefits through a standalone PDP.MA PFFS plan that offers Part D coverage may only obtain Part D benefits through that plan. If the PFFS plan does not offer Part D coverage, the beneficiary may enroll in a standalone PDP. Cost plan may obtain Part D benefit through their plan (if offered) or through a standalone PDP. Medicare-Medicaid plan may only receive Part D benefits through that plan. PACE plan may only receive Part D benefits through that plan.

Mrs.Ramos can obtain care from any provider who participates in Original Medicare, but generally will be charged a lower co-payment if she goes to one of the plan's preferred providers. Preferred Provider Organizations (PPOs), local and regional; 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. 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 an out-of-network provider, but may be encouraged to contact the plan to be sure the service is medically necessary and will be covered. Regional PPOs are PPOs that serve an entire region, made up of one or more states.

Medigap plans help beneficiaries cover coinsurance, co-payments, and/or deductibles for medically necessary services

You should tell your colleague no because participation in an educational event may not include a sales presentation

When a new generic drug for the same condition becomes available or when the FDA or manufacturer withdraws the drug from the market, a brand name drug can be replaced.

Most individuals who are citizens and over age 65 are covered under Part A by virtue of having paid Medicare taxes while working, though some may be covered as a result of paying monthly premiums.

He generally would pay a monthly premium, annual deductible, and per-prescription cost sharing

She only needs to enroll in the new MA-PD plan and she will automatically be disenrolled from her old MA plan

Marketing materials include any MA, MA-PD, section 1876 cost, or PDP plan or plan sponsor informational materials targeted to Medicare beneficiaries which: ▪ Promote the plan sponsor or any plan offered by the plan sponsor; ▪ Inform Medicare beneficiaries that they may enroll, or remain enrolled in a plan offered by the plan sponsor; ▪ Explain the benefits of enrollment or rules that apply to enrollees; or ▪ Explain how Medicare services are covered under the plan, including conditions that apply to such coverage. General audience materials such as brochures, direct mail, newspapers, magazines, television, radio, billboards, yellow pages or the Internet. ▪ Marketing representative scripts or outlines for telemarketing, enrollment or other presentations. ▪ Presentation materials such as slides and charts. ▪ Promotional materials such as brochures or leaflets, including materials for circulation by physicians, other providers, or third parties. ▪ Enrollee communications including rules; agreements; handbooks; contractual changes; changes in providers, premiums, or benefits; plan procedures; and wallet card instructions to enrollees. ▪ Social media (e.g., Facebook, Twitter, YouTube, etc.) posts that meet the definition of marketing materials, specifically those that contain plan-specific benefits, premiums, cost-sharing, or Star Ratings.

During individual appointments, marketing representatives may: ▪ Distribute plan materials such as an enrollment kit or marketing materials. ▪ Provide educational information. ▪ Provide and collect enrollment forms. During individual appointments, marketing representatives may not: ▪ Discuss plan options that were not agreed to in the Scope of Appointment. ▪ Market non-health care related products. ▪ Ask for referrals. Solicit/accept an enrollment request for a January 1st effective date prior to the start of the Annual Election Period on October 15 unless the beneficiary is entitled to another enrollment period (for example, an initial enrollment period or special enrollment period) Personal/Individual marketing appointments are defined by the intimacy of the appointments' location or format and typically take place in person at the beneficiary's home or a venue such as a library or coffee shop or via telephone call. All individual appointments ▪ Are considered sales/marketing events; ▪ Must meet sales/marketing event requirements; ▪ Must follow scope of appointment requirements (See following slides)

Some prescription drug plans may have higher operating costs and/or may offer enhanced coverage in return for an additional premium amount. He could look at plan designs to see if one of the enhanced plans would serve his needs better than a plan based on the standard design. Part D enrollees have three options for paying their Part D premium. (1) Automatic electronic monthly mechanism, such as withdrawal from their checking or savings bank account or automatic deduction from their credit or debit card; (2) Direct monthly billing from the plan; or (3) Automatic deduction from their monthly Social Security Administration (SSA) benefit check. • Typically it takes 2-3 months for SSA withholding to begin or end. • When withholding begins, it will be for the 2-3 months of premiums owed. • If a beneficiary is considering this option, he/she should call the plan first. Generally the beneficiary must stay with the premium payment option for the entire year.

For MA and Part D plans the individual must Permanently 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. Be a U.S. citizen or lawfully present in the United States on or before the enrollment effective date. (CMS makes this determination

Plans are responsible for ensuring compliance with Medicare rules by their marketing representatives. Plan marketing representatives include: ▪ individuals employed by a plan and ▪ individuals or entities under contract to the plan through a direct or downstream contract ▪ This would include brokers and agents (contracting directly with the plan or through an agency or other entity), third party marketing organizations (TMOs) such as a field marketing organizations (FMOs), general agents (GAs), or other marketing contractors).

Marketing representatives cannot say: ▪ The government wants you to join a Medicare health 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 without 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. ▪ (Name of plan) is the best Medicare plan you can buy. ▪ Medicare Advantage plans are the same as Medigap plans. ▪ You should opt out of MMP enrollment because everyone knows you will get a higher quality care through a Medicare Advantage plan.

Who is eligible for a SEP based on gaining eligibility for Part D LIS? 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 Who is eligible for a SEP based on loss of eligibility for Part D LIS? (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. Example: Ms. Perry is awarded LIS. CMS facilitates her enrollment into a PDP, effective October 1st. She decides she would rather be enrolled in another PDP or an MA-PD plan and submits a request in November. She does so using this SEP and her enrollment is effective December 1st.

Who is eligible for a SEP based on change of residence? 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 MA eligible and Part D eligible beneficiaries who experience certain qualifying events are allowed an SEP 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.

You may correct this information as long as you add your initials and date next to the correction

Marketing materials include any MA, MA-PD, section 1876 cost, or PDP plan or plan sponsor informational materials targeted to Medicare beneficiaries which: ▪ Promote the plan sponsor or any plan offered by the plan sponsor; ▪ Inform Medicare beneficiaries that they may enroll, or remain enrolled in a plan offered by the plan sponsor; ▪ Explain the benefits of enrollment or rules that apply to enrollees; or ▪ Explain how Medicare services are covered under the plan, including conditions that apply to such coverage.

You will NOT be able to represent any MA or Part D plan until you compete the training and achieve an adequate score, although you will NOT have to take a test if you exclusively market employer/union group plans and the companies do not require testing.

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 The SEP is available each year beginning on December 8 and may be used once through November 30 of the following year. For example, the SEP for calendar year 2018 can be used from December 8, 2017 through November 30, 2018. Disenroll from an MA plan, PDP or Cost plan or leave Original Medicare Enroll in a 5-star MA plan, PDP or Cost plan Eligible individuals may enroll in a 5-star plan through 1-800-MEDICARE, Medicare.gov, or directly through the 5-star plan.

You need to get Mr. Schmidt's phone number and include it on the enrollment form because the plan must call him after you leave to ensure that he understood the nature of the PFFS plan he selected and to verify his intent to enroll

PFFS options available to beneficiaries may include: Enrolling in a PFFS plan offering only Medicare A/B benefits and not obtaining Part D coverage; Enrolling in a PFFS plan that combines Medicare A/B and Part D prescription drug benefits (MAPD plan); or Enrolling in a PFFS plan offering Medicare A/B benefits and enrolling in a stand-alone Part D prescription drug plan (PDP). Individuals enrolled in a PFFS plan receive their Medicare benefits through the plan. PFFS is not the same as Original Medicare. PFFS is not a Medicare supplement, Medigap, or a Medicare Select policy

An agent attends a community-sponsored health fair, and hands out plan-specific benefits information including premium and/or copayment amounts; ▪ An agent participates in a health fair and hands out enrollment forms; ▪ An agent hands out only educational materials but gives a brief presentation that mentions plan-specific premiums and/or copayment amounts; ▪ An agent distributes business cards to attendees and asks them to call him about getting the best Medicare coverage representatives may NOT: ▪ Conduct sales presentations; ▪ Discuss or distribute plan-specific premiums, benefits, or materials including provider and pharmacy directories; ▪ Distribute or collect enrollment applications; ▪ Collect names/addresses of potential enrollees; ▪ Distribute or display business reply cards, scope of appointment forms, or sign up sheets; ▪ Attach business cards or plan/agent contact information to educational materials (business cards free of marketing information may be provided upon beneficiary request); ▪ Ask participants if they want information about a specific plan or limited number of plans; ▪ Set up personal sales appointments or get permission for an outbound call to the beneficiary; or ▪ Distribute or make available marketing materials.

If Mr. Block enrolls in the stand-alone Medicare Rx plan, he will be dis-enrolled from the MA plan. Individuals' eligibility to enroll in a stand-alone PDP depends on how they receive their medical benefits. 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.

If she does not sign up for a Medicare prescription drug plan as soon as she is eligible to do so, if she does sign up at a later date, her premium will be permanently increased by 1% of the national average premium for every month that she was not covered If you do not have a Medicare Advantage plan that includes Part D drug coverage, you must sign up for it separately. You should sign up for Medicare Part D at the same time that you enroll in Part B. Do not delay even if you do not take any prescription drugs regularly right now. If you wait until later to sign up, you will be charged extra on your premium for every month that you waited. The amount of the premium penalty changes every year.

Marketing representatives should contact 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

A meal CAN'T be provided, but light snacks would be permitted. 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 may offer gifts to potential enrollees if they attend a marketing presentation as long as the gifts are of nominal value and 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 other monetary reward, even if their worth is less than $15. Cash gifts include charitable contributions on behalf of an attendee and those gift certificates or gift cards that can be readily converted to cash. ▪ There is an exception where state law requires that the gift certificate or gift card must be convertible to cash and the cash value is no more than $2.00. ▪ 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. 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 given to current enrollees during the year. Plan sponsors and their marketing representatives may not willfully structure pre-enrollment activities with the intent to give people more than $75 per year.

Employed or independent agents/brokers must be state-licensed and follow all state appointment regulations in order to sell Medicare Advantage plans

Mr. Carlini can stay with Original Medicare and also enroll in a Medicare prescription drug plan through a private company that has contracted with the government to provide only such drug coverage to eligible Medicare beneficiaries

Agents/brokers must be licensed in the State in which they do business, annually complete training and pass a test on their knowledge of Medicare and health and prescription drug plans, and follow all Medicare marketing rules. Agents/brokers are subject to rigorous oversight by their contracted health or drug plans and face the risk of loss of licensure with their State and termination with their contracted health or drug plans if they don't comply with strict rules related to selling to and enrolling Medicare beneficiaries in Medicare plans.