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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

1. The Medicare prescription payment plan will deduct the out-of-pocket amount beneficiaries have already paid before enrollment in the program.
2. 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.

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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

1. OTC benefit details.
2. Details of all the different ways to shop for OTC items.
3. 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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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.

Need a SOA – Click here

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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Medicare Part D cap

Although Medicare Part D provides catastrophic coverage for high out-of-pocket prescription prices, there is no limit on the total amount beneficiaries pay out-of-pocket annually.  Beneficiaries with high drug costs exceeding the catastrophic level are required to pay 5% of their total drug costs unless they qualify for LIS.  The Inflation Reduction Act 2022 addresses the high cost of prescription drugs for Medicare beneficiaries.  The inflation reduction will reduce the out-of-pocket cost beneficiaries pay for medications and reduce federal government spending.  Some of these cost saving measures include changes to the benefits provided by Medicare Part D. This includes a Part D cap on out-of-pocket prescription costs for Medicare Part D plan enrollees.

The Part D cap makes both PDP plan providers and drug companies pay more of the costs associated with expensive drugs.  Some of this cost usually falls on the beneficiary and the federal government.

Watch a quick video on our YouTube channel about the Part D drug cap

Changes to Medicare prescription drug plans coming in 2024

In order to better understand the changes coming for 2024, we will quickly explain the 4 phases of prescription drug coverage as they are in 2023.

1. Deductible phase – beneficiaries pay 100% of their drug costs.  In 2023 the highest deductible amount is $505, although some plans do not charge a deductible.
2. Initial coverage phase – beneficiaries pay a co-insurance rate of 25% of their prescription costs and their Part D plan pays 75%.  This phase lasts until the costs reach $4,660 in 2023.  Many PDP plans charge co-payments and co-insurance in this phase instead of the standard 25% co-insurance rate.
3. Coverage gap (donut hole) phase – beneficiaries pay 25% of the prescription cost for all covered drugs both generic and name brand.  The PDP plan pays the remaining 75% for generic prescriptions and 5% for name brand drugs while drug manufacturers give beneficiaries a 70% discount for these drugs.
4. Catastrophic phase – In 2023 the catastrophic threshold is $7,400.  Once the threshold is reached, Medicare pays 80% of the drug cost while the PDP plan pays 15% and the beneficiary pays the remaining 5%.

The beneficiary’s costs in the catastrophic phase will change in 2024

In 2024 the 5% coinsurance payment for beneficiaries will be eliminated.  The PDP plans will pay 20% of the drug costs in this phase instead of the 15% they paid in previous years.  The catastrophic threshold in 2024 will be $8,000. The threshold limit includes the amount beneficiaries spend as well as the value of the manufacturers discount on prescriptions in the coverage gap phase.

In other words, there will be a spending cap for beneficiaries who take name brand drugs of about $3,2500 in 2024.  In 2025, there will be a hard cap of $2,000 on out-of- pocket costs for prescriptions.

Beneficiaries can save thousands on expensive medications

Beneficiaries who currently need expensive lifesaving medications to treat serious illnesses can now concentrate on recovering instead of worrying about how to pay the high cost of their medications.

The elimination of the 5% coinsurance spent in the catastrophic phase of Part D coverage will save enrollees thousands of dollars.

Please note:  this program benefits those enrollees who do not receive LIS for the cost of prescription medications.

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Medicare enrollment periods

In order for agents to sell Medicare plans, one of the first things they need to understand are the Medicare enrollment periods.  There are many different enrollment periods available to beneficiaries. Each one depends on their personal circumstances.

If a beneficiary already receives Social Security benefits, they will automatically be enrolled in Original Medicare.  In other words, they do not need to sing themselves up for Medicare Part A or Part B.  Beneficiaries who do not qualify for automatic enrollment should enroll during the Initial enrollment period.

There are three enrollment periods available for Original Medicare

1. The first and most commonly used is the IEP or initial enrollment period.
2. Second is the AEP or annual enrollment period which can be used for a number of different reasons.
3. Third is the GEP or general election period that beneficiaries use to enroll in Original Medicare if they missed their IEP for some reason.

Medicare IEP (Initial Enrollment Period)

The Medicare IEP (Initial Enrollment Period) is a seven-month window available to beneficiaries to enroll in Medicare Part A & Part B.  The IEP is based on either your 65th birthday or once a qualified beneficiary receives their 24th Social Security disability payment. This enrollment period starts 3 months before the qualifying event and continues through the month of the event.  The IEP ends 3 months after the month of the qualifying event.  If the beneficiary’s birthday falls on the first of the month, The IEP begins 4 months before the 65th birthday of the beneficiary and ends 2 months after the beneficiary’s birth month.

Coverage for beneficiaries who enroll in the months before their birthday begins the first day of their birth month.  If they enroll either during or after their birth month, coverage begins the first day of the month after they enroll.

During the IEP, beneficiaries can choose to either enroll in both parts of Original Medicare or they may choose to delay enrollment in Part B if they have other credible coverage such as from their own or a spouse’s employment.

Medicare AEP (Annual Enrollment Period)

The AEP starts each year on October 15 and runs until December 7.  AEP is an opportunity for anyone on Medicare to make changes to their Part C or Part D coverage.  Please note: changes made during this enrollment period will go into effect January 1 of the following year.

Click here to learn more about the AEP

Medicare GEP (General Enrollment Period)

If a beneficiary neglects to enroll during their IEP and does not have other credible coverage, they may need to use the GEP to enroll in Medicare.  The GEP starts January 1 and runs through March 31 each year. During the GEP, coverage begins the first day of the month after you enroll.  Beneficiaries who enroll during the GEP may have to pay a late enrollment penalty depending how long they have gone without credible coverage.

Other Enrollment Periods

There are still more enrollment periods available.  There are the Medicare Advantage Open Enrollment Period as well as the Medicare Supplement Open Enrollment Period. Each if these enrollment periods apply to the specified type of coverage.  Although some individuals qualify for one of the many SEPs (Special Enrollment Periods).

Medicare Supplement Open Enrollment Period

The Medicare Supplement Open Enrollment Period starts the day their Medicare Part B is effective and runs for 6 months. This enrollment period gives beneficiaries guaranteed issue right to enroll in any Medigap plan available to them. Several supplement carriers let beneficiaries apply for a plan up to 6 months before their Part B start date.  The supplement will not start until the day Part B benefits are in place.  If the beneficiary misses their Medicare supplement open enrollment period, they can apply for a Medicare supplement plan any time of year.  Keep in mind, they may have to go through underwriting and can be denied coverage.

Medicare Advantage Open Enrollment Period

When a beneficiary first enrolls in Medicare Part A and Part B during their IEP, they are eligible to enroll in a Medicare Advantage plan.  If they do not choose to enroll at that time, they have to wait until the AEP (Annual Enrollment Period) unless they have an SEP available to them.

There is a specific Medicare Advantage Open Enrollment Period available to those who are already enrolled in a Medicare Advantage change their coverage.  This enrollment period runs from January 1 through March 31 each year.

To learn more about the Medicare Advantage OEP, click here

Special Enrollment Periods for Medicare

The most difficult to understand enrollment period may be the Special Enrollment Period. This enrollment period can apply to several different circumstances and does not apply to all Medicare beneficiaries. SEPs may require the beneficiary to provide proof of eligibility.

The most common reason for enrolling during an SEP is loss of employer coverage due to the fact that many benficiares choose not to enroll in Medicare PArt B because they have employer coverage.

Find out the rules for SEPs

Ready to contract with Crowe – click here

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What’s the Medicare GEP

Please note:

Those who did not enroll in Medicare Part B because they had insurance coverage through theirs or a spouse’s employment, do not pay an LEP.  There is also no penalty for beneficiaries who qualify for an MSP (Medicare Savings Program).

Before 2023, no matter what date beneficiaries enrolled in Medicare during the GEP, their coverage would start July 1.  Since the CMS rule change that began is 2023, there are no longer delays in Medicare effective dates for beneficiaries who enroll during the GEP.  In other words, coverage begins the first day of the month following the enrollment.

Our YouTube channel has many important guidelines and updated rules for Medicare sales – subscribe to our channel and take a look.

Why contract with multiple Medicare carriers

If you are just getting started in Medicare sales it can be overwhelming.  I am sure there are many questions you have including why contract with multiple Medicare carriers. In this post we will provide an answer to that question.

As a Medicare agent, the main reason you chose this business should be to provide the best possible advice to individuals who are looking for Medicare coverage.  In order to do that, you need access to the best options for each individual.  In other words, you need to be able to offer plans from multiple Medicare carriers.

Avoid rapid disenrollment – learn more

Beneficiaries can compare several plans

Providing beneficiaries the ability to compare the benefits of several plans lets them make a well-informed decision on their coverage. Many clients like to see as many options as possible.  If you can provide information on many plans, they know you are giving them the best choices available, and they can feel more confident in their choice.  There is no need to go to other agents to view other options. Contracting with several carriers gives you a broader knowledge of the Medicare market and that is good for both you and your clients. A diverse portfolio ensures potential clients you will truly find the best plan for their personal needs.

Agents who contract with only one carrier, leave clients wondering what else is available and are they getting the best coverage. In this instance, clients do not have all the information available to get the best coverage.

Click here to learn about our quoting tools Sunfire and Connecture – watch a quick YouTube video

Plan pricing

One important factor for Beneficiaries is the cost of the plan they chose.  When you have many options available, it is far more likely to find a plan that offers the desired coverage at an affordable price.  This provides your clients a chance to find the plan that does not stretch the budget too thin once you inform them of all the costs associated with each plan and available benefits.

 Build your book

Medicare beneficiaries need an agent they trust who provides knowledge as well as the best plan options.  If your clients know you are available to address any concerns they have and you offer several great plan choices, they will tell their friends and family. Many Medicare beneficiaries are overwhelmed with information; bombarded by phone calls and mail.  If they have an actual person they can trust for sound advice, beneficiaries appreciate this. If your clients know you available to address any concerns they have and offer several great plan choices, they will tell their friends and family.  This is a fantastic and free way to generate new leads.  A good agent is a valuable asset and provides beneficiaries with peace of mind.

Learn how to make a business plan for you Medicare business

More opportunity to earn commission

Any agent who does not offer multiple carriers is leaving money on the table.  Our job as agents is to provide the coverage beneficiaries want.  If you offer only 1 or 2 carriers, you are letting many opportunities slip through your fingers.   Beneficiaries are presented with multiple plan choices every day and they know what benefits they want.  They also know what they can afford.  You need to be prepared to find them what they are looking for or someone else will.

Watch our YouTube video on how to choose Medicare carriers to contract with

Find out what a good FMO offers 

Medicare Savings Plan CT 2024

The Medicare savings plan CT 2024 could make a big difference in the lives of many people struggling to pay their health care costs.

Connecticut provides financial assistance to eligible Medicare enrollees through Medicare Savings Programs.

Qualified beneficiaries receive help through one of three available Medicare Savings Programs.  qualification for each level depends on your income. If you qualify for any of the three levels, DSS will pay your monthly Medicare Part B premium. In some cases, enrollees receive help paying both Medicare deductibles and co-insurance. Medicaid funds the MSP program in CT.

The three levels of Medicare Savings Plan help

Each level of extra help is decided by your gross income.  If you are married, your spouse’s income is included. Every level of the MSP program pays for your Part B premium.  The monthly income limits are effective from March 1, 2023, until February 29, 2024.  After that date, the new income limits take effect.  When CT releases the new amounts, will add them in.

QMB – This level of help pays your Part B premium.  Part B covers doctor visits, some preventative care and outpatient hospital services.  QMB also covers your Medicare deductibles.  The deductible is how much you pay before your Medicare insurance starts to pay. QMB benefits also cover Co-insurance payments. Co-insurance is the part of Medicare approved services that beneficiaries are responsible for paying.

The QMB is the only level of the Medicare Savings Program that acts like a Medicare Supplemental or Medigap plan.  It will cover the costs of the deductibles or co-pays of Medicare Part A and Medicare Part B up to the Medicaid approved rate.  It will also pay the premium for Medicare Part A for qualified adults 65 years of age or older when they are not eligible for premium free Medicare due to work earnings.  You are protected by federal law from being “balanced billed” or billed for services after Medicare Part A and B pays its portion of the bill, if a provider agrees to treat you, whether or not the provider is a Medicaid provider.

SLMB – This level of extra help pays your Part B premium only.

ALMB – This level of extra help also provides payment for your Part B premium only. Help on this level is available on a first come first served basis as it is subject to available funding.   Beneficiaries who receive Medicaid are not eligible for this program.

Click here to download a quick benefits guide.

Every level of MSP automatically enrolls you into LIS (Low Income Subsidy) also referred to as Extra Help.  Extra Help either pays the entire cost of a benchmark Medicare Part D plan, or part of a non-benchmark plan.  It also covers the annual deductible, co-insurance and co-pays. Extra Help coverage stays the same even in the coverage gap (donut hole). Beneficiaries who receive the LIS also have additional SEPs to change Medicare Part D or Medicare Advantage plans if they want to.

How to Apply for MSP

You can apply for these benefits online, through the mail or by brining your application to a local DSS office. If you need help completing the application, you can authorize someone to do the application for you.

 Click here for a list of local offices.

To apply for benefits online, go to www.connect.ct.gov, look for the ‘Apply for Benefits” and go from there.  To apply for MSP only, complete the Medicare Savings Programs application/redetermination form below:

Medicare Savings Program Application (W-1QMB)

Formulario de Renovación de programas de ahorro de Medicare (W-1QMBS)

Click here to learn about Medicaid redetermination

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Medicare commission chargebacks

Medicare commission chargebacks are just a normal part of Medicare sales. If you plan ahead, you can avoid chargebacks turning into a bigger problem.

What is a Chargeback

In Medicare sales, a chargeback is when a portion of an agent’s commission for a sale is lost.  This happens when a client’s policy is terminated early.  This happens when a client either cancels their plan or passes away.  When this happens, the agent must pay back a portion of the commission they received previously.

Many Medicare agents choose to receive commission advances.  This means the carrier pays several months of commissions on the sale of a policy up front, before the client pays the premium payments.  This is great because you do not have to wait to get the payment, however this is also a potential problem if your client cancels their policy, and you incur a debt to the insurance carrier.

Please note: every insurance carrier has their own payment schedule and chargeback rules.

Be prepared for chargebacks

Because there are things you cannot predict, clients pass away or change their mind on their coverage choice, you need to be prepared for at least a few chargebacks each year. It is a good idea to have money set aside for such situations.

Pay Your Medicare commission chargebacks

This is a no brainer.  If you have a bill, you need to pay it.  If you neglect to pay it, you may have a Vector hit against you.  This is a service insurance companies use to report unpaid debts. This will harm your credit score as well as you chance to sell products with some carriers.  Some carriers will not contract brokers with a Vector hit until they pay their debt.

Agents can pay some chargebacks out of the commission the insurance company owes you.  If you do not have enough commission coming in to pay the debt, some carriers will allow you to set up a payment plan to clear the debit.

AEP Enrollments can lead to MA OEP Disenrollments

When enrollments occur during AEP (Oct 15 through Dec 7), agents receive half the commission for each sale in Jan and the other half in Feb.  Because full MA/MAPD compensation is only paid out once on each enrollee, agents receive renewal commission rates for each beneficiary who enrolls in a plan.  Agents receive full commission only if the beneficiary is a first-time MA/MAPD plan enrollee.

When your client decides to either move or drop their MA/MAPD plan during the OEP (Jan 1 through Mar 31), the agent receives a chargeback. Because another agent could talk your client into a plan change during the MA OEP, you may receive a chargeback.

Click here to find out about the MAPD commissions 2024

Medicare commission Chargebacks for Medicare Supplement sales

Luckily chargebacks for Medicare Supplements are a less common occurrence. Usually, carriers pay Medicare Supplement commissions as earned.  In other words, your client pays their monthly premium, then you receive commission.

In some cases, agents have the opportunity to receive advanced commission which are normally 3, 6 or even 12 months ahead of schedule. Because many carriers charge a nominal fee for advancing commissions, most agents opt for commission payments on an as-earned basis.  If you do get a chargeback for a Medicare Supplement sale, the amount is usually not very large.

Communicate with your clients – avoid Medicare commission chargebacks

It is extremely important to stay in contact with your clients.  If they know you are available to answer questions as a trusted and valuable resource, they will call you if they are thinking about a plan change.  This may help prevent them from seeking advice from another agent who may contact them.  If your clients change plans during AEP, it may be good advice to check to see if they are happy with the new plan after words.  If they are not, you will be able to enroll them in another plan instead of them going to another agent.

There is no way to predict losing a client due to death or other unforeseen reasons.  The best thing to do is let clients know you are available even when they are unhappy.  Remember to prepare ahead for a few chargebacks.

Learn a few Medicare sales tips

Watch free Medicare agent training videos on our YouTube channel