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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.

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.

1. In store
2. Online through the member portal
3. 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.

1. Shop for healthy foods in store
2. Choose from the items online through the member account,
3. 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.

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.

1. In one of the thousands of participating stores.
2. They can also choose to shop online through the member portal.
3. 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:

1. Members can shop in-store
2. Online through the member portal
3. 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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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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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.

1. 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.
2. 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.
3. 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.

1.  Scan the item’s barcode to make sure it is an approved item (eligible items should have a blue tag).
2. When you are ready to check out, show the cashier the digital barcode from your phone.
3. 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.

1. 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.
2. Sign into your account and view your available benefit amount as well as products.
3. Add products to your cart and then click checkout.  Confirm your shipping address, review your items and place your order.
4. You will receive an email with tracking information.  Items will arrive in about 14 days.

Order items over the phone

1. To place an order, call 1-833-331-1573 (TTY:711).
2.   You must enter your birthdate to verify your account.  You will also need to verify your name and address.
3. 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.
4. 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

1. create an account by following the instructions on the page.
2. Once you are logged in, you can search for items, read product descriptions and check your benefit balance.
3. Place items in your cart.
4. 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.

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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

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What is a DSNP

If you are an insurance agent or you have seen some of the Medicare commercials on tv, you have probably heard about dual eligible special needs plans or DSNPs.  This might make you wonder, what is a DSNP.

DSNPs are Medicare Advantage plans that provide specialized healthcare benefits to qualified individuals who have both Medicare and Medicaid benefits.

Why are DSNP plans a good choice

For many beneficiaries who qualify for dual-eligible healthcare benefits, it may be difficult to coordinate their health care benefits between Medicare and Medicaid. That is why the DSNP (special needs plans) area a good choice.  These plans provide members with an easy way to manage their healthcare coverage with the use of 1 plan as opposed to multiple plans and ID cards.

DSNP plans all include prescription drug coverage as well as some of the benefits in listed below.

Please note: each plan provides its own list of benefits.  To view a full list of benefits for a particular plan, check the Summary of benefits or evidence of coverage.

1. $0 plan premiums
2. Coordination of healthcare services
3. Dental benefits
4.  Hearing benefits
5.  Hearing benefits
6.  An allowance for OTC items
7.  Free transportation to and from doctor’s visits
8.  Fitness programs
9.  Telehealth services
10.  An allowance for healthy foods or other items

Who offers DSNP plans

DSNPs are offered to qualified beneficiaries through private insurance companies. The insurance companies that offer the plans are required to include all benefits that Original Medicare covers (Part A & Part B). Each individual state controls the extra benefits that providers can offer.  These plans are not available in all states.

You can quickly find out which plans are available in each state by running a quote on Connecture or Sunfire.

Click here to watch a quick YouTube video on using Connecture and Sunfire

There are different types of DSNP plans

Each type of DSNP is based on your level of eligibility for Medicaid.  Insurnace carriers offer a limited choice of DSNP plans based on the service area.  The level are as follows:

1. All-Dual
2. Full-Benefit
3. Medicare Zero Cost Sharing
4. Dula Eligible Subset
5. Dual Eligible Subset Medicare Zero Cost Sharing

Who is eligible for a DSNP plan

Beneficiaries may be eligible for a DSNP plan if they have dual coverage from both Medicare and Medicaid. In order to qualify for Medicare benefits you must:

1. Either be a US citizen or a legal resident for a minimum of 5 years.
2. Be 65 years old or have a qualifying disability if you are under 65 years old.
3. To qualify for free Medicare Part A, you need to have worked at a Social Security qualified job for at least 40 quarters (10 years).

In order to receive Medicaid benefits, you must:

1. Be a US citizen or meet other immigration requirements and reside in the state in which you qualify.
2. Have a valid Social Security number.
3. You must either be 65 or older or have a permanent disability as defined by the Social Security administration.
4. Have an income level that does not exceed your state’s income threshold.

Find out if you qualify for state Medicaid benefits

As a licensed insurance agent, you can help sort out all the plan choices as well as the additional benefits each plan offers so your clients feel confident in their plan choice.

Learn the difference between Medicare and Medicaid

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Common Medicare terminology

If you are getting started in Medicare sales, there are plenty of terms that can be confusing. This list of common Medicare terminology can help you moving forward with your Medicare sales career.

Ancillary products 

These are plans are offered by private insurance companies outside of Original Medicare or Medicare Advantage.   Some examples of Ancillary plans include life insurance, LTC policies, stand-alone dental or vision as well as many other stand-alone insurance products.

Annual Enrollment Period (AEP)  

During this time from October 15 through December 7 each year eligible beneficiaries can either enroll in or change their current Medicare coverage.

ANOC (Annual Notice of Change) 

Each year beneficiaries receive a letter from the plan they are enrolled in.  This letter explains any changes that the plan will have in January when the plan year begins. It lets beneficiaries know about cost and benefit changes. This letter arrives each fall so beneficiaries can decide if they want to change plans during the Annual Enrollment Period that starts in October.

Coinsurance 

This is the amount, usually a fixed percentage, the insured must pay toward a covered claim after the deductible is satisfied.

Co-payment 

The set fee a plan charges the insured at the time of each doctors visit or when you purchase prescription medication or other medical service.

CSNP (Chronic Condition Special Needs Plan)  

A type of Medicare Advantage plan for beneficiaries with specific chronic conditions such as end stage renal disease (ESRD).

Deductible 

The pre-determined amount you have to pay before your insurance coverage begins to pay for covered services.

Donut Hole aka the coverage gap 

This refers to a gap in your Medicare Part D prescription drug benefit.  This occurs when your prescription drug expenses exceed the initial coverage limit of your plan but have not yet reached the catastrophic coverage level.

Dual eligible Special Needs Plan (DSNP)

DSNPs are specialized Medicare Advantage plans that provide healthcare benefits to beneficiaries who have both Medicare and Medicaid.

Durable Medical Equipment (DME)  

DME refers to medically necessary, prescription healthcare devices that Medicare Part B usually covers. This includes things like wheelchairs, infusion pumps and blood sugar monitors, to name a few.

Extra Help (LIS, Low-Income Subsidies) 

These terms refer to a program that helps eligible Medicare beneficiaries with limited income pay for prescription drug coverage.

Formulary 

The list of drugs that each Medicare plan covers.  Each plan separates the drugs on the formulary by tier the tier corresponds to the price the plan member pays.

General Enrollment Period (GEP) 

Eligible beneficiaries who miss their Initial Enrollment Period, can use this time to sign up for Medicate.  The GEP runs from January 1 through March 31 and is only available to first-time Medicare enrollees.

HMO (Health Maintenance Organization) 

A type of Medicare Advantage plan that requires the selection of a primary care physician.  Your PCP will coordinate your care and needs to provide a referral if you need to see a specialist.

Hospice  

This is a type of healthcare for terminally ill patients that provides pain management, counseling, hospital care, and more. Coverage for hospice is included in Part B of Medicare.

Initial Enrollment Period (IEP) 

The time when eligible beneficiaries can first sign up for Medicare coverage. It begins three months before your 65th birthday and ends three months after. This is the time that most people enroll in Medicare.

In-network 

When a provider (doctor, hospital, pharmacy, etc.) is in-network, they accept your Medicare plan.  Beneficiaries who use in network providers are covered under their plan when you use in-network providers.

ISNP (Institutionalized Special Needs Plan)  

A type of Medicare Advantage plan for people living in nursing home institutions.

Medicare Advantage (Medicare Part C, MA/MAPD) 

A Medicare plan offered by private insurance companies.  These plans cover everything that Original Medicare covers as well additional benefits like prescription drugs, dental, vision, fitness, etc.  When they are called MAPDs they refer to Medicare Advantage plans that include prescription drug coverage.

Medicare Savings Programs (MSP) 

MSPs are Medicaid-run programs.  These programs help cover Medicare premiums and other cost-sharing expenses for people with low incomes. Eligible Medicare beneficiaries receive help with premiums, copayments, and deductibles.

Medicare Supplements 

A separate, private insurance plan that helps pay deductibles, and copayments for Medicare covered medical services.  These plans work with Original Medicare.

Open Enrollment Period (OEP) 

This enrollment period is available only to Medicare Advantage plan enrollees. It runs from January 1 through March 31. Enrollees can use it to switch between Medicare Advantage plans or to go back to Original Medicare and a PDP plan.

Out-Of-Pocket Limit (MOOP)

Many Medicare plans place a maximum dollar amount beneficiaries can spend out of pocket on their healthcare costs each year. Once they surpass the out-of-pocket limit, Medicare-covered services are 100% covered.

PDP (Part D)

PDP plans provide coverage for prescription drugs and are offered by private companies.

PPO (Preferred Provider Organization)

A type of Medicare plan that provides care through a specific network of medical providers and facilities.  Plan members can seek care outside the network, although it will usually cost more.  In most cases, PPO plans don’t require referrals to see a specialist.

Special Enrollment Period (SEP)

Eligible Medicare beneficiaries with special circumstances are entitled to enroll in Medicare plans outside of the traditional enrollment periods.

TRICARE

This is a healthcare benefit for both active duty and retired service members as well as their families.

Take a look at some of our free agent training videos on YouTube

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Medicare fact finder

Each time a Medicare agent meets a new client a Medicare fact finder is a great way to address what they want and what they need.  This is a great tool to help you make personalized suggestions for coverage.

If you are in the senior market, your fact finder should focus on Medicare coverage.  It may also include additional options like hospital indemnity, life products or other relevant products you offer. You should design your fact finder to fit your client’s needs and the services that you have to offer.  The only way to know what the client is looking for is to ask questions.

We have a few examples of Medicare fact finder questions below:

1. Do you understand the different parts of Medicare

This question is very important to ask.  Clients need to understand the parts of Medicare and how they work to know what type of coverage they want and need.  Your job is to make sure they know about all the coverage options available and make an informed decision.  This includes what is covered by Part A, Part B, Part C and Part D.

2. Can you tell me what you like and don’t like about your current Medicare coverage

When you ask this question as part of your fact finder, you gain valuable insight into what type of coverage the client is looking for.  This will help sort out which benefits are important to them, and which are not. This can be very useful in sorting out MA/MAPD plan benefits as there are so many to choose from and they offer different benefit packages.

3. How often do you see a doctor or specialist

The answer to this question can help decide if a Medicare Supplement or a Medicare Advantage plan is a better option for your client. That is a reason to include it in your Medicare fact finder.  Many of your clients’ plan choices will come down to simple mathematics.  Medicare Advantage plans require a copayment for visits to either PCPs or specialists.  The amount of each copay can make a difference in your client’s budget.

4. Are there doctors and medical facilities that you like to use for your health care needs

If a client uses medical care from several providers on a regular basis, they may have a difficult time finding a Medicare Advantage Plan that all their chosen providers participate with.  It is your job to be sure they can continue to use the providers they want and are aware of the cost for each visit.  In some cases, an MAPD plan may not be the best option for the client.

5.  Find out if the client is currently taking any prescription medications and which pharmacy they like to use

Please be aware, it is up to the client if they want to disclose this information.  However, it is important to help them find the best coverage options for their needs and can be very costly if they make an ill-informed decision.   Each MAPD and PDP plan has a specific formulary.  This means they cover each medication differently. There can be very large differences in the cost for prescriptions that may place a burden on your clients when they are trying to maintain their health.

The cost of each prescription also depends on the pharmacy your client chooses to use.  This must be explained to them as well.  Carriers for Part D coverage often have preferred network pharmacies that can save the client money when they fill prescriptions there.

6. Does your client have any chronic health conditions

There are specific Medicare Advantage plans that provide coverage of certain chronic health conditions, such as ESRD.  Although they cannot enroll in most Medicare Advantage plans, these SNP plans cover their specific needs, and they cannot be denied coverage for pre-existing conditions.

7. Do they travel often or have a home in another state

This may be an important question to include in you Medicare fact finder.  Medicare supplement plans are good in any doctor’s office or facility that accepts Medicare assignment. On the other hand, Medicare Advantage plans have a local provider network and clients may not find an in-network provider when they spend months living out of their home state.  This can end up costing quite a bit out of pocket for care. It is important to check the benefits of each plan for travel and residency coverage.

8. Are they covered through a former employer or other organization

In some cases, client have retiree plans that work with Medicare to provide coverage for health care needs.  If this is the case, the client should check with their company’s benefits coordinator to see how a Medicare plan affects their retiree coverage and how they work together.

These are just a few possible questions to use.  It is important to decide which questions to add or subtract based on your personal preferences.

A few more thoughts

Let your client know what you are doing and why.  This will help them understand that you see each client as an individual and will do your best to fill their personal health coverage needs. It is best to finish the questions and go over the answers before you try and make any sales presentation to the client.  Making the suggestions at the end will let the client know you are listening to every answer and using all the information to make the most informed suggestions.

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