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Medicare Compliance



Plan N Guidance

For the past few years, many Medicare beneficiaries have been looking at a Medicare Supplement Plan N as an option to save on premiums, while still retaining access to Original Medicare’s freedom of providers. But there are always many questions surrounding Plan N. Namely, what are these copays for? Plan N includes nominal copays for both office visits (maximum $20 copay) and Emergency Room visits that do not result in an admission (maximum $50 copay). So, the common question is, “What will I pay, and when?”

The NAIC has updated its guidance on Plan N, Revised Questions and Answers Regarding Implementation of Medicare Supplement Plan N Copayment, Deductible and Coinsurance. We have included a chart and cost sheet that outlines exactly which billing codes trigger a plan N copay, as well as a couple of examples of how copays are calculated for members on a plan N supplement. While agents should generally not speculate on the exact costs a client may experience, this sheet gives the client a great baseline understanding of why a copay may be less than the $20/$50 maximum. As a reminder, Plan N beneficiaries must also pay the part B deductible before these more fixed copays “kick-in.”

The following important details are not included in the chart: Plan N members will pay the part B deductible first (before being subject to any of these copays), and the emergency room copay does not apply if the member is subsequently admitted as an inpatient.

2022 Medicare Marketing Final Rule

Advocates, SHIP and agents have decried misleading Medicare enrollment T.V. ads for years. The Joe Namath ads are reviled and have become the posterchild for misleading seniors into contacting call centers that switch the beneficiaries into plans that may not fit their needs. CMS released a proposed rule, CMS-4192-P, CY 2023 Medicare Advantage and Part D proposed rule which included a provision on Marketing and Communications Oversight. NAHU convened the FMO Council to discuss the proposal to require agents to record enrollment encounters and particularly, the definition of Third-Party Marketing Organization (TPMO), which included licensed agents.

To learn more about the Medicare Marketing Rule and how it impacts you, check out our Medicare Marketing Rule Resources page.

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NAHU has released new, informative flyers for you and your Medicare clients, including the newest information on navigating enrollment periods. Click here to access them.

CMS, the federal agency that regulates the Medicare program, also regulates the Medicare’s Part C and D products you may be recommending to beneficiaries. NAHU will post compliance issues or other information you need to know as a Medicare specialists serving Medicare beneficiaries. If there is an issue or concern, you can contact us here.

COVID-19

Administration Drives Telehealth Services in Medicaid and Medicare

CMS expanded the list of telehealth services that Medicare Fee-For-Service will pay for during COVID-19. The agency is also providing additional support to state Medicaid and Children’s Health Insurance Program (CHIP) agencies in their efforts to expand access to telehealth. 

History of Observation Status and Current Developments, Including Suspension of 3-Day Rule Due to COVID-19

A recent news article on the JAMA Health Forum explored the recent history of and recent policy changes in hospital observation care payment policy and the 3-day rule brought about by the COVID-19 pandemic.

CMS Increases Medicare Payment for High-Production Coronavirus Lab Tests

Medicare will pay the higher payment of $100 for COVID-19 clinical diagnostic lab tests making use of high-throughput technologies developed by the private sector that allow for increased testing capacity, faster results, and more effective means of combating the spread of the virus. Medicare will pay laboratories for the tests at $100 effective April 14, 2020, through the duration of the COVID-19 national emergency.

CMS Issues Waivers of Observation Status Due to COVID-19

On March 14 2020, CMS issued two waivers to aid skilled nursing facilities in addressing the national COVID-19 outbreak. CMS is waiving both the 3-Day Stay and Spell of Illness requirements – nationally.

CMS Issues Guidance to help Medicare Advantage and Part D Plans Respond to COVID-19

On March 10, 2020 CMS issued guidance where they outlined the flexibilities MA and Part D plans have to waive certain requirements to help prevent the spread of COVID-19. 

CMS Releases Fact Sheet on Telehealth

On March 9, 2020, CMS released a fact sheet on telehealth, coverage and payment related to COVID-19.

General Medicare News

Medicare Advantage: Beneficiary Disenrollments to Fee-for-Service in Last Year of Life Increase Medicare Spending

The Government Accountability Office found that Medicare Advantage beneficiaries in the last year of life disproportionately disenrolled to enroll in fee-for-service, indicating possible issues with their care. Shifting end-of-life costs to fee-for-service increased Medicare spending by hundreds of millions of dollars.

Inspector General Warns About New Social Security Benefit Suspension Scam

Beneficiaries have been receiving fraudulent letters threatening suspension of Social Security benefits due to COVID-19 or coronavirus-related office closures. Social Security will not suspend or discontinue benefits because their offices are closed. Read more here.

NAIC and Medigap C & F

The Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”) prohibits new sales of Medigap Plans C and F for newly eligible beneficiaries beginning in 2020. NAIC outlines model regulation deadlines and requirements to states effective January 1, 2020.