Last updated December 21, 2023
When to use:
As a guide to help a caller compare Medicare plans and options and to screen for MSP and LIS.
Plan considerations:
Narrow down the deciding factors. Instead of trying to think of everything, try to limit what coverage the person may want to purchase.
Remember: It's far easier to make an objective decision based on limited pieces of information than it is based on many. By asking a person which factors are most important to them, you can narrow down options and help them choose the coverage that will work best.
Provider networks:
If a network of provider applies, are the individual’s current doctors and healthcare providers included and listed as an in-network provider? It is important to note that this information can be found on the plan’s website and is not available on Medicare.gov.
- Out of network providers will typically have higher cost sharing under a COST or Advantage plan and Medicare Advantage plans may not pay for any out-of-network services.
- Provider and pharmacy networks may change at any time. All plans now use preferred pharmacies, which can reduce the persons costs substantially.
Prescription drug coverage:
Are the individual’s current medications included in the plan’s formulary, or list of covered drugs? What are the copayment and coinsurance costs for their drugs?
Note that the formulary is subject to change, but the plan must provide a 60-day notice before any changes take effect.
Costs:
Some plans may have premiums as low as $0. But remember that individuals will still need to keep paying the Medicare Part B premium, along with any copayments, coinsurance or deductibles the plan requires. A general rule of thumb is that the lower the monthly premium, the higher the out-of-pocket costs. Some questions to ask include:
- Is the individual comfortable with the annual deductible, if there is one?
- What are the initial coverage and out-of-pocket limits? Unlike Original Medicare, every Medicare Advantage and Cost Plan has a yearly maximum spending limit that does not include prescription drugs. Once the beneficiary reaches this limit (which includes the deductible), the plan covers 100% of covered medical costs for the rest of the year.
Lifestyle:
For example, what happens if they are in Florida for the winter or traveling abroad?
Additional benefits:
Such as routine vision, dental, hearing, or health wellness programs?
You will find the most accurate and up to date information about these additional benefits on the plan websites, not Medicare.gov or in Health Care Choices. They vary greatly plan to plan.
Star ratings:
Star ratings are one way to rate a Medicare Health or Drug plan’s performance. Each plan is given a rating between one to five stars, with five stars being the highest.
Note: Individuals can enroll in a five star plan outside of typical enrollment periods.
Medicare enrollment:
Senior LinkAge Line specialists are mandated to ensure that plan enrollments are submitted only when the following are true:
- The person is making an informed decision.
- Example statement: Are you comfortable that you are making the decision that will best suit your health and drug coverage needs?
- The specialist has obtained verbal consent from the person, power of attorney, guardian, or authorized representative. If the authorized representative has no legal authority, verbal permission must be obtained from the person.
- Example statement: I am going to submit a plan enrollment on your behalf via Medicare.gov with your consent. Your plan will start (effective date of the coverage) once I submit the form. Would you like me to proceed?
- The specialist has reviewed all portions of the enrollment process and read them to the person.
- Verify that all person’s information is correct as entered in the Medicare.gov by reading and spelling out all entries.
- Read the legal language of the application to the person/authorized representative in full and ensure he/she understands what was read.
- Example statement: As I move through the enrollment form, I will be verifying all the information I enter, as well as reading the legal language as stated on the Medicare.gov website. Please stop me if anything is incorrect or you would like me to clarify anything.
Screening for Medicare Savings program (MSP) and Low Income Subsidy (LIS) / Extra Help:
Each caller with Medicare should be screened for the MSP and LIS. Use the Financial assistance for people with low to modest income quick reference to insert the current income and asset limits.
Begin the screening with the following script:
- There are free programs available that can help pay for your Medicare and drug costs. It only take a minute for me to screen you for the programs. Are you interested?
- If yes, proceed with the income review:
- The programs have income guidelines that do include income such as Social Security and pension benefits.
- The income guideline is _____ for an individual/couple (whichever applies). Is your monthly income at or below this amount?
- If yes, proceed to asset review:
- The programs also have asset guidelines that do not include your home or car.
- The asset guideline is _____ for an individual/couple (whichever applies). Do you have less than this amount in assets such as savings, stocks, bonds, etc.?
- If yes, ask if the person would like to apply.
- If yes, determine the following:
- Eligibility for MSP? Because enrollment in MSP means a person is automatically eligible for LIS, first screen for MSP. Mail out the DHS application for the MSP.
- Eligibility for LIS? If the person needs help, assist them with applying for the LIS at the Social Security website.