Enrollment Guidance for Medicare Part D Plans Presented by America’s Health Insurance Plans (AHIP) and The National Association of Health Underwriters (NAHU)

August 14, CMS Guidance for Eligibility, Enrollment and Disenrollment  Part D plans include PDP, MA-PD, Cost Plans that offer Part D, and PACE plans.  CMS provides instruction for enrolling Medicare beneficiaries in Medicare Prescription Drug Plans (PDPs) in the Agency’s PDP Guidance for Eligibility, Enrollment and Disenrollment. Website: P_EnrollmentGuidance_ pdf (Final 2006 pending) P_EnrollmentGuidance_ pdf  Guidance for Eligibility, Enrollment and Disenrollment procedures for Medicare Advantage (MA) plans, including MA-PD plans, is provided in Chapter 2 of the Medicare Managed Care Manual. Website:

August 14, Broker/Agent Disclosure Requirements  When conducting marketing to enroll beneficiaries brokers and agents must disclose to beneficiaries that they are: Contracted with the sponsor they are representing; and Compensated based on the person’s enrollment in the plan.  This disclosure must be in writing.

August 14, Who is Eligible to Enroll in a Part D Plan?  An individual is eligible to enroll in a Part D plan if the individual is entitled to Medicare benefits under Part A or enrolled in Part B.  An individual must reside in the service area of the plan.

August 14, Restrictions for Enrolling In PDPs  Medicare beneficiaries may be enrolled in only one Part D plan at a time.  If enrolled in an MA coordinated care plan or MA PFFS plan that includes Medicare prescription drugs, the enrollee may not enroll in a PDP unless they disenroll from the HMO, PPO, or MA PFFS plan.  Enrollees in PFFS without prescription drug coverage or an MA Medical Savings Account (MSA) plan may enroll in a PDP.  Enrollees in a 1876 Cost plan may enroll in a PDP.

August 14, Restrictions for Enrolling in MA-PDs  The Medicare prescription drug benefit of a MA-PD is only available to members of the MA-PD plan.  If a beneficiary is already enrolled in a MA- PD plan, the enrollee must receive their Medicare prescription drug benefit through that plan.

August 14, Who May Decide to Enroll?  Presentations must be made directly to the prospective enrollee, and/or their legal representative.  Decisions to enroll in a plan must be made by people of sound mind who are capable of understanding the plan benefits.  CMS will recognize State laws that authorize persons to effect a Part D enrollment or disenrollment request for Medicare beneficiaries. Persons authorized under State law may include court-appointed legal guardians, persons having durable power of attorney for health care decisions, or individuals authorized to make health care decisions under state surrogate consent laws, provided they have authority to act for the beneficiary in this capacity.  A spouse or family member cannot decide for and/or sign for another without a legal authority. If both spouses cannot attend the sales presentation, you may speak to and enroll the present spouse and schedule a follow-up appointment for the absent spouse.

August 14, Beneficiary Information It is important to be aware of your individual clients circumstances. For example:  What is the client interested in? Medicare Advantage, Medicare Advantage with prescription drugs, or stand-alone prescription drug coverage.  What health coverage do they have now? Original Medicare,  Only or with Medigap Medicare Advantage plan, Medicaid, or Employer/union sponsored plan.  Do they have drug coverage?

August 14, Beneficiary Information  Beneficiaries may only enroll in or change plans during an election period that occurs at specific times of the year. Previous Medicare health plan elections will impact what Medicare choices are now available.  It is helpful to know: When the current coverage was effective. Whether the client already made changes for the current calendar year.

August 14, Election Periods  Initial Election Period (IEP) – Beneficiary Dependent  Annual Election Period (AEP) – November 15 to December 31  Open Enrollment Period (OEP) – January 1 to March 31  Special Enrollment Period (SEP) – Beneficiary Dependent

August 14, Initial Election Period (IEP)  Beneficiary dependent – based on date the beneficiary becomes eligible for Medicare  Generally concurrent with IEP for Part B - during the period that starts three months before the month he/she turns age 65 and ends three months after the month he/she turns age 65.  If a beneficiary does not join during the IEP, and does not have current drug coverage that is creditable, he/she may have a penalty. The premium cost will go up at least 1% per month for every month that he/she waits to join. Like other insurance, the individual will have to pay this penalty as long as they have Medicare prescription drug coverage.  Individuals have one IEP to use, once enrollment is effective, the IEP is used.

August 14, Annual Election Period (AEP)  November 15 – December 31  Beneficiaries may add or drop MA and/or drug coverage  Beneficiaries may switch to a different plan offering drug coverage: From a PDP to a different PDP, Form MA-PD to a different MA-PD, From a PDP to an MA-PD or vice versa, or To a Cost Plan offering Part D  Beneficiaries have one AEP to use, once the enrollment is effective, the AEP has been used.

August 14, Open Enrollment Period (OEP)  From January 1, 2007 through March 31, 2007 beneficiaries may make one change to how they receive their Medicare health benefits, but they may not add or drop drug coverage. The following two tables outline the changes they may make.

August 14, Medicare Open Enrollment Period Rules If a beneficiary has drug coverage he/she must keep drug coverage during an OEP. *PFFS plans with drug coverage are included in the definition of MA-PD. **Through SEP enrollment in a PDP plan. If current coverage includes prescription drugs. During an OEP they could choose to: MA-PD*  Change to another MA-PD*  Switch to Original Medicare and a PDP** Original Medicare and a PDP  Switch to a MA-PD*

August 14, Medicare Open Enrollment Period Rules If a beneficiary has no drug coverage, he/she cannot switch to a Plan with drug coverage during an OEP. * PFFS plans without drug coverage are included in the definition of MA plans. If their current coverage does not include prescription drugs. During an OEP they could choose to: MA only*  Change to another MA only*  Switch to Original Medicare Only Original Medicare Only  Switch to a MA Only*

August 14, Special Enrollment Period (SEP)  Special Enrollment Periods are beneficiary dependent.  An SEP generally allows an individual to: disenroll, change plans, or sometimes to enroll.  CMS has identified in its Manual a number of circumstances in which a beneficiary can have a special enrollment period.

August 14, SEPs - Some Typical Circumstances  Medicaid Individuals who receive assistance from Medicaid can change plans at any time. If a person loses his/her Medicaid benefits, he/she has a three month period to make an enrollment decision.  Moving If a person has a service area based plan (MA,MAPD, PDP) and moves outside the service area, he/she can apply the month prior to the move and up to 2 months after the move. The individual may choose an effective date of up to 3 months after the month in which the enrollment form is received, but may not be earlier than the date of the permanent move.

August 14, SEPs - Some Typical Circumstances  Misrepresentation CMS may grant the individual an SEP if a plan representative materially misrepresented the plan during marketing.  Involuntary loss of creditable coverage (coverage at least as good as Medicare) Involuntary loss, including a reduction in the level of coverage Begins with the month in which the individual is advised of the loss of creditable coverage and ends 60 days after either the loss occurs or the individual received notice, whichever is later.

August 14, SEPs - Some Typical Circumstances  Institutionalized Individuals For an individual who moves into, resides in, or moves out of a:  Skilled nursing facility (SNF) or nursing facility (NF);  Intermediate care facility for the mentally retarded (ICF/MR);  Psychiatric hospital or unit;  Rehabilitation hospital or unit; or  Long-term care hospital or swing-bed hospital. Effective dates: first of the month following the month in which the enrollment/disenrollment request is received, but not prior to the month residency begins. Up to 2 months after he/she moves out of the facility.

August 14, SEPs - Some Typical Circumstances  Employer Group Health Plan (EGHP) changes For individuals enrolling in employer group/union-sponsored Part D plans, For individuals to disenroll from a Part D plan to take employer/union-sponsored coverage of any kind, and For individuals disenrolling from employer/union-sponsored coverage to enroll in a Part D plan. The SEP EGHP may be used when the EGHP would otherwise allow the individual to make changes to their EGHP plan choice. Effective date of enrollment or disenrollment: up to 3 months after the month in which the request is made. However, the effective date may not be earlier than the date the EGHP (or PDP sponsor, as appropriate) received the completed enrollment or disenrollment request.

August 14, Medicare Enrollment Guidelines  Health questions may not be asked (unless it is a question of eligibility).  Appointments may not be avoided due to the health or financial status of the beneficiary.  Plans and agents/brokers cannot work with a provider to direct any beneficiary to a particular plan, e.g., only the healthier members to a medical practice.

August 14, Medicare Enrollment Guidelines  If a paper enrollment form is used, it must be signed.  If the beneficiary is not competent to enroll, a legal representative must sign the enrollment form for the beneficiary.  The legal representative must attest on the form that they have the authority to make healthcare decisions under State law to effect the enrollment request on behalf of the beneficiary.  Proof of legal representation includes court-appointed legal guardianship or power of attorney for healthcare.

August 14, Medicare Enrollment Guidelines  If an Agent or Broker helps the beneficiary fill out the enrollment request, they must also sign the enrollment form and indicate their relationship to the individual.  Agents or Brokers must not: Give advice on legal documents; Give in to pressure from a family member who wants to enroll a beneficiary without legal authority.

August 14, Medicare Health Care Plan Premium Payment Members can pay their premiums by: Coupon book Automatic bank withdrawal Credit card Withholding from Social Security Administration check IMPORTANT: Agents cannot collect plan premiums at the time of enrollment. Plans will verify enrollment via a phone call or other means.

August 14, Post Enrollment Materials for the Beneficiary  After the plan receives the application, the plan sponsor provides the member with: A notice acknowledging receipt of the complete enrollment request providing the expected effective date of enrollment; A copy of the completed enrollment form; The plan sponsor rules; The member’s rights and responsibilities; Evidence of health insurance coverage so that he/she may begin using the plan services as of the effective date. How to obtain services prior to the receipt of an ID card (if the sponsor has not yet provided the ID card).

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