Last updated October 16, 2023
When to use:
To find a relevant Medicare update as originally presented in the Medicare 2024 updates training.
Original Medicare updates:
Colorectal Cancer Screenings:
• We are still moving through the changes in Medicare’s coverage for colon cancer screening.
• Starting in 2023, the minimum age for screening dropped from 50 to 45.
• Prior to 2023, if a polyp or tissue was found during a colonoscopy, 20% Medicare coinsurance for the removal generally applied
o 2023 – 2026 coinsurance is 15%
o 2027 – 2029 coinsurance is 10%
o By 2030, no coinsurance
• Coverage timeline varies and includes services such as:
• Barium enema
• Multi-target stool DNA tests
• Flexible sigmoidoscopy
• Colonoscopy
Competitive Bidding Program for DMEPOS:
• The DMEPOS CBP has been an essential tool to help Medicare set market-based payment rates for DMEPOS items, save money for people with Medicare and taxpayers, and limit fraud, waste, and abuse in the Medicare Program.
• The current round of the durable medical equipment (DME) competitive bidding program (CBP) product categories include, Off-The-Shelf back braces and knee braces.
• CMS announced a temporary gap to the program starting January 1.
o This is a temporary gap and a timeline for restarting the CBP has not been decided.
• During this temporarily gap, CMS will:
o Complete the formal public notice and comment process.
o Implement some necessary changes.
Consolidated Appropriations Act (CAA):
• The CAA or the BENES Act, was intended to:
o Remove gaps in coverage by allowing someone who enrolled in Medicare during the General Enrollment Period (GEP) or their Initial Enrollment Period (IEP) to begin benefits the first of the following month.
o Extend coverage for immunosuppressive drugs for people eligible for Medicare because of end-stage renal disease
o Expand access to mental health services through telehealth
Enrollment timing changes
• One of the biggest and most welcome changes we saw last year was regarding the General Enrollment Period (GEP).
• Now, people who enroll during the GEP start Medicare benefits the first of the following month.
• For people who enroll during the GEP, the late enrollment penalty (LEP) calculation includes the months that elapse between the close of the individual’s IEP and the close of the month in which they enroll.
• In addition, when someone enrolls in Medicare during the last three months of their Initial Enrollment Period (IEP) their coverage will start the first of the following month.
o Prior to 2023, if someone enrolled in Medicare during the last three months of their IEP, their coverage was delayed several months.
GEP – New SEP
• Last year when changes were made to GEP, similar changes were not made to when a person could enroll in a Medicare Advantage Plan or a Medicare Part D Plan.
• In 2024, people who enroll in premium Part A and/or Part B during the GEP will now have a SEP to enroll in a Medicare Advantage Plan and/or Part D plan.
o They have two months after they enroll in Part B to join a plan.
o Coverage starts the first of the following month.
Exceptional SEP
• An SEP was added in 2023 for people who did not enroll in Medicare when they were first eligible but were impacted by circumstances beyond their control. These include people who:
o Were impacted by an emergency or disaster
o Experienced a health plan or employer error that constitutes material misrepresentation of information related to enrolling in Medicare timely.
o Were formerly incarcerated
o Are no longer eligible for Medical Assistance
o Had other exceptional circumstances beyond their control (case-by-case basis).
• People who enroll during this SEP are not subject to a late enrollment penalty (LEP).
• People calling the Senior LinkAge Line may need your help in contacting Medicare to request this SEP.
Exceptional SEP – enrolling in Part C and Part D
• Starting in 2024, people who enroll in premium Part A and/or Part B during the GEP will now have a SEP to enroll in a Medicare Advantage Plan and/or Part D plan.
o They have two months after they enroll in Part B to join a plan.
o Coverage starts the first of the following month.
Immunosuppressive drug benefit
• As a reminder, last year Medicare added a new Part B-ID benefit.
• This new benefit allows people who have a kidney transplant while on Medicare to continue coverage for immunosuppressive drugs even 36 months after a successful transplant.
• Eligible people can not enroll in any other part of Medicare
• The benefit includes:
o A monthly premium
o No other Medicare Part B benefits
o No Late Enrollment Penalty (LEP) for delaying enrollment
COVID-19 Tests and Vaccines:
• COVID-19 Tests:
o Medicare no longer covers over-the-counter tests for COVID-19.
o Medicare does cover lab tests for COVID-19 under Medicare Part B.
o Medical Assistance will continue to pay for over-the-counter and lab tests through September 2024.
o In September, the Minnesota Department of Health announced it would be offering free test kits until they ran out.
• COVID-19 Vaccines:
o Medicare is continuing to cover COVID-19 vaccines and people pay nothing.
o Medical Assistance will continue to cover COVID-19 vaccines without cost-sharing through September 2024.
Other COVID-19 treatment through 2024
• Antiviral drugs are covered by Medicare if someone tests positive for COVID-19, has a mild to moderate case, and they are at high risk for developing a severe case or require hospitalization.
• Certain hospitals can treat select patients with in-patient level of care in their homes.
• Some telehealth service changes remain in effect through 2024; other permanent telehealth changes include:
o Certain facilities can serve as a distant site provider for behavioral and mental telehealth services.
o People on Medicare can get telehealth behavioral/mental health care at home.
o People can get behavioral/mental telehealth services wherever they are located. They don’t need to be at the originating site and there are no geographic restrictions.
o Behavioral/mental telehealth services can be delivered using audio only.
o Rural Emergency Hospitals (REHs) are eligible originating sites for telehealth under certain circumstance
End of Public Health Emergency:
Information on the end of the public health emergency can be found in the Unwinding of Medical Assistance/end of PHE: Policies and procedures quick reference.
Regarding considerations for 2024, there is anticipation that beginning January 2024, affected beneficiaries will become aware that they have lost their Medical Assistance and with that, their Medicare Savings Program and Part D LIS eligibility. This could result in a large increase in a beneficiary’s out-of-pocket costs. Senior LinkAge Line’s role is to assist Medicare beneficiaries with submitting applications for Medical Assistance, Medicare Savings Program and Part D LIS, if it appears they may be eligible. If the person is clearly not eligible based on income and assets, assistance should be provided to help them request a SEP if applicable, help them review their Medicare options such as Medicare Advantage or Medigap policies or Part D plans.
Guaranteed Issue Rights (GIR):
Interpreting the rules that apply to Guaranteed Issue Rights (GIR) can be tricky and somewhat vague. For example, it was our understanding that people who lost their Medicare Advantage Special Needs Plans (SNP) because they were no longer eligible for Medical Assistance would have Guaranteed Issue Rights. What we have found is that while some companies do allow people to join their plan without underwriting, other companies have not. The MN Department of Commerce has not determined whether these people should have GIR, instead they have asked that when someone is not provided with GIR after losing their SNP plan that we should assist them in filing a complaint with the Department of Commerce.
To file a complaint, either contact the Minnesota Department of Commerce at 651-539-1600 or send an email with the information to consumer.protection@state.mn.us.
Livanta - New way to file appeals:
• Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIO) help people on Medicare with concerns on quality of care.
• People can also contact their BFCC-QIO to help in filing a fast appeal when they think their Medicare coverage is ending too soon. Examples include:
o Being discharged from a hospital too soon
o Skilled nursing services or home health services ending too soon
• Livanta is the BFCC-QIO for people in Minnesota.
• Since COVID Livanta has seen a large increase in the number of people filing appeals and/or grievances (approx. 5,000 per week).
• Sometime in September 2023, people will be able to file appeals through Livanta online.
Postal Reform Act:
• Currently, about 20% of retired postal workers are not enrolled in Medicare.
• We want you to be aware that starting in 2025, future retired postal workers and eligible family members will be required to enroll in Medicare Part A and Part B to be eligible for the Postal Services Health Benefits (PSHB) Program.
• A new postal version of the Federal Employee Health Benefit would be available and act as secondary coverage to Medicare.
• Current retirees who are not enrolled in Medicare will be allowed to enroll in Medicare Part B without a late enrollment penalty.
o Enrolling in Medicare will typically eliminate any cost-sharing.
o They can choose not to enroll in Medicare Part B and keep their current coverage. However, if they decide later to enroll in Part B they will be subject to a penalty.
Therapy Threshold:
• There are no caps on the amount of therapy a person can receive. However, therapy that goes above a certain dollar amount requires a code to show the services provided are medically necessary and meets certain criteria.
o This code is called a KX Modifier.
o Threshold amounts are:
• $2,330 for physical therapy (PT) and speech-language pathology (SLP) combined
• $2,330 for occupational therapy (OT) alone
• Therapy that goes above $3,000, requires a targeted medical review.
Medicare Part D updates:
Extra Help:
Changes to Extra Help
• Extra Help is a program through Social Security that helps people with their Medicare Part D premium and medication costs.
• Currently, there are two levels of Extra Help, partial and full.
• Beginning January 1, full Extra Help will be expanded to people with incomes up to 150% of the Federal Poverty Level (FPL).
o Partial Extra Help will be eliminated.
o People who are currently on partial Extra Help will now be eligible for a full subsidy.
• People with incomes at or below 100% of the FPL will continue to pay lower co-pays.
Costs in 2024
• In 2024, benchmark plans have no premium or deductible and copayments will not be more than $4.60 for generic prescriptions and $11.20 for brand-name prescriptions (on formulary medications).
• People with incomes at or below 100% of the FPL pay the lower amounts.
• As a reminder, people who are deemed eligible automatically get a subsidy:
o Medical Assistance (MA)
o MA with a spend-down (met at least one month)
o MA for Employed Persons with Disabilities (MA-EPD)
o Medicare Savings Program (MSP)
o Supplemental Security Income (SSI)
• Co-pays are the same in all plans (if the medication is covered by the plan).
• If a person enrolls in a plan that is not a benchmark plan, they must pay the portion of the premium that is above the benchmark amount plus the enhanced portion of the premium.
Inflation Reduction Act (IRA):
• Some of the provisions took effect in 2023; however, it will take through 2029 for all the provisions of the legislation to be implemented.
Changes in 2023 included:
• Insulin was capped at $35 a month.
• The elimination of cost-sharing for adult vaccines covered under Part D (including those for shingles)
• Required drug manufacturers to pay the government rebates, if Part B or Part D drug prices increase faster than the rate of inflation (except when price averages below $100)
• Delayed implementation of the Rebate Rule
• This is a Trump administration rule that would have eliminated rebates negotiated between drug manufactures and Pharmacy benefit managers or health plan sponsors in Medicare Part D.
The Inflation Reduction Act - Future Changes
• In January several key provisions of the IRA will take affect:
• As mentioned earlier, the 5% coinsurance once someone reaches the catastrophic coverage limit will be eliminated.
• Part D premium growth will be limited to 6% through 2029.
• We also discussed that full Extra Help income eligibility will be expanded to 150% of FPL.
• In 2025:
• Caps Medicare Part D out-of-pocket costs at $2,000 per year.
• People will have the option to pay their drug costs over a 12-month period. This will prevent high drug costs at the beginning of the year.
• In 2026:
• The federal government will be allowed to negotiate prices of some Part B & D drugs. This occurs over several years.
IRA Timeline
Negotiated Drug Prices in 2026
• The IRA also included a provision that would allow the federal government to begin negotiating drug prices in 2026.
o Drugs are chosen based on their cost and the fact that they have been on the market for several years and no generic or biosimilar version of the drug is available.
• Recently, the names of the first Part D 10 drugs were released.
o It’s estimated that people who took these medications likely paid on average as much as $6,500 out of pocket in a given year.
o These drugs account for about 20% of total Part D drug costs.
• In 2028, Part B drugs can be included in the negotiation process.
• Companies that don’t agree to negotiate will be subject to a large excise tax.
• Multiple lawsuits have been filed recently by pharmaceutical companies to prevent price negotiation.
LI NET Program:
• The Limited Income Newly Eligible Transition Program (LI NET) provides people who are eligible for Extra Help but have no Part D plan immediate and retroactive Part D drug coverage.
• LI NET has been acting as a demonstration program since 2010.
• In 2024, LI NET will become a permanent program.
Medicare Part D Benchmark Plans:
• Enrollment in these plans means the people with Extra Help do not pay any premium for their Part D plan.
Medicare Part D 2024 Benchmark Plans:
WellCare Classic
SilverScript Choice
Clear Spring Health Value Rx
*Mutual of Omaha Rx Plus (New in 2024)
**AARP MedicareRx Basic from United Health Care (formerly AARP MedicareRx Saver Plus)
WellCare Classic
SilverScript Choice
Clear Spring Health Value Rx
*Mutual of Omaha Rx Plus (New in 2024)
**AARP MedicareRx Basic from United Health Care (formerly AARP MedicareRx Saver Plus)
No longer benchmark plans in 2024:
Cigna Secure Rx
Humana Basic Rx
Cigna Secure Rx
Humana Basic Rx
• Cost sharing is limited to copays.
• These plans are standard Part D plans (not enhanced) with a premium of $42.16 or less (this is the 2024 Regional Benchmark premium amount).
• Prescription drug plans or Medicare Advantage Plans with prescription drug coverage (MA-PD) may volunteer to waive the portion of the monthly premium that is $2.00 above the benchmark amount.
o This is called the de minimis amount.
o The law prohibits CMS from reassigning LIS members from plans who volunteered to waive the de minimis amount.
Standard D Benefit:
• Deductible Phase:
o In 2024 a plan's deductible cannot exceed $545. People may pay up to 100% during this phase. Costs during the deductible typically vary for people in enhanced plans.
• Initial Coverage Period:
o Costs can vary for plans not considered standard (most are not).
• Coverage Gap:
o Total drug costs exceed $5,030. Pay no more than 25% for plan formulary drugs.
• Catastrophic Coverage:
o Once a person reaches the out-of-pocket limit of $8,000.
o Costs that help a person reaches this limit include:
§ Money paid during the deductible and the initial coverage phase.
§ Most of the brand-name discount received during the coverage gap phase.
§ Money paid by others on a person’s behalf (family and charities).
o Beginning January 1, 2024, once someone reaches this phase, they pay nothing for formulary drugs for the remainder of the calendar year.
Medicare Health Plan updates:
Marketing and Communications:
• Complaints about the marketing of Medicare Advantage and Medicare Part D plans has continued to grow.
o As a result, in 2024 the federal government is continuing to address concerns by strengthening it’s marketing and communication oversight.
• Companies must limit their advertisement of plans/benefits to locations where they are available to people on Medicare.
• Companies are not allowed to advertise savings available based on a comparison with people who are uninsured or who are dual eligible.
• Ads must list the organizations name, the Part D sponsor, or marketing names registered with CMS.
• Plans must provide written notice to people at least once a year letting them know they can opt out of future calls regarding plan business.
• Prior to someone enrolling, plans are required to explain the effect enrolling will have on the person’s current coverage.
• In addition, medical benefits must be listed in a specific order and at the top of the plan’s Summary of Benefits.
• Marketing events will be prohibited from taking place in the same location within 12 hours of an educational event.
• Unscheduled in-person meetings must be initiated by the customer.
• Third party marketing organizations (TPMO) disclaimer must include:
o SHIP as an option to get additional help.
o A list of all the organizations/plans they represent.
• CMS is requiring there be 48 hours between a Scope of Appointment record and a scheduled personal appointment with a person on Medicare.
• Agents must complete a scope of appointment form prior to their customer meetings and keep on file for 10 years.
• Companies can’t market any health care related product or plans during any marketing appointment that is beyond the agreed upon scope which is valid for 12 months after the person with Medicare’s signature date or their request for information.
• A sales agent can only call a potential enrollee: up to 12 months following the date that the enrollee first asked for information.
• Companies must record calls between third-party marketing organizations (TPMOs) and people with Medicare to marketing (sales) and enrollment calls.
Medicare Cost Plans:
• Medicare Cost Plans are a type of Medicare health plan.
• Up until 2019 they were a very popular option but ended in all but 21 Minnesota counties because of a federal law change.
• The same 21 counties with cost plans available in 2023 will also be available in 2024:
• People must live in one of the counties where plans can be sold.
• Cost plans are not Medicare Advantage Plans.
• Plans have a network, but peoples can see providers outside the plans network and use their Original Medicare.
o People will be responsible for paying the Medicare cost-sharing.
Network Adequacy and Behavioral Health:
• CMS evaluates Medicare Advantage (MA) plan networks for adequacy.
• Beginning January 1, 2024, MA plan networks must include and will be evaluated for:
o Clinical psychologists and
o Licensed clinical social workers
• CMS also finalized wait time standards for behavioral health and primary care services and more specific notice requirements to patients when providers are dropped from their networks.
• In addition, CMS is requiring most types of Medicare Advantage Plans to include behavioral health services in care coordination programs, ensuring that behavioral health care is a core part of person-centered care planning.
Prior Authorization Requirements:
• Important protections have been put into place so that people on Medicare who choose to enroll in a Medicare Advantage Plan have the same access to medically necessary care that they would have gotten if they were enrolled in Original Medicare.
o Prior authorization policies can only be used to confirm the presence of a diagnosis or medical criteria to ensure an item or services is medically necessary.
o Once the approval is granted it must remain valid as long as medically necessary.
o If an enrollee switches to a new plan, there is a minimum 90-day transition period required if they are already undergoing active treatment.
Special Enrollment Periods (SEP):
• SEPs are times outside the initial or open enrollment periods when people can make changes to their Medicare Advantage or Medicare Part D plan(s).
• People with Extra Help have a SEP during each of the first three-quarters of the year, but not during the last quarter.
o Changes made during the last quarter of the year take affect January 1.
o People whose plan will no longer be available in 2024, will have a SEP that lasts from December 8 to the last day in February.
• SEPs are complicated:
o Customer representatives may not be well-versed on the details.
o Offer to make a three-way call to the plan when appropriate.
o Reach out to CSC with questions.
Questions & Answers:
Client Services Center:
- How to get help from CSC
- Staff at the Client Services Center (CSC) are there to support you.
- Use the New Senior LinkAge Line Medicare & Benefits Support Chat to get help from the CSC:
- Tell CSC what your name is and then ask your questions.
- CSC staff may not respond right away if they are on the phone and/or on another chat at same time.
- Help provided (some examples)
- MMIS and MAXIS lookups
- Questions that are complex and/or unusual
- Contacts with senior level staff from specific plans, Social Security and DHS to address difficult issues
- People who can’t get medication, but should have Extra Help
Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS):
- Medicare Advantage Plans and DMEPOS
- CMS discontinued the use of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment (DME) Information Forms (DIFs) for claims with dates of service on or after January 1, 2023.
- In addition, Medicare Advantage Plans can choose to cover specific brand-name equipment.
- If you use a different brand, they may require that you change.
- If your doctor feels a particular brand is medically necessary, there is a process by which you can request a reconsideration.
- People should contact their plan for more information or to ask specific questions.
Medicare Advantage Plans:
- New Plans:
- Allina Health Aetna Medicare Smart Fit H3219-008
- Allina Health Aetna Medicare Value H3219-007
- Humana USAA Honor H5216-278
- Humana USAA Honor H5216-354
- Humana Choice H5216-397
- Humana Gold Choice H8145-006
- Blue Cross Medicare Advantage Freedom Blue H5959-018
- HealthPartners Journey Stride H4882-011-001
- HealthPartners Journey Stride H4882-011-002
- Plans Leaving:
- Humana Gold Plus H6622-062
- Lasso Health Care Growth MSA H1924-001
- Lasso Health Care Growth Plus MSA H1924-004
- HealthPartners Journey Stride H4882-001
- People who are dual eligible and enroll in an Advantage Plan that is not a SNP
- These people will get their Medical Assistance through MSC+ and not through the Medicare Advantage Plan.
- People who are dual eligible must pay the plan’s health care premium.
- They may also be charged an additional premium for the Part D portion if the plan includes enhanced coverage, or the premium is above the benchmark amount.
- People must follow all the rules and restrictions of the plan.
- Lasso Medicare Medical Savings Account (MSA) plans in 2024
- Lasso plans are not available to people living in Minnesota in 2024.
- People enrolled in a Lasso MSA plan must enroll in a new plan for 2024, or they will be returned to Original Medicare.
- Remember, if a plan leaves the market people losing coverage have GIR.
- Changes to prior authorization procedures in Medicare Advantage Plans.
- Prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary.
- Second, plans must provide a minimum 90-day transition period when an enrollee is currently undergoing treatment and switches to a new MA plan. During this period the new may not require prior authorization for the active course of treatment.
- Third, all MA plans must establish a Utilization Management Committee to review policies annually and ensure consistency with Traditional Medicare’s decisions and guidelines.
- Finally, the approval of a prior authorization request for a course of treatment must be valid for as long as medically reasonable and necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.
- Medicare Advantage Plan marketing changes in 2024
- Plans must notify people annually (in writing) of their ability to opt out of phone calls regarding plan business.
- Prohibition on door-to-door contact without an appointment still applies after collection of a business reply card or scope of appointment (SOA).
- SOA cards may not be collected at educational events.
- There must be a 48-hour window between the SOA being completed and an agent’s meeting with a beneficiary.
- Sales agents may call a potential enrollee no later than 12 months following the date that the enrollee first asked for information.
- Medical benefits must be listed in a specific order at the top of a plan’s Summary of Benefits.
- Sales, marketing, and enrollment calls between third-party marketing organizations (TPMOs) and beneficiaries must be recorded.
- TPMOs must list or mention all the MAPs or PDP sponsors that they represent in marketing materials.
- Plans must require agents to explain the effect of an enrollee’s enrollment choice on their current coverage whenever the enrollee makes an enrollment decision.
- Plans must have an oversight plan that monitors agent/broker activities and reports agent/broker noncompliance to CMS.
- A marketing event may not occur within 12 hours of an educational event at the same location.
- The following are prohibited:
- Advertisements that (1) do not mention a specific plan or (2) use the Medicare name or logo in a misleading way.
- Marketing benefits in a service area where they are not available.
- The use of superlatives (e.g., words like “best” and “most”) in marketing unless the material provides documentation to support the statement and the documentation is based on data from the current or prior year.
- Reporting marketing violations.
- Complete a support request.
- Kelli Jo will then report the issue to CMS.
- CMS will complete an investigation.
- Be as complete as possible; CMS likes to ask questions that sometimes we don’t anticipate.
- Your supervisor may also want to be notified.
Medicare coverage for colorectal screening:
- Multi-target stool DNA testing
- Medicare does cover multi-target stool DNA tests once every three years if you meet certain conditions.
- See Multitarget Stool DNA Test Coverage (medicare.gov) for more information.
- Diagnostic vs. preventative
- Colorectal screening could be preventive or diagnostic, depending on the situation.
- Get more information at:
Medicare coverage for vaccines and medications:
- The parts of Medicare that cover vaccinations
- Medicare Part B covers vaccines for COVID, Flu, Hepatitis B, and Pneumonia.
- A tetanus booster is covered when someone has a puncture wound.
- Medicare Part D covers vaccines for RSV, shingles, Tdap, and hepatitis A.
- A tetanus booster is covered if not related to an injury or illness.
- Medicare Part B covers vaccines for COVID, Flu, Hepatitis B, and Pneumonia.
- Costs for vaccines
- People pay nothing for Part D adult vaccines recommended by the Advisory Committee on Immunization Practices.
- People may have to pay an administration fee, but they can request reimbursement from their Part D plan.
- If they get the vaccine at a doctor’s office, they must make sure the office can bill their Part D plan.
- It is easiest to get these vaccines administered through a contracted pharmacy who can bill the Part D plan.
- People pay nothing for vaccines covered under Medicare Part B.
- If someone receives the vaccination at their doctor’s office and other services were provided at the same time, they could be charged for the office visit and for the other services that were provided.
- People pay nothing for Part D adult vaccines recommended by the Advisory Committee on Immunization Practices.
- Medication coverage under the different parts of Medicare
- Medications can be covered by Medicare A, B, C, and D. What is covered by which part of Medicare can depend on a variety of factors such as, when, where, and why the drug was administered.
- Keep in mind that if you are doing someone’s Medicare Part D research, it is important not to add a drug to someone’s list if it is covered under Medicare Part A or Part B. Doing so will significantly skew the results.
- Use these documents as a source of truth.
- This can be complex so, if you need help or have questions reach out to the Client Services Center.
Medicare Part D/Extra Help:
- Medicare Part D out-of-pocket costs in 2024
- Coverage gap
- People go into the coverage gap after they and their plan have cumulatively spent $5,030.
- Catastrophic coverage
- When your out-of-pocket spending reaches $8,000 you move to catastrophic coverage.
- The following count toward Troop
- Your yearly deductible, coinsurance, and copayments
- The discount on brand-name drugs in the coverage gap
- Coverage gap
- People who are deemed (automatically eligible) eligible for Extra Help
- Certain people are deemed eligible (don’t need to apply). If they are deemed, they should not complete an application for Extra Help.
- This includes people who have Medicare Parts A or B, or both, and are:
- Already entitled to Supplemental Security Income (SSI),
- Eligible for full Medicaid coverage, or
- Covered under a Medicare Savings Program (QMB, SLMB, QI).
- Note: Qualified Disabled Working Individuals (QDWI) are not deemed eligible for Extra Help; they need to apply.
- 2024 Benchmark plans
- AARP MedicareRx Basic
- Clear Spring Health Value Rx
- Mutual of Omaha Rx Plus
- SilverScript Choice
- Wellcare Classic
- Eligibility for full Extra Help in 2024
- People who are eligible for partial Extra Help in 2023 will be transitioned to full Extra Help effective 1/1/24.
- People’s assets will not be reviewed with this transition.
- After 1/1/24 assets as well as income will be reviewed.
- We have not been given information at this time as to what the asset levels will be.
- People eligible for the Medicare Savings Program (MSP) automatically get full Extra Help.
- In MN, asset limits for MSPs are $10,000 single/$18,000 couple.
- People who are eligible for partial Extra Help in 2023 will be transitioned to full Extra Help effective 1/1/24.
- Screening for Extra Help
- It is important to identify people who may be eligible for Extra Help.
- An easy way to do this is to say something like the following:
- I am not sure if you are aware, but there are programs that help people pay their costs for Medicare, including your medications under Medicare Part D.
- For example, if your income is at or below $___ and your assets are at or below $___ you may be eligible. Would you like more information?
- Use your professional judgment to determine whether someone needs your help in applying for Extra Help.
- Redeeming for people who are deemed eligible for Extra Help
- People who are deemed eligible for Extra Help go through an annual process, called redeeming.
- This process is to determine from one year to the next if someone remains eligible for Extra Help in the upcoming year.
- People who are deemed eligible and continue to be eligible for the same program (see list above), for at least one month beginning in July (or later) will be automatically eligible for Extra Help the entire next year.
- If the person is not eligible for one of these programs from July 1 through December 31, they will not automatically be eligible for Extra Help.
- People will receive written notice in the fall letting them know they are no longer automatically eligible.
- The notice will include an application for Extra Help that they can complete and send back to Social Security to determine if they are eligible based on income and assets and not program eligibility.
- If people did not receive a notice, but it appears they are no longer eligible based on your search using Medicare.gov, you can contact SHIP to verify future eligibility.
- CSC can do this for you if you do not have a SHIP ID.
- People who are deemed eligible for Extra Help go through an annual process, called redeeming.
Medigaps:
- Medigap Plan N cost-sharing
- $20 for office visits
- $50 for an emergency room visit (that does not result in an inpatient hospital admission)
- Medigap area (Rural 1 vs. Rural 2)
- A few Medigap plans list a different premium for rural 1 and rural 2 areas.
- People must contact the plan for information on specific locations included in each area.
- Purchasing a Medigap policy without underwriting
- People have certain times when they can enroll in a Medigap policy without underwriting. These are called Guaranteed Issue Rights (GIR).
- People have GIR during the first six months of enrolling in Medicare Part B. This is called their Medigap Open Enrollment Period.
- People also have GIR at other times, depending on their specific circumstances.
- If someone enrolls after their Medigap open enrollment period using GIR they are allowed to enroll in any Basic plan and add up to two riders.
- Companies may allow them to enroll in other Medigap plans at their discretion.
- For more information or details on GIR see:
- People have certain times when they can enroll in a Medigap policy without underwriting. These are called Guaranteed Issue Rights (GIR).
- Using GIR when you are no longer eligible for a Medicare Advantage Special Needs Plan (SNP)
- There have been some companies denying people GIR after they have been disenrolled from a SNP because they were no longer eligible for Medical Assistance.
- The Minnesota Department of Commerce is currently uncertain about whether these people have GIR.
- They are in the process of researching and we are waiting for more information.
- Until we get a final answer, people should be encouraged to file a complaint with Commerce and staff should submit a support request.
- Use your professional judgement on whether you should provide help in filing the complaint.
- Note: People in Minnesota are eligible for GIR even if they are under age 65. This is not the case in all states.
Resource materials:
- OEP training materials
- The 2024 Medicare update community presentation is posted on the Extranet.
- MBA Is preparing a document that will provide you information about plan changes and Medicare cost-sharing.
- Health Care Choices (HCC)
- Medigap plan information is updated in Health Care Choices (HCC) when it is received from the MN Department of Commerce.
- Generally, this occurs monthly.
- Other information in HCC is also updated on a regular basis.
- Do not save the pdf to your desktop or print out the copy.
- MBA staff are managing the project this year so issues, errors, or concerns should be sent to MBA through a Support request.
- Medigap plan information is updated in Health Care Choices (HCC) when it is received from the MN Department of Commerce.
Special Enrollment Periods (SEPs):
- Payment liability when using a SEP to change plans or return to Original Medicare during an active skilled nursing facility stay
- You are not expected to know detailed billing information.
- If a person has a Medicare Advantage Plan, encourage them to contact the plan for more information.
- If they have Original Medicare, they can call 1-800-Medicare for more information.
- The patient’s status at admission determines financial liability.
- If a person goes from one Medicare Advantage Plan to another during the SNF skilled stay the previous plan is responsible for the stays payment until they discharge.
- If the person was on Original Medicare when they admitted, the federal government is liable for this inpatient stay because the patient had Original Medicare at the time of admission.
- Medicare three-day qualifying stay:
- If a person goes from a Medicare Advantage Plan to Original Medicare during the skilled stay and the person meets the level of care criteria through the effective date of disenrollment, Medicare will waive the requirement for a qualifying hospital stay and the person is eligible for the number of days remaining out of the 100-day benefit period.
- If they readmit, under the 30-day rule, all Original Medicare criteria (including 3-day stay) must be met.
- You are not expected to know detailed billing information.
- SEPS after enrolling in Medicare during the General Enrollment Period (GEP)
- In 2024, people who enroll in Medicare during the GEP, will have a SEP to enroll in a Medicare Part D plan and/or a Medicare Advantage Plan.
- They have a two-month period to join a plan.
- They may be subject to paying a Medicare Part D premium penalty.
- Getting access to a SEP because of an exceptional circumstance, inaccurate information, or fraud.
- Information to be added