PART B MEDICATIONS (5/16/17)
Have you ever been confronted with the question about whether a prescribed drug is covered under Part B? A good place to start is the information that CMS has provided to help agents guide Medicare beneficiaries through the investigation process.
Prescription drugs (oupatient)
How often is it covered?
Medicare Part B (Medical Insurance) generally doesn't cover most prescription drugs used at home, but it does cover a limited number of outpatient prescription drugs under limited conditions. Generally, drugs covered under Part B are drugs a beneficiary wouldn't usually give to themselves, like those they get at a doctor's office or hospital outpatient setting. Drugs not covered under Part B may be covered under a Medicare Prescription Drug Plan (Part D). If the beneficiary has Part D, check their plan's formulary to see what outpatient drugs are covered. Examples of drugs covered by Part B:
- flu shots
- Pneumococcal shots
- Helatitis B shots
- Other shots: Medicare helps pay for some other vaccines when they're directly related to the treatment of an injury or illness.
- If the beneficiary is entitled to Medicare only because of permanent kidney failure, their Medicare coverage will end 36 months after the month of the transplant. Medicare won't pay for any services or items, including transplant drugs, for patients who aren't entitled to Medicare.
- Medicare will continue to pay for their transplant drugs with no time limit if the beneficiary meets either of these conditions:
- They were already entitled to Medicare because of age or disability before they got ESRD.
- They became entitled to Medicare because of age or disability after getting a transplant that was paid for by Medicare, or paid for by private insurance that paid primary to their Medicare Part A (Hospital Insurance) coverage, in a Medicare-certified facility. Note
Transplant drugs can be very costly. If the beneficiary is worried about paying for them after their Medicare coverage ends, the beneficiary may talk to their doctor, nurse, or social worker. There may be other ways to help them pay for these drugs.
All people with Part B are covered under limited conditions.Costs in Original Medicare
For specific information, it is always best to check with the Part D plan being considered or contact CMS.
Correspondence from CMS (4/21/17)
CMS regulations are designed to level the playing field and to maintain the integrity of the program(s). There are times that as agents, we become aware of obscure regulations and/or CMS practices. One such CMS practice is that CMS sends out specific mailings at specific times. CMS even color codes some of the correspondence. As an agent, it is important to know what the mailings are and when they are sent out.
An example of one such mailing is due to be sent out in May 2017. This mailing to consumers informs people who may be eligible for Medicare Savings Programs (MSPs) about MSPs and the Extra Help available for Medicare prescription drug coverage.
For more information about CMS Consumer mailings throughout the year, click on the link below.
Click here to download and view CMS Consumer mailings
PPACA OEP is underway!... (11/01/16)
PPACA OEP is underway. There was a new requirement that was introduced during FFM training. The Individual Marketplace and SHOP Privacy & Security Agreements require all agents and brokers to ensure openness and transparency about policies, procedures, and technologies that directly affect consumers’ PII. AHIA, LLC has drafted a Privacy Notice Statement for you to use.
As a reminder PII is any information that can be used to distinguish or trace a consumer’s identity (e.g., his or her name, Social Security Number, biometric records) alone or when combined with other personal or identifying information that is linked or linkable to a specific consumer (e.g., date of birth, place of birth, mother’s maiden name).
Click here to download and view Affordable Care Act Privacy Notice Statement
ACA SECTION 1557 REGULATION... (10/06/16)
The U.S. Department of Health and Human Services (HHS)/Office of Civil Rights issued a Final Rule implementing Section 1557 of the Affordable Care Act (ACA). The new regulations prohibit discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs and activities. The law establishes new protections and applies to any health programs funded by HHS, including Medicare Advantage, Medicare Part D, and the Marketplace. The law strictly prohibits discrimination on the basis of sex, pregnancy, false pregnancy, termination of pregnancy, or recovery therefrom, childbirth or related medical conditions, sex stereotyping and gender identity.
Each carrier has instituted their own requirements and are part of the carrier training/communications. I have provided the United HealthCare agent communication and link as an example. Please make sure to check with the carriers that you contract with in order to stay compliant.
Click here to download and view UnitedHealthcare new Requirement 10.
Dear Valued Business Partners,
We are reaching out to you today regarding new requirements mandated by UnitedHealthcare (UHC) relating to: Informal Sales Events, Formal Sales Events, Scope of Appointments, and Business Reply Cards.
New Required Disclaimer For Display at UHC - only Sales Meetings
Effective immediately, a new disclaimer (see attached pdf file) must be displayed at any UnitedHealthcare-exclusive formal or informal marketing/sales event (e.g., community meeting / kiosk). Please print the attached pdf and display at your UHC-only sales meetings until the new tabletop displays are ready.
NOTE: This disclaimer requirement only applies to sales events where UnitedHealthcare is the only carrier being presented. If you are presenting multiple carriers at your sales events, this disclaimer requirement does not apply to those events.
UnitedHealthcare will provide tabletop displays of this new disclaimer in the near future via the UHC Agent Toolkit path detailed below. Once you receive the tabletop, please use the tabletop instead of pdf printout.
New UHC Scope of Appointment and Business Reply Cards
UnitedHealthcare has also updated their Scope of Appointment (SOA) and Business Reply Cards (BRCs). Updated versions of SOA’s and BRC’s were scheduled to be available on the Agent Toolkit by the end of the day Friday, September 30. Please begin using these new SOA’s and BRC’s for all UHC sales efforts as soon as possible.
To access the Agent Toolkit, use the login information provided previously by UHC and use the following path:
Agent Toolkit Path
English Material > Community Meeting and Event Marketing Materials > Presentations and Workbooks > Workbooks
If you have any questions, please contact the Producer Help Desk at firstname.lastname@example.org. If you have compliance questions, please email email@example.com and be sure to include your full name, contact information and writing number. More information
Golden Outlook Agent Engagement Team
Pre-AEP Do's and Dont's... (10/04/16)
The Annual Election Period is soon to begin. This is a great time to help current clients and prospects make sure that their needs are met for the following benefit year. This is also a time of year when you as an agent must be aware and proficient in balancing the knowledge and use of current year and upcoming year regulations and benefits.
Although much of what is in this article is common knowledge, it is important to review and have as a reference just in case there is a question. The following is from the Medicare Advantage Enrollment and Disenrollment Manual. I have included the whole regulation; much of what is written is for carriers. Please keep in mind that carriers may have more restrictive regulations than what Medicare requires. It is important that you are aware of what each one of the carriers that you represent requires of you. Carriers will not accept paper applications from agents during Pre AEP and the submission of an AEP application will result in an investigation. It is very important to remember that if beneficiaries that have an IEP or SEP can be submitted as normal.
Special Rule for the Annual Election Period (AEP):
Medicare Advantage (MA) organizations may not solicit submission of paper enrollment forms or accept telephone or on-line enrollment requests prior to the beginning of the AEP. Brokers and agents under contract to MA organizations may not accept or solicit submission of paper enrollment forms prior to the start of the AEP. MA organizations and their brokers and agents also should remind beneficiaries that they cannot submit enrollment requests prior to the start of the AEP. Despite these efforts, CMS recognizes that MA organizations may receive unsolicited paper enrollment forms prior to the start of the AEP, given that marketing activities may begin prior to this date. To be considered unsolicited, the MA organization must have received the paper AEP enrollment request directly from the applicant and not through a sales agent or broker. Other enrollment request mechanisms may not be accepted prior to the actual start of the AEP. Paper AEP enrollment requests received prior to the start of the AEP for which there is indication of sales agent or broker involvement in the submission of the request (i.e., the name or contact information of a sales agent or broker) must be investigated by the organization for compliance with the requirements in the Medicare Marketing Guidelines. If an MA organization receives unsolicited paper enrollment forms on or after October 1st but prior to the start of the AEP, it must retain and process them as follows:
- Within 7 calendar days of the receipt of a paper enrollment request, the MA organization must provide the beneficiary with a written notice that acknowledges receipt of the complete enrollment request, and indicates that the enrollment will take effect on January 1 of the following year (refer to Exhibits 4, 4a, 4b and 4c for model notices).
- For AEP enrollment requests received prior to the start of the AEP, the MA organization must submit all transactions to CMS systems (MARx) on the first day of the AEP with an “application date” of the same date. For example, unsolicited AEP paper enrollment requests received October 1 through October 14 must be submitted on October 15th with an “application date” of October 15th of the current year in the appropriate data field on the enrollment transaction. If a beneficiary has submitted more than one AEP paper enrollment request prior to the start of the AEP, the beneficiary will be enrolled in a plan based on the first application that is processed.
- Once the MA organization receives a MARx TRR from CMS indicating whether the individual’s enrollment has been accepted or rejected, it must meet the remainder of the requirements (e.g., sending a notice of the acceptance or rejection of the enrollment within 10 calendar days following receipt of the TRR from CMS) provided in §40.4.2. Note: If organizations receive incomplete unsolicited AEP paper enrollment requests prior to the start of the AEP, they must follow existing guidance for working with beneficiaries to complete the applications (refer to §40.2.2). Again, this policy applies only to the receipt of unsolicited paper enrollment forms prior to the beginning of the AEP. To help ensure a successful AEP season, it is imperative that organizations follow these steps and submit valid enrollment transactions promptly as directed.
AHIP Certification... (8/15/16)
It is that time again. The AHIP certification is in full swing. AHIP has combined the Marketing Medicare Advantage, Compliance and Fraud, Waste and Abuse requirements into a single modular course. The comprehensive online program gives you the background to make informed decisions on Medicare, including plan options, marketing, enrollment requirements, and FWA guidelines. The courses cover the following:
Fraud, Waste & Abuse (FWA)
There is a cost for the AHIP and some carriers are offering discounts for the AHIP certification. We have done the research and the carriers are listed below with the discount or reimbursement that is offered.
Remember that most carriers require you to access AHIP through their online portal or hyperlink. Carriers will also have their carrier/product specific training that you must complete.
Don’t miss out… get your certification done so that you can take advantage of the selling season.
Customer PHI Data Breach... (7/04/16)
What happens if you are responsible for the unauthorized dissemination of a customer's PHI? You may be subject to penalties imposed by federal law up to $1Million per incident. Here are a few DO's and DON'Ts regarding sensitive member or consumer information:
Handling sensitive member or consumer information
Informing Consumers About Health Appeals... (5/24/16)
The Affordable Care Act ensures a consumer’s right to appeal health insurance plan decisions, including asking that an issuer reconsider its decision to deny payment for a service or treatment, or to rescind coverage.
The Centers for Medicare & Medicaid Services (CMS) has released a new resource that describes:
These appeal rights and processes apply to consumers enrolled in non-grandfathered qualified health plans through a Health Insurance Marketplace.
Please see the “Internal Claims and Appeals and External Review Processes Overview” resource slides for more information. You can also link to these slides from the Agents and Brokers Resources webpage, which provides other resources to help you assist consumers in making use of their health coverage.
Medicare Lock-In News (3/15/16)
During this time of Lock In, it can be difficult to focus on Medicare Beneficiaries as prospects. It is important to have all the facts in order to take advantage of opportunities that present themselves.
Please review the following to make sure that you have the latest information:
For income levels, see the 2016 federal poverty level guidelines at:
See the Medicaid.gov webpage that details the 2016 Dual Eligible Standards for the Medicare Savings Programs, available at:
2016 Dual Eligible Standards for the Medicare Savings Programs
See the Medicare.gov webpage that details Medicare costs in 2016, available at: Medicare Cost At A Glance
See the Programs and Operations Manual System (POMS) from Social Security for the LIS/Extra Help (and therefore, the MSP resource levels) asset levels for 2016.
Alignment of License Expiration Dates (3/1/16):
When was the last time that you checked your license expiration date?
You might be in for a surprise.
One agent was set to have his license expire the middle of April 2016. After checking the tdi.texas.gov website, he found that his license expiration was extended and would not expire until almost a year later. You may be in for a pleasant surprise as well.
This is all due to recent 84th Legislative Session Licensing Updates ( SB876) that are designed to align license expiration dates. The following is from the TDI website.
To assist license holders with maintaining their licenses and simplify the license renewal process, SB 876 required TDI to align all individual and entity licenses as follows:
The alignment of license expiration dates to an individual licensee’s birth month and birth day, without a pending renewal, has been implemented for licenses expiring on or after January 1, 2016. No additional continuing education hours will be required for any extended periods provided, as part of the implementation of the alignment.
The expiration date of any renewals pending on January 14, 2016, will be aligned as they renew. Going forward, any new license issued to a license holder will have an initial period that aligns its expiration date to the same expiration date of licenses already held.
TDI will not be providing updated copies of existing licenses reflecting the new expiration dates. The new license expiration dates may be viewed as early as January 19, 2016 at: TDI Insurance Licensing Search and Renewal.
OEP is almost done... (1/14/16)
OEP is almost done... and now is the time to start preparing for potential opportunities outside of the OEP. Take some time to review these life events that can extend your selling season.
Common Special Enrollment Periods (SEP) Enrollment Windows
Not all special enrollment periods are the same length. Some life events trigger a special enrollment period, some trigger a hardship exemption, some trigger shorter periods with no exemption, and some only trigger the ability to purchase outside of open enrollment. Below are common qualifying life events and enrollment windows. See full lists of qualifying events below.
NOTE: You can apply early to ensure your coverage starts on the day you would lose coverage. Even though you can enroll before the Special Enrollment window, your coverage won’t start until the day of the event or denial.
While not a hardship exemption, it’s worth noting that you are allowed a coverage gap of less than 3 months each year. That covers two full months. For any other month, you’ll need to have coverage for at least one day of the month to avoid the fee unless you qualify for an additional exemption. When you qualify for special enrollment, you may qualify for additional exemptions that extend the time you can go without coverage.