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Medicare Part D 2024

In this post, we will discuss some important information about Medicare Part D 2024.

Medicare Part D plans cover the cost of prescription drugs for Medicare enrollees.  Private insurance companies offer these plans to beneficiaries.   In order to remain complaint, all plan providers must follow CMS’ rules.

Prescription plan costs

There are a few costs associated with Medicare prescription plan coverage.  One of those costs include the monthly plan premium, this amount can range greatly depending on the plan and carrier.  Beneficiaries can opt to have the premium deducted from their monthly Social Security payment.  If the beneficiary has a greater than average income, they may be subject to an IRMAA, an adjusted premium amount based on income.  The premium may also be adjusted for those who have a lower-than-average income and qualify for Extra Help.

Other costs associated with Part D prescription are co-pays and coinsurance amounts paid at the pharmacy.  Many plans also include an annual deductible.  In 2024, the maximum annual deductible has increased from $505 in 2023 to $545 for 2024.

For those who neglect to sign up for a Medicare Part D plan on time, a late enrollment penalty is added to the monthly cost.  The penalty applies to anyone who goes without creditable Part D coverage for a period of 63 or more days.  CMS applies the penalty for as long as the beneficiary has Part D coverage.

Changes for Medicare Part D for 2024 

Because of the Inflation Reduction Act that was signed into law in 2022, there will be changes to the Medicare Part D program.   One important change has to do with the cost Medicare beneficiaries pay for prescription drugs.

 Click here to learn about prescription drug caps

Here are some of the changes in place for 2024:

In 2024, Medicare PDP members who reach the catastrophic phase ($8,000 in 2024) will not pay any additional out-of-pocket costs for the remainder of the year.  This means they are no longer subject to a 5% copay.

PDP plans are no longer able to raise their premiums over 6% per year starting in 2024.

Beneficiaries who use insulin will pay no more than $35 for a 1-month supply for covered insulin brands.  It is important to check your plan’s formulary to confirm which brands they include.  This pricing is in effect until the end of 2025.

Medicare covers many adult vaccines at no cost to Medicare beneficiaries.  this includes the Shingles vaccine as well as TDAP (tetanus vaccine), Covid, flu vaccine, Hepatitis A and many others.

More Medicare beneficiaries will qualify for Extra Help to pay for their health care needs in 2024. This is because beneficiaries with an income of up to 150% of the federal poverty level (up from 135% in 2023) may be qualified for the Part D Extra Help.  This program pays the Part D annual deductible, monthly premium and ensures beneficiaries pay a lower cost for generic and brand name drugs.

A few changes to prescription drug plans in 2025 and 2026

In 2025, one of the changes to the Part D program is a $2,000 out-of-pocket maximum in place for PDP beneficiaries.  CMS is also starting a prescription payment plan program.  The program is referred to as “smoothing” and begins Jan 1, 2025.  This program gives beneficiaries an opportunity the spread out the cost of prescription medications out over the year by using a payment plan.

Click here to learn more about the prescription payment program

In 2026 price negotiations will begin for expensive drugs that have no generic alternatives.

Learn the details of the price negotiation program

To view a comprehensive guide to all the ins and outs of Medicare for 2024, click this link and  download a copy of CMS Medicare and You handbook for 2024.    Information on Medicare Part D starts around page 79.

Watch a quick YouTube video on the drug cap proposed for 2025

Take a look at some of the other compliance updates CMS has in place or has proposed for agents :

Watch a quick YouTube video on the CMS proposed rule CMS 4205-P an how this could effect our business

Find out more about the 2024 CMS call recording requirements

Make sure you are up-to-date with the SOA rules – click here and learn more

Take a look at our video on TPMO rules for 2024

If you are unsure of the differences between an educational event and a sales event, click here.  You may also want to read our blog on “Things you can’t say when selling Medicare“.

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Please note: agents who offer Medicare Part D plans need to complete annual carrier certifications as well as AHIP before they can offer the plans.  AHIP is an annual certification that CMS requires.  It includes marketing and compliance guidelines as well as FWA laws.

If you don’t follow the Medicare marketing rules, you risk losing commissions, termination of your contracts, losing your license and receiving fines.

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Medicare Final Rule 2024

Every year, the Center for Medicare and Medicaid Services (CMS) adjusts and makes amendments to the requirements and regulations that govern Medicare Advantage plans. For this coming year, 2024, there are important new requirements for third-party marketing organizations (TPMOs). Aetna, one of the primary carriers of Medicare Advantage insurance plans, sent a press release explaining the key points of the final ruling for the new marketing requirements.  What is the Medicare Final Rule 2024?

Beginning September 30, 2023

These are some of the most pertinent changes and new regulations that will govern how brokers can market Aetna Medicare Advantage plans in the coming year. The following changes will be effective on September 30 of 2023:

Third-party marketing organizations that are authorized to sell Medicare Advantage must submit their multi-plan marketing materials to the Health Plan Management System (HPMS). This happens after it has been pre-reviewed by Medicare Advantage organizations. Health Plan Management System is a website where health insurance and prescription insurance plans, plan consultants, third-party vendors (like agents), and pharmaceutical manufacturers can fulfill the compliance requirements of Medicare Advantage and Medicare Part D plans.

Superlatives (best, most, etc.) are no longer to be used in marketing communications unless certain pre-existing documentation needs are met.

Any marketing materials that use the Medicare ID card image must be approved and authorized by CMS before use.

When marketing any products, plans, costs, etc., the Medicare Advantage organization name must be visible as it is listed in the HPMS.

Plan benefits must be advertised in the area that is eligible for their services.

Marketing materials cannot compare the costs of the uninsured in order to advertise potential savings due to a Medicare Advantage plan.

In addition to these new requirements, CMS has updated the definition of marketing. This new, clarified definition broadens the content that is classified as marketing. Any type of materials that mention plan benefits is now considered marketing material.

Medicare Final Rule 2024 – Marketing Materials

In order to be in compliance with the updated regulations from CMS (the Center for Medicare and Medicaid Services), third-party marketing organizations (TPMOs) such as brokers must make sure their sales and marketing materials are in line with the following requirements:

It is always prohibited to visit a beneficiary without an appointment. This is the rule even if the beneficiary has expressed that they are interested in a Medicare Advantage insurance plan or product.

Medicare Advantage organizations need to provide customers with an annual opportunity to opt out of plan marketing calls. There will likely be further clarification on this topic from carriers such as Aetna to their third-party marketing organizations (TPMOs).

Events

If a Medicare Advantage organization is holding an educational event, they can no longer set up personal marketing appointments for the future at said educational event. The organization is also prohibited from asking beneficiaries to complete the Scope of Appointment forms at the educational event. There needs to be a sharp divide between educational and marketing events.

Marketing events and educational events must take place more than 12 hours apart in the same location. When the regulation uses the term “same location,” it means the same building or adjacent buildings.

There must be at least 48 hours between the beneficiary completing the Scope of Appointment forms and the beginning of the personal marketing appointment.

A beneficiary’s request for information is valid for 12 months from the signature. This applies to Scope of Appointment forms, business reply cards, and any other requests to receive additional information.

Before enrollment, the beneficiary must be provided with a pre-enrollment checklist (PECL). This applies to enrollments made over the telephone.

In their disclaimer, TPMOs must provide the number of plans and products they offer. Those who offer all plans and products must also provide a version of this information in their disclaimer.

Beneficiary health plan needs will be reviewed before enrollment.

TPMOs must record the entirety of all of their marketing, sales, and enrollment calls. This includes the audio of any web-based marketing calls. Other types of calls do not need to be recorded in their entirety.

As is evident by the new requirements for compliance from CMS, the industry takes the ethics of marketing and selling Medicare Advantage very seriously and will continue to adjust to a changing marketplace.

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Enhancements to Medicare Advantage for 2024

CMS is constantly looking at the regulations that govern the sale, provision, and use of Medicare and Medicaid. They examine the experiences of the insurers that are contracted by the government to provide the insurance plans.  Additionally, they examine the experiences of the beneficiaries who purchase them. Any amendments they choose to make are intended to take effect the following year. In 2023, CMS looked at the rules surrounding Medicare Advantage in particular.  What changes are planned for Medicare Advantage 2024?

CMS Final Rule

The CMS issued a final proposal on April 5th of 2023 for the enhancement of Medicare Advantage. They did not address the comments that the public had given on the proposed amendments.   However,  did say that they plan to address them at a later, more appropriate date. The amendments proposed have to do with prior authorization and how that affects beneficiaries’ access to healthcare. Previously, prior authorization meant that beneficiaries who had Medicare Advantage health insurance plans had to essentially request permission before receiving care. That indirectly means that beneficiaries could be denied care. (Traditional Medicare does not require prior authorization.) There were concerns that Medicare Advantage customers were not receiving the same quality of care as Original or Traditional Medicare beneficiaries because of these rules.

Changes to Medicare Advantage 2024

This is about to change, however, as the new rules proposed by CMS are designed to make sure that Medicare Advantage customers have the same access to necessary tests, scans, prescriptions, and procedures that their counterparts in Original Medicare to. The American Medical Association says that the new rules have, “taken important steps towards rightsizing the prior authorization process.” UnitedHealthcare, which is just one of the insurers with Medicare Advantage plans, says it plans to reduce their number of denials of care by nearly three million a year.

CMS’ new rule requires that prior authorization policies may only be used to confirm the presence of a diagnosis.  This ensures that the treatment is medically necessary. CMS is also requiring that all Medicare Advantage plans develop committees to ensure that denials and approvals are working effectively to get beneficiaries the care they need within the new guidelines. Finally, the new rules require that a prior authorization approval is effective for the entire course of treatment as long as medically reasonable and necessary to avoid disruptions in care.

All together, beneficiaries and insurers alike hope that these new regulations will help ensure that Medicare Advantage plans provide equitable access to care moving forward.

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