Medicare Advantage Plans - Overview & Benefits
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10182021
Broker Training
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:
History of Medicare
Medicare “ABCDs”
Medicare Enrollment Periods
Plans and Service Area
Medicare Products
Sales Office Locations
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Medicare is a federally sponsored health insurance program for seniors and the
disabled.
Medicare was first created in 1965 and is designed to provide medical coverage
to people on Social Security.
Medicare is commonly confused with Medicaid. Medicaid was created for those
in poverty.
Medicare is funded through individuals contributing to a payroll tax throughout
their working lives.
Beneficiaries generally become eligible for Medicare when they reach age 65,
regardless of income or health status.
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“
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A
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”
(
M
A
)
P
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s
Offered by private
companies
approved by
Medicare
Covers hospital and
doctor’s visits
May cover
prescription drugs
Could include
dental, hearing &
vision benefits
P
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D
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s
:
A standalone
prescription drug
plan (PDP)
−
O
R
−
Medicare
Advantage-
Prescription Drug
Plan (MAPD) that
offers both medical
and drug benefits
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“
A
B
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A
Part of Original Medicare
Helps cover inpatient care in hospitals, skilled nursing facilities, short-term nursing home
care, hospice and home healthcare.
Most beneficiaries do not pay a premium for Part A.
o
Part A is premium-free to beneficiaries if they (or their spouse) had been employed and
paid Medicare taxes for 40+ quarters (10+ years) in their lifetime.
o
For those who worked less than 30 quarters (approximately 7.5 years) in 2021, the
premium can be up to $471 per month.
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y
(
L
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)
The Part A LEP increases the monthly Part A premium by 10%.
Beneficiaries subject to this LEP will be required to pay the higher premium for twice the
number of years that they could have had Part A but did not enroll.
o
For example: if a beneficiary was eligible for Part A for two years but didn’t sign up,
he/she would have to pay the higher premium for four years.
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B
Covers medically necessary outpatient services and supplies like physicians’ services, home health
services, some preventive services, durable medical equipment (DME) and other medical services.
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B
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(
L
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)
The Part B LEP increases the monthly Part B premium by 10%.
Beneficiaries subject to this LEP will be required to pay the higher premium for twice the number of
years that they could have had Part B but did not enroll.
o
For example: If a beneficiary was eligible for Part B for two years but didn’t sign up, he/she would
have to pay the higher premium for four years.
Although your Part B premium amount is based on your income, your penalty is calculated based on the
base Part B premium. The penalty is then added to your actual premium amount.
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B
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:
Under Original Medicare, a calendar
year deductible must be satisfied for
most Part B services before Medicare
begins to pay its share of the cost.
Most covered preventive services are
not subject to the deductible.
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:
Once the deductible is satisfied, a Medicare beneficiary will
typically pay 20% of the Medicare-approved amount for covered
Part B services, if the provider accepts Medicare assignment.
Beneficiaries pay $0 for most Medicare-covered preventive
services.
There is no maximum out-of-pocket limit for beneficiaries
covered under Original Medicare.
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.
All Part A and Part B benefits are obtained
through the private plan.
Cover ALL services that Original Medicare
covers, except hospice care. Hospice will be
covered by Original Medicare.
May offer extra coverage such as vision, dental
and hearing.
Most include prescription drug coverage, Part D.
Medicare pays a fixed amount directly to the plan
for the members’ care on a per- member, per-
month basis.
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C
Plans must be approved by Medicare
annually
. Continued coverage in a specific
plan type is not guaranteed year to year.
Medicare Advantage Plans are
NOT
supplemental coverage.
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y
To be eligible to enroll on a Medicare Advantage
plan, the beneficiary must:
Be entitled to Medicare Part A
Be enrolled in Medicare Part B
Live in the plan’s service area
If the beneficiary is currently paying an additional premium for Part A and/or Part B,
the beneficiary must continue paying this premium even if on a Medicare
Advantage plan.
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D
Part D is prescription drug coverage and is
offered to everyone with Medicare.
To get Part D, the beneficiary must join a plan
run by an insurance company or other private
company approved by Medicare.
Each plan will vary in cost and covered drugs.
Part D plans can change from year to year.
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(
L
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)
There is a late penalty premium for not joining
a Medicare Part D drug plan when the
beneficiary first becomes eligible for Medicare.
For example: If the average monthly prescription drug premium is $33.19, the penalty fee
will be calculated as 1% of $33.19, multiplied by the number of months late enrolling in
Part D. If the beneficiary was 12 months late in enrolling, the penalty would be $3.98, paid
on top of the drug plan’s monthly premium.
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Most Medicare Prescription Drug Plans have
a coverage gap (also called the “donut hole”).
This is a temporary limit on what the drug
plan will cover for drugs. Not everyone will
enter the coverage gap.
The coverage gap begins after the
beneficiary and plan have spent a certain
amount for covered drugs.
Most Part D plans are subject to the gap.
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D
Coverage Gap
“Donut Hole”
Little or no coverage,
members are
discounted until they
reach $7,050
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(
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(
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-
O
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P
)
Timeframe when member is
initially eligible for Medicare.
During this span of time, a
member may join Medicare Parts
A, B, C and D.
Medicare beneficiary may add,
change or drop their Medicare
Advantage or PDP plan.
Anyone with:
Medicare Parts A & B can switch
to a Part C plan
Medicare Part C can switch back
to Parts A & B
Medicare Part C can switch to a
new Part C plan
Anyone who has or is signing up
for Medicare Parts A or B can join,
drop or switch a Part D
prescription drug plan.
Anyone enrolled in a Medicare
Advantage (MA) plan on January 1
can change MA plans.
Medicare beneficiaries already
enrolled in a Medicare Advantage
plan are allowed a one-time election
to either:
Switch to a different MA plan
-OR-
Switch from a Medicare Advantage
plan to Original Medicare and a
standalone Part D plan.
Does not allow switching from
original Medicare to a Medicare
Advantage plan.
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a
It is important to understand the difference between Service Area
and Provider Network.
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a
The Service Area defines which counties are eligible for either Health First Health Plans or
AdventHealth Advantage Plans plan coverage. For example, a member residing in Brevard
County would only be eligible for the Health First Health Plans brand products.
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The Provider Network, combines all providers contracted with both Health First Health Plans
and AdventHealth into a single network.
Contracted Providers, either via Health First Health Plans or AdventHealth will be accessible
to all Medicare members, regardless of Service Area.
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H
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P
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s
Classic HMO-POS
Value HMO
Rewards HMO
Secure HMO (no Part D coverage)
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SunSaver HMO
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:
Worldwide Coverage for Emergency & Urgent Care
Free Gym Membership
No referrals needed to see a Specialist (the specialist may require one, but the plan does not)
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O
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s
:
Sales kits (can be mailed upon request)
Home appointments
Websites
https://www.hf.org/health_plans/brokers/medicare.cfm
or
https://hf.org/ahap/brokers/medicare.cfm
Medicare (medicare.gov or 1.800.MEDICARE)
Phone – Customer service 1.800.716.7737
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:
1.
Beneficiary initiates contact
2.
Agent completes Scope of Appointment
3.
Agent conducts sales presentation
Medicare Basics, Part D, Enrollment Periods
Benefits at a Glance (BAG)
Summary of Benefits, Formulary, Directory
Answer questions
Complete Enrollment Application
4.
Agent submits enrollment within 24 hours of signed application
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The Sales representative must clearly identify the
types of product(s) that will be discussed, obtain
agreement from the beneficiary and document that
agreement.
A completed SOA should be
submitted to Health First Health Plans or
AdventHealth Advantage
Plans with each enrollment application.
The Scope of Appointment (SOA) form is located
from the public website
Brokers
page and also
from the Medicare Enrollment Portal electronic
enrollment platform.
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,
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m
a
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n
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t
:
Promote non-healthcare-related products
Solicit/accept an enrollment request for a January 1 effective date prior to the
start of the Annual Election Period on October 15
Discuss plan options that were not agreed to in the Scope of Appointment
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Conducting health screenings
Providing cash or monetary rebates
Making unsolicited contact
Use “Absolute Statements” when describing the plans
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:
Verify name and spelling
Verify and record the Medicare Beneficiary Identifier
Verify and record Medicare Part A and Part B effective dates
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A
l
w
a
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u
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a
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m
p
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e
t
e
k
i
t
:
Benefits at a Glance (BAG)
Summary of Benefits
Enrollment application
Postage-paid return envelope
Multi-language insert
Provider Directory, Formulary
Privacy Policy
Stars Rating
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P
a
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m
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n
t
O
p
t
i
o
n
s
For monthly premium plans or late enrollment penalties (LEPs):
Monthly invoices
Electronic funds transfer (EFT)
S
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e
c
u
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y
w
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h
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(
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d
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n
)
N
O
T
E
:
Brokers
may
make payments on behalf of their members using the
member’s
mode of payment.
Brokers
may never
make payments for their members using the
broker’s
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Dive into the comprehensive overview of Medicare Advantage Plans, covering the history of Medicare, Medicare ABCDs, enrollment periods, service areas, and product details for 2022. Learn about the different parts of Medicare, including Part A which covers inpatient care, Part B for physician services, Part C for Medicare Advantage plans, and Part D for prescription drug coverage. Gain insights into the policies and figures reflecting the 2022 guidelines, making informed decisions about your healthcare coverage.
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Presentation Transcript
Medicare Advantage Plans Overview Broker Training 10182021
Module Description This module is designed to explain: History of Medicare Medicare ABCDs Medicare Enrollment Periods Plans and Service Area Medicare Products Sales Office Locations Policies and figures throughout reflect 2022 guidelines
History of Medicare Medicare is a federally sponsored health insurance program for seniors and the disabled. Medicare was first created in 1965 and is designed to provide medical coverage to people on Social Security. Medicare is commonly confused with Medicaid. Medicaid was created for those in poverty. Medicare is funded through individuals contributing to a payroll tax throughout their working lives. Beneficiaries generally become eligible for Medicare when they reach age 65, regardless of income or health status. Policies and figures throughout reflect 2022 guidelines
Medicare ABCDs Part A Original Medicare Hospitals Hospice Home Health Skilled Nursing Facility Deductible and Cost-Sharing are applied Part D Prescription Drug Plan options: A standalone prescription drug plan (PDP) OR Medicare Advantage- Prescription Drug Plan (MAPD) that offers both medical and drug benefits Part C Medicare Advantage (MA) Plans Offered by private companies approved by Medicare Covers hospital and doctor s visits May cover prescription drugs Could include dental, hearing & vision benefits Part B Original Medicare Physician services Diagnostic services Preventive services Outpatient services Medical equipment Some prescriptions Deductible and Cost-Sharing are applied Policies and figures throughout reflect 2022 guidelines
Medicare Part A Medicare Part A Part of Original Medicare Helps cover inpatient care in hospitals, skilled nursing facilities, short-term nursing home care, hospice and home healthcare. Most beneficiaries do not pay a premium for Part A. o Part A is premium-free to beneficiaries if they (or their spouse) had been employed and paid Medicare taxes for 40+ quarters (10+ years) in their lifetime. o For those who worked less than 30 quarters (approximately 7.5 years) in 2021, the premium can be up to $471 per month. Part A Late Enrollment Penalty (LEP) The Part A LEP increases the monthly Part A premium by 10%. Beneficiaries subject to this LEP will be required to pay the higher premium for twice the number of years that they could have had Part A but did not enroll. o For example: if a beneficiary was eligible for Part A for two years but didn t sign up, he/she would have to pay the higher premium for four years. Policies and figures throughout reflect 2022 guidelines
Medicare Part B Medicare Part B Covers medically necessary outpatient services and supplies like physicians services, home health services, some preventive services, durable medical equipment (DME) and other medical services. Part B Late Enrollment Penalty (LEP) The Part B LEP increases the monthly Part B premium by 10%. Beneficiaries subject to this LEP will be required to pay the higher premium for twice the number of years that they could have had Part B but did not enroll. o For example: If a beneficiary was eligible for Part B for two years but didn t sign up, he/she would have to pay the higher premium for four years. Although your Part B premium amount is based on your income, your penalty is calculated based on the base Part B premium. The penalty is then added to your actual premium amount. Part B Cost Shares: Deductible: Under Original Medicare, a calendar year deductible must be satisfied for most Part B services before Medicare begins to pay its share of the cost. Most covered preventive services are not subject to the deductible. Cost Sharing: Once the deductible is satisfied, a Medicare beneficiary will typically pay 20% of the Medicare-approved amount for covered Part B services, if the provider accepts Medicare assignment. Beneficiaries pay $0 for most Medicare-covered preventive services. There is no maximum out-of-pocket limit for beneficiaries covered under Original Medicare. Policies and figures throughout reflect 2022 guidelines
Medicare Part C Medicare Part C Also known as Medicare Advantage or Medicare Replacement Plans. All Part A and Part B benefits are obtained through the private plan. Cover ALL services that Original Medicare covers, except hospice care. Hospice will be covered by Original Medicare. May offer extra coverage such as vision, dental and hearing. Most include prescription drug coverage, Part D. Medicare pays a fixed amount directly to the plan for the members care on a per- member, per- month basis. Plans must be approved by Medicare annually. Continued coverage in a specific plan type is not guaranteed year to year. Medicare Advantage Plans are NOT supplemental coverage. Policies and figures throughout reflect 2022 guidelines
Medicare Part C Medicare Part C Eligibility To be eligible to enroll on a Medicare Advantage plan, the beneficiary must: Be entitled to Medicare Part A Be enrolled in Medicare Part B Live in the plan s service area If the beneficiary is currently paying an additional premium for Part A and/or Part B, the beneficiary must continue paying this premium even if on a Medicare Advantage plan. Policies and figures throughout reflect 2022 guidelines
Medicare Part D Medicare Part D Part D is prescription drug coverage and is offered to everyone with Medicare. To get Part D, the beneficiary must join a plan run by an insurance company or other private company approved by Medicare. Each plan will vary in cost and covered drugs. Part D plans can change from year to year. Part D Late Enrollment Penalty (LEP) There is a late penalty premium for not joining a Medicare Part D drug plan when the beneficiary first becomes eligible for Medicare. For example: If the average monthly prescription drug premium is $33.19, the penalty fee will be calculated as 1% of $33.19, multiplied by the number of months late enrolling in Part D. If the beneficiary was 12 months late in enrolling, the penalty would be $3.98, paid on top of the drug plan s monthly premium. Policies and figures throughout reflect 2022 guidelines
Medicare Part D Medicare Part D Coverage Gap Most Medicare Prescription Drug Plans have a coverage gap (also called the donut hole ). This is a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the coverage gap. The coverage gap begins after the beneficiary and plan have spent a certain amount for covered drugs. Most Part D plans are subject to the gap. Coverage Begins (Jan 1) Covered for the Rest of the Year (Dec 31) Initial Coverage: Plan and member pay their share of the costs until reaching a total drug cost of $4,430 Coverage Kicks Back In (Catastrophic Coverage) Coverage Gap Donut Hole Little or no coverage, members are discounted until they reach $7,050 Policies and figures throughout reflect 2022 guidelines
Medicare Enrollment Periods Initial Enrollment Period (IEP) Annual Enrollment Period (AEP) Medicare Advantage Open Enrollment Period (MA-OEP) Anyone enrolled in a Medicare Advantage (MA) plan on January 1 can change MA plans. Medicare beneficiaries already enrolled in a Medicare Advantage plan are allowed a one-time election to either: Switch to a different MA plan -OR- Switch from a Medicare Advantage plan to Original Medicare and a standalone Part D plan. Does not allow switching from original Medicare to a Medicare Advantage plan. Medicare beneficiary may add, change or drop their Medicare Advantage or PDP plan. Anyone with: Medicare Parts A & B can switch to a Part C plan Medicare Part C can switch back to Parts A & B Medicare Part C can switch to a new Part C plan Anyone who has or is signing up for Medicare Parts A or B can join, drop or switch a Part D prescription drug plan. Timeframe when member is initially eligible for Medicare. During this span of time, a member may join Medicare Parts A, B, C and D. Policies and figures throughout reflect 2022 guidelines
Medicare Advantage Plans Sales Territory and Plan Type Health First Health Plans Classic, Value, Rewards, Secure AdventHealth Advantage Plans Sunsaver HMO and POS Plans offered in: Brevard Indian River HMO Plan offered in: Volusia Flagler Seminole Highlands Hardee Policies and figures throughout reflect 2022 guidelines
Medicare Advantage Plans Service Area It is important to understand the difference between Service Area and Provider Network. Service Area The Service Area defines which counties are eligible for either Health First Health Plans or AdventHealth Advantage Plans plan coverage. For example, a member residing in Brevard County would only be eligible for the Health First Health Plans brand products. Provider Network The Provider Network, combines all providers contracted with both Health First Health Plans and AdventHealth into a single network. Contracted Providers, either via Health First Health Plans or AdventHealth will be accessible to all Medicare members, regardless of Service Area. Policies and figures throughout reflect 2022 guidelines
Medicare Service Area Policies and figures throughout reflect 2022 guidelines
Medicare Products Health First Health Plans Classic HMO-POS Value HMO Rewards HMO Secure HMO (no Part D coverage) AdventHealth Advantage Plans SunSaver HMO All our plans include: Worldwide Coverage for Emergency & Urgent Care Free Gym Membership No referrals needed to see a Specialist (the specialist may require one, but the plan does not) Policies and figures throughout reflect 2022 guidelines
Sales and Enrollment Procedures Prospective Member (PM) Education Options: Sales kits (can be mailed upon request) Home appointments Websites https://www.hf.org/health_plans/brokers/medicare.cfm or https://hf.org/ahap/brokers/medicare.cfm Medicare (medicare.gov or 1.800.MEDICARE) Phone Customer service 1.800.716.7737 Policies and figures throughout reflect 2022 guidelines
Sales and Enrollment Procedures For compliance, follow these best practices: 1. Beneficiary initiates contact 2. Agent completes Scope of Appointment 3. Agent conducts sales presentation Medicare Basics, Part D, Enrollment Periods Benefits at a Glance (BAG) Summary of Benefits, Formulary, Directory Answer questions Complete Enrollment Application 4. Agent submits enrollment within 24 hours of signed application Policies and figures throughout reflect 2022 guidelines
Sales and Enrollment Procedures Scope of Appointment The Sales representative must clearly identify the types of product(s) that will be discussed, obtain agreement from the beneficiary and document that agreement. A completed SOA should be submitted to Health First Health Plans or AdventHealth Advantage Plans with each enrollment application. The Scope of Appointment (SOA) form is located from the public website Brokers page and also from the Medicare Enrollment Portal electronic enrollment platform. Policies and figures throughout reflect 2022 guidelines
Sales and Enrollment Procedures During individual appointments, brokers may not: Promote non-healthcare-related products Solicit/accept an enrollment request for a January 1 effective date prior to the start of the Annual Election Period on October 15 Discuss plan options that were not agreed to in the Scope of Appointment Inappropriate and Prohibited Marketing/Sales Activities Conducting health screenings Providing cash or monetary rebates Making unsolicited contact Use Absolute Statements when describing the plans Policies and figures throughout reflect 2022 guidelines
Sales and Enrollment Procedures Sales Events Example of Do s & Don ts: Do provide light snacks and refreshments Don t solicit enrollment applications prior to start of the Annual Election Period (AEP) Don t require information as a prerequisite for events (contact information) Educational Events Example of Do s & Don ts: Do provide light snacks and refreshments Don t talk about Medicare plan-specific premiums and/or benefits Don t display and/or distribute summary of benefits or provider directory Don t conduct or promote sales activities Policies and figures throughout reflect 2022 guidelines
Sales and Enrollment Procedures Use the beneficiary Medicare ID card to: Verify name and spelling Verify and record the Medicare Beneficiary Identifier Verify and record Medicare Part A and Part B effective dates It is not required to submit a copy of the Medicare card. Policies and figures throughout reflect 2022 guidelines
Sales and Enrollment Procedures SALES KITS Always use a complete kit: Benefits at a Glance (BAG) Summary of Benefits Enrollment application Postage-paid return envelope Multi-language insert Provider Directory, Formulary Privacy Policy Stars Rating Policies and figures throughout reflect 2022 guidelines
Sales and Enrollment Procedures Premium Payment Options For monthly premium plans or late enrollment penalties (LEPs): Monthly invoices Electronic funds transfer (EFT) Social Security withholding (preferred option) NOTE: Brokers may make payments on behalf of their members using the member s mode of payment. Brokers may never make payments for their members using the broker s mode of payment. Policies and figures throughout reflect 2022 guidelines
Consequences Potential Consequences of Engaging in Inappropriate or Prohibited Marketing/Sales Activities: Disciplinary action Appointment termination Forfeiture of future compensation Complaints received by members or prospective members in reference to a Broker with any aspect of the Health Plan s operations, activities or behavior are addressed via the Complaints Tracking Module (CTM). Members may contact Health First/AdventHealth Advantage Plans to file a grievance in writing or by telephone. Health First/AdventHealth Advantage Plans will legally comply with all State Insurance Department investigations. Policies and figures throughout reflect 2022 guidelines
Sales and Enrollment Procedures Does Your Enrollee Have Other Insurance? If you currently have health coverage from an employer or union, joining a plan could: Affect your employer or union health benefits, including prescription drug coverage Cause loss of your employer or union coverage Important: Read the communications your employer or union sends. If you have questions, visit their website or contact the office listed in their communications. If there isn t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help. Policies and figures throughout reflect 2022 guidelines
What to Expect Next Within 10 calendar days, a member will receive: An acknowledgment letter showing their member number, plan name and effective date. This can be used as proof of coverage until he/she receives their ID card. Within 15 calendar days, a member will receive: An enrollment verification letter. This letter verifies their enrollment request into our plan. A member ID card that will be used for all medical and prescription needs in place of the red, white and blue Medicare card. Within 90 calendar days, a member will receive: A welcome call from the Member Engagement Department. Policies and figures throughout reflect 2022 guidelines
What to Expect Next In 2022, the members Evidence of Coverage (EOC), Formulary and Provider/ Pharmacy Directory will NOT be included in the Annual Notice of Change mailing. Annual Notice of Changes mailings will include the ANOC Postcard, which will contain instructions to order hard copies of the following 2022 plan documents: 2022 Evidence of Coverage 2022 Provider/Pharmacy Directory 2022 Prescription Drug Formulary Policies and figures throughout reflect 2022 guidelines
What to Expect Next Members may order an Evidence of Coverage, Provider/Pharmacy Directory and Prescription Drug Formulary in one of three ways: Order online through our Health First Health Plans or AdventHealth Advantage Plans websites, or By contacting Customer Service via the phone number listed on the post card, callers will have the option from the phone menu to order their documents. This option will connect the caller to a live representative for assistance, or In person Members may order hard copies of their upcoming plan documents beginning October 1 Policies and figures throughout reflect 2022 guidelines
Broker Compensation Medicare Advantage (MAPD) New Medicare Advantage (MAPD) Change from other Carrier 2022 Plan Year 2022 Plan Year Initial Year Renewal Year Initial Year Renewal Year $287 annually, or prorated based on member effective date with Health First $287 annually, or prorated based on member effective date with Health First MAPD Plans MAPD Plans $287 $573 Policies and figures throughout reflect 2022 guidelines
Sales Office Locations Office Location Services Available Main Office: 6450 U.S. Highway 1 Rockledge, FL 32955 Customer Service All Sales functions General office hours: Weekdays, 8 a.m. to 5 p.m. AdventHealth Advantage Plans: 1425 W. Granada Blvd., Suite 4 Ormond Beach, FL 32174 AdventHealth Advantage Plans Medicare Sales only General office hours: Weekdays, 8 a.m. to 5 p.m. Policies and figures throughout reflect 2022 guidelines
