Humana Vantage broker portal
The Humana Vantage broker portal is an invaluable tool for Humana appointed agents. If you are appointed with Humana and have your Humana writing number, you can access the Vantage broker portal. Just go to humana.com, go to the sign in and enter your username and password. For new agents, just click to activate your online profile and use the prompts to setup your Humana portal access.
Click here to add Humana to an existing Crowe contract or to start a new contract with Crowe.
What’s on the Vantage home page
After you sign in, you can view the menu as well as “Agent Profile”, “Notifications” and other valuable information. The 3 horizontal lines (hamburger menu) provides agents quick access to many valuable tools. Some of the links take you to tools such as; quote and enroll, your certifications and training as well as the agent portal.
Notifications
You can find urgent as well as general messages. There is also a way to access older notifications by going to archives. Any urgent notifications are displayed in a banner at the top of the page. General notifications are in the notification center and include things such as recertifications and general information.
Licensing, Certification and Contracts
In this section of the portal agents find their status for licensing, certification and contracts. This helps agents stay up-to-date and ready to sell.
Education
The education section takes you to Humana MarketPoint University. Once you are in MarketPoint, you have access to complete certifications and any training you need. You can also access training webinars and job aids.
Sales and Marketing
Find sales presentations and videos as well as other marketing materials.
Quote and Enroll
In this area of Vantage, you will find Humana’s enrollment tools. Some of the things agents find here are the enrollment hub, fast app tool, scope of appointment, HRA, health risk assessment, and digital marketing materials.
Watch a video on see how to use the Sunfire quoting tool
Compare the Connecture quoting and enrollment site
Drug Cost Lookup
This section includes tools such as, the prescription calculator and the Medicare drug list search. This is an easy way to check the out-of-pocket costs for prescriptions drugs. Find the best Humana plan for any client’s prescription coverage needs. Both of the links in the Drug Cost Lookup can import client’s drug lists from the CMS website.
Doctor & Pharmacy
Verify that doctors, hospitals, pharmacies and vision or dental providers are in-network with any plan the client is thinking about.
My Humana Business
In this area you can check application status as well as submit customer service inquires.
Commissions
This area is available to Humana partner agents, Humana employees do not have access to this area. Some of what you can vies in this area include; Commission statements, payment assignments, direct deposit information and delegated commission forms.
Compliance
From here you can view policy documents and agent agreement documents.
Click here for scope of appointment rules
The Humana Vantage portal gives agents a quick way to access any information they need to answer most questions they have about Humana products and their clients.
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What is a Medicare HRA
If you are in Medicare sales, you may have heard the term HRA. In this post we will explain what is a Medicare HRA and why insurance carriers use this tool.
What is a Medicare HRA
HRA stands for Health Risk Assessment. Medicare Advantage plans must do an HRA for every beneficiary within 90 days of their initial enrollment. MA/MAPD plans require qualified health care professionals to conduct HRAs for existing members once a year. These assessments are an important tool for both health plans and providers. Insurance carriers use HRAs to identify the health status of members. Once the HRA is completed, insurance companies make risk adjustments and providers can put a managed care plan in place when necessary. Clients may decide to have the HRA done either in a provider’s office or at home.
The HRA is required by CMS for all members of both Medicare Advantage and traditional Medicare fee-for-service plans. If the member is enrolled in a traditional Medicare Fee-for-service plan, The member’s initial (welcome to Medicare) or preventative visit is used for the HRA. When the member is enrolled in a MA/MAPD plan, the member will be asked to have the HRA. Medicare advantage plans must make a “best effort” to have the member complete the HRA each year.
Click here to watch a quick YouTube video on Medicare Advantage vs. Medicare Supplement plans
HRAs (Health Risk Assessments) help collect important information
The information obtained through a HRA provides a view of the enrollee’s general health, health risk factors, as well as a glimpse into their ability to complete activities of daily living. All these factors provide a view of overall health as well as find gaps in care and provide a basic diagnosis.
Any information obtained can help providers and health plans to create population health initiatives as well as to put an individual health plan in place. The plan may include care management, coordination of care, identification of high-risk individuals and the development of comprehensive care plans with referrals to suitable care team members.
Agents who want to offer Medicare Advantage plans, click here for online contracting
How to conduct a Health Risk Assessment
CMS has not put any specific format in place to conduct the assessments. In many cases, a health care professional asks the beneficiary a series of questions. The questions cover a large range of topics that include family medical history, the beneficiaries current health, their lifestyle and their willingness to adapt behaviors that can improve their health. The answers provided all correspond with a numerical value that determines the weighted risk value and health of the beneficiary.
Because Medicare Advantage companies receive payments from Medicare for each enrollee, Medicare uses this information to help calculate the payments. Health plans receive a prospective capitated payment that is based on the projected cost of care for each beneficiary. Medicare adjusts the payment according to the amount of risk the company assumes per enrollee. This helps ensure the company is able to cover the costs for the care for it’s enrollees. That is why so many Medicare Advantage plan carriers offer their agents an incentive to ensure that new plan enrollees have the HRA completed.
For CMS to accept the HRA for the risk-adjusted payment, it must be either documented in the patient’s medical record or performed as a face-to-face visit with a licensed medical provider and the beneficiary.
Learn about CMS’ Part D drug cap
HRAs are an important tool
HRAs along with a good care management team are a great way to identify and support the specific health care needs of the individual to ensure improved health and better quality of life.
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CMS 72 hour rule
The CMS 72 hour rule is one of the many laws in place to help make the Medicare program run smoothly. The Centers for Medicare & Medicaid Services (CMS) sometimes refers to their three-day rule as the 72‐hour rule.
This rule states that outpatient diagnostic or other services preformed within 72 hours before a hospital stay must be billed as part of the hospital stay. The hospital cannot bill these diagnostic tests as separate procedures.
Click here to view the CMS 72-rule information
When a beneficiary undergoes diagnostic services within 3 days before a hospital stay, the services are considered inpatient and are included with the bill for the hospital stay. This is true for any diagnostic test or service provided in the hospital facility within a 3-day period before a patient’s admission.
A few examples of outpatient diagnostic services that the rule applies to include:
- Lab tests
- Radiology
- CT Scans
- Cardiology
- EKG
- EEG
- Nuclear Medicine
- Osteopathic test
Other times hospitals may add in-patient services together
In some instances, under the 72-hour rule, hospitals may bundle unrelated outpatient services with an inpatient surgery. Although, if the outpatient service is not diagnostic, the hospital can bill it as a separate charge.
Medicare agents, watch a quick YouTube video on the CMS final rule 2024 for agent compensation
To better understand; please take a look at the example below.
If a beneficiary has an in-patient surgery scheduled in the next 3 days, but she trips and falls and goes to the hospital for an x-ray, the hospital can include the bill for her x-ray with her in-patient surgery bill. This is true even if it is un-related. In most cases, the patient receives a separate bill for the individual service. If this patient has in-patient surgery within 3 days of the diagnostic test (x-ray), the hospital adds the cost of the x-ray with the surgery charges. The surgery can be completely unrelated to the area she had an x-ray of.
It is important to note, that because the nature of the service provided was diagnostic, it can be included in the in-patient charges. Although, if the service a patient receives is not diagnostic but a service such as physical therapy, the provider bills this service separately and cannot include it in the in-patient bill.
How does the 72 hour rule help
CMS has this rule in place to stop providers from double-billing Medicare. Both CMS and the OIG (Office of Inspector General) actively enforce the rule. This helps prevent fraud and over payment for medical services. If a provider is caught not complying with this rule, they face thorough investigations as well as the responsibility of paying for the recovery of overpayments they received. Providers may also lose out on payments for services they provided.
The 72-hour rule helps limit both overpayments and underpayments. It is important that hospitals ensure their billing and coding representatives understand the rule and how to apply it.
Learn about the Medicare call recording rules
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UHC Jarvis login
Agents who are appointed to offer UHC/AARP Medicare plans can access many helpful tools in the UHC Jarvis portal. In order to access the Jarvis portal, you must have a writing number and a UHC Jarvis login.
Do you want to add UHC to your appointments, click here to contact online with Crowe
Once you are in the portal, you can either sign in with your One Healthcare ID or register for a One Healthcare ID . You can also login through the One Healthcare mobile app.
To learn more about the mobile app, click here.
When you get to the Home page, you will see a menu at the top of the page. If you hover over the items, you will see a drop-down menu with several options for each category.
Sales Tools
In this section you have the following options:
Sales Materials with this tab, you can order or download applications or enrollment guides.
Medicare Medicaid Eligibility lookup.
Plan Search with this tab, you have the ability to look up available plans in an area once you enter a zip code.
LEAN is an online enrollment HUB. LEAN includes a scope of appointment and voice signature options for applications. There are also tools to lookup providers and medications.
Marketing Resources includes forms for events including new event request and cancellation forms. There are also a marketing sales event checklists as well as sample verbiage.
Application Status
This tab is pretty self-explanatory. Once you are in this screen, you can view a list of clients and see details of their application and enrollment. This includes their member ID.
Commissions
Commissions Search this tab is useful for both agents and agencies. Run a report by agent and date.
Statements and More use this tab to download statements by date.
Commissions Calendar view the calendar and to see when commissions are set to be paid each month.
Direct Deposit access your direct deposit information and update it when necessary.
Assignment of Commissions this tab allows you to download an assignment of commissions form as well as view a FAQ sheet.
Release view instructions for releases.
1099 instructions to get a copy of your 1099.
Successor Agent this area is used for the transfer of both members and commission payments.
Book of Business
Use this tab to view a complete list of your clients. Agents can apply filters to narrow down their search by area, status or name.
The final tab is Knowledge Center
Medicare Product Portal view the UHC product portfolio and search for available plans in a specific market area.
Training and Certifications form here you will access the Learning Lab where you can view product training and continuing education resources.
Agent Guide this area provides rules, policies and procedures for marketing UHC products.
Portfolio Overview view all the plan types UHC offers.
Selling Resources from here, you can access resources and product guides to find out what’s new and what benefits members can expect.
Enrollment Resources here you will access LEAN (The Landmark Electronic Application Navigator). This tool makes enrollments quicker and easier. LEAN supports all Medicare Plans, including Medicare Supplement. Agents can use LEAN as a website on either desktop or laptop as well as mobile app for iOS and Android tablets.
Agent News View special election periods as well as several other announcements.
Member Experience in this tab you can view examples of common communications members receive from the plan based on the plan type.
Compliance Access resources for CMS sales and marketing compliance information.
Forms agents can easily find forms for events, scopes, PTC, commissions or other forms pertaining to specific plan types.
Click here to watch a quick YouTube video on the scope of appointment rules
FAQs learn how to find anything you need in Jarvis.
The top of the Home page shows enrollment statistics
View at a glance, how many applications are pending, how many have been approved in the last 60 days and how many active members you have. There are links to view clients in each one of the categories.
There is a scrolling news feed with recent information as well as a plan finder and application status tool. The center of the screen provides quick links to tools such as:
Medicare & Medicaid lookup
LEAN
UHC Agent Toolkit
Book of Business
Prescription Drug Lookup cost estimator
Pharmacy Finder
Dental Provider lookup
Medical Provider lookup (Rally)
Renew Active Fitness locator shows locations of clubs, classes and provides information for members to join a Fitbit community etc.
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Humana Vantage login
Medicare agents who contract to offer Humana Medicare plans should make sure they have a Humana Vantage login. Vantage provides access to several helpful tools that will make it easy to find answers to both agent and client questions.
How to access Vantage
You need to be contracted to sell Humana and have your writing ID before you can access Vantage. Once you are ready to go, visit the Humana website. Once you are on the site, click sign in on the top right corner of the screen and enter your username and password. If you forgot your username or password, click the links below the sign in button and reset either one.
Contract with Crowe to offer Humana Medicare plans, click here
Are you a new to the Humana Vantage site
If this is your first time on the site, just click activate online profile to follow the prompts to get set up.
Vantage home page
Once you are signed into Vantage, you will see the menu on the top left of your screen. You will also see options for Notifications, Agent Profile and more.
Click the 3 horizontal lines under the word menu to get quick access to the different areas in Vantage such as:
- Favorites
- Quote & Enroll
- Commissions
- Certifications & Training
- Agent Portal
- Connection Hub
- Delegated User Access
Please Note: The menu appears differently based on the type of agent.
There are several sections on the Vantage home screen.
Notifications
Notifications shows both urgent and general messages for agents. You can access the same notifications in the link at the top of the page. You can see prior notifications by clicking on archives.
Urgent notifications will be displayed in a banner across the top of Vantage.
General notifications are found in the notification center. These may include dates for events like recertifications or other general announcements.
Licensing, Certification and Contracts
Licensing, Certification and Contracts lets agents know what their current status is for all Humana licensing and certifications.
Education
Agents can find a link to the Humana MarketPoint University (aka HMU) in the Education section. In MarketPoint University, agents can complete certifications and courses as well as find training webinars and job aids.
Sales and Marketing
Sales and Marketing provides agents an easy way to find marketing materials such as, sales presentation videos and more.
Quote and Enroll
Access all Humana’s enrollment tools in this area. Some things Quote and Enroll includes are as follows:
- Enrollment Hub
- Fast App
- Scope of Appointment
- Upload Paper Applications
- Eligibility Verification
- Health Risk Assessment
- Digital Marketing Materials
Click here to watch a quick video on the 48-hour scope of appointment rule
Drug Cost Lookup
This tool allows agents to verify out-of-pocket costs for prescriptions drugs. Agents can view several plans side-by-side to find out which one would best suit their client’s prescription coverage needs. Both of the links in the Drug Cost Lookup area have the ability to import client drug lists from the CMS website.
This section of the portal provides the following tools:
Prescription Calculator
Medicare Drug List Search
Doctor & Pharmacy
This is a helpful tool that will help you find doctors, hospitals, vision or dental provider as well as pharmacies. This helps ensure the client’s doctors are in-network with plan they are considering.
My Humana Business
Agents can use My Humana Business to check application status and submit customer service inquires for clients. Service Inquiries is the best way to start a customer service request.
Some inquiries may include:
Client address changes
Billing questions
Verification of benefits
PCP changes
Commissions
Commissions is only available to Partner Agents; Humana employees cannot view this area. Some of the things you can view in this area:
Commission Statement Portal
Create a Pay Audit Request
See Payment Assignments
Set up Direct Deposit
Complete the Delegated Commission Assignment Form
You can also view the Agent of Record Protection Pledge and the Agent of Record Change Policy.
Compliance
Compliance is a quick way to access policy documents as well as agent agreement documents.
As you can see, the Humana broker portal (Humana Vantage) provides all the information agents need to be successful.
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United Healthcare OTC catalog 2024
Members of participating UHC Medicare advantage plans have access to the United Healthcare OTC catalog 2024. There are 3 different types of UHC Medicare Advantage plans that have their own OTC benefit package. Members of all 3 plan types can access their OTC benefit through their UCard. The UCard is more than just a member ID card, it is a way to access all the extra benefits UHC members receive.
Members of these plans have access to an over-the-counter credit. United Healthcare adds the credit to members UCards either monthly or quarterly. This depends on the plan each member enrolls in. To find out if your plan offers this benefit and the details, check the evidence of coverage for your plan.
Member can shop in over 55 thousand participating stores. Participating stores include CVS, Kroger, Walgreens, Walmart as well as Meijer, Sam’s Club and Save A Lot.
Shopping in stores provides a greater product selection for members that include both generic and Brand-name items. Members also have the option to order items online, by phone or through the mail.
Please note: This year the OTC catalog is too large to add as a download to the blog, that is good for plan members! Members can call the member services number on the back of their card to request a copy be mailed to them.
The best way to see the OTC items is either online or through the mobile app.
View the catalog with the UHC Mobile app – click here for instructions
Click here to access the OTC store finder
Unused benefits for Plans that provide a monthly combined credit for OTC/Healthy Foods/Utilities expires at the end of each month.
Ways to order OTC items
Members of participating UHC MAPD (non-SNP plans) have 4 ways to order OTC items with their UCard or prepaid card. In 2024, 68% of all non-DSNP members have access to the OTC benefit.
UHC 2024 OTC (Non-SNP) brochure
1. Order in store at one of over 55k participating locations.
2. Purchase OTC items online whenever it’s convenient for you 24/7.
3. Use the phone to order OTC items.
4. Use the mail order form in the OTC catalog to order items.
Please note, items ordered either online, over the phone or by mail will usually be delivered within 2-3 days of receipt. Orders over $35 are eligible for free shipping.
Click here to download the 2024 UCard Quick Reference Guide
Information for C-SNP members
UHC 2024 OTC and Healthy Foods (CSNPs) brochure
C-SNP members have access to a monthly credit for OTC benefits as well as healthy foods benefits on their UCard.
Members have a few ways to shop for OTC items.
- In store
- Online through the member portal
- Use the catalog and purchase items by mail.
Delivery is free on orders of $35 or more.
C-SNP members can choose from thousands of healthy food items including meat, fruit. vegetables, dairy bread cereal and much more. There are a few ways to shop for healthy foods using the monthly allowance on the UCard. Delivery is free with Walmart or Roots.
In 2024, there are 42 C-SNP plans that offer the OTC healthy food card. In past years, this benefit was only available on the DSNP plans.
- Shop for healthy foods in store
- Choose from the items online through the member account,
- Use the UnitedHealthcare mobile app to check your account balance or locate local retailers. Use the scan to find available products and check outin stores without your UCard.
Orders can be placed by calling 1-888-628-2770 (TTY: 711). You can talk to an agent Monday to
Friday, from 9 AM to 8 PM local time. Please have your order ready before you call.
OTC benefit information for D-SNP members
UHC 2024 OTC, Healthy Foods and Utilities Credit (DSNPs) members
OTC benefits for D-SNP plan member in 2024 include over-the-counter items as well as healthy foods and utilities benefit. This benefit is loaded onto the UCard each month and member can choose to use it in any of the ways mentioned above. Credits are loaded onto the UCard each month
D-SNP members can decide to use their benefit to shop one of the following ways.
- In one of the thousands of participating stores.
- They can also choose to shop online through the member portal.
- Members may also use the catalog to order items through the mail using the form in the catalog.
Members can purchase Healthy Foods in one of the following ways:
- Members can shop in-store
- Online through the member portal
- They may also use the catalog to choose food items and have them shipped to their home, the same as with OTC items. Home delivery is free with Walmart or enrollees may choose Roots for fresh produce and premade meal delivery.
The utility benefit can help members pay electric bills, water and sewer usage, sanitation, heating or internet service. FOr utilities, the service address must be the same as the member’s home address that is on file with United healthcare.
Member can request a replacement catalog online or by contacting member services.
The number for each plan’s member services team is found on the back of the member ID card.
Medicare agents- get contracted to sell United Healthcare plans
Additional information
In most cases, United Healthcare will answer member inquiries. There are some benefits supported by different vendors depending how the member orders the product. Items that are ordered online, over the phone or with the catalog will be filled by Solutran. Some orders are supported by Walmart.
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Do you have any questions?
Questions and requests
Medicare prescription payment plan
The Medicare prescription payment plan is also referred to as “smoothing“. This is a way to help Medicare beneficiaries pay for the high cost of prescription medications. The Medicare prescription payment plan is one small part of the inflation reduction act of 2022.
Watch a quick YouTube video on potential changes to commissions in 2025
When will the program start
In 2025, Medicare Part D (PDP) plan enrollees have a chance to opt for a prescription payment program. The plan will help beneficiaries pay out-of-pocket costs for prescriptions. Everyone in a PDP plan has a chance to enroll in the payment program, it is not based on income. Enrollees have the option to enroll before the plan year starts or during any month of the year. Please note, the payment plan does not include plan premium payments.
Here are some of the details
Participation in the Medicare prescription payment plan is optional. PDP plan enrollees must choose to be part of the program. Once an enrollee joins the program, and has out-of-pocket prescription costs, they receive a monthly bill to cover those costs. Any out-of-pocket costs for prescriptions are included even during the deductible phase of PDP coverage. There is no minimum out-of-pocket amount required before anyone can join. Participants receive a monthly bill as long as they remain part of the program.
How is the monthly payment amount decided
There will be an annual cap of $2,000 on out-of-pocket costs in 2025. The amount each beneficiary pays for their monthly plan depends on a few different factors. It is not as easy as dividing $2,000 over the course of 12 months.
Learn more about the Part D drug cap
- The Medicare prescription payment plan will deduct the out-of-pocket amount beneficiaries have already paid before enrollment in the program.
- Any remaining costs are then divided by the number of months left in the year.
CMS will create a payment calculator so Part D beneficiaries can decide if enrolling in the payment plan is a good idea or not.
CMS is still working out the details of this program
We do not know exactly how the prescription payment program will work yet because the details have not been finalized by CMS yet. We will post additional details as they are available to the public.
Please note: This program is set to start in 2025, the same year the annual drug cap will be set at $2,000. In other words, no Part D enrollee will pay more than $2,000 out-of-pocket for their prescriptions.
UHC Care Advantage IESNP Prequalification
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If the member is dual or has any level of drug help, they MAY automatically qualify for the plan. Please do not assume they qualify. Check Jarvis to see if they show as eligible.
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If the member does not show as eligible in Jarvis, you will need to have them do the WellSky assessment call to see if they qualify. It is very important the Wellsky assessment is done before you submit the application. Once the assessment is completed you will get a notice stating if they are eligible or not. If eligible, you can submit the application.
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This plan is available to anyone that can qualify either by having some level of help (MAKE SURE TO CHECK JARVIS TO SEE IF ELIGIBLE) or if they don’t have drug help, they can qualify through the Wellsky call.
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You can put a full dual or someone with any level of help in this plan, but the more obvious candidate would be someone on drug help only or someone that has no help at all. The benefits of the plan will look far superior to the benefits of any non-dual MAPD plan. It is also a very good Medicare supplement replacement option given the low MOOP of the plan ($1,600 in most states and as low as $500 in some) This is especially true in states with high Medicare supplement rates like NY and CT.
UHC Care Advantage IESNP Prequalification – Broker Eligibility
Webinar training
Anthem OTC catalog 2024
The Anthem OTC catalog 2024 provides members of participating plans access to many useful items at no charge with their prepaid Benefits Mastercard. Plan members have the choice to pick up items in store or have them delivered to their doorstep.
Download a copy of the 2024 Anthem OTC Catalog
Here’s what you can find in the catalog
- OTC benefit details.
- Details of all the different ways to shop for OTC items.
- Eligible items listed by category.
Members can call the number on the back of their Benefits Prepaid card for any assistance they need. Members can also get answers to their questions by logging into their secure account in the Benefits Pro Portal at MyBenefits.NationsBenefits.com.
Here’s how to create an online account
Access your benefits when it’s convenient for you 24/7 at MyBenefits.NationsBenefits.com
First time users need to create an account visiting the Benefits Pro Portal or using the Benefits Pro mobile app. Once you are on the Nations Benefits portal, just click the “register” button and follow the prompts from there.
If you need assistance, just call 866-413-2582 (TTY: 711)
Once your portal is set up you can log in and view your spending allowance. Find participating stores nearby, view and track recent orders and look for eligible products.
How to shop for OTC products
Because there are many ways to shop for OTC products, you can easily find the one that works best for you.
In a participating store
Members can use their Benefits Prepaid Card to purchase eligible OTC products at one of the many participating stores. TO find a store near you, visit MyBenefits.NationsBenefits.com and enter the area you want to shop in. You will quickly find a list of local stores. The OTC catalog provides an instore shopping guide with information on the available items. You can also find eligible items in your member portal as well as by scanning the UPC code found on any product by using the Nations Benefits Pro app.
Once you finish shopping, place your benefits card into the card reader and choose “credit” when prompted. You do not need a PIN to use the card. You r eligible spending amount will apply to the purchase. If you’re spending more than your available balance, you can use another form of payment to cover the remaining balance.
Have items delivered to your home
Members can order products for home delivery from the NationsBenefits catalog or by going to MyBenefits.NationsBenefits.com search by product type or UPC code.
Selected items are shipped to your home at no cost.
Download a copy of the 2024 Anthem OTC Catalog
Order through the Benefits Pro App
You can download the app either by scanning the QR code you find in the OTC catalog or by going to the App Store or Google Play
Once you have the app downloaded, you can choose the items you want to purchase and follow the instructions to pay and checkout.
Place an order by Phone
Find the items and the items number of the OTC products you want to purchase and call the number on the back of your NationsBenefits card. Member Experience Advisors will assist you Monday through Friday from 8:00AM until 8PM local time.
To order by Mail
Find the items you wish to purchase and fill out the order form at the back of the OTC catalog.
Send your completed order form to:
NationsBenefits
1700 N. University Drive
Plantation, FL 33322
Mail your completed form no later than 12/20/24 to use your available spending allowance before it expires.
More information
The products in the OTC catalog are subject to change. In some cases, an item, quantity or size may change depending on availability. Some items may be added or removed without notice.
Visit our homepage for OTC catalogs from other Medicare carriers
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Part D catastrophic coverage
In 2023, when a beneficiary’s out-of-pocket spending for prescription drugs reaches $7,400, they reach the Part D catastrophic coverage level. If this happens, the beneficiary pays 5% co-insurance for prescriptions covered by Medicare Part D for the rest of the year.
2024 catastrophic cost change
On January 1, 2024, the 5% co-insurance payment in the catastrophic phase will end. Beneficiaries who reach $8,000 in out-of-pocket spending on Part D prescriptions in 2024 will automatically receive catastrophic coverage. Medicare Part D plan provider will have to pay 20% of the total drug cost instead of the 15% they paid in the past. Once beneficiaries reach this level, they no longer have to pay either copayments or co-insurance for covered Part D prescriptions for the remaining part of the year.
Learn more about Medicare Part D plans
This updated rule applies to Part D enrollees who do not have an LIS (low-income subsidy). When a Beneficiary reaches the catastrophic level in Part D coverage. they no longer pay 5% of their prescription costs. In other words, there is a cap on Part D out-of-pocket spending for enrollees in 2024. the catastrophic threshold is $8,000.
How the catastrophic limit is calculated
The catastrophic limit includes the prescription costs paid out-of-pocket by Part D enrollees, as well as the value of the manufacturers price discount on brands of medications in the coverage gap phase. In 2024, a Part D enrollee who uses only brand-name drugs and spends about $3,250 out-of-pocket pays no additional amount for their prescriptions. The remaining part of the $8,000 catastrophic limit is taken from the manufacturer’s price discount for the medications.
What this means for beneficiaries
For beneficiaries who do not qualify for LIS and require expensive medications to maintain their health, annual out-of-pocket costs can be as high as $15,000 annually. This cost applies to individuals who may take some lifesaving cancer medications. This cost on top of fighting for their lives adds a terrible amount of stress for them. Once a beneficiary reaches the catastrophic phase, eliminating the 5% coinsurance in 2024 means that Part D enrollees who require high-cost medications covered by Part D can save thousands of dollars.
Click here to watch a quick video about the Part D changes
Changes in costs for Part D plan providers
Due to the end of the beneficiaries required 5% coinsurance payment in the catastrophic coverage phase, Part D plans will have to pay 20% of total drug costs during the catastrophic phase in 2024. This is 5% over the 15% they currently pay in 2023 and in previous years.
Changes for 2025
CMS is putting a hard cap of $2,000 on out-of-pocket, prescription drug spending in 2025. They will also end the coverage gap phase (donut hole). Part D plans will have a greater responsibility for prescriptions in the catastrophic phase and more manufacturer price discounts will be added. These measures will reduce the liability for Medicare in this phase of coverage. There will be changes to Part D plan costs as well as manufacturer price discounts in the initial phase of Part D coverage.
Please note: the drug cap does not apply to out-of-pocket costs for Part B prescription drugs.
Medicare scope of appointment rules
The Medicare scope of appointment rules are put in place by CMS. The SOA (scope of appointment) is a form that clients or potential clients as well as their agent must complete before meeting to discuss Medicare plan options. The scope is mandatory if you are discussing either a Medicare Advantage or Part D prescription drug plan. Although, it is a good idea to collect a SOA before any client meeting to protect both the agent and the client. The SOA form should be kept no less than 10 years and may be collected either physically, verbally or electronically.
Watch a quick video on the scope of appointment rules for 2024
Verbal scope of appointment
When the pandemic began, it was not advisable to host in-person meetings to discuss coverage options. Because of this, many appointments took place over the phone. That lead to the use of verbal scope of appointments which are recorded and saved. Many carriers offer this option as well as quoting/enrollment tools such as Sunfire and Connecture.
Click here to watch a Sunfire enrollment demonstration on YouTube
General information about a verbal SOA
- If the client calls the agent (inbound call), the 48-hour rule does not apply.
- The scope is good for 12 months from the date it is signed. You must complete the appointment within that time or obtain a new scope. The scope is still good if the call drops and the same agent calls the client back.
- If additional benefits are added to the discussion, a new scope is necessary.
How long is a SOA good for
As we mentioned above, a scope of appointment is good for 12 months from the date it is signed. It is important that you discuss only products that were agreed to and included in the scope. If additional products are added, the beneficiary needs to sign a new scope.
If the client asks about Medicare Advantage plans during the 48-hour waiting period and they had not included them on the original scope, you will need to have them sign a new scope before your discussion. This will restart the 48-hour waiting period and may move your meeting date out further. This rule applies to any product regulated by CMS.
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CMS guidelines
In order to be complaint with CMS, agents need to have their clients complete a Medicare Scope of Appointment form. The 2024 CMS final rule went into effect September 30. 2023 and has added some changes to how agents obtain the SOA.
The SOA rules apply to agents and brokers who discuss Medicare coverage options and plans. The 48-hour rule was put in place so beneficiaries could avoid the high-pressure sales tactics some agents use. The 48-hour period provides beneficiaries time to consult friends, relatives or anyone they like to research their options. This time also provides agents time to prepare for the discussion.
Agents are able to contact the beneficiary once the SOA is completed for up to 12 months. It is essentially permission to contact until the meeting takes place. The beneficiary has the option to opt out annually.
Please note, if the beneficiary does not select a coverage option on the SOA, Medicare requires the agent to avoid discussing that option without a new SOA where the option is clearly selected.
Find out about the proposed CMS rule 4205-P, see how it could affect agents!
Exceptions to the 48-hour rule
If the beneficiary is in the last four days of a valid election period, agents may collect a same-day SOA.
When the beneficiary walks into your office and initiates a conversation about coverage options, agents can take a same-day SOA. This same rule applies to inbound call initiated by the beneficiary to the agent requesting advice.
How long do you need to keep a SOA
Agents must be able to access the SOA form for ten years. Clients have the right to request a copy anytime within that time frame without any issues. The SOA can provide help in the event that an issue or dispute occurs. The Scope is in place to protect the consumer, but it can also protect the agent.
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Aetna Medicare OTC catalog 2024
Both current members and anyone considering enrollment in an Aetna MAPD plan should take a look at the benefits in the Aetna Medicare OTC catalog 2024.
Aetna has two separate catalogs for 2024. The first one is for members of their participating MAPD plans, this catalog is called Over-the-Counter Health Solutions (OTCHS). There are three ways to order products from the OTCHS.
Download the MAPD OTC catalog 2024
Order in a participating CVS pharmacy
Use the following link to find a participating store: CVS.com/storelocator.
Please note: CVS pharmacies inside either Target or Schnucks stores do not participate in the OTCHS program.
- Look in your OTC catalog to find items you would like to purchase. It is important to know; only items in the catalog are available to purchase with this plan.
- Locate products marked with the blue shelf tag in the store. Prices of in store items may not be the same as the catalog price.
- Use your benefit at any register. Tell the cashier you have the OTC benefit and show them your member Id card to verify your eligibility.
Use the OTC Health Solutions app to access OTCHS benefits
Download the app from either the App Store (for apple devices) or from Google Play (for Android devices). Look below for three easy steps to use the app in stores.
- Scan the item’s barcode to make sure it is an approved item (eligible items should have a blue tag).
- When you are ready to check out, show the cashier the digital barcode from your phone.
- Use the app to check on your remaining benefit balance or get answers to some FAQs.
Order items online
Create an account by visiting CVS.com/otchs/myorder.
- Click on the create account button and follow the prompts. Please note: you will need your member ID, birthdate, zip code and a valid email address.
- Sign into your account and view your available benefit amount as well as products.
- Add products to your cart and then click checkout. Confirm your shipping address, review your items and place your order.
- You will receive an email with tracking information. Items will arrive in about 14 days.
Order items over the phone
- To place an order, call 1-833-331-1573 (TTY:711).
- You must enter your birthdate to verify your account. You will also need to verify your name and address.
- Please have the code for the items you wish to order. If the code is A10, just enter the numerical code 10. After your items is located in the system, you verify it is correct.
- Once you finish your order, you can review items and submit the order.
The second catalog is for Aetna DSNP plan members:
Download the Aetna DSNP OTC catalog 2024 Nations benefits
The catalog for DSNP members is referred to as Nations Benefits. There are 3 ways to order items from the Nations Benefits catalog,
order by mail
Members receive an order form in their Nations Benefits catalog. Fill out the form provided and mail it to: NationsBenefits, 100 N. University Drive, Plantation, FL 33322.
Order online
Go to Aetna.NationsBenefits.com
- create an account by following the instructions on the page.
- Once you are logged in, you can search for items, read product descriptions and check your benefit balance.
- Place items in your cart.
- You will receive an email so you can track your items. You should receive your order in about 14 days.
Order by phone
Call 1-877-204-1817 (TTY: 711). Speak with a member experience advisor from 8AM – 8PM, local time 7 days a week, except for holidays.
Please note: Language support is available if needed.
All beneficiaries should be aware:
Because of the personal nature of the items, there are no returns or exchanges. Please call OTC health solutions within 30 days of receipt if you receive a damaged item.