America's Benefit Specialist March 2023

MEDICARE MATTERS

is especially helpful, as it provides a step-by-step informa tion-gathering tool and documents your review. Ask about their physicians, including primary care and specialists. Most will request that you assist them with their prescrip tion-drug-coverage needs. Make sure to document the name, dosage, frequency and their preferred pharmacies. Ask if there any concerns with upcoming or scheduled procedures. Remember, you cannot ask about health history but, if available in their county, you should mention that there are special-needs plans for conditions such as COPD or diabetes. Don’t forget that it is always the beneficiaries’ final decision on what type of coverage and plan they want to enroll in. Your job is to make sure that they understand the options and coverages clearly. Review the plans thoroughly, including the star ratings for MAPD and stand-alone drug plans and their prescription coverages under the plans including the initial, coverage gap and the catastrophic coverages stages. Review how to access information for finding their phy sicians and networks and how the referral process works if enrolling into a MAPD plan. If it is a PPO plan, make sure they understand how to use the plan’s out-of-network benefits. Again, I find having a checklist is helpful to make sure I have covered all the important information. Provide the required materials, such as an outline of benefits, and if they are enroll ing in a Medicare Supplement Plan, include the CMS Guide to Choosing a Medigap Policy booklet. One piece of information many agents forget to mention is that when an individual has left an employer plan after their initial enrollment period and enrolled in a MAPD or stand-alone Part D plan, they will receive a letter from their plan requesting proof of prior coverage. Make sure these

clients know they need to respond within three weeks by phone or letter to confirm the prior coverage to avoid late-enrollment penalties. One of the biggest delays for coverage is the submission of incomplete applications. Make sure to review that your submission is as complete as possible. This is where the online submissions really are an asset to you, as it makes sure that the application is fully complete and it is handled on an expedited basis. Once you start using them, you will be hard pressed to go back to paper and faxing submissions. Finally, send a thank-you letter to your new clients. Make sure to include the plans they have applied for, the effective date applied for and the plan’s member services contact numbers. If prescription drug coverage is included, remind them of the coverages in the different stages. For MAPD and stand-alone drug plans, I remind them that they need to pay their premiums by the method they selected and that they must maintain their Medicare Part A and B coverage. Also remind them that you will be reviewing the plans during annual open enrollment. Today’s marketplace is becoming more and more com petitive. Agents who strive to meet their clients’ needs and concerns, help them enroll in the plan(s) that best fit their needs, and continue to provide ongoing service will see their practice continue to grow and thrive. Through the commit ment to providing excellent service and your expertise, you can make a difference!

Note: This article is from the February edition of NABIP’s Medicare News email.

CMS ISSUES FINAL RULE TO PROTECT MEDICARE, STRENGTHEN MA AND HOLD INSURERS ACCOUNTABLE

and aligning CMS’s oversight of the Traditional Medicare and MA programs. As required by law, CMS’s payments to MAOs are adjust ed based on the health status of enrollees, as determined through medical diagnoses reported by MAOs. Studies and audits done separately by CMS and the HHS Office of Inspector General have shown that Medicare Advantage enrollees’ medical records do not always support the diag noses reported by MAOs, which leads to billions of dollars in overpayments to plans and increased costs to the Medicare program as well as taxpayers. Despite this, no risk-adjust ment overpayments have been collected from MAOs since payment year 2007.

In late January, the Department of Health and Human Ser vices (HHS), through CMS, finalized the policies for the Medi care Advantage Risk-Adjustment Data Validation (RADV) program, which is CMS’s primary audit and oversight tool of MA program payments. Under this program, CMS identi fies improper risk-adjustment payments made to Medicare Advantage organizations (MAOs) in instances where medical diagnoses submitted for payment were not supported in the beneficiary’s medical record. The policies finalized in the RADV final rule (CMS-4185-F) will help CMS ensure that people with Medicare are able to access the benefits and services they need, including in Medicare Advantage, while responsibly protecting the fiscal sustainability of Medicare

36 ABS | benefitspecialistmagazine.com

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