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CMS proposed rule 2024

Because there are many rules and proposals we will clarify, this post explains the CMS proposed rule 2024 (CMS-4205-p).  This rule was proposed in early November 2023.

Some of the changes included in this proposal

Agent compensation adjustment

CMS is proposing putting a maximum allowable commission in place for all agents.  This amount will be based on national level of $611 for new Medicare Advantage enrollments and $306 for renewals of Medicare Advantage plans.

In some states the proposed amount is lower than the commissions agents are currently earning.  both CA and NJ, have current commission levels for new Medicare Advantage enrollments of $762.  In CA and NJ the renewal commissions are $381 annually.  The states of CT, PA & DC Medicare Advantage commissions rates for new enrollees is $689 and $345 for renewals.  The wording on this part is a little tricky so we are not sure if the commission rate would all remain as it is or if it will all be one standard amount no matter which state you sell in.

Learn about Medicare commissions 2024

CMS has also proposed the  addition of a $31 admin fee for each application.  This may seem like a good thing, but it is not nearly enough to replace the overrides and other monies they propose to eliminate.

Overrides and Admin fees

If CMS passes the proposed rule as it is written, it will have a much bigger impact on uplines than it will on individual agents.

The proposal includes the elimination of all administration fees as well as overrides at all levels (GA, MGA, SGA, FMO & NMO).  This means agencies at any level that have direct pay agents would lose all revenue eared through overrides.  That part of the proposal would essentially end the direct pay agency model.

Click here to learn about pro-rated Medicare commissions

How this effects agents

Agents would lose access to all the services provided by their uplines.  Some of what they stand to lose are:

1. Assistance with contracting.  Uplines make the contracting process much easier by providing a much more streamlined option to agents.  Some carriers currently do not contract directly with agents at all.
2. Connecture and Sunfire or any upline provided quoting and enrollment tools that their upline currently provides.
3. Education and training.  This is an important one.  A good upline provides agents with many different training options that can include in-person, telephonic or training through teams or zoom calls. Just to mention a few.  These trainings include updated CMS compliance information, carrier specific products or assistance with basic knowledge or sales practices.
4. Back office support, the back office provides agents with a myriad of answers to their questions as well as training to use enrollment portals or help processing applications as well as various other assistance.
5. Marketing reimbursements; these are a great help to agents, especially when they are trying to get up and running.

These are just a few examples of what an upline provides it’s downline agents.  The list may vary depending on the upline you are currently working with.

Click here to see the programs that Crowe has to offer

More of what CMS proposes to eliminate

CMS wants to eliminate all marketing money.  This includes marketing money from carriers weather it goes toward expenses or lead costs.  Reimbursement of expenses will not be permitted at any level.  This will effect; agents, agencies, FMOs and even NMOs.

They want to stop all payments agents receive for helping clients complete HRAs.

Take a look at a our YouTube video on this topic

Would any agency survive this

The proposal would not eliminate all agency models.  If the agency is LOA, they may be able to survive if they offer agents a lower commission rate and operate on a much smaller budget.  An agency that sells a large volume of ancillary products  such as; cancer, critical illness, life or annuities, may also remain viable.

If the main revenue source of the agency/FMO comes from the sale products such as  annuities, life P&C or other products and does not rely on Medicare sales, they could stay afloat.  Any business that uses Medicare sales as a secondary income source may suffer a loss but could still remain profitable.

Visit out Events and information page to see upcoming webinars or other informative information

When will this go into effect

Although the final draft of the proposal may be decided in January, the timeline of when we will know what it actually says may not be until the spring.  CMS was receiving comments on the proposal until Jan 5, 2024.  That window is now closed.  NABIP(a huge advocate for agents/agencies) was also collecting a 5 question survey on this proposal in an effort to get our voices heard.

If the current version of the rule remains as is, it will create a substantial impact in the entire industry.  It will effect everyone from NMOs to the clients.

To view the proposal in it’s entirety, go to  www.regulations.gov

You can download the entire 486 page document .  The pages that pertain to Medicare agents are 6, 236-248.  There you will be able to view the specifics on the agent compensation changes.

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Clover Health OTC catalog 2024

The Clover Health OTC catalog 2024 provides members with numerous choices to help them get the most out of their OTC benefit.  Members of Clover Health MAPD plans have the added benefit of the LiveHealthy Rewards Program.

To get started with your Clover benefits, just go to the clover member site and register for your My Clover account.  From there, you can check your reward status as well as your OTC benefit balance, shop online or find a local, participating store and much more.  Clover plan members can access both their OTC and LiveHealthy rewards benefits with their LiveHealthy Flex Plus card.

Agents, watch a quick YouTube video on how to choose carriers to contract with.

OTC catalog benefits:

Clover provides all MAPD plan members with a quarterly OTC benefit allowance of between $30 and $75 (amount depends on the plan benefit).  At the beginning of each quarter, OTC and LiveHealthy rewards dollars are loaded onto the Live Healthy Flex Plus card automatically.

OTC Benefit amounts do not roll over to the next quarter. Plan members must use the benefits before the end of each quarter.  Cards are only valid at participating merchants for approved items.

To download o copy of the OTC catalog and how to use this benefit, Click here

Download the Clover OTC benefit and live healthy rewards guide

Existing Clover members:

Existing plan members will not receive a new LiveHealthy Visa Flex Plus card.  Their current card will have OTC as well as LiveHealthy rewards loaded onto it.  Any unused Livehealthy dollars roll over from 2023 to 2024.

If you need a replacement card, you can either order one online at cloverhealth.com/livehealthy or call 1-800-607-2348 (TTY711) 8:00 AM – 8:00PM, local time 7 days a week.

LiveHealthy Rewards:

Members who complete the following activities earn rewards.
1.  Earn $100 per year to complete the “Getting to Know You Survey”.  This survey is a modified health risk assessment.  Each member can complete the survey online, over the phone with member services or by filling out the paper form included in your welcome kit. Rewards are loaded onto the card 3-5 business days after survey is complete.  Rewards are not available to spend until after the plan start date.  Member may complete a survey each year to earn rewards.

Brokers please note; if you help a new member fill out the online survey within 72 hours of submitting the application earn $50.

To learn more about HRAs, click here.

2.  Members earn up to $50 annually for preventative care.  This includes $10 for receiving a flu vaccine, $20 for an A1C test and $20 for a retinal eye exam.  Clover validates completion through claim or by self-attestation for flu vaccine.  Clover loads reward dollars 3-5 business days after they receive the claim.

3.  Complete a LiveHealthy visit to earn $150 annually.  Members call the phone number on the back of the LiveHealthy Flex Plus Visa card to set up the appointment. The appointment takes place either in the office of a provider, in-home or via telehealth visit.  members are eligible to complete a Livehealthy visit each year.  Benefits are loaded onto the card within 3-5 business days after claim is received.  Please note: providers have up to 90 days to submit the claim.

4.  Get Active rewards are worth $25 per quarter ($100 per year).  Member must participate in one of the following to earn rewards:  SilverSneakers gym or class, either virtual or in-person.  Attend a Clover sponsored event or Clover poll.  Log into the Clover member portal at least 1 time per year.  Clover confirms member participation and rewards dollars are loaded 3-5 business days.

Click here to contract with Crowe and offer Clover health plans.

The difference between the OTC benefit and LiveHealthy Rewards:

OTC benefits provide plan members a monthly allowance to purchase common health care items while members earn Live Healthy rewards by completing activities that promote good health.

The annual OTC benefit amount is between $120 and $300 per year while members can earn up to $400 in Healthy rewards benefits annually.

While there are restrictions on what members can purchase with the OTC card, members can use Rewards dollars to purchase of most items with the exception of alcohol, tobacco and firearms.  Members who go over the OTC limit, can use rewards dollars to complete the purchase if they are available.  Any purchase in excess of the Rewards dollar is the responsibility of the member.

Important: Members may not use LiveHealthy Rewards dollars to purchase alcohol, tobacco products, or firearms. Rewards are not redeemable for cash.  Some other limitations apply, members should check with Clover member services for more information.

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Pro-rated Medicare commissions

Pro-rated Medicare commissions are something that all agents who offer Medicare products need to understand.  The Medicare carriers pay pro-rated commissions to make sure agents do not end up owing the carriers too many chargebacks for disenrollments.  This also protects the carriers from the chore of trying to collect unearned money from brokers who may not have it to pay back.  It is better for both parties.

Agents receive pro-rated Medicare commissions for enrolling individuals in either Medicare Advantage or Medicare prescription drug (Part D) plans.  Once an agent submits an application for a beneficiary, the agent receives commission.  The amount of commission is based on the number of months the enrollee remains active in that specific plan.

How pro-rated commissions work

Agents receive a partial commission payment for every month their client stays in the carrier’s plan. This payment system is considered more equitable than carriers paying out the full commission at once.  As we stated earlier, this avoids chargebacks for any unearned commissions.  Agents may be motivated to give clients ongoing support to ensure they do not switch plans on the advice of another broker.  On the whole, agents who are available to clients, maintain their book of business.

The way to figure out the amount of a pro-rated commission, divide the total commission for each enrollee by the number of months the member is enrolled in the plan.  Let’s say the total commission for an enrollee is $600 and they stay in the plan for 10 months; this means the agent receives $60 for each month.

Find out more about commission payments

How beneficiaries benefit from this payment structure

We cannot stress enough how important forming a good relationship with your clients is.  The pro-rated commission structure provides an incentive for agents to make the extra effort.  Having a vested interest in providing a greater standard of customer service, helps beneficiaries develop trust toward their agent.  If the agent continuously provides good advice and follow up, the client in turn provides an important service to the agent.  In most cases, happy clients tell their friends and family.  This is great benefit to the agent who receives new client recommendations and an opportunity to grow their book.

Watch a YouTube video on Medicare commissions

To Sum it up

The pro-rated Medicare commission system provides is a clear and fair way for Medicare companies to pay agents.  It helps incentivize a good agent/client relationship.  It can ensure agents provide the best plan options to their clients, so they receive coverage options that align with their healthcare needs.  This helps everyone avoid dis-enrollments.

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Devoted broker portal

The Devoted broker portal is designed to provide all the tools you need to make selling Devoted products easy.  If you’re ready to sell with Devoted, you will receive an email from Devoted with the subject line “Devoted Agent Broker Portal Log-in Details”’.  This email contains a link to use to create a password for your account, your username is your NPN.  After the agent does this, they can login to the portal by going to agent.devoted.com.

What’s in the portal

Individual agents have access to the following tools in the portal:

1.  On the Home Page agents will find their ready to sell status.  They can also access sales tools, training and educational resources.

2.  Submit your client’s applications or HRAs online while you are with them in person or when they are on the phone with you.

3.  Send a digital scope of appointment via email.

4.  Check your client’s application or enrollment status.  You can also access member IDs from here.

5.  Check your commission statements.

6.  If you want to host either a Devoted sales or educational even, just submit an event request.

 To add Devoted to your Medicare sales products, click here for an online contract

Agency administrators have access to the following tools in the portal:

1. A summary of your downline agents; this includes their NPN, ready to sell status by state as well as application activity.
2. Agencies can verify the states they are actively contracted in.
3. View monthly commission statements for payments received by your agency.

Please note: agencies have access to one admin account.  This account is limited to read only access in the agent portal.  In other words, admins cannot create or edit applications in the portal.

Manage your clients

This portal allows agents to view client information including, client name, phone number, plan, effective date, end date (if applicable), member ID and status.  There are many ways to filter and sort your view of the client lists. 

Submit an electronic SOA

Agents can submit SOAs electronically, over the phone, by paper, or through email.  Take a look at a quick video on Devoted’s  Scope of appointment tool. 

If you need a scope of appointment, click here to download one

Online enrollment

Agents can quickly enroll a client through the portal.  Just click “Start enrollment” at the top of the page. Fill out the Create Contact page, click the orange “Start Application” button to complete the application.

Host a Devoted event

Just follow these easy steps:

1.  Log into your Devoted portal and go to the “Events” tab. Choose “Submit New Event Request”.
2. Enter your event information.  Please note, agents must answer items marked with a red asterisk before they can proceed.
3. After you fill out all the information and agree to the broker event guidelines (guidelines can be found in the broker manual) be sure you save the event.
4. Once you are done, the information goes to local market contacts for review.  If there are any questions, representatives contact the agent by email.
5. Agents can easily view the status of their request in the events tab.

Learn more about how to conduct a compliant sales event

Devoted has a new feature on the portal

Agents can request help through a support ticket system.  Agents receive a response to their questions within 48 hours.  Just follow the prompts and click on the Add to submit the ticket.  It is easy to track the progress of your request in the portal.  Once the Devoted representative solves the problem, the agent receives a confirmation email.

Because there are so many things agents can access in the portal, we listed some of the highlights.

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Starting a Medicare agency

If you are a licensed Medicare agent and would like to expand your Medicare business into a Medicare agency, here are a few things to do before starting a Medicare agency.

1. File and register your LLC or Corp with the state that you plan to have your headquarters in.
2. Go to your state department of insurance to apply for the appropriate license under your LLC or Corp.
3. Purchase E&O insurance (errors & omissions) for your agency.  This protects business owners from lawsuits connected to insurance sales.
4. Choose one person to act as the principal of your agency.  This person should be listed on any state license you apply for.  Be sure the individual is licensed in any state you wish to do business in as they will be listed as principal on any license your agency applies for.
5. Check all CMS compliance laws and be sure that both your agents and agency follow all applicable rules.  The agency principal must complete AHIP annually on behalf of themself and the agency.

Click here to learn the CMS final rule for 2025

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.

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.

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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.

There are several sections on the Vantage home screen.

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.

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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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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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