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The New Improved Medicare Chapter 3
Medicare Parts C and D
Medicare Advantage (MA)
The Balanced Budget Act of 1997 created Part C of Medicare. The Balanced Budget Act expanded the kinds of private health care plans available to Medicare beneficiaries; this is referred to as Part C or Medicare Advantage (MA). Part C provides new products and new ways to enroll in Medicare. Medicare beneficiaries are not required to enroll in Part C; they can remain with their Original Medicare Plan if they wish to. Medicare provides Medicare beneficiaries with information on the new Part C plans that are now available.
The Centers for Medicare & Medicaid Services (CMS), formerly known as the Health Care Financing Administration, is a division of the U.S. Department of Health and Human Services. It is CMS that administers the Medicare program. Although they set the standards and policies, it is the Social Security Administration that processes Medicare applications and answers enrollees questions about eligibility. Beneficiaries will deal mostly with the private insurance companies and managed care organizations that they receive their health care services through. Since Medicare Part C is totally about managed care, anyone who decides to participate in Part C will be dealing with managed care organizations.
Most people will automatically be enrolled in Medicare Parts A and B, although it is not mandatory to participate in Part B (it must be purchased). When Part B was a new opportunity many people did not choose to participate but that is no longer true. Today virtually all who are eligible for Medicare does participate in both Parts A and B. If a person delays in signing up for Part B, they will pay a lifelong penalty for late participation unless they can show that the benefits were available elsewhere and provided creditable coverage.
Many individuals are familiar with HMOs (Health Maintenance Organizations). HMOs are paid a lump sum payment each month to provide care to the Medicare beneficiary. The individual receives care from their primary care physician (PCP), specialists, hospitals, nursing homes, and home health agencies that participate with the HMO (contracted providers). HMOs may provide additional services such as vision care, drug benefits, transportation, and other types of services. In some areas, HMOs do not charge the beneficiary an additional premium, instead relying solely on the income they receive from Medicare.
Preferred Provider Service Organizations (PPO) provides services similar to the HMOs. PPOs receive a monthly fee from Medicare just as HMOs do. They are operated by a hospital or an affiliated group of health care providers. The affiliated members of the PPO provide most of the care. Beneficiaries can choose doctors and services outside the PPO network, but it will cost them an additional fee.
Provider Sponsored Organizations (PSO) are affiliated hospitals and doctors who run the plan and bear the risk. Most of the services are provided by the hospitals and physicians and do not include an insurance company at all. These may be attractive to rural areas. The PSO receives a fixed monthly fee form Medicare to assume the risk for providing care. The enrollees also typically pay a fee each month to belong to the PSO.
Private Fee-for-Service organizations (FFS) are insurance plans that pay the providers directly without a network. Services received under the Private FFS plan are independent of the services received under Medicare. Individuals can receive services from other providers as long as those providers accept Medicare. The plan reimburses doctors, hospitals, and other medical providers on a fee-for-service basis at a rate determined by the plan, not at the Medicare rate. However, even though Medicare does not set the rate, Medicare limits the rate to a maximum of 115 percent of the Medicare approved charges. In other words, the medical provider may charge no more than 115 percent of the rate approved by Medicare. As previously stated, this limitation is called the limiting charge.
Medical Savings Accounts (MSA) purchase a health insurance plan that has a deductible limited to $6,000. After the individuals medical expenses exceed the deductible, the MSA pays for 100 percent of the Part A and B expenses. In addition to the monthly tax-deductible premium paid by the individual, Medicare pays the MSA plan the difference between the monthly premium and the enrollees capitation rate (the amount that would be paid to an HMO). Funds can be carried over from one plan year into the next plan year.
Part C provides five products. If individuals choose to make a change from their existing coverage, they must choose the type of plan they prefer. Then the individual would need to research the various providers of the type of plan they wish to enroll in and select one of the offering companies or organizations. Not all of the five types of plans will be available in all areas.
Challenging Payment or Care Provided
In the past, one of the concerns about managed care organizations, such as HMOs, had been the ability to challenge a claim or provider decision when the patient or their family felt it was not made in the patients best interest. Traditionally, managed care organizations had been required to inform beneficiaries of their appeal rights when there was a denial of services. Appeals took a long time and enrollees often felt it was not worth the trouble.
In August 1997 new rules were published which expedited the appeals process. Where appeals had previously taken 60 days to process they were required to be expedited within three days. These rules were again modified as part of the Balanced Budget Act for Medicare Advantage Plans.
It is important to note that there is a difference between an appeal and a grievance. Grievances are a concern that does not necessarily have to do with the entitlement to service or payment for a service. A grievance may be procedural, such as the amount of time it takes to get an appointment with a specialist. It can be personal activities, such as the attitude of an office staff member or the doctor. It can even concern member expectations that may have nothing to do with their medical provider services. A common member expectation has to do with medical records where the patient may feel they have the right to have them while the provider considers them the property of the organization. Medicare Advantage Plans must have procedures allowing enrollees to voice their concerns about management and operation.
Appeals In the fee-for-service contracts, appeals typically relate to payment of services. Services were delivered, but payment is denied due to one of several reasons. Where Medicare is concerned, Medigap fee-for-service contracts pay only if Medicare approved some portion of the bill. If Medicare totally denied the claim then the Medigap policy paid nothing (Medigap policies always supplement the decision made by Medicare). Often Medicare denies a claim due to non-medical necessity or a non-covered service.
In a managed care system most services are pre-authorized so it is known whether or not payment will be made prior to the delivery of care. Even emergency room care is often pre-authorized.
When there is a conflict between the patient and medical care provider, the enrollee has specific rights, including: 1. The right to have grievances between the enrollee and the Medicare Advantage plan heard and resolved in a timely manner. 2. The right to a timely organization determination. 3. The right to an expedited organization determination. 4. If dissatisfied with the organization determination, the right to reconsideration of the adverse organization determination. 5. The right to request an expedited reconsideration determination. 6. The right to reconsideration determination. 7. The right to an automatic reconsidered determination by an independent, outside entity if there is an adverse reconsideration determination in part or whole. 8. The right to an Administrative Law Judge hearing if the services are more than $100. 9. The right to request a Departmental Appeals Board review. 10. The right to judicial review of the hearing if the controversy is more than $1000.
There are several types of denials that an individual might receive. They are: Organization determination Reconsideration determination Reconsideration for the Center for Health Dispute Resolution Administrative Law Judge Department Appeals Board at HCFA Judicial Review
The states have moved many of the appeal processes to telephone formats where there is a three-way telephone conference between the enrollee, the medical organization and the person hearing the appeal. This allows the appeal to be handled much more quickly and it allows those who are appealing to do so from their home telephone.
Single-Payer System
Many people consider Part C to be a single-payer system. It has been estimated that approximately 59 percent of the population will move into Part C medical care plans.[1] Medicare would become that single-payer system by paying managed care plans a set monthly income per enrollee. Some of the plans will charge enrollees an additional fee, while others will operate solely on the income provided by Medicare.
Some have suggested that private fee-for-service plans will have to become more efficient, but that is not easy to do since patients will be seeking out their own care from providers that are not necessarily interested in capping their fees. In some areas medical care has seen competition, which has driven down fees, but this is not widespread.
Medicare Part D: Prescription Drug Coverage
Part D of Medicare is prescription drug coverage. Originally Medicare had only Parts A and B. Now there are four parts: A, B, C, and D, although parts A and B are still the main sections. What precisely is Medicares prescription drug coverage? According to the handbook issued by the Department of Health and Human Services (Medicare & You), Medicares prescription drug coverage helps cover your prescription drug costs. You must choose a plan to get this coverage. You pay a monthly premium. If you have limited income and resources, you may get this coverage for little or no cost. You can choose to take advantage of this coverage by joining a Medicare Prescription Drug Plan that covers prescription drugs only, and keep the rest of your Medicare coverage just the way it is. Or, you can join a Medicare Advantage or other Medicare Health Plan that covers your doctor and hospital care as well as prescriptions. Many Medicare beneficiaries may already belong to a Medicare Health Plan so that adding prescription coverage is very easy.
The federal government passed a 600-page long Medicare overhaul legislation bill in 2003. Many beneficiaries will be aware of only one result of this: the prescription drug benefit. Medicare recipients that have had to struggle to afford their prescriptions hope this legislation will enable them to buy their required drugs without giving up some other necessity of life.
Although the main focus seems to be on the drug benefits that began in 2006, it provided other programs as well. In 2004 beneficiaries were able to purchase drug cards that gave them discounts of 10 to 15 percent off their prescriptions. Although the cards were sanctioned by the government they were marketed by private firms offering different lists of covered drugs (along with different prices). Not all were convinced that the discount cards were a good idea since the discounts were small and all drugs might not be available. Individuals earning less than $12,000 per year received a free card plus a $600 prescription-drug credit.
The 2006 prescription drug coverage required beneficiaries to begin enrolling in November of 2005. Medicare recipients had until May 15, 2006 to decide to sign up with one of numerous programs available. Under the new benefit, the government will help those 65 or older pay for their prescriptions, picking up about a third of the tab for many. The amount paid will vary (less for some and more for others) with low-income individuals receiving the most help.
Many Medicare beneficiaries expressed confusion over their Part D choices. The drug benefit, estimated to cost $724 billion over the next 10 years, is the biggest expansion of Medicare since its creation in 1965 under President Lyndon B. Johnson. The introduction of Part D prescription drugs may be considered President Bushs biggest achievement in domestic policy. Despite the expressed concern over the benefit, it is not as difficult to understand as one might think. Help is everywhere for those who want it. Cities are holding seminars, senior groups are discussing it, and Medicare has a Web site that will maneuver the price comparison choices for the beneficiary with a few clicks of the mouse.
The time table for Part D included November 15, 2005 as the first day a Medicare beneficiary could sign up for Part D prescription drugs. The coverage began on January 1, 2006 for those who had selected and signed up for a drug plan by December 31, 2005. May 15, 2006 was the last available day to join a plan offering coverage for 2006. If an individual failed to sign up by this date, he or she would be charged a penalty for late signup, unless the individual had creditable coverage through employment or some other organization. This penalty lasts the duration of Part D. The actual amount of the penalty is 1 percent per month of delay or 12 percent a year.
Individuals on Medicaid who also qualified for Medicare were automatically switched to private plans selected by the government unless they chose a plan for themselves.
Those who had purchased Medigap plans I or J offering prescription coverage had to decide whether they preferred to remain with their current Medigap plan (which works with the Original Medicare Plan) or change to a new plan and sign up for Part D of Medicare. The federal government hoped most people would change from the Original Medicare plan and Medigap policy in favor of one of the managed care plans.
It should be noted that Part D of Medicare (prescription coverage) is voluntary not mandatory. Since there is an additional cost for Part D it is likely that some people will reject it not sign up. Therefore, the first decision Medicare beneficiaries must make is whether or not to purchase Part D. When Medicare was first created in 1965 many people did not sign up for Part B (doctor fees and outpatient services) because they were not sure they would use it and they did not want to pay for something they didnt use. Today, nearly everyone signs up for Part B, electing to pay the premium required to obtain it. Part D may experience the same thing with many people not initially purchasing it. As those on Medicare become more comfortable with the added cost of Part D it is likely that (like Part B) most people will buy it when first eligible to do so. They first become eligible when they turn 65 and qualify for Medicare.
Those who still have coverage through an employer may not need to sign up immediately for Part D. It is important for individuals who think this might include them to check with their benefits administrator to be sure. If the coverage is Medicare creditable there will be no penalty for late Part D signup. However, if the benefits offered by Medicare exceed those offered by the employer, a late sign up penalty might be levied. Creditable means the benefits offered under the employers medical plan meet or exceed those offered by Medicare. Individuals will have a Special Enrollment Period to sign up for a drug plan if their employer or union stops offering equitable prescription coverage. That means those involved would not have to pay a penalty if they join a drug plan after the deadline.
The cost of the prescription drug portion of Medicare (Part D) will vary depending upon the plan selected. It might also depend upon the beneficiarys financial situation since there are options for those who cannot afford the premiums. All available Medicare drug plans will offer coverage at least as good as the Medicare minimum standard coverage. The law only requires plans to meet these minimum standards, however, so some plans may offer higher benefits than others. Those who offer better than minimum benefits will cost more than those that only offer the minimum requirements.
Minimum Drug Benefit Standards In All Plans: Participants in the Part D prescription drug program pay part of the cost; Medicare pays for the remainder of the cost. The enrollee will pay a monthly premium for the benefit. The actual amount paid will depend upon many factors, including the extensiveness of the coverage. The premium paid for Part D benefits will be in addition to that paid for Part B services. Those enrolled in a Medicare Advantage Plan or a Medicare Cost Plan will see their current monthly premium increase if they add Part D coverage to their plan. The actual plan increase or cost will depend upon the type of Part D coverage chosen. All Part D plans must cover the minimum requirements set down by Medicare (but, as we said, some will give greater benefits than the required minimum).
Standard Coverage Standard coverage includes specified deductibles and copayments. Since these are minimum standards, there will be variations in the plans offered by private companies. Plans can offer greater coverage, but not lesser. What does that mean? It means that a plan can require no more than the initial $250 deductible (they cant impose a $300 deductible for example) but they can allow coverage that is more advantageous for the enrollee (such as eliminating the $250 deductible). Minimum standards always dictate the least benefits that can be acquired; they do not address the maximum benefits that an enrollee can receive.
What will a Medicare beneficiary pay for their Part D coverage? For the standard coverage (the minimum coverage that must be provided under Medicares guidelines) a beneficiary will pay:
Who should consider buying Part D, prescription drug coverage? Lauren Moughon, the Washington lobbyist for AARP, the largest advocacy group for people over 50 in the nation, offers these tips:
Signing up may also be wise for higher-income individuals who do not currently have prescription coverage. Even if the beneficiary purchases a plan that is lower priced because it offers lower benefits it might be wise to at least sign up. Most companies allow upgrades in coverage. It is impossible to know what the future will bring, but statistically most people do use more prescriptions as they age. If a Medicare beneficiary does not sign up when eligible, there will be a penalty to sign up at a later date. Therefore, it makes sense to at least sign up, even if a very low benefit plan is selected. This prevents a late-signup penalty that will last throughout the beneficiarys life.
Many Americans are purchasing their drugs through Canada. Medicare Part D prescription coverage will not reimburse expenses for Canadian-purchased drugs. Nor will drugs bought in Canada count towards the deductible in a Medicare Part D plan.
Navigating the Prescription Choices:
The type of drug plan chosen will depend upon many factors. How benefits are paid will depend upon whether they are paid through: An HMO that tends to limit its members to specific network providers. A PPO, which allows a wider choice when choosing doctors. A stand-alone drug plan that will accompany coverage the beneficiary chooses to keep. It is important to consider each plans listed formulary, which is the list of medications that are approved by the prescription plan. The formulary is likely to have variations between plans. Each beneficiary will want to check with the pharmacy that they primarily use to be sure that the drug plan they are considering is accepted there.
Individuals desiring Part D coverage sign up independently of anyone else. In other words, there are no discounts for signing up as a married couple.
Individuals who are on Medicare due to a disability or due to permanent kidney failure may sign up for Medicare Part D even though they are not yet 65 years old.
There are many plans available to Medicare beneficiaries. Individuals may go to Medicares Web site at www.medicare.gov and click on Compare Medicare Prescription Drug Plans to compare available plans. It is also possible to sign up for one of them by clicking on Enroll in a Medicare Prescription Drug Plan. It will request specific information, including the information on the beneficiarys Medicare card, current prescription medication, and the pharmacy that is being used. The program will automatically list plans that meet the needs of the individual, with the cheapest plan at the top. Since the program compares premiums, deductibles, and other costs, the math is done for the inquiring person. It is also possible to call Medicare at 1.800.Medicare for personalized help, although call volume at some times makes it difficult to get through.
All prescription drug plans approved by Medicare may use a specific seal in their brochures and other materials: Medicare ℞Prescription Drug Coverage
Everyone with Medicare can join a drug plan to obtain prescription coverage benefits. Everyone with Medicare must make a decision about their drug coverage, just as they had to regarding Part B of Medicare. Just as it is with Part B, if the beneficiary chooses not to purchase Part D and later changes their mind they will have a permanently higher rate (due to a permanent penalty) for joining after they were first eligible.
It is true that many people may not be taking many prescriptions at age 65, but as we age we tend to have additionally more medical needs and those needs usually include prescription drugs. Although Medicare has done all it could to convince elderly Americans to join managed care groups, there are many who are on the Original Medicare Plan supplemented by an insurance policy. As we have said, insureds may purchase Part D coverage through their current insurance company or through an entirely different company.
Initial Difficulty
It is never easy getting accustomed to dealing with something new; it is never easy administering something new. Both have been the case with the Part D Medicare benefit. This program certainly has its share of critics. Many people have found that their benefits are not easy to collect on, whether due to bureaucratic bungling, pharmacy inexperience, or delays that are due to misunderstandings, bookkeeping errors, and undereducated bureaucrats.
Deborah Vrana said in Medicares Drug-Plan Mess[2] Since the January 1 rollout, the plan has been plagued by problems even some of its sharpest critics didnt expect: Some beneficiaries are being told they dont have coverage when they do. Others find that the drugs are covered but other needed supplies arent. Some beneficiaries havent received enrollment cards. Many with chronic conditions find that no plan covers all their medications. Wait times for information are long, and the information dispensed is not always correct. The Social Security Administration, which administers some aspects of the Medicare plan, says its help lines have been so overwhelmed that other services are beginning to suffer. Some beneficiaries are being overcharged dramatically, charged hundreds of dollars when they owe only a copayment of $1 or $5. Some pharmacists have yet to be paid. California and Missouri have sued over a requirement involving how excess money must currently be handled. Savings accrued by state plans due to Medicare changes must currently be returned to the federal government. Both states say its taking hundreds of millions of dollars away from those who need it most. Some plans require beneficiaries to switch to a particular pharmacy. Some of the problems experienced are the result of dual-eligibility where individuals were previously covered under both federal and state programs, such as Medicaid. A provision in the Part D legislation automatically switched about 6 million low-income and disabled people into the new program on January 1, 2006. In many cases, these recipients had better coverage prior to the switch since the state programs they were previously covered under were more generous. Additionally, the influx of people overwhelmed the system. It left many of those with dual eligibility with no coverage at all. Almost a third of this group is mentally ill with little ability to understand why they are now having problems getting their medications.
Preface From the Centers For Medicare & Medicaid Services
The Centers for Medicare and Medicaid Services (CMS) printed the followed:
Marketing Guidelines reflect CMSs current interpretation of the marketing requirements and related provisions of the Medicare Advantage (MA) and Medicare Prescription Drug Benefit rules (chapter 42 of the Code of Federal Regulations, Parts 422 and 423). These guidelines were developed after careful evaluation by CMS of current industry marketing practices, recent advancements in communication technology and how best to protect the interests of Medicare beneficiaries.
The following marketing guidelines are for use by Medicare Advantage Plans (MAs), Medicare Advantage Prescription Drug Plans (MA-PDs), Prescription Drug Plans (PDPs) and 1876 Cost Plans. The 1876 Cost Plans that do not offer or do not mention Part D as an optional supplemental benefit will follow MA specific guidance. Cost Plans that mentions Part D as an optional supplemental benefit in their marketing materials will follow MA-PD guidance.
The drug benefit is offered through Medicare Advantage Prescription Plans, Private Prescription Drug Plans, Program of All Inclusive Care for the Elderly (PACE), and 1876 Cost Plans.
This section will be using the following terms: MA for Medicare Advantage Plans MA-PDs for Medicare Advantage Prescription Drug Plans PDPs for Prescription Drug Plans
Readers will need to remember these abbreviations in order to understand the following material.
The marketing guidelines that have been established are intended to meet several goals:
Organizations were not allowed to distribute any marketing materials on the Part D drug benefit until notification was received from CMS (Centers for Medicare & Medicaid Services). Prior to marketing or distributing materials they must have first contracted with CMS and be able to initiate enrollment and operate as a Medicare Organization in accordance with Title 42 of the Code of Federal Regulations. Organizations meeting the specified requirements and complying with CMS Marketing Review Guidelines were able to start releasing their 2006 marketing materials on October 1, 2005.
Plan Names
While we generally consider a Medicare beneficiary to be at least 65 years old there are many people who are eligible for Medicare that are younger. These individuals qualify on the basis of an eligible disability. When an organization is considering the development of their plan name they may not select one that would suggest the plan is available only to those who are age 65 or older. This prohibition generally bars plan names from incorporating such terms as seniors, 65+ and so forth. CMS will allow the grandfathering of MA and MA-PD plan names that were established by Medicare Advantage organizations prior to June 29, 2000. This would not include PDP names. Nor may organizations use any name that suggests it is available only to those who have disabilities.
Organizations may use ethnic or religious affiliations in their plan names if the legal entity offering the plan has a similar proper name or affiliation. For example, a plan that was affiliated with the Swedish Hospital System of Minnesota could use a tag line Swedish Plan, offered by the Swedish Hospital System of Minnesota.
As we know, Original Medicare Plans may not suggest or say they are affiliated with the government in any way. The same is true of prescription drug plans. Organizations may not use such things as Medicare Endorsed as part of their Plan name or anything similar suggesting that such endorsement exists. They may, however, use the term Medicare in their names. Plan names that were submitted to CMS after August 15, 2005 with the word Medicare in it had to insert some other word before it. The example used by CMS is Acme Medicare Plan. In this way, there is no confusion as to whether or not the organization is affiliated with Medicare since the name clearly indicates it merely relates to Medicare. Regardless of when the Plan name was submitted to CMS, it cannot be misleading or otherwise fail to comply with applicable laws and CMS policies.
Existing MA organizations may use the term Advantage in their plan names. All plans in existence as of January 1, 2004, who had the name Medicare Advantage organization may continue to use that name indefinitely. As of the implementation of the Medicare Prescription Drug Benefit, new Medicare Advantage plans are no longer allowed to do business under the name of Medicare Advantage. Those organizations that decided to keep doing business under Medicare Advantage plan names must insert the company name before it, such as Acme Medicare Advantage Plan.
Part D Plans that are licensed by a state as a risk-bearing entity can jointly enter into a single contract with CMS to offer a Regional Preferred Provider Organization (RPPO) or PDP in a multi-state region. The participating organizations would contract with each other to create a single Joint Enterprise and would be considered an entity for purposes of offering a RPPO or PDP. Joint Enterprises are expected to:
Marketing materials for the Joint Enterprise may only be distributed in a state where one or more of the contracted health plans creating the single entity is licensed by that state as a risk-bearing entity or qualifies for a waiver under 42 C.F.R. 423.410 or 422.372.
All marketing materials must be submitted under the Joint Enterprises contract number and must follow the appropriate marketing guidelines.
HIPAA Provisions Relating to All Organizations
On April 14, 2003, new Federal rules governing the use and disclosure of certain individually identifiable health information by health plans, health care clearinghouses, certain health care providers (called covered entities) became enforceable. Medicare Prescription Discount Drug Card Sponsors were added as a covered entity by the Medicare Prescription Drug Improvement and Modernization Act of 2003. The regulatory text of the final rule is generally referred to as the HIPAA Privacy Rule. Plan D Plans may use or disclose their members protected health information as permitted by these regulations and any other applicable privacy laws. For example, if a state law were stricter than the federal law, the state law would likely then be applicable.
The HIPAA Privacy Rule generally allows covered entities to use or disclose this information without beneficiary authorization for treatment, payment, or health care operations, as defined by the rule, and for a number of public interest or benefit purposes. Organizations are not required to obtain authorizations prior to using their Medicare beneficiary members data to provide information to such members regarding their benefit packages.
Definitions Pertaining to Part D
Just as an insurance contract or policy will have a section defining terms used in it, so does Part D require specific terminology, which must then be defined.
Enrollment Assistance: Assisting a potential enrollee with the completion of an application and/or objectively discussing characteristics of different plans to assist a potential enrollee with appraising the relative merits of all available individual plans, based solely on the potential enrollees needs. The individual or entity performing this service must not receive compensation directly or indirectly form the plan for such assistance in enrollment.
Marketing: Steering, or attempting to steer, an undecided potential enrollee towards a plan or limited number of plans, and for which the individual or entity performing marketing activities expects compensation directly or indirectly from the plan for such marketing activities. Assisting in enrollment and education does not constitute marketing.
Education: Informing a potential enrollee about Medicare Advantage or other Medicare Programs, generally or specifically, but not steering, or attempting to steer, a potential enrollee towards a specific plan or limited number of plans.
Provider Promotional Activities: Activities that a provider may perform to educate potential enrollees or to assist potential enrollees in enrollment.
Marketing Materials: includes any informational material that performs one or more of the following actions:Promote an organization. Provide enrollment information for an organization. Explain the benefits of enrollment in an organization. Describe the rules that apply to enrollees of an organization. Explain how Medicare services are covered under an organization, including conditions that apply to such coverage. Communicate with the individual on various membership operational policies, rules, or procedures.
The definition of marketing materials extends beyond the publics general concept of advertising materials to include notification forms and letters used to enroll, dis-enroll, and communicate with the member regarding many different membership scenarios. The Internet is considered another vehicle for the distribution of marketing information. Therefore, all regulatory rules and requirements associated with all other marketing conveyances, such as the newspaper, radio, TV, or brochures, are applicable to Medicare organization marketing activity on the Internet. CMS marketing review authority extends to all marketing activity the Medicare organization pursues via the Internet, including advertising, pre-enrollment, and post-enrollment activity. The specific requirements that apply depend on the type of material.
Press releases are not considered marketing materials and do not need to be submitted for review, even if such materials contain marketing information, such as a description of the plan benefits or cost sharing.
Health education materials are generally not under the purview of CMS marketing review; however, materials that perform the actions of marketing materials as defined above must be approved by CMS prior to use.
Explanatory Materials: Explanatory materials are a subset of marketing materials primarily intended to explain the benefits, operational procedures, cost sharing, and/or other features of an organization to current members or to those considering enrollment. Explanatory materials are further subdivided into Pre-Enrollment materials and Post-Enrollment materials, both of which are defined below.
Examples of Explanatory Materials: Evidence of Coverage Summary of Benefits Enrollment and disenrollment forms or letters Pharmacy Directory Formulary Member ID Card Appeals and grievance letters Exceptions process letters Sales scripts/sales presentations
Pre-Enrollment Marketing Materials: Pre-enrollment materials, including sales scripts, direct mail that includes an enrollment form, and sales presentations, provide more detail on the organization than what is provided in an advertisement and are generally used by prospective enrollees to decide whether or not to enroll in the organization. Organization rules and organization benefits are among the information included in pre-enrollment materials.
Post-Enrollment Marketing Materials: Post-Enrollment materials are those used by an organization to convey benefits or operational information to enrolled plan members. Post-enrollment marketing materials include all notification forms and letters and sections of newsletters that are used to communicate with the individual on various membership operational policies, rules, and procedures. Post-enrollment marketing materials include, but are not limited to, the Evidence of Coverage, the Summary of Benefits, and the Pharmacy Directory. These materials are also called beneficiary notification materials and are subject to additional CMS requirements.
Advertising: Advertising materials are primarily intended to attract or appeal to a potential organization enrollee. Advertising materials are intended for quick view, so they do not contain the same level of detail expected in other marketing material. Outdoor advertising, banner advertising, and banner-like advertising are materials designed to catch the attention of a person and influence them to call for detailed information on the product being advertised. Such advertising would include television, radio and billboards. It would also include direct mail advertising as long as it does not include enrollment forms. The purpose of advertising, as used in this context, is to give recipients the opportunity to request additional information on the plan.
Value Added Items and Services (VAIS): These are items and services offered to plan members by a plan that does not meet the definition of benefits under the Medicare program and involves only administrative or minimal costs. VAIS may not be funded by Medicare program dollars. If VAIS are discontinued, plans are required to notify their enrollees in a timely manner.
Health-Related VAIS are intended to maintain or improve the health status of enrollees, where PDPs incur an administrative or minimal cost that is not included within the PDP bid to CMS. Examples of health-related VAIS are discounts on eyeglasses and health clubs. Organizations are permitted to contact Medicare beneficiaries about VAIS health-related items and services provided by the organization without prior written authorization to the extent permitted under the HIPAA Privacy Rule.
Non-Health-Related VAIS are not intended to improve or maintain the health status of enrollees, and the cost incurred by the organization is usually only administrative and is not included within the Organizations bid to CMS. To the extent required under the HIPAA Privacy Rule, organizations must receive prior written authorization from Medicare beneficiaries before contacting them regarding non health-related VAIS items and services.
Types of Plans Based on Service Areas
The MMA requires a number of changes to the Medicare program. In order to implement the new Medicare Prescription Drug Benefit and changes to the Medicare Advantage program, CMS defined appropriate regions for PDPs and regional MA Plans as required under the Medicare Modernization Act. On December 6, 2004, CMS announced the establishment of 26 MA regions and 39 PDP regions (CMS PDP Regions, including the 5 territories).
National Plans PDPs: A PDP can market itself as a national plan if, at a minimum, it covers the 34 CMS PDP regions that include the 50 states and the District of Columbia. PDPs that cover more than the minimum 34 PDP regions (that is, those that include the 50 states, the District of Columbia, and one or more territories) are also considered national plans. PDPs sponsored by more than one organization, a Joint Enterprise, can also use the term national if the Joint Enterprise covers at least the 34 CMS PDP regions that include the 50 states and the District of Columbia. MAs/MA-PDs: An MA/MA-PD can market itself as a national plan if it covers at least the 26 SMS MA regions that include the 50 states and the District of Columbia. MAs/MA-PDs that cover more than the minimum 26 regions (the 50 states, District of Columbia and one or more territories) are also considered national plans.
Regional Plans PDPs: A regional PDP is a plan that serves one or more entire PDP regions, but not all the 34 PDP regions that include the 50 states and the District of Columbia. MAs/MA-PDs: A regional MA/MA-PD is a coordinated care plan structured as a Preferred Provider Organization (PPO) that serves one or more entire MA regions but not all 26 CMS MA regions that include the 50 states and the District of Columbia. All regional plans must have a network of contracting providers that have agreed to a specific reimbursement for the Plans covered services. Regional Plans must provide uniform benefits within their service area. Local Plans (MA, MA-PDs, 1876 Cost Plans): A local plan is offered by a legal entity that is not a regional plan. Local plans may choose the counties in which they operate. Local plans may also vary benefits and premiums at the county level. The uniform benefit requirement applies to local plans at the service area or segment level.
An organization is prohibited from advertising outside of its defined service area unless the advertising is unavoidable, such as newspaper advertisements that might have a wider circulation than their service area. Organizations are required to clearly disclose their service area in the advertisement to avoid consumer misunderstandings.
Medigap Insurers
If a Medigap issuer chooses to sponsor a MA-PD or PDP, it will be allowed to use its existing enrollment information from its Medigap insurance plans to market its Part D Plan to its enrollees, to the extent allowed by the HIPAA Privacy Rule and other applicable Federal or State privacy laws. However, if the Medigap issuer plans to market the plan, it must do so to all of its members, not just a portion of them, which would be considered discrimination.
When preparing to market plans, materials must first be submitted to the appropriate CMS Regional Office via email, facsimile, or the US Postal Service for approval. Upon submission of their materials, organizations have the following responsibilities:
CMS or its designee reviews marketing materials to ensure they meet the Marketing Material Guidelines and are not materially inaccurate or misleading. Certainly they are not allowed to misrepresent who they are or the benefits and services they are offering. The organization is not allowed to claim CMS, Medicare, or the Department of Health and Human Services endorses them. It may state, however, that the organization is approved for participation in Medicare programs and that it is contracted to administer Medicare benefits. They may use the term Medicare-approved to describe their benefits and services within their marketing material.
Model and Standardized Materials
Language Marketing materials containing standardized language has been drafted by CMS. The desire is to have standardized language in all marketing materials so that consumers can easily compare one plan with another without confusion (or at least with as little confusion as possible). For certain pre- and post-enrollment documents, CMS has drafted model language, which entitles the organization to a ten-day marketing review period as long as they do not modify the language in their marketing materials. The use of CMS model language is optional. However, if the organization chooses not to use the model language it must include all elements of the model language and required disclaimers as outlined in the appropriate sections of the law.
CMS has developed a list of model materials that are available, including model pharmacy directory, Explanation of Benefits (EOB), comprehensive formulary, and abridged formulary. This is not a full list of what is available.
Organizations are prohibited from comparing their company or plan with another company or plan by name. Advertising materials are defined as materials that are primarily intended to attract or appeal to a potential enrollee. They may not be used to downgrade another company or plan by name.
Advertising may state some specific claims. For example, it may state virtually no paperwork required for claims. They may not state no paperwork required for claims. In many cases, organizations must list the hours of operation for its customer service department with telephone numbers provided in the advertisement. This includes listing the hours of operation for 1-800-MEDICARE any time the 1-800-MEDICARE number is listed. This requirement does not apply to any phone numbers included on advertising materials for persons to call for more information.
Some advertising requires TTY/TDD numbers to appear in conjunction with other telephone numbers in the same font size and style. The TTY/TDD numbers must include the hours of operation if they relate to customer service departments. Organizations may use either their own or State Relay Services, as long as the number included is accessible from TTY/TDD equipment. There are some exceptions to this. For example, in television ads, the TTY/TDD number does not have to be the same font size and style as other numbers since it may result in confusion and cause some prospective enrollees to call the wrong telephone number. Nor are they required in radio ads for the same reason.
Many advertisements use product endorsements or testimonials. When these are used they must follow specific guidelines:
Product endorsements and testimonials cannot use anonymous or fictitious quotes by physicians, health care providers or Medicare beneficiaries. Nor can they use negative testimonials about other plans.
Organizations may not use free gifts or prizes as an inducement to enroll in their plan. Any gratuity must be made available to all participants regardless of enrollment. The value of any gift must be less than the nominal amount of $15. In accordance with this guideline, organizations offering drawings, prizes or giveaways must state one of the following phrases in at least 12-point font:
They may not state Eligible for free drawing and prizes. Cash gifts are prohibited, including charitable contributions made on behalf of people attending a marketing presentation, and including gift certificates that can be readily converted to cash, regardless of the dollar amount. The dollar amount associated with the definition will be periodically reassessed by CMS, so any figures stated here could change. Dollar amounts higher than $15 can be offered as a prize as long as the prize is offered to the general public and not just to Medicare beneficiaries.
Pre-Enrollment Materials
If model language is available and not used in pre-enrollment materials, plans must include all elements of the model language and all required disclaimers. In other words, the essential information must still be in the materials even if the exact words of the model language are not used.
Lock-In Statement/Access Information When used by MA HMO plans the lock-in statement means that the beneficiary is locked into a provider network so if the beneficiary obtains routine care from out-of-plan providers, neither Medicare nor the plan will be responsible for the cost of care. It is important to note that not only the plan refuses payment Medicare also refuses payment. Limits apply when the beneficiary makes an enrollment health care choice. Therefore, when appropriate for the plan, the concept of lock-in must be clearly explained in all pre-enrollment materials. For marketing pieces that tend to be short it is suggested that some type of statement be used, such as You must receive all routine care from plan providers or You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. A more expanded version is suggested if possible, such as If you obtain routine care from out-of-plan providers neither Medicare nor [name of organization] will be responsible for the costs.
In the case of PPOs, POS plans, private fee-for-service plans and Visitors Programs for any plan type explain that use of non-plan or non-preferred providers, while allowed, may cost the beneficiary additional expense.
For Medicare 1876 cost plans, enrollees must be informed that after enrollment is effective, in order for them to receive the full coverage offered, services other than emergency or urgently needed services must be obtained through the HMO or CMP. In the case of cost enrollees, however, they may receive services that are not provided or arranged by their HMO or CMP, but they would be responsible for payment of all Medicare deductibles and coinsurance as well as any additional charges as described by the Medicare program. They would also be liable for any charges that are not covered by the Medicare program.
Benefit and Plan Premium Information
Pre-enrollment materials must include specific information: The following statement must be included: You must continue to pay your Medicare Part B premium with the premium information, even if the premium happens to be zero. When specifying benefits, specify annual limits, annual benefit payout, and applicable copayments. Clearly state major exclusions and limitations. Clearly state all monetary limits, as well as any restrictive policies that might impact a beneficiarys access to services. When annual dollar amounts or limits are provided, it must also mention the applicable quarterly or monthly limits and whether any unused portion of that benefit can be carried over from one calendar quarter to the next. Include a closing statement such as: For full information on the organization or benefit, call our Customer Service Department at 000-0000. Office hours are 8 am5 pm Monday through Friday. Cost contractors must describe their premiums and cost sharing for services received through the cost plan, and any optional supplemental benefit packages they offer. They must also indicate that premiums, cost sharing, and optional supplemental benefits may change each year and include information on when such benefit options can be selected or discontinued. Make the statement that the Medicare health plans contract with CMS is renewed annually and that the availability of coverage is not guaranteed beyond the end of the current contract year.
Organizations are required to include a statement indicating that members may enroll in a plan only during specific times of the year. Organizations may either describe all enrollment periods in detain or refer eligible individuals to the Organizations customer service department to obtain specific information.
Plan Eligibility Requirements
Each plan will have eligibility requirements. Organizations must clearly state in their pre-enrollment materials that an individual is eligible to enroll in the plan if he or she:
Part D payment demonstration plans must include the following statement: You cannot enroll in this plan if your current or former employer help pay for your drugs.
In the case of PDPs, it must state that Medicare beneficiaries:
In the case of MA-PDs, it must state that:
1876 Cost Plans must state that Medicare beneficiaries may be enrolled in only one Part D Plan at a time. These plans must also indicate that all Medicare beneficiaries may apply to enroll in the 1876 Cost Plan.
If benefits are mentioned in pre-enrollment materials, organizations must inform eligible persons of the types of pharmacies included in their network, such as retail, or mail order. If mail order prescription drug service is available, organizations must provide ways for the potential beneficiary to obtain additional information regarding this feature. Organizations must note that generally benefits are only available at the contracted network pharmacies, except under emergency situations. Organizations must provide contact information for obtaining additional network pharmacy information, including a toll-free number, a TTY/TDD number if applicable, and a mailing address.
Organization materials must include a statement either in the text of the material or as a footnote that the organization contracts with the Federal government. The SB, EOC, Member Handbook and all pre-enrollment materials must include this statement.
Low Income Subsidy Premium Disclaimer
MA-PD and PDP plans must include a low-income subsidy premium disclaimer. In all pre-enrollment marketing materials where Part D monthly premiums and other member costs are described the Part D organization must include the following language: If you qualify for extra help with your Medicare Prescription Drug Plan costs, your premium and drug costs will be lower. When you join [name of plan], Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay. If you arent getting any extra help, you can see if you qualify by calling: 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, or Your State Medicaid Office, or The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m. Monday through Friday. TTY/TDD users should call 1-800-325-0778.
Summary of Benefits (SB)
The Summary of Benefits (SB) is the primary pre-enrollment document to inform prospective as well as existing enrollees of the benefits offered by the organizations plan. The information contained in the SB uses standardized language to allow beneficiaries to adequately compare the benefits offered by different organizations. If the language was not standardized it would be difficult to compare, as the saying goes, apples to apples when looking at different plans.
The Summary of Benefits is a stand-alone marketing document that includes the following sections:
Section 1: The introduction and the beneficiary information section, which informs prospective members of important aspects of enrolling in the organizations plans.
Section 2: The benefit comparison matrix, which is an output report of the organizations Plan Benefit Package, referred to as PBP.
Section 3: An optional free-form text area, which is limited to six pages. This section can be used by plans to further describe special features of their program.
The Summary of Benefits (SB) is a summary document, so it is not intended to include benefit information in the same detail as the Evidence of Coverage would. All organizations, except 1876 Cost Plans are required to use the standardized SB. 1876 Cost Plans that intend to have a plan appear in the Medicare Personal Plan Finder should refer to the summary of Benefits for Cost Plans.
The general requirements for SBs used in MA-PD, PDP, MA organizations, include: Standardized language and format. Any deviation from the standard use must first be approved by CMS. Changes in language and format in a Summary of Benefits will result in disapproval or delay of approval. The title Summary of Benefits must appear on the cover page so that it clearly identifies the document. The entire SB must be provided together as one document. This means that all three sections, if three exist, must be together. It is not allowed to divide the three potential sections in multiple documents. Since some will have only two sections, these two must appear together, if the third section is not used. The entire SB must be submitted for review as one document. If plans opt to utilize Section 3, the entire SB will receive a 45-day review. It is permissible to use a front and back cover. Font size must be at least 12-point, but may be larger. Even footnotes must be in at least a 12-point font. Organizations may use bold or capitalized text to aid in readability, as long as any such changes do not steer beneficiaries to or away from particular benefit items, which might interfere with the legibility of the total document. Since Sections 1 and 2 will not be generated from the PBP in 12-point font, the MA organization should change the font to ensure that the font size is at least 12-point. Colors or shading techniques are permitted, but they must not direct a beneficiary to or away from any particular benefit item and must not interfere with the legibility of the document. The Summary of Benefits may be printed in either portrait or landscape page format. Organizations offering more than one plan may describe several plans in the same document by displaying the benefits for different plans in separate columns within the benefit comparison matrix. Organizations offering plans with identical benefits within one contract may display the information for these in the same column with the benefit comparison matrix. PDPs may display identical benefits in different regions. In this case, the benefits must be the same, with only the service areas differing. If the SB describes more than one plan, the organization must identify the specific plan in which the member is currently enrolled with the cover letter included with the SB. If the SB describes only one of several plans offered, the availability of other plans must be noted in the Annual Notice of Change (ANOC). Organizations may include additional information about covered benefits within a separate flyer or other material and may provide this with the SB. Organizations may display header information, such as the company name, telephone number and so forth on either the front page or on each page of the Summary of Benefits. If an organization chooses to submit an SB for CMS review without utilizing Section 3 and containing no hard copy changes, it will be treated as a model without modification, so will be reviewed within ten days. Organizations that offer plans exclusively to persons through an employer-sponsored group are not currently included in the mandated use of the standardized SB for either annual notification or initial marketing purposes. In the case of an MA organization, if it wants to include mandatory supplemental benefits beyond those found in the comparison matrix, the MA organization must place the information in Section 3 of the SB. It must include a brief description of the benefits and any co-pay requirements.
As we have stated, Section 3 is used to describe special features of a program or to provide additional information about benefits described within Sections 1 and 2 of the Summary of Benefits. Section 3 is optional and is not standardized with regard to format or content. It may contain text, graphics, pictures, maps or any item or subject the organization feels is pertinent.
Section 3 is limited to a maximum of six pages of text and/or graphics. The page limit is defined as six single-sided pages or three double-sided pages. There is, however, one exception to this limit: organizations translating the SB to another language may add pages as necessary to ensure the translation conveys the same information as the English language version.
Footnotes
Some footnotes are mandatory: 1. Where monetary amounts are subject to change, this must be noted. It would state: [year], you pay a total of one $(current) deductible. This footnote must be referenced after every statement in the Original Medicare column that describes the required Medicare coinsurance. The only exception where the footnote would not need to be referenced is mammograms, pap smears or pelvic exams and prostrate cancer screening exams. 2. This footnote must appear at the bottom of each applicable page: NOTE: The Medicare Part B deductible may change each year. 3. If a doctor or supplier choose not to accept assignment, their costs are often higher, which means you pay more. This footnote must be referenced after every statement in the Original Medicare (OM) column that describes deductible benefits and after the footnote described under 1 of this section. The text of this footnote would appear at the bottom of each applicable page. 4. The term benefit period must be footnoted with the following explanation: A benefit period begins the day you go to the hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. 5. Lifetime reserve days can only be used once. This footnote must be referenced after the statement, Days 91-150: $00 lifetime reserve days in the OM column describing Inpatient Hospital Care. Where we placed zeros it will state the actual dollar amount, which changes from year to year. Additionally, if the footnote is applicable to the plan it must also be referenced in the plan column. The text of this footnote must appear at the bottom of the page on which these benefits are described.
Summary of Benefits for 1876 Cost Plans
1876 Cost Plans are not required to use the standardized Summary of Benefits. They are required to provide members with an SB, though. If an 1876 Cost Plan intends to have the plan appear in Medicare Health Plan Compare and Medicare Personal Plan Finder, it will need to complete the Plan Benefit Package (PBP) to create a standardized Summary of Benefits. 1876 Cost Plans that create a standardized SB should follow all required instructions. 1876 Cost Plans follow the instructions outlined for Summary of Benefits, but they also follow instructions that are specific to the 1876 Cost Plans. Therefore, in general, the benefit description column and the Original Medicare column must remain unchanged. All sentences in the plan column of the matrix must be completed with applicable co-pays or coinsurance amounts, with footnotes as previously covered.
Under Section 1 of the Summary of Benefits, the pre-enrollment language in Cost Plans will not apply if they are closed to new enrollment. As a result, these Cost Plans should include the following disclaimer in their ANOC:
If you go to a provider outside of [insert name of plan] who accepts Medicare patients, your coverage would be the same as Original Medicare. Original Medicare deductibles and coinsurance apply.
The CMS requires the Summary of Benefits (SB) to be used in both pre-enrollment and annual notice of change (ANOC) functions. Any additional information regarding the contractors closed status should also be included in the cover letter.
Under Section 2, 1876 Cost Plans may include the following footnote on each page of the benefit comparison matrix. The text of the footnote should appear at the bottom of every page.
If you go to a provider outside of [insert name of plan] who accepts Medicare patients, your coverage would be the same as Original Medicare. Original Medicare deductibles and coinsurance apply.
Following Enrollment
Once a person has enrolled in a medical plan, it is called post-enrollment. There are requirements for post-enrollment in the organizations printed material. If model language is available and not used, the plans must still include all the elements of the model language as well as all required disclaimers.
In MA-PD and MA plans, the concept of lock-in must be clearly explained in the Summary of Benefits, Explanation of Coverage, and the Member Handbook. For Medicare cost plans, all post-enrollment materials must clearly explain that members may use plan and non-plan providers. It must also explain the benefit/cost sharing differentials between use of plan and non-plan providers.
For Preferred Provider Organizations (PPO) it must clearly state in their marketing materials that all covered benefits are available from in-network and out-of-network providers. Some PPOs may require or request that members notify them prior to receiving certain services. In such cases, the organization must clearly define the benefit of voluntary member compliance in their marketing materials. It must also include the information in the PBP Notes section so that the appropriate language regarding the reward that would accrue to members that voluntarily comply may be used in marketing materials.
PPOs must state in the EOC and the SB all cost-sharing requirements with regard to emergency hospital admissions, including whether the in-network or out-of-network cost-sharing is required for enrollees who are stabilized and receive post-stabilization care in a non-preferred (out-of-network) hospital following an emergency situation. If the demonstration includes a cap on enrollee out-of-pocket costs for such services, it must state the out-of-pocket maximum amount. In the EOC (explanation of coverage), it must clearly state any other requirements associated with an out-of-network emergency hospital admission.
If a PPO states in its marketing materials that prospective enrollees may save money if they join the plan, it must also acknowledge the potential added cost of accessing services out-of-network and/or that using services in-network can cost less than using services out-of-network. Pre-enrollment materials must explain that, with the exception of emergency care, it may cost more to get care from non-plan or non-preferred providers.
MA organizations may market their plans directly to beneficiaries of former Medicare plans that have chosen not to renew their contracts as long as the marketing does not begin until after the beneficiary has received the plan termination letter. In addition to the targeted message, any pre-enrollment marketing pieces must contain a statement indicating that the Medicare health plan is open to all Medicare beneficiaries eligible by age or disability in the plans service area.
Enrollment Materials
As every agent knows, there are required materials for enrolling in a medical care plan. Organizations must provide the following information at the time of enrollment and also on an annual basis: An Annual Notice of Change. As the name implies, this is provided annually (once per year). All organizations are required to give members notice of any program changes taking place on January 1 of the upcoming year. This notice must be provided by October 31 prior to the time of change. It must be sent to all members or enrollees of the organization. The term give notice is used in reference to this requirement. The notice itself is called the Annual Notice of Change, or ANOC. The ANOC must be member-specific meaning it must have the members name either on the envelope addressed to them or on the ANOC itself. It may not be addressed to occupant for example. A Summary of Benefits (SB) form; An Evidence of Coverage form; An Abridged Formulary, including information on how the beneficiary may obtain a complete formulary list (applies to MA-PD, or PDP only). An ID Card, if applicable to the plan, must be provided at the time of enrollment. Provide a provider directory at the time of enrollment.
Part D plans must provide a member identification card to each enrollee, based on the National Council for Prescription Drug Programs (NCPDP) Pharmacy ID Card Standard. Those requirements include: 1. Plans offering medical benefits and Part D benefits may merge their existing ID card with the Part D benefit, adding additional elements that would identify the Part D benefit, or create a separate ID card for the Part D Benefit. If a Part D specific ID card is to be developed, it must conform to the layout specifications defined by the NCPDP Pharmacy ID Card Implementation Guide. 2. For combination cards (medical and Part D benefits), the RxBIN, RxPCN, and RxGrp must be on the front of the card, grouped together and in the order specified in the NCPDP Pharmacy ID Card Implementation Guide. 3. If a machine-readable ID card is issued, the physical characteristics of the ID card are defined by the INCITS 284 standard. If a non-machine-readable ID card is issued the physical characteristics of the card are at the discretion of the card issuer, provided that the card is not smaller than 3-1/8 inch by 2 inches in physical size and not larger than 3-5/8 inches by 2-3/8 inches. 4. All mandatory data elements required to be on the front of the ID card must actually be there. Plans issuing combination ID cards may vary the location of these elements, however. 5. All mandatory data elements required to be on the back of the ID card also must actually be there. Plans issuing combination ID cards, again, may vary the location of these elements. 6. At their option, plans can add co-pay information on the ID card, provided that the co-pays are appropriately labeled.
The Part D Member ID cards contain both NCPDP mandatory elements and several CMS-required elements, including:
On the front of the Plan D card: 1. The front size for the front of the ID card must be 8-point or larger for mandatory elements. 2. The name or logo of the benefit administrator and/or processor issuing the identification card, including co-branding symbols and logos. 3. Card Issuers ID. This should default to 80840 until a HIPAA authorized number has been enumerated by the National Payer ID. 4. The cardholders identification number, which cannot be the Social Security number or Healthcare Insurance Claim Number. The plan or the claim administrator generates the cardholders ID number. 5. The cardholders first name, middle initial (if available), and last name. 6. Complete electronic transaction routing information, including the International Identification Number (RxBIN). The Processor Control (RxPCN), and Group Numbers (RxGrp) are mandatory when required by the benefit administrator to electronically route a prescription claim. 7. CMS Part D Contract and Plan Benefit Package numbers. This information must be right margin justified. 8. The Medicare Symbol.
On the back of the Plan D card: 1. The font size on the back of the ID card must be 8-point or larger for mandatory elements. 2. Claims submission names and addresses. 3. Customer Service Numbers and Customer Service TTY/TDD number. 4. Bar coding, where required by state law. 5. Optional elements include: a. Medicare Contact Information (Medicare telephone number). b. PO Box or address to return lost cards to. c. Benefit Administrator Web site information.
Although it is optional, CMS recommends that all Medicare health plans, especially PPOs and PFFS Plans, include the phrase Medicare limiting charges apply on Member ID cards. They also recommend that PPOs and PFFS Plans include the statement that the provider should bill the PPO or PFFS organization and not Original Medicare. It is hoped that this will avoid processing errors. Member ID numbers cannot be Social Security numbers or Health Care Insurance Claim Numbers.
Pharmacy Directories for MA-PD and PDP Plans Part D Plans and 1876 Cost Plans offering Medicare prescription drug coverage must include information regarding their participating network pharmacies within their marketing materials and provide it upon beneficiary request. A network pharmacy is a pharmacy where beneficiaries can make use of the prescription drug benefits.
The Pharmacy Directory for non-chain pharmacies will include the pharmacy name, address, phone number, and type of pharmacy, such as retail, mail order, or institutional. If there are several locations, instead of listing the pharmacy address it may list a toll-free customer service number and TTY/TDD number so that enrollees can call to get the address of the pharmacy nearest them. Organizations may also include the chain pharmacy locators or search engines on their Web sites. Organizations may include a disclaimer such as pharmacy addresses may change without notice.
Organizations must include information somewhere in their marketing materials that informs individuals that they will have adequate access to covered Part D drugs dispensed on a non-routine basis by out-of-network pharmacies when the enrollees cannot reasonably be expected to obtain such prescriptions at a network pharmacy. This would not include routine medications, such as those received for high blood pressure.
When mail order prescription drug services are used for MA-PD or PDP plans, the organization must include a description of any mail order services that are offered. The description would include a statement that enrollees are not required to use mail-order prescription drug services to obtain their extended supplies of maintenance medications. Enrollees have the option of using a preferred or non-preferred retail pharmacy in the network to obtain a maintenance supply of medications. Literature for mail-order prescription drug services should state that if a retail pharmacy does not agree to accept the mail-order reimbursement rate for an extended supply of medications, the enrollee should have no out-of-pocket payment differences. If the retail pharmacy does not agree to accept the mail-order reimbursement rate but has accepted an alternative retail/mail-order pharmacy rate for an extended supply of medications, the enrollee will be liable for any difference in the charge. Literature should state the maximum expected turnaround time for the processing and shipment of all mail orders so that the enrollees can see how far ahead they need to place their orders. There should also be instructions for enrollees on how to obtain a prescription if a mail order is delayed. As always, there must be a toll-free telephone number and TTY/TDD to call if there are questions.
MA organizations/Medicare Health Plans are required to disclose the following information to each enrollee in clear, accurate, and standardized form at the time of enrollment and at least annually thereafter (they can notify enrollees more often than annually but not less often). MA organizations/Medicare Health Plans usually include this information in their Provider Directory. The directory is then given to new members upon enrollment and existing members on an annual basis. Medicare cost plans are required to send a Provider Directory to members at the time of enrollment and annually.
The directory must include the number, mix, and distribution, including addresses of providers from whom enrollees may obtain services, as well as any out-of-network coverage or point-of-service option. Additionally, the directories must include: 1. Names, complete addresses, and telephone numbers of the primary care physicians. 2. Names and city of specialists, skilled nursing facilities, hospitals, outpatient mental health providers, and pharmacies, where outpatient prescriptions drugs are offered by the MA plan. 3. General information regarding network lock-in, including the role of the primary care physician (PCP). The process for selecting a new PCP must also be included in the directory. Any specific requirements regarding referrals to specialists and ancillary providers would need to be listed. 4. A description of the plans service area, including a list of cities or towns. 5. Telephone numbers for customer service or appropriate contact information, including hours of service for members who may have questions or require help in selecting their PCP. 6. When non-contracting providers submit a bill directly to enrollees, there should be instructions telling the enrollee not to pay the bill, but rather submit it to the MA organization for processing and determination of enrollee liability, if any. 7. Information regarding out-of-area coverage and emergency coverage. This would include the process and procedures for obtaining emergency services and the location where the services can be obtained. It must also provide information on other locations where contracting physicians and hospitals provide emergency services, and post-stabilization care. 8. Prior authorization rules and other review requirements that must be met in order to ensure payment for the services. 9. A general disclaimer that indicates that the directory is current as of a particular printing date and that a providers listing in the directory does not guarantee the provider is still in the network or accepting new members of the plan.
Medicare health plans may publish separate primary care physician and specialty directories provided that both directories are given to enrollees at the time they join and at least yearly thereafter. Organizations that use sub-networks of providers must clearly make this distinction, preferably by listing the providers as a separate sub-network in the directory. It is important that the directory make this distinction since a beneficiary could choose their primary care physician (PCP) without realizing that their choice restricts them to a specific group of specialists, ancillary providers, and hospitals. The process for obtaining services in these networks and sub-networks must be clearly stated, including any referral requirements and out-of-network coverage or point-of-service options.
When mailing out directories, the organization must include at least one per address each year. When multiple enrollees live at the same address one directory may be provided per four members. If five members live at the address, then two would have to be provided yearly. If the address happens to be an apartment building separate apartment numbers would not be considered the same address. It is permissible to list the name of only one of the four members living at the address when mailing the directory. However, CMS recommends that all four names be included in the address to prevent one of the members from thinking that he or she was not provided with a directory. If a member of the household requests a personal directory, it must be provided even if a single issue intended for all members had been sent. At the time of enrollment each member must be given a directory as well.
Contract Termination MA organizations/Medicare Health Plans must make a good faith effort to provide enrollee notice of a contracted provider termination at least 30 calendar days prior to the termination. Patients who are seeing the provider on a regular basis must have time to make other arrangements. When the contract termination involves a primary care professional, all enrollees who are their patients must be notified.
Organizations that have a web site or that provide Plan information through the Internet must post copies of its Evidence of Coverage, Summary of Benefits and provider information, such as names, addresses and telephone numbers, on the network. The exception to this would be Employer Group plans; they can direct their members to their employer for specific information.
Formulary Information
By the time one reaches Medicare age it is likely that prescription drugs are part of their health care routine. Therefore, the formulary under Part D is very important to them. Section 423.128 of the Final Rule requires Part D Plans to provide a list of drugs included on the Part D Plans formulary to enrollees upon enrollment and at least annually thereafter. The final rule does not specify whether this list should be an abridged or comprehensive list of covered drugs. It is widely felt that a comprehensive formulary would be costly for the organization to provide and might even confuse their enrollees since such lists tend to be very technical. Therefore, CMS (Centers for Medicare & Medicaid) has allowed organizations to provide an abridged version of their formulary.
CMS has a model abridged formulary for organizations to use if they wish. The model document provides detailed guidance regarding the requirements. If the model is not followed the document must provide at least a minimum amount of information, which includes: 1. The definition of formulary. 2. An explanation of how to use the Part D plans formulary that is provided by the organization. 3. The statement: [plan name] covers both brand-name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. 4. It must include the following disclaimer: This is not a complete list of drugs covered by the Part D Plan. For a complete listing please call [customer service telephone number] or log onto [plans web site address]. 5. Any additional disclaimers that are determined by CMS to be necessary. 6. A statement describing the Part D Plans general utilization management procedures and a statement that the formulary can change during the year. A Part D Plan may not change its formulary from the beginning of the annual coordinated election period through 60 days after the beginning of the contract year. Any change would have to occur outside that specified time period. 7. The document must include the date the formulary was last updated and describe how to obtain updated formulary information. 8. A chart that has been approved by CMS of the covered drugs organized by therapeutic category that includes at least two covered drugs for each therapeutic class. If only one drug exists, then of course only one would be listed. Part D Plans may include the therapeutic classes as subheadings within the abridged formulary. The chart must have at least three columns: drug name, tier placement, and utilization management. 9. Since beneficiaries may only know the name of their prescription and not its therapeutic class, the abridged formulary must include an index listing drugs in alphabetical order. It would then direct the beneficiary to the page containing complete drug information. 10. An explanation of how to obtain an exception to the Part D Plans formulary, utilization management tools, or tiered cost sharing. 11. Abridged formularies must be submitted to CMS or its designee for review to ensure they comply with the Guidelines. Updated formularies are not required to be submitted for re-review as long as the changes are simply to update the document date, add or delete drugs, or update tier placement or utilization management designations.
If an individual calls their Part D Plan provider to request a comprehensive formulary, the provider may offer only the information that is specific to the drugs in question rather than the entire formulary. In that case, the service representative would look up the individuals prescriptions and provide all the information (tier placement and utilization management procedures included) that is relative to the drugs he or she is taking.
If a Part D Plan has a Website, it must be updated at least once per month so that it stays current. Like the printed formulary, it must be accessible by the drug name. The online document must be in a PDF format, but it can also be posted in other formats as well. The online formulary must meet all requirements of a printed formulary.
Plan formularies do experience change. Part D Plans must provide at least 60 days notice to CMS, SPAPs, authorized prescribers and network pharmacies before removing a Part D drug from the plans formulary or making changes in the preferred or tiered cost-sharing status of a drug. Part D Plans can determine the most effective means of posting formulary changes, including electronic means. Enrollees must be notified in one of the following ways: Provide direct written notice to those who will be affected by the change at least 60 days prior to the actual change. At the time an affected enrollee requests a refill of the Part D drug, provide the enrollee with a 60-day supply and provide written notice of the coming formulary change.
It should be noted that Part D Plans can immediately change their formulary if a particular drug is deemed unsafe by the Food and Drug Administration or if the drug is removed from the market by their manufacturer without any advance notice. The plan would provide retrospective notice to those enrollees that would be affected by the removal of the drug by the FDA or manufacturer.
The plan would provide retrospective notice to those enrollees that would be affected by the removal of the drug by the FDA or manufacturer.
Evidence of Coverage for Prescription Drug Plans (PDP)
PDPs are required to provide Evidence of Coverage (EOC) to all enrollees, including employer group enrollees, annually. While the EOC can provide more information it cannot include less than: 1. The Plans service area. 2. The statement: If you currently have a Medicare Supplement (Medigap) policy that includes coverage for prescription drugs, you must contact your Medigap issuer and tell them you have enrolled in [plan name]. If you decide to keep your current Medigap policy, your Medigap issuer will remove the prescription drug coverage portion of your policy and adjust your premium. In addition, under certain circumstances, you may be able to purchase a different Medigap policy from the same company. The Medigap insured should have received a letter in the fall of 2005 from their Medigap issuer explaining his or her options and how the removal of drug coverage from their policy would affect their premiums. If this letter was not received, they should contact their Medigap issuer. 3. When specifying benefits several things must be listed: the annual deductible amount, initial coverage limits, cost sharing under the initial coverage limits, and cost sharing between the initial coverage limits and the annual out-of-pocket threshold. 4. Major exclusions and limitations must be stated, such as utilization management programs applied to drugs on the formulary. 5. All monetary limits, as well as any restrictive policies that might impact an enrollees access to drugs or services. 6. A description of quality assurance policies and procedures, including drug utilization management and medication therapy management programs. 7. State that the Part D Plans contract with CMS is renewed annually, that the availability of coverage beyond the end of the current contract year is not guaranteed. 8. The EOC must define the term formulary, describe how the formulary functions, including any tiered formulary structures and utilization management procedures, state that the drugs may change during the year, explain how to obtain an exception and describe how to obtain additional information on the formulary. 9. Explain how to access their benefits, particularly at a retail network pharmacy and through the plans mail-order service if applicable. 10. Explain that extra help is available to people with limited incomes. 11. Describe the grievance, coverage determinations, exceptions process, and appeals rights and procedures. It must also describe disenrollment rights, responsibilities, and procedures.
Evidence of Coverage for MA, MA-PD, and 1876 Plans must be given to all members annually in addition to the one provided at the point of enrollment. The EOC must do the following: 1. Disclose specific rules for referrals for follow-up specialty care. 2. HMOs must explain that when a beneficiary enrolls in a plan, he or she agrees to use the network of physicians, hospitals, and providers that are affiliated with the plan for all their health care services, except emergencies, urgently needed care, or out-of-area renal dialysis services. 3. Explain that use of non-plan or non-preferred providers is allowed, but may cost more to the beneficiary (this requirement applies to PPOs and POS plans and, if appropriate, Visitors Programs for many plan types). 4. Explain the impact of using the Medicare card for out-of-plan utilization that is not an emergency or urgent care. 5. Explain that a plan member selects a primary care physician to coordinate all of the members care. A PCP is usually a family practitioner, general practitioner, or internist. The PCP understands that plans network and can guide the member to plan specialists when needed. The member always has the option to change to a different PCP. Changes will be effective according to the plan guidelines, not necessarily immediately. 6. For HMOs, explain that neither the MA organization nor Medicare will pay for medical services that the member receives outside of the network, unless it was authorized, emergency, or urgently needed care, or out-of-area dialysis service. The member may be responsible for paying the bill him or herself. 7. For PPOs, explain that with the exception of emergency or urgent care, it may cost more to get care from non-plan or non-preferred providers. 8. Explain prior authorization rules for any in and out-of-network services and describe other review requirements that must be met in order to ensure payment for the services. 9. For Medicare cost plans, enrollees must be informed that after enrollment is effective, in order for them to receive the full coverage offered, services other than emergency and urgently needed services must be obtained through the HMO or CMP. In the case of cost enrollees, however, they may receive services that are not provided or arranged by their HMO or CMP but they would be responsible for payment of all Medicare deductibles and coinsurance as well as any additional charges as prescribed by the Medicare program. They also would be liable for any charges not covered by the Medicare program.
For emergency care MA-PD and MA plan EOCs must describe the rules for emergency care and post-stabilization care. In particular they must explain that members are not required to go to health plan-affiliated hospitals and practitioners when an emergency exists. MA organizations must define the terms emergency medical condition and emergency services.
Since urgent care is not the same as emergency care, EOCs must also describe the rules for receiving urgent care, including a definition of urgent care. It should specifically say that when such care is needed and available within the plans service area, the care must be received from the plans providers. If the enrollee is outside of the service area it may be sought elsewhere.
Explanation of Benefits for PDPs
A PDP must send an Explanation of Benefits, called an EOB, to plan enrollees during months in which enrollees use their prescription drug benefits. The EOB will list several things, including: 1. The items or services for which payment was made and the amount of that payment. 2. A notice of the enrollees right to request an itemized statement, their appeal/grievance rights, and exceptions process. 3. The cumulative, year-to-date total amount of benefits relating to any deductible for the current year, the initial coverage limit if there is one, and total out-of-pocket expenditures. 4. The cumulative year-to-date total of incurred costs to the extent practicable. 5. Any applicable formulary changes that the plan is required to provide notice for.
All year-to-date total amounts should not include amounts that were paid by the members current or former employer, union, or another insurance plan.
Low Income Subsidy for Part D Plans Under MA-PD or PDPs
The need to help individuals who cannot afford their required medications has been a concern for some time. The low-income subsidy is extra help with prescription drug costs for Medicare-eligible individuals whose income and resources are limited. This help is in the form of payments to the Prescription Drug Plan that the individual joins. Those eligible for Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program qualify for the extra help automatically and so do not need to apply. All others can apply through Social Security by mail, by telephone, or on the Internet at http://socialsecurity.gov or in person at a community SSA office or Medicaid office.
PDPs must provide information in marketing materials regarding the availability of the low-income subsidy for Part D eligible individuals in a way that protects the membership from receiving undue pressure or violates their privacy. The marketing materials could be letters sent directly to the membership, telephone scripts, pre-enrollment packets or websites that provide this information. They may not conduct door-to-door solicitation prior to receiving an invitation from the member to come. The plan may not store or share any member information, financial or otherwise, specific to the low-income subsidy with any entity not directly involved in the outreach process.
In all pre-enrollment materials where PDP monthly premium and other member costs are described, the PDP must include the following language with any such discussion:
If you qualify for extra help with your Medicare Prescription Drug Plan costs, your premium and costs will be lower. When you join [plan name], Medicare will tell us how much extra help you are getting. Then we will let you know the amount you will pay. If you arent getting this extra help, you can see if you qualify by calling 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-4862048 (24 hours a day/7 days a week), or Your State Medicaid Office, or The Social Security Administration at 1-800-325-0778.
The Medicare Modernization Act of 2003, also known as the MMA, allows MA organizations to offer plans that serve special needs individuals (called Special Needs Plan or SNP). The legislation designates three specific segments of the Medicare population as having special needs: 1. Institutionalized individuals, such as those residing in nursing homes, 2. Those entitled to Medical Assistance under a State Plan under Title XIX, and 3. Other chronically ill or disabled beneficiaries who would benefit from a specialized MA plan.
Institutional Special Needs Plan (SNP) By definition, an institutional SNP will enroll a limited group of beneficiaries and may also have limited enrollment options, such as a single long-term care facility under that specific plan or even just a specific number of beds within a facility. Given these limitations, CMS may not require such an SNP to broadly market its plan since it would be open to so few people. Even so, all Medicare beneficiaries, including those who meet the SNP eligibility requirements, must have reasonable access to information describing all MA plans, including an institutional SNP, which is available in the service area. Importantly, information on these plans must be made available on the CMS Website so that interested beneficiaries or their families can identify institutional SNPs that are available in their area.
All Medicare beneficiaries, including those who meet the SNP eligibility requirements, must have reasonable access to information describing all MA plans, including an institutional SNP, which is available in the service area.
SPAP Materials for MA-PD and PDPs State Pharmaceutical Assistance Programs (SPAP) are state-financed prescription drug programs providing drug coverage to limited income or disease-specific populations. SPAPs also provide pharmaceutical assistance to limited income Medicare beneficiaries. Beginning January 1, 2006 many of these beneficiaries were eligible for Part D and had to enroll with a plan in order to receive the Medicare Prescription Drug Benefit.
The SPAP beneficiaries are familiar with the SPAP benefits and may feel uncomfortable switching to a Part D Plan. The Centers for Medicare & Medicaid felt that additional promotion might be necessary to persuade these individuals to make the change.
Dual Eligible Memberships for Medicare Advantage Plans
A number of MA plan members are, due to financial status, eligible for State financial assistance through State Medicaid Programs. This assistance provides them an array of financial savings ranging from partial payment of Medicare Part B premiums to full payment of Medicare premiums and other plan cost sharing. Historically, some of those eligible do not apply for these programs for a variety of reasons. Some equate Medicaid with Welfare and do not want the stigma they feel comes with acceptance of the program. In some cases, individuals are not aware of the savings that are available to them. Some may not understand the eligibility requirements so they are not aware they qualify. Some fear the application process so simply avoid doing so.
Some Medicare Advantage Plans conduct outreach programs to their members to educate and assist them in applying for these savings programs. This might especially be true when CMS capitates MA organizations at a higher rate for some dual eligible members. The CMS encourages (but does not require) MA organizations to assist their members with applying for State financial assistance because of the potential benefits to both the members and to the MA organizations.
The CMS encourages (but does not require) MA organizations to assist their members with applying for State financial assistance
There are several categories of dual eligibility, with each having specific income requirements and providing different levels of financial assistance to those who qualify at that level. The categories are outlined in a CMS chart:
* The monthly income requirements list a specific dollar amount on the CMS chart but since these figures are open to change we did not list them here. Each Eligibility Category may list different Monthly Income Requirements. For specific income requirement amounts go to http://www.cms.hhs.gov/medicaid/. Income requirements for Hawaii and Alaska are specifically noted since they are different. Income levels may vary by state for specific resource amounts so it is possible that other states besides Alaska and Hawaii will vary.
Value-Added Items and Services for All Organizations
Value-Added Items and Services, also referred to as VAIS, are items and services provided to an organizations enrollees that do not meet the definition of benefits under the program and may not be funded by Medicare program dollars. Since VAIS may offer real value to the organizations enrollees, CMS does not wish to deny the availability of them.
All organizations must comply with all applicable HIPAA laws. This includes obtaining authorization before using or disclosing protected health information for the purpose of marketing as defined under HIPAA Privacy Rules. If the communication is merely to describe a health-related product or service there is no need to obtain prior member authorization. This would include an item or service that is available only to enrollees that adds value to, but is not part of the organizations benefits. In such a case, authorization would not be required. In order to qualify as a Value-Added Item and Service under HIPAA the benefit must be health-related and must demonstrably add value to the Plans membership. The value cannot merely be a pass-through of a discount or item available to the general public. A non-health related VAIS would include such things as restaurant discounts, entertainment or travel. Health related VAIS would include discounts on eyeglasses or a health club membership.
As you can see, VAIS are partly defined by what they are not they are not benefits under the MA program or the Prescription Drug Benefit program. Benefits are designed using a three-prong test: 1. Health care items or services that are intended to maintain or improve the health status of enrollees. 2. Plans must incur a cost or liability related to the item or service and not just an administrative cost, and 3. The item or service is submitted and approved through the bid process. All three parts of this definition must be met for an item or service to be considered a benefit. If it fails to meet one or more of these parts, it not a benefit. However, it may be offered to the organizations members as a VAIS, subject to VAIS restrictions.
VAIS Restrictions Organizations may make VAIS available to Medicare enrollees in accordance with the following restrictions: 1. VAIS must be offered uniformly to all organization enrollees and potential enrollees. 2. Organizations may not describe VAIS as covered Medicare benefits. 3. Organizations may not engage in activities that could mislead or confuse Medicare beneficiaries. 4. Organizations may not claim or imply that the VAIS are recommended by or endorsed by CMS or Medicare. 5. Organizations must maintain privacy and confidentiality of enrollee records in accordance with all applicable statutes and regulations. 6. To the extent required under the HIPAA Privacy Rule, organizations must not use or disclose a beneficiarys protected health information for the purpose of distributing non health-related VAIS (Part D only) without prior written authorization from the enrolled Part D beneficiary. The MA/Part D organization is prohibited form selling names, addresses, or information about the individual enrollees for commercial purposes. If the MA/Part D organization uses a third party to administer VAIS, the MA/Part D organization is ultimately responsible for following confidentiality requirements.
If the Value-Added item or service is provided to an employer group under any type of organization, they may be offered to the employer rather than the employees. The value-added items and services are offered outside of the core benefit package, so they are outside of CMSs purview.
Anti-Discrimination for All Organizations
Organizations may not discriminate based on race, ethnicity, religion, gender, sexual orientation, health status, or geographic location within the service area. All items and services of an organization are available to all eligible beneficiaries in the service area with the following exceptions: There may be additional eligibility standards for enrollment in the low-income subsidy. Certain products and services may be made available to enrollees with certain diagnoses, such as medication therapy management program for those with chronic illnesses, or medically necessary coverage provisions that would not be required by the general membership.
Organizations may not engage in discriminatory practices such as targeting their advertising only to beneficiaries from higher income areas or by implying plans are available only to seniors rather than to all Medicare beneficiaries.
End of Chapter Three |