Opinions on what is expected with the final rule for Medicare

[YourMiHealthAgenc]

Hello,
I wanted to start a thread with what peoples expectations are on what will happen with the MAPD/Medicare market with the recent proposed updates. I have read so many different interpretations and expect that things will change a few more times before it is truly "final." Nevertheless, here are some of our thoughts. . . What are yours?



Final Medicare Marketing Rule

1. Agent and Broker Compensation: Standardizes compensation to prevent steering enrollees towards specific plans based on commissions. Increases base compensation for agents and brokers by $100 (previously proposed increase was $31) first year with a $50 renewal. Prohibits contract terms that incentivize biased recommendations. A fixed amount will be paid to agents and brokers regardless of the plan an enrollee chooses. It aims to eliminates bias caused by commissions that were previously tied to specific plans. This will be up to the carrier to decide to pay this increase.
2. Prohibition on Biased Contracts: The rule prohibits contract terms between Medicare Advantage plans and marketing organizations that create incentives for agents/brokers to favor certain plans over others.
3. Personal Beneficiary Data: Limits sharing of personal data by third-party marketing organizations. Requires explicit consent for data sharing between organizations.
   1. Will impact lead generators.
4. Access to Behavioral Health Care: Establishes network adequacy standards for a new "Outpatient Behavioral Health" category, encompassing various providers. Requires plans to include telehealth providers for behavioral health services.
5. Transparency of Supplemental Benefits: Requires plans to notify enrollees about unused supplemental benefits in mid-year. Standardizes information provided about available benefits. This might get changed to quarterly.
6. New Standards for Supplemental Benefits for Chronically Ill: Requires plans to demonstrate the effectiveness of these benefits with research. Updates marketing and communication requirements to prevent misleading information.
7. Health Equity Analysis of Utilization Management: Requires plans to analyze utilization management practices for potential bias against underserved populations. Mandates public reporting of these analyses.
8. Appeals Process for Termination of Services: Expands enrollee rights to appeal termination decisions through a faster review process.
9. Increasing Integration for Dually Eligible Individuals: Encourages enrollment in Medicare Advantage plans affiliated with Medicaid managed care plans. Limits enrollment in certain plans for individuals not enrolled in affiliated Medicaid plans (reduces aggressive marketing tactics). Creates a new monthly enrollment period for switching to standalone prescription drug plans and DSNP MAPD plans (previously quarterly).
10. Medicare Advantage D-SNP PPO Out-of-Network Cost Sharing: Limits out-of-network cost-sharing for specific services starting in 2026 (reduces cost-shifting to Medicaid, impact figures not yet available).
11. Contracting Standards for Dual Eligible Special Needs Plan Look-Alikes: Lowers the D-SNP look-alike threshold from 80% to 70% in 2025 and to 60% in 2026 (to ensure plans meet D-SNP requirements).
12. Standardization of Medicare Advantage Risk Adjustment Appeals Process: Streamlines the appeals process for disagreements over payment calculations.
13. Increased Flexibility for Biosimilar Substitution in Part D Plans: Allows for faster substitution of biosimilar drugs for more affordable options. Provides enrollees with earlier access to cost-effective alternatives.
14. Improved Targeting for Medicare Part D Medication Therapy Management: Expands access to medication management services for enrollees with specific chronic conditions (including HIV/AIDS) and high medication costs (threshold set at $1,623 for annual cost in 2025).

Short-Term Health Plan Rule

1. Beginning September 1, 2024, short-term products are restricted to a term of no more than 3 months with an option one month renewal or extension, for a maximum duration of no more than 4 months.
   1. At this point, you would need to move them to another plan and do the same thing as long as healthy. (This is added interpretation)
2. The regulation prohibits policy stacking by the same underwriter or another affiliate under same control group within a rolling 12-month period beginning on the effective date of initial enrollment.
3. A new short-term consumer notice must be displayed in 14-point font type on first page of the policy certificate and application. It also must be prominently displayed in all print and electronic marketing materials, including websites.
4. More to come…..

 

[goillini52]

Hello,
I wanted to start a thread with what peoples expectations are on what will happen with the MAPD/Medicare market with the recent proposed updates. I have read so many different interpretations and expect that things will change a few more times before it is truly "final." Nevertheless, here are some of our thoughts. . . What are yours?



Final Medicare Marketing Rule

1. Agent and Broker Compensation: Standardizes compensation to prevent steering enrollees towards specific plans based on commissions. Increases base compensation for agents and brokers by $100 (previously proposed increase was $31) first year with a $50 renewal. Prohibits contract terms that incentivize biased recommendations. A fixed amount will be paid to agents and brokers regardless of the plan an enrollee chooses. It aims to eliminates bias caused by commissions that were previously tied to specific plans. This will be up to the carrier to decide to pay this increase.
2. Prohibition on Biased Contracts: The rule prohibits contract terms between Medicare Advantage plans and marketing organizations that create incentives for agents/brokers to favor certain plans over others.
3. Personal Beneficiary Data:Limits sharing of personal data by third-party marketing organizations. Requires explicit consent for data sharing between organizations.
   1. Will impact lead generators.
4. Access to Behavioral Health Care: Establishes network adequacy standards for a new "Outpatient Behavioral Health" category, encompassing various providers. Requires plans to include telehealth providers for behavioral health services.
5. Transparency of Supplemental Benefits: Requires plans to notify enrollees about unused supplemental benefits in mid-year. Standardizes information provided about available benefits. This might get changed to quarterly.
6. New Standards for Supplemental Benefits for Chronically Ill: Requires plans to demonstrate the effectiveness of these benefits with research. Updates marketing and communication requirements to prevent misleading information.
7. Health Equity Analysis of Utilization Management: Requires plans to analyze utilization management practices for potential bias against underserved populations. Mandates public reporting of these analyses.
8. Appeals Process for Termination of Services: Expands enrollee rights to appeal termination decisions through a faster review process.
9. Increasing Integration for Dually Eligible Individuals: Encourages enrollment in Medicare Advantage plans affiliated with Medicaid managed care plans. Limits enrollment in certain plans for individuals not enrolled in affiliated Medicaid plans (reduces aggressive marketing tactics). Creates a new monthly enrollment period for switching to standalone prescription drug plans and DSNP MAPD plans (previously quarterly).
10. Medicare Advantage D-SNP PPO Out-of-Network Cost Sharing: Limits out-of-network cost-sharing for specific services starting in 2026 (reduces cost-shifting to Medicaid, impact figures not yet available).
11. Contracting Standards for Dual Eligible Special Needs Plan Look-Alikes: Lowers the D-SNP look-alike threshold from 80% to 70% in 2025 and to 60% in 2026 (to ensure plans meet D-SNP requirements).
12. Standardization of Medicare Advantage Risk Adjustment Appeals Process: Streamlines the appeals process for disagreements over payment calculations.
13. Increased Flexibility for Biosimilar Substitution in Part D Plans: Allows for faster substitution of biosimilar drugs for more affordable options. Provides enrollees with earlier access to cost-effective alternatives.
14. Improved Targeting for Medicare Part D Medication Therapy Management: Expands access to medication management services for enrollees with specific chronic conditions (including HIV/AIDS) and high medication costs (threshold set at $1,623 for annual cost in 2025).

Short-Term Health Plan Rule

1. Beginning September 1, 2024, short-term products are restricted to a term of no more than 3 months with an option one month renewal or extension, for a maximum duration of no more than 4 months.
   1. At this point, you would need to move them to another plan and do the same thing as long as healthy. (This is added interpretation)
2. The regulation prohibits policy stacking by the same underwriter or another affiliate under same control group within a rolling 12-month period beginning on the effective date of initial enrollment.
3. A new short-term consumer notice must be displayed in 14-point font type on first page of the policy certificate and application. It also must be prominently displayed in all print and electronic marketing materials, including websites.
4. More to come…..

CMS Final Rule for MA/part D overrides

Many individuals with Medicare rely on agents and brokers to help navigate complex Medicare choices as they comparison shop for coverage options. The Medicare statute requires that CMS must establish guidelines to ensure that the use of compensation creates incentives for agents and brokers to...

www.insurance-forums.com

 

[goillini52]

Hello,
I wanted to start a thread with what peoples expectations are on what will happen with the MAPD/Medicare market with the recent proposed updates. I have read so many different interpretations and expect that things will change a few more times before it is truly "final." Nevertheless, here are some of our thoughts. . . What are yours?



Final Medicare Marketing Rule

1. Agent and Broker Compensation: Standardizes compensation to prevent steering enrollees towards specific plans based on commissions. Increases base compensation for agents and brokers by $100 (previously proposed increase was $31) first year with a $50 renewal. Prohibits contract terms that incentivize biased recommendations. A fixed amount will be paid to agents and brokers regardless of the plan an enrollee chooses. It aims to eliminates bias caused by commissions that were previously tied to specific plans. This will be up to the carrier to decide to pay this increase.
2. Prohibition on Biased Contracts: The rule prohibits contract terms between Medicare Advantage plans and marketing organizations that create incentives for agents/brokers to favor certain plans over others.
3. Personal Beneficiary Data:Limits sharing of personal data by third-party marketing organizations. Requires explicit consent for data sharing between organizations.
   1. Will impact lead generators.
4. Access to Behavioral Health Care: Establishes network adequacy standards for a new "Outpatient Behavioral Health" category, encompassing various providers. Requires plans to include telehealth providers for behavioral health services.
5. Transparency of Supplemental Benefits: Requires plans to notify enrollees about unused supplemental benefits in mid-year. Standardizes information provided about available benefits. This might get changed to quarterly.
6. New Standards for Supplemental Benefits for Chronically Ill: Requires plans to demonstrate the effectiveness of these benefits with research. Updates marketing and communication requirements to prevent misleading information.
7. Health Equity Analysis of Utilization Management: Requires plans to analyze utilization management practices for potential bias against underserved populations. Mandates public reporting of these analyses.
8. Appeals Process for Termination of Services: Expands enrollee rights to appeal termination decisions through a faster review process.
9. Increasing Integration for Dually Eligible Individuals: Encourages enrollment in Medicare Advantage plans affiliated with Medicaid managed care plans. Limits enrollment in certain plans for individuals not enrolled in affiliated Medicaid plans (reduces aggressive marketing tactics). Creates a new monthly enrollment period for switching to standalone prescription drug plans and DSNP MAPD plans (previously quarterly).
10. Medicare Advantage D-SNP PPO Out-of-Network Cost Sharing: Limits out-of-network cost-sharing for specific services starting in 2026 (reduces cost-shifting to Medicaid, impact figures not yet available).
11. Contracting Standards for Dual Eligible Special Needs Plan Look-Alikes: Lowers the D-SNP look-alike threshold from 80% to 70% in 2025 and to 60% in 2026 (to ensure plans meet D-SNP requirements).
12. Standardization of Medicare Advantage Risk Adjustment Appeals Process: Streamlines the appeals process for disagreements over payment calculations.
13. Increased Flexibility for Biosimilar Substitution in Part D Plans: Allows for faster substitution of biosimilar drugs for more affordable options. Provides enrollees with earlier access to cost-effective alternatives.
14. Improved Targeting for Medicare Part D Medication Therapy Management: Expands access to medication management services for enrollees with specific chronic conditions (including HIV/AIDS) and high medication costs (threshold set at $1,623 for annual cost in 2025).

Short-Term Health Plan Rule

1. Beginning September 1, 2024, short-term products are restricted to a term of no more than 3 months with an option one month renewal or extension, for a maximum duration of no more than 4 months.
   1. At this point, you would need to move them to another plan and do the same thing as long as healthy. (This is added interpretation)
2. The regulation prohibits policy stacking by the same underwriter or another affiliate under same control group within a rolling 12-month period beginning on the effective date of initial enrollment.
3. A new short-term consumer notice must be displayed in 14-point font type on first page of the policy certificate and application. It also must be prominently displayed in all print and electronic marketing materials, including websites.
4. More to come…..

CMS Final Rule for MA/part D overrides

Many individuals with Medicare rely on agents and brokers to help navigate complex Medicare choices as they comparison shop for coverage options. The Medicare statute requires that CMS must establish guidelines to ensure that the use of compensation creates incentives for agents and brokers to...

www.insurance-forums.com

 

[DonP]

This has been discussed at length in other threads . The answer to you question is nobody knows what this will look like in the end . We have no idea what cms’s response is to questions for clarification carriers are asking . We have no idea how carriers determine what they want to do once clarification is made . They might want to keep most of the overrides and sink it into internal call centers .On your pt #1 compensation has always been up to the carrier what to pay up to fmv comp . They could take that and allocate to fmo’s . Your #9 for duals they’ll only be able to move monthly if their dual is integrated . Very few states have full integration as far as i know . I’ve read non integrated dual plans/lis will have the same enrollment periods as regular plans next yr like oep.aep etc

 

[YourMiHealthAgenc]

Thanks for the response! I did see after the post a few other threads. Appreciate your feedback.

 

[TwoCents]

This has been discussed at length in other threads . The answer to you question is nobody knows what this will look like in the end . We have no idea what cms’s response is to questions for clarification carriers are asking . We have no idea how carriers determine what they want to do once clarification is made . They might want to keep most of the overrides and sink it into internal call centers .On your pt #1 compensation has always been up to the carrier what to pay up to fmv comp . They could take that and allocate to fmo’s . Your #9 for duals they’ll only be able to move monthly if their dual is integrated . Very few states have full integration as far as i know . I’ve read non integrated dual plans/lis will have the same enrollment periods as regular plans next yr like oep.aep etc

I guess no one's shared the actual final rule with you all? It's sitting out there waiting publication. It has all CMS responses to submitted comments, etc.

Federal Register :: Request Access

Edit to add: Is it easy reading? Not the most fun for sure. The sub-regulatory guidance will be easier to digest as it's released.

 

[Surancedawg]

Your #9 for duals they’ll only be able to move monthly if their dual is integrated . Very few states have full integration as far as i know . I’ve read non integrated dual plans/lis will have the same enrollment periods as regular plans next yr like oep.aep etc

There seems to be a lot of confusion about changes to the LIS SEP. This is kind of important to those of who must rely on leads mostly coming from the Final Expense demographic - i.e. the "I need a food card" folks.

 

[TwoCents]

There seems to be a lot of confusion about changes to the LIS SEP. This is kind of important to those of who must rely on leads mostly coming from the Final Expense demographic - i.e. the "I need a food card" folks.

The currently quarterly SEP goes monthly and can only be used for PDP enrollment.

Then there's the monthly integrated SEP.

The "other" LIS/Medicaid SEP for those with a gain/loss/change in benefit level stays the same.

Does that clear it up?

 

[DonP]

The currently quarterly SEP goes monthly and can only be used for PDP enrollment.

Then there's the monthly integrated SEP.

The "other" LIS/Medicaid SEP for those with a gain/loss/change in benefit level stays the same.

Does that clear it up?

Correct . People with no lose ,gain , change in lis or Medicaid can only move during regular enrollment periods unless they move to an integrated plan . Most states don’t have integration so those people can’t move quarterly . If you do have an integrated plan you can move monthly . As far as confusion on the new rules . There’s mass confusion surround cam carriers pay fmos a try or of fee ? We know it can’t be an override for enrollments

 

[Duaine]

Beginning September 1, 2024, short-term products are restricted to a term of no more than 3 months with an option one month renewal or extension, for a maximum duration of no more than 4 months.

Ok, so I enroll Joe Blow into a Short Term plan on 01/01/24. He has answered NO to all health questions and thinks that he's healthy. Then he goes to the doctor for a pain a month later and finds out that he has cancer, needs heart surgery etc. Surgery scheduled for 04/01.

His ST policy has ended and he can't qualify for a new ST and he's passed the ACA open enrollment. So he is Sh*t out of luck until the next ACA open enrollment.

Is he just supposed to suck it up and die?