new medicare rules Archives

Medicare scope of appointment rules

By Ed Crowe | General Articles | 0 comment | 3 December, 2023 | 0

Medicare scope of appointment rules

The Medicare scope of appointment rules are put in place by CMS. The SOA (scope of appointment) is a form that clients or potential clients as well as their agent must complete before meeting to discuss Medicare plan options. The scope is mandatory if you are discussing either a Medicare Advantage or Part D prescription drug plan. Although, it is a good idea to collect a SOA before any client meeting to protect both the agent and the client. The SOA form should be kept no less than 10 years and may be collected either physically, verbally or electronically.

Watch a quick video on the scope of appointment rules for 2024

Verbal scope of appointment

When the pandemic began, it was not advisable to host in-person meetings to discuss coverage options. Because of this, many appointments took place over the phone. That lead to the use of verbal scope of appointments which are recorded and saved. Many carriers offer this option as well as quoting/enrollment tools such as Sunfire and Connecture.

Click here to watch a Sunfire enrollment demonstration on YouTube

General information about a verbal SOA

If the client calls the agent (inbound call), the 48-hour rule does not apply.
The scope is good for 12 months from the date it is signed. You must complete the appointment within that time or obtain a new scope. The scope is still good if the call drops and the same agent calls the client back.
If additional benefits are added to the discussion, a new scope is necessary.

How long is a SOA good for

As we mentioned above, a scope of appointment is good for 12 months from the date it is signed. It is important that you discuss only products that were agreed to and included in the scope. If additional products are added, the beneficiary needs to sign a new scope.

If the client asks about Medicare Advantage plans during the 48-hour waiting period and they had not included them on the original scope, you will need to have them sign a new scope before your discussion. This will restart the 48-hour waiting period and may move your meeting date out further. This rule applies to any product regulated by CMS.

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CMS guidelines

In order to be complaint with CMS, agents need to have their clients complete a Medicare Scope of Appointment form. The 2024 CMS final rule went into effect September 30. 2023 and has added some changes to how agents obtain the SOA.

The SOA rules apply to agents and brokers who discuss Medicare coverage options and plans. The 48-hour rule was put in place so beneficiaries could avoid the high-pressure sales tactics some agents use. The 48-hour period provides beneficiaries time to consult friends, relatives or anyone they like to research their options. This time also provides agents time to prepare for the discussion.

Agents are able to contact the beneficiary once the SOA is completed for up to 12 months. It is essentially permission to contact until the meeting takes place. The beneficiary has the option to opt out annually.

Please note, if the beneficiary does not select a coverage option on the SOA, Medicare requires the agent to avoid discussing that option without a new SOA where the option is clearly selected.

Find out about the proposed CMS rule 4205-P, see how it could affect agents!

Exceptions to the 48-hour rule

If the beneficiary is in the last four days of a valid election period, agents may collect a same-day SOA.

When the beneficiary walks into your office and initiates a conversation about coverage options, agents can take a same-day SOA. This same rule applies to inbound call initiated by the beneficiary to the agent requesting advice.

How long do you need to keep a SOA

Agents must be able to access the SOA form for ten years. Clients have the right to request a copy anytime within that time frame without any issues. The SOA can provide help in the event that an issue or dispute occurs. The Scope is in place to protect the consumer, but it can also protect the agent.

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Inflation Reduction Act and Medicare Changes

By Ed Crowe | General Articles | 0 comment | 7 August, 2023 | 0

Inflation Reduction Act and Medicare Changes

This post will go over the Inflation Reduction Act and Medicare changes. The goal of the Inflation Reduction Act is to provide some financial relief for Medicare beneficiaries by making adjustments to the Medicare program. The new prescription law improves the Medicare program by expanding benefits, lowering drug costs and keeping the drug plan premiums stable.

Inflation Reduction Act and Improvements to Medicare Part D:

Medicare beneficiaries will have access to lower prescription drug costs as well as a redesigned prescription drug program. This new program includes benefits such as:

A $35 monthly co-pay for covered insulin prescriptions.

An annual cap of $2,000 on out-of-pocket costs, starting in 2025.

No cost for recommended adult vaccines.

Starting in 2024 the LIS/Extra Help program under Part D will be expanded to include 150% of the federal poverty level.

Inflation Reduction Act and Price negotiation of Medicare prescription drugs:

This is an important change. It gives Medicare the power to negotiate the cost of prescription drugs directly with the manufacturers. This will lead to lower costs on some of the most expensive, brand-name Medicare Part B and Part D drugs. Because of this change, more people will be able to afford the life saving treatments they need.

The inflation reduction act requires drug companies that raise their prices faster than the rate of inflation to pay Medicare a rebate. Because of this, drug manufacturers will be discouraged from charging Medicare beneficiaries ridiculous price increases.

Inflation Reduction Act and Changes to Medicare Part B:

Changes in the Medicare Part B program will improve access to high quality, affordable biosimilars for people with Medicare as well as impose a $35/month cost-sharing cap on insulin used in durable medical equipment pumps.

The Inflation Reduction Act makes Medicare stronger for current and future enrollees. It makes health care more accessible, equitable, and affordable by lowering what Medicare spends for prescription drugs and limiting increases in prices.

Find the answers to some FAQs on the Medicare drug price negotiation

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Medicare Final Rule 2024

By Ed Crowe | General Articles | 0 comment | 28 June, 2023 | 0

Medicare Final Rule 2024

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

Beginning September 30, 2023

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

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

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

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

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

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

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

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

Medicare Final Rule 2024 – Marketing Materials

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

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

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

Events

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

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

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

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

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

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

Beneficiary health plan needs will be reviewed before enrollment.

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

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