1. Overview of Medicare Broker Training
Overview of Medicare Advantage Plans
Updated: August 2018

2. Basic Medicare Overview
Medicare Defined
Signed into law in 1965
Medicare is government sponsored health insurance for seniors and the disabled.
Medicare is not the same as Medicaid, which is generally for individuals with low income.
Medicare, is a federal health insurance program, signed into law in 1965…
for people age 65 and older, or those under age 65 with certain disabilities
- Medicare is NOT the same as Medicaid, which is a state program with benefits that may vary from state to state.

3. A B Original Medicare Medicare is… It covers people who are:
Health insurance through the Federal Government
Created in 1965
It covers people who are:
65 or older
Under age 65 with certain disabilities
Any age with End Stage Renal Disease (ESRD)
permanent kidney failure requiring dialysis or a kidney transplant
Some people receive Part A & Part B automatically
If you’re already receiving benefits from Social Security or the Railroad Retirement Board (RRB), you'll automatically receive Part A and Part B starting the first day of the month you turn 65. If your birthday is on the first day of the month, Part A and Part B will start the first day of the prior month. If you qualify for Medicare due to a disability, you automatically receive Part A and Part B after you receive disability benefits from Social Security or certain disability benefits from the Railroad Retirement Board (RRB), for 24 months.
If you’re automatically enrolled on Medicare, you will receive your Red, White & Blue Medicare card in the mail 3 months prior to your effective date. Here is an example of a Medicare card (refer to slide).
Some people need to sign up for Part A & Part B 
You need to sign up for Part A and Part B if:
You are not collecting Social Security or Railroad Retirement Board benefits (for example, because you're still working).
You qualify for Medicare because you have End Stage Renal Disease (ERSD).
Applicable Disclaimers Appear at the End

4. A B C D Basics of Medicare Hospital insurance Medical insurance
Part A
Part B
Part C
Part D
Hospital
insurance
Covers:
Hospitals
Hospice
Home Health
Skilled Nursing
Has deductible and cost-sharing.
Medical
insurance
Covers:
Physician services
Diagnostic services
Preventive services
Outpatient services
Medical equipment
Some drugs
Has deductible
and cost-sharing.
Medicare Advantage
Provided by private insurance companies
Includes benefits / services covered under Original Medicare
Plan may include Prescription Drug Coverage
Prescription
drug coverage
Options:
A stand-alone plan that goes with Original Medicare
—OR—
a Medicare Advantage- Prescription Drug Plan that offers medical and drug benefits together
Here are the Basics of Medicare – A, B, C & D. I will go into more detail on each part of Medicare.
Under Medicare Part A you are covered for inpatient care in hospitals, skilled nursing rehabilitative care, home health care and hospice care.
Those on Original Medicare may be responsible to pay a deductible and cost-share per benefit period.
Part B covers other medical services that Part A does not cover. It helps pay for covered medical services and items when they are medically necessary.
Part B also covers some preventative services.
There is a monthly premium for Part B.
Part B has an annual deductible which must be met before Original Medicare starts to pay its share. Once you reach your annual deductible, Medicare will typically pay 80% of your medical expenses.
Medicare Part C are Medicare Advantage plans, which are offered through private insurance companies.
Medicare Part D, under Original Medicare, beneficiaries are not covered for prescription drug coverage. Prescription drug plans are offered by private companies to cover generic and brand medications. They can be purchased as part of a Medicare Advantage Plan or a stand-alone Prescription Drug Plan.
All applicable disclaimers are on page <13>

5. Original Medicare Original Medicare consists of 2 parts:
Medicare Part A
Helps cover inpatient care in hospitals, skilled nursing facilities, hospice and home health care.
Medicare Part B
Helps cover medically necessary outpatient services and supplies like physicians’ services, home health services, some preventive services, durable medical equipment (DME) and other medical services.
Under Medicare Part A you are covered for inpatient care in hospitals, skilled nursing rehabilitative care, home health care and hospice care. Part A does not cover personal or custodial care. Those on Original Medicare may be responsible to pay a deductible and cost-share.
Medicare Part B covers other medical services that Part A does not cover. It helps pay for covered medical services and items, when they are medically necessary. Part B also covers some preventative services.

6. Original Medicare – Part A
Part A Premium
Most beneficiaries (about 99%) do not pay a premium for Part A.
A beneficiary (or their spouse) must be employed and pay Medicare taxes for 40+ quarters in their lifetime in order to receive premium-free Part A.
For those who worked less than 40 quarters, the premium can be up to $411 per month.
Part A late enrollment penalty (LEP)
- Most people automatically receive Part A coverage without having to pay a monthly premium because they or a spouse paid taxes while working (10 years or 40 quarters). If you buy Part A, you could pay up to $411 each month. In most cases, if you choose to buy Part A, you must also have Medicare Part B and pay monthly premiums for both.
- Under Medicare Part A you are covered for inpatient care in hospitals, skilled nursing rehabilitative care, home health care and hospice care. Part A does not cover personal or custodial care.
- Part A Late Enrollment Penalty (LEP):
The Part A LEP increases the monthly Part A premium by 10%.
Beneficiaries subject to this LEP will be required to pay the higher premium for twice the number of years that they could have had Part A but did not. (For example: if a beneficiary was eligible for Part A for 2 years but didn’t sign up, he/she would have to pay the higher premium for 4 years.)

7. Original Medicare Rules and Restrictions
Beneficiaries may use any provider that accepts Medicare (“accepts assignment”)
The service must be medically necessary and covered under the Medicare program.
There are no prior authorization requirements.
Rules and Restrictions
Beneficiaries may use any provider that accepts Medicare (“accepts assignment”)
The service must be medically necessary and covered under the Medicare program.
There are no prior authorization requirements.

8. Medicare – Part D
Part D was introduced in 2006 and covers outpatient prescription drugs.
There are 2 ways a beneficiary can obtain drug coverage:
Cannot be enrolled in both plan types simultaneously
Important Note:
A Medicare beneficiary cannot be enrolled in a Medicare stand alone prescription drug plan (PDP) and a Medicare Advantage Plan simultaneously. Enrolling in one plan type will automatically dis-enroll the beneficiary from the other plan. This is true even if the Medicare Advantage Plan does not include drug coverage.

9. Medicare – Part D Premium
Premiums vary based on:
Plan selected
Whether or not the beneficiary receives financial assistance (will reduce the premium)
Income (higher premium when income is greater than $85,000 per individual or $170,000 if filed jointly)
Part D LEP (will increase premium, when applicable)
Beneficiaries with limited income and assets may qualify for assistance paying for their Part D costs. Assistance may be received through a Medicare Savings Program, Medicaid or some other type of assistance program.
Part D Late Enrollment Penalty (LEP):
A penalty applied to Medicare beneficiaries who did not sign up for Part D when they were first eligible and who also did not have creditable prescription drug coverage.
The penalty varies based on how long the beneficiary delayed enrolling. Medicare will permanently add 1% of the current base beneficiary premium (the national average Part D premium at the time the beneficiary enrolled) to the monthly premium for every month the beneficiary was late enrolling.
Medicare tells HFHP how much the beneficiary’s LEP is.
For those subject to the LEP, they will have it for their lifetime, and the penalty will follow the beneficiary no matter which Part D plan they choose.
If the beneficiary has Low Income Subsidy (LIS), the penalty is waived for the time they are enrolled in the LIS program.

10. Medicare – Part D Eligibility
If joining through a Medicare Advantage plan:
Must have and maintain Medicare Part A and Part B
Must live in the plan’s service area
Brevard and Indian River Counties for HFHP
Volusia, Flagler, Hardee, and Highland Counties for FHCA
Must not have end stage renal disease (ESRD)
If joining through stand-alone drug plan (PDP):
Must have and maintain Medicare Part A or Part B
If joining through a Medicare Advantage plan:
Must have and maintain Medicare Part A and Part B
Must live in the plan’s service area
If joining through stand-alone drug plan (PDP):
Must have and maintain Medicare Part A or Part B

11. The Coverage Gap Also known as “the donut hole”
Most Part D plans are subject to the gap.
3 stages of Medicare drug coverage:
Stage 1: Initial Coverage Period
Stage 2: Coverage Gap
Stage 3: Catastrophic Coverage
Most Medicare Prescription Drug Plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs.

12. Medicare Advantage (MA) Plans
Also known as Part C or Medicare Replacement Plans
All Part A and Part B benefits are obtained through the private plan.
Must cover all services that Original Medicare covers, except hospice care
May offer extra coverage
(vision, hearing, etc.)
Most include prescription drug coverage (Part D)
Medicare Advantage plans are replacement plans.
With Medicare Advantage plans, Medicare services are covered through the plan and are not paid under Original Medicare.
Medicare Advantage Plans eliminate Part A and Part B deductibles and often have no deductible of their own, they have low to no additional monthly premiums, offer some enhanced benefits such as dental, hearing, vision and fitness center memberships.
Medicare Advantage Plans also feature an out-of-pocket maximum to give you more financial protection than Original Medicare.

13. Medicare Advantage Plans
Medicare pays a fixed amount directly to the plan for the members’ care (per member, per month)
Plans must be approved by Medicare annually, so continued coverage in a specific plan type is not guaranteed year to year.
Medicare Advantage Plans
are NOT supplemental coverage.
These plans have a contract with the Centers for Medicare & Medicaid Services (also known as CMS) and are renewed on an annual basis.
Medicare Advantage plans are a replacement plan and are not Medigap or Medicare Supplement.

14. Types of MA Plans Health Maintenance Organization (HMO)
Point of Service (POS)
Preferred Provider Organization (PPO)
Private Fee for Service
Beneficiary can generally go to any provider that accepts Medicare. The plan determines how much it will pay.
Special Needs Plans (SNP)
Provide focused and specialized health care for specific groups of people
HMO Plans:
A member is required to use the plan’s network providers, except in an emergency or for renal dialysis. Some plans even require referrals from the PCP. Prior authorization would be required to access care outside of the network.
POS Plans:
A member has the option to receive services outside of the plan’s network; however, he/she generally pays more for out-of-network services.
PPO Plans:
A member has a network of providers and pay less when they use them. PPO’s generally do not require prior authorization or referrals for services to be covered. The member has the flexibility to go out of the plan’s network, but pay a higher cost share when they do. These plans are very similar to POS plans.
Special Needs Plans (SNP):
Provide focused and specialized health care for specific groups of beneficiaries, such as those who have both Medicare and Medicaid, who live in a nursing home, or have certain chronic medical conditions.

15. Medicare – Part C Eligibility
Must have and maintain Medicare Parts A and B
Must permanently live within the plan’s service area
Brevard and Indian River Counties for Health First Health Plans
Volusia, Flagler, Hardee, Highland, and Seminole Counties for Florida Hospital Care Advantage
May not have ESRD, with limited exceptions
To be eligible to enroll on a Medicare Advantage plan you must:
Be entitled to Medicare Part A;
Be enrolled in Medicare Part B;
Live the plan’s service area
Not have End Stage Renal Disease (ESRD)
If you currently pay a premium for Part A and/or Part B, you must continue paying this premium.

16. Health First Health Plans (HFHP)
HFHP 2018 MAPD/MA Plans
Health First Health Plans (HFHP)
4 Individual Medicare Advantage plans:
Classic HMO-POS
Value HMO
Rewards HMO
Secure HMO (no Part D)
Brevard & Indian River Counties
4 Group Medicare Advantage plans:
Group Plus A HMO
Group Plus B HMO
Group POS
Please refer to the Health First Health Plans Benefits at a Glance sheet for general information on each plan.

17. Florida Hospital Care Advantage (FHCA) administered by HFHP
FHCA 2018 MAPD/MA Plans
Florida Hospital Care Advantage (FHCA) administered by HFHP
1 Individual Medicare Advantage plans:
SunSaver HMO-POS*
Volusia, Flagler, Hardee, Highland & Seminole Counties
3 Group Medicare Advantage plans:
Group Plus C HMO
Group Plus D HMO
Group POS
Please refer to the Florida Hospital Care Advantage Benefits at a Glance sheet for general information on each plan.

18. Medicare Enrollment Periods
Initial Enrollment Period (IEP)
7 month period when an individual first becomes eligible for Medicare
Annual Enrollment Period (AEP)
October 15th through December 7th of each year
Medicare Advantage Disenrollment Period
January 1st through February 14th of each year
Special Enrollment Period (SEP)
Allows beneficiaries with special circumstances to make changes in their Medicare coverage
The Initial Enrollment Period applies when you first become eligible for Medicare Part A and/or Part B. This is a seven month period that begins 3 months before the month you are eligible, the month you are eligible, and ends 3 months after you are eligible.
If you have chosen to enroll in a Medicare Advantage Plan or a Prescription Drug Plan, you will have an opportunity every year to switch to a different plan. The time in which you can do this is called the Annual Election Period (AEP), which runs from October 15th to December 7th of each year with January 1st effective date.
The Medicare Advantage Disenrollment Period (MADP) begins January 1st and ends February 14th. During this time, you can only disenroll from a Medicare Advantage Plan and go back to Original Medicare. Medicare will allow you to enroll on a stand-alone Prescription Drug Plan.
From February 15th through December 31st, you will be locked into the plan you have selected.
A Special Enrollment Period may apply if you meet certain life changing events, such as moving out of the plan’s service area. Those qualifying for Low Income Subsidy have the ability to change their plan on a monthly basis. Please refer to handout to see if you qualify Special Enrollment Period.

19. Medicare Member Enrollment
Sales provides enrollment application to the Enrollment Department
Enrollment Department performs application verification call to verify the PM does want to enroll
Enrollment Department submits application to CMS
If the PM is eligible, they are enrolled.
Member receives an ID card, plan materials, and enrollment verification letter and call.
Member receives welcome call from CSD within 90 days
Within 10 calendar days a member will receive:
An Acknowledgment letter showing their Member number, plan name and effective date. This can be used as proof of coverage until he/she receives their ID card.
A Medicare Enrollment Confirmation letter included with their Evidence of Coverage (EOC) document, also known as their contract.
Within 15 calendar days a member will receive:
An Enrollment Verification letter. This letter verifies their enrollment request onto our plan.
And a Membership ID card that will be used for all medical and prescription needs in place of the red, white and blue Medicare card.