CMS 2023 Agent Broker Compensation Guidelines

CMS has released the 2023 Agent Broker Compensation Guidelines that govern the maximum allowable first year and renewal compensation for agent level MA and PDP commissions. There is a significant increase in compensation for 2023.

 

 

These new rates reflect, roughly, a 4.9% increase in both initial and renewal compensation for MA and Cost Plans. Puerto Rico and the US Virgin Islands have an increase closer to 4.3%.  For PDPs, there is a 5.7% bump on initial and 4.5% bump on renewal commissions.  CMS also reaffirmed the standard referral fee limitations for MA/PDP plans at $100/$25, respectively.

 

Plan sponsors were reminded that compensation schedules must be submitted by 11:59 pm ET, July 20, 2022.

 

CMS also reminded plan sponsors of their obligation to ensure agents and brokers selling Medicare products are trained annually on Medicare A, B, C, and D, as well as on plan-specific information.  CMS annually publishes the testing and training requirements, including a sample test each year for guidance.

 

If you have questions about what these compensation changes mean for you, please reach out to your team at Cornerstone Senior Marketing.

CY 2023 Medicare Advantage and Part D Final Rule (CMS-4192-F)

CMS FACT SHEET: CMS is issuing a final rule that advances CMS’ strategic vision of expanding access to affordable health care and improving health equity in Medicare Advantage (MA) and Part D through lower out-of-pocket prescription drug costs and improved consumer protections.
An increasing number of Medicare beneficiaries receive services through MA and Part D plans. Over 27 million beneficiaries are enrolled in MA plans (including plans that offer Part D prescription drug coverage), and approximately 24 million beneficiaries are enrolled in standalone Part D plans. Additionally, an increasing number of beneficiaries who are dually eligible for both Medicare and Medicaid are enrolled in MA plans, Medicaid managed care, or both. About 4.1 million dually eligible beneficiaries currently receive their Medicare services through MA dual eligible special needs plans (D-SNPs).
The final rule revises the MA and Part D regulations related to marketing and communications; the criteria used to review applications for new or expanded MA and Part D plans, including compliance with MA provider network adequacy requirements; quality ratings for MA and Part D plans; medical loss ratio reporting; special requirements during disasters or public emergencies; how MA organizations calculate attainment of the maximum out-of-pocket (MOOP) limit for Parts A and B services; and the use of pharmacy price concessions to reduce beneficiary out of pocket costs for prescription drugs under Part D. This final rule also revises regulations for D-SNPs, and in some cases, other special needs plans, related to enrollee advisory committees, health risk assessments, and ways to improve integration of Medicare and Medicaid. Many finalized policies are based on lessons learned from the Medicare-Medicaid Financial Alignment Initiative.

CMS Marketing Changes

The marketing guidelines for Medicare Advantage and Prescription Drug Plans were updated on May 9, 2022. Among the provisions that apply directly to agents, the two most critical, which are to be in use by October 1, 2022, for Plan Year 2023, are a new required disclaimer and a requirement to record all sales calls with beneficiaries. While not comprehensive, the FAQ’s below will provide details. 

Required Disclaimer 

Disclaimer Language To Use:

“We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.” 

Who must use this disclaimer?

Any third-party marketing organization (which includes agents and brokers) must include this disclaimer. 

When and where do I have to have the disclaimer?

  • On all marketing materials: print (if possible, use a 12pt font), electronically, television, and radio
  • Within the first minute of all sales calls
  • Prominently displayed on TPMO websites
  • Verbally, electronically, or in writing, during any sales meeting with a beneficiary

What if I DO offer all plans in my area? 

While the regulation does provide a carve-out for TPMO’s that truly offer all plans in their area, it is exceedingly rare for an agent to truly be able to do this. In most areas, there are one or more plans that are offered only through captive agents, direct to consumer, or certain types of plans that agents and brokers cannot sell. Even if you do offer all plans in one county or service area, it is possible your marketing or referrals may extend to an area where that is not true, so the disclaimer would still be required. 

Requirement to Record Sales Calls

Under these new guidelines, all sales calls with beneficiaries and TPMO’s MUST be recorded and retained for 10 years, including enrollment calls. 

What constitutes a sales call? 

Any call that is related to what CMS calls the “chain of enrollment,” which has been defined as the events from a beneficiary becoming aware of an MA/PDP plan to the end of the enrollment process. This means that calling leads, scheduling appointments, collecting scopes of appointment (telephonically), presenting plans, collecting drug and doctor lists, and phone enrollments would all fall under this guidance. This list is not exhaustive, and other calls that contain marketing content will also need to be recorded and retained. 

How can I record and store calls? 

We recommend reaching out to your current phone provider to see if they offer call recording. If they do not, or it seems cost prohibitive, consider a VOIP phone system that can be used in the office or the field. Some common options are Ring Central, 8×8, and Vonage. For storage, you will need to develop a process for sorting and storing the calls either on a local drive or cloud-based storage. Since these calls contain sensitive data, most free storage accounts will not be HIPAA compliant. We are currently researching the best options for agents to compliantly store this data. 

What about in person appointments? 

In-person marketing and sales appointments do not need to be recorded, however, calls to set appointments or follow-up calls to answer benefit questions would require recording. Servicing questions about current plan business, such as claims, billing, and requesting in force plan documents, are not sales calls and would not require recording. 

I use my cell phone. How can I handle this? 

Most VOIP services have a mobile app version that would allow calls to be recorded from your mobile device. There are also recording apps that would allow for recording calls without VOIP. Be cautioned, however, as a stand-alone recording app will not include any disclaimers that may be required by your jurisdiction before recording, whereas most VOIP systems offer/include these options.

Please reach out with any questions to your team at Cornerstone Senior Marketing.  (614) 763-2255 |  [email protected]quirement to Record Sales Calls

Medicare weighs premium cut after limiting Alzheimer’s drug

File – The Biogen Inc., headquarters, Wednesday, March 11, 2020, in Cambridge, Mass. Medicare says it’s considering a cut in enrollee premiums, after officials stuck with an earlier decision to sharply limit coverage for a pricey new Alzheimer’s drug projected to drive up program costs. (AP Photo/Steven Senne, File) (ASSOCIATED PRESS)

RICARDO ALONSO-ZALDIVAR and MATTHEW PERRONE

Thu, April 7, 2022

WASHINGTON (AP) — Medicare said Thursday it’s considering a cut in enrollee premiums, after officials stuck with an earlier decision to sharply limit coverage for a pricey new Alzheimer’s drug projected to drive up program costs.

The agency “is looking at that, and is still going through the process,” spokeswoman Beth Lynk said of a potential reduction in premiums, as Medicare announced its final coverage decision for Aduhelm, a drug whose benefits have been widely questioned in the medical community.

Officials said Medicare will keep coverage restrictions imposed earlier on the $28,000-a-year medication, paying for Aduhelm only when it’s used in clinical trials approved by the Food and Drug Administration or the National Institutes of Health.

The projected cost of Aduhelm was a major driver behind a $22 increase in Medicare’s Part B premium this year, boosting it to $170.10 a month. That price hike is already being paid by more than 56 million Medicare recipients signed up for the program’s outpatient coverage benefit. Lawmakers have called for a rollback and Health and Human Services Secretary Xavier Becerra already directed Medicare to reassess.

Thursday’s coverage decision illustrates the impact that a single medication can have on the budgets of individuals and taxpayers. It comes as legislation to authorize Medicare to negotiate prescription drug prices remains stuck in the Senate, part of President Joe Biden’s stalled social and climate agenda.

That’s left Democrats with nothing to show on their midterm election-year promises to cut prescription drug costs, unless they can overcome internal disagreements. Most Medicare recipients have their premiums deducted from their monthly Social Security checks. And despite a big cost-of-living increase, they’re feeling the bite of inflation.

Medicare’s determination on Aduhelm included an important caveat. Officials said that if it or any other similar drug in its class were to receive what’s called “traditional” FDA approval, then Medicare would open up broader coverage for patients. Such approval is granted when a medication shows a clear clinical benefit.

That was not the case with Aduhelm. It received what’s known as “accelerated” approval last year because of its potential promise. But manufacturer Biogen is required to conduct a follow-up study to definitively answer whether Aduhelm truly slows the progression of Alzheimer’s. If that study is successful, FDA would grant full approval.

That would also open up Medicare coverage.

Dr. Lee Fleisher, chief medical officer of the Centers for Medicare & Medicaid Services, said “there will be quick access for Medicare beneficiaries” for Alzheimer’s drugs that receive the traditional FDA approval, after demonstrating a clear benefit.

Aduhelm hit the market as the first new Alzheimer’s medication in nearly two decades. Initially priced at $56,000 a year, it was expected to quickly become a blockbuster drug, generating billions for Cambridge, Mass.-based Biogen.

But although the company slashed the price in half — to $28,000 a year — Aduhelm’s rollout has been disastrous.

Pushback from politicians, physicians and insurers left the company with just $3 million in sales from Aduhelm last year. Doctors have been hesitant to prescribe it, given weak evidence that the drug slows the progression of Alzheimer’s. Insurers have blocked or restricted coverage over the drug’s high price tag and uncertain benefit.

The CMS decision means that for Medicare to pay, patients taking Aduhelm will have to be part of clinical trials to assess the drug’s safety and effectiveness in slowing the progression of early-stage dementia.

Tamara Syrek Jensen, head of CMS’s coverage and analysis unit, said “it’s status quo” as far as limitations the agency initially imposed on Aduhelm in January.

The limits stayed on despite a massive lobbying push by the Alzheimer’s Association to change Medicare’s position, including outreach to members of Congress, online advertising and social media campaigns directed at the agency.

The association, the largest group of its kind, has received contributions from drugmakers, including Biogen.

The group’s CEO said he was “very disappointed” after reviewing Medicare’s decision.

“Denying access to FDA-approved Alzheimer’s treatments is wrong,” Harry Johns said in a statement. “At no time in history has CMS imposed such drastic barriers to access FDA-approved treatments for people facing a fatal disease.”

Aduhelm has sparked controversy since the FDA approved it against the recommendation of outside advisers.

The medicine, administered intravenously in a doctor’s office, hasn’t been shown to reverse or significantly slow Alzheimer’s. But the FDA said its ability to reduce clumps of plaque in the brain is likely to slow dementia.

Many experts say there is little evidence to support that claim. And a federal watchdog and congressional investigators are conducting separate probes into how the FDA reviewed the medication.

Alzheimer’s is a progressive neurological disease with no known cure. The vast majority of U.S. patients are old enough to qualify for Medicare, which covers more than 60 million people, including those 65 and older, and disabled people under 65.

The reason Aduhelm falls under Medicare’s outpatient benefit, and not its pharmacy drug program, is that it’s given in a doctor’s office. Beneficiary premiums are set to cover about 25% of the cost of outpatient care.

 

CMS ALERT February 3, 2022

Biden-Harris Administration Will Cover Free Over-the-Counter COVID-19 Tests Through Medicare

CMS News Alert – February 3, 2022 

CMS Developing Initiative to Enable Access to Eight Free Over-the-Counter COVID-19 Tests for Medicare Beneficiaries in Early Spring

As part of the Biden-Harris Administration’s ongoing efforts to expand Americans’ access to free testing, people in either Original Medicare or Medicare Advantage will be able to get over the-counter COVID-19 tests at no cost starting in early spring. Under the new initiative, Medicare beneficiaries will be able to access up to eight over-the-counter COVID-19 tests per month for free. Tests will be available through eligible pharmacies and other participating entities. This policy will apply to COVID-19 over-the-counter tests approved or authorized by the U.S. Food and Drug Administration (FDA).

This is the first time that Medicare has covered an over-the-counter test at no cost to beneficiaries. There are a number of issues that have made it difficult to cover and pay for over the-counter COVID-19 tests. However, given the importance of expanding access to testing, CMS has identified a pathway that will expand access to free over-the-counter testing for Medicare beneficiaries. This new initiative will enable payment from Medicare directly to participating pharmacies and other participating entities to allow Medicare beneficiaries to pick up tests at no cost. CMS anticipates that this option will be available to people with Medicare in the early spring.

 

Until then, people with Medicare can access free tests through a number of channels established by the Biden-Harris Administration. Medicare beneficiaries can:

  • Request four free over-the-counter tests for home delivery at covidtests.gov.
  • Access COVID-19 tests through healthcare providers at over 20,000 free testing sites nationwide. A list of community-based testing sites can be found here.
  • Access lab-based PCR tests and antigen tests performed by a laboratory when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional at no cost. In addition to accessing a COVID-19 lab test ordered by a health care professional, people with Medicare can also already access one lab-performed test without an order, also without cost sharing, during the public health emergency.

In addition:

  • Medicare Advantage plans may offer coverage and payment for over-the-counter COVID-19 tests as a supplemental benefit in addition to covering Medicare Part A and Part B benefits, so Medicare beneficiaries covered by Medicare Advantage should check with their plan to see if it includes such a benefit.
  • All Medicare beneficiaries with Part B are eligible for the new benefit, whether enrolled in a Medicare Advantage plan or not.

For more information, please see these Frequently Asked Questions, https://www.cms.gov/files/document/covid-19-over-counter-otc-tests-medicare-frequently-asked-questions.pdf

Insurance Companies and Group Health Plans to Cover the Cost of At-Home COVID-19 Tests

Posted by CMS Jan 10, 2022:
As part of its ongoing efforts across many channels to expand Americans’ access to free testing, the Biden-Harris Administration is requiring insurance companies and group health plans to cover the cost of over-the-counter, at-home COVID-19 tests, so people with private health coverage can get them for free starting January 15th.  The new coverage requirement means that most consumers with private health coverage can go online or to a pharmacy or store, buy a test, and either get it paid for up front by their health plan, or get reimbursed for the cost by submitting a claim to their plan. This requirement incentivizes insurers to cover these costs up front and ensures individuals do not need an order from their health care provider to access these tests for free.

Beginning January 15, 2022, individuals with private health insurance coverage or covered by a group health plan who purchase an over-the-counter COVID-19 diagnostic test authorized, cleared, or approved by the U.S. Food and Drug Administration (FDA) will be able to have those test costs covered by their plan or insurance. Insurance companies and health plans are required to cover 8 free over-the-counter at-home tests per covered individual per month. That means a family of four, all on the same plan, would be able to get up to 32 of these tests covered by their health plan per month. There is no limit on the number of tests, including at-home tests, that are covered if ordered or administered by a health care provider following an individualized clinical assessment, including for those who may need them due to underlying medical conditions.

“Under President Biden’s leadership, we are requiring insurers and group health plans to make tests free for millions of Americans. This is all part of our overall strategy to ramp-up access to easy-to-use, at-home tests at no cost,” said HHS Secretary Xavier Becerra. “Since we took office, we have more than tripled the number of sites where people can get COVID-19 tests for free, and we’re also purchasing half a billion at-home, rapid tests to send for free to Americans who need them. By requiring private health plans to cover people’s at-home tests, we are further expanding Americans’ ability to get tests for free when they need them.”

Over-the-counter test purchases will be covered in the commercial market without the need for a health care provider’s order or individualized clinical assessment, and without any cost-sharing requirements such as deductibles, co-payments or coinsurance, prior authorization, or other medical management requirements.

As part of the requirement, the Administration is incentivizing insurers and group health plans to set up programs that allow people to get the over-the-counter tests directly through preferred pharmacies, retailers or other entities with no out-of-pocket costs.  Insurers and plans would cover the costs upfront, eliminating the need for consumers to submit a claim for reimbursement.  When plans and insurers make tests available for upfront coverage through preferred pharmacies or retailers, they are still required to reimburse tests purchased by consumers outside of that network, at a rate of up to $12 per individual test (or the cost of the test, if less than $12). For example, if an individual has a plan that offers direct coverage through their preferred pharmacy but that individual instead purchases tests through an online retailer, the plan is still required to reimburse them up to $12 per individual test. Consumers can find out more information from their plan about how their plan or insurer will cover over-the-counter tests.

“Testing is critically important to help reduce the spread of COVID-19, as well as to quickly diagnose COVID-19 so that it can be effectively treated. Today’s action further removes financial barriers and expands access to COVID-19 tests for millions of people,” said CMS Administrator Chiquita Brooks-LaSure.

State Medicaid and Children’s Health Insurance Program (CHIP) programs are currently required to cover FDA-authorized at-home COVID-19 tests without cost-sharing. In 2021, the Biden-Harris Administration issued guidance explaining that State Medicaid and Children’s Health Insurance Program (CHIP) programs must cover all types of FDA-authorized COVID-19 tests without cost sharing under CMS’s interpretation of the American Rescue Plan Act of 2019 (ARP). Medicare pays for COVID-19 diagnostic tests performed by a laboratory, such as PCR and antigen tests, with no beneficiary cost sharing when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional. People enrolled in a Medicare Advantage plan should check with their plan to see if their plan offers coverage and payment for at-home over-the-counter COVID-19 tests.

This effort is in addition to a number of actions the Biden Administration is taking to expand access to testing for all Americans. The U.S. Department of Health and Human Services (HHS) is providing up to 50 million free, at-home tests to community health centers and Medicare-certified rural health clinics for distribution at no cost to patients and community members. The program is intended to ensure COVID-19 tests are made available to populations and settings in need of testing. HHS also has established more than 10,000 free community-based pharmacy testing sites around the country.  To respond to the Omicron surge, HHS and FEMA are creating surge testing sites in states across the nation.

CMS Announces 2022 Medicare Parts A & B Premiums

Nov. 12, 2021 | Medicare Parts A & B

Today, the Centers for Medicare & Medicaid Services (CMS) released the 2022 Medicare Parts A and B premiums, deductibles, and coinsurance amounts, and the 2022 Part D income-related monthly adjustment amounts. Most people with Medicare will see a 5.9 percent cost-of-living adjustment (COLA) in their 2022 Social Security benefits—the largest COLA in 30 years. This significant COLA increase will more than cover the increase in the Medicare Part B monthly premium.

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A. The increase in the standard monthly premium—from $148.50 in 2021 to $170.10 in 2022—is based in part on the statutory requirement to prepare for expenses, such as spending trends driven by COVID-19, and prior Congressional action in the Continuing Appropriations Act, 2021 that limited the 2021 Medicare Part B monthly premium increase during the COVID-19 pandemic. It also reflects the need to maintain a contingency reserve for unanticipated increases in health care spending, particularly certain drug costs. There is significant uncertainty regarding the potential for future coverage of clinician-administered Alzheimer’s drugs (i.e., Aduhelm™), requiring additional contingency reserves. Potential Medicare drug coverage is currently the subject of a Medicare National Coverage Determination (NCD) analysis, which, if covered, could increase Medicare spending. The proposed NCD on Aduhelm (as well as any drugs in this category) is still to be determined.

Most people with Medicare will see a significant net increase in Social Security benefits. For example, a retired worker who currently receives $1,565 per month from Social Security can expect to receive a net increase of $70.40 more per month after the Medicare Part B premium is deducted.

“CMS is committed to ensuring high quality care and affordable coverage for those who rely on Medicare today, while protecting Medicare’s sustainability for future generations,” said CMS Administrator Chiquita Brooks-LaSure. “The increase in the Part B premium for 2022 is continued evidence that rising drug costs threaten the affordability and sustainability of the Medicare program. The Biden-Harris Administration is working to make drug prices more affordable and equitable for all Americans, and to advance drug pricing reform through competition, innovation, and transparency.”

By law, the Medicare Part B monthly premium must equal 25 percent of the estimated total Part B costs for enrollees age 65 and over. CMS has a responsibility to establish an annual Part B premium that will adequately fund projected Medicare spending and maintain an adequate reserve in case actual costs are higher than estimated.

The annual deductible for Medicare Part B beneficiaries grows with the Part B financing and is increasing from $203 in 2021 to $233 in 2022.

Read the full article

CMS Announces Long-Awaited Medicare Plan Finder Improvements

Sourced from: Medicarerights.org 

CMS has announced plans to improve and update the Medicare Plan Finder (MPF) and the Health Plan Management System (HPMS). HPMS is the system that Medicare Advantage and Part D plans use to provide data about their plan offerings to Medicare, and the MPF is the online tool that allows beneficiaries to evaluate, compare, and enroll in those plans. The changes will be in place for the start of the Medicare Open Enrollment Period starting on October 15 for 2022 plans.

 

VIEW COMPLETE ARTICLE 

CMS: 2022 Max Broker Commissions for MA & Medicare Part D

Medicare Advantage commissions will increase 6.31% in 2022! 

Each year, CMS publishes the Fair Market Value (FMV) amounts for initial and renewal compensation.

The amounts for 2022 plan years for Medicare Advantage and PDP are as follows:

READ FULL CMS RELEASE HERE

If you have any questions please reach out to your Cornerstone Senior Marketing representative. 

NAHU: BENES Act Passes

Announcement from NAHU from 12/23/20: 

BENES Act Passes Congress

 

NAHU has advocated for passage of the BENES Act and we are pleased to let you know it was included in the final package passed by the Senate early Tuesday morning. We believe its provisions will help your clients who are transitioning to Medicare and those who may need an SEP:

  • The Coverage Gap Closure. The bill eliminates the up to seven-month-long wait for coverage that people can experience when they sign up for Medicare during the General Enrollment Period or in the later months of their Initial Enrollment Period. Beginning in 2023, Medicare coverage will begin the month after enrollment.
  • The “Exceptional Circumstances” SEP. It reduces barriers to care by expanding Medicare’s authority to grant a Special Enrollment Period for “exceptional circumstances.” A long-standing flexibility within Medicare Advantage and Part D, in 2023 this critical tool will be available to facilitate enrollments program-wide, enhancing beneficiary access and administrative consistency.
  • The Enrollment Alignment Study. To further maximize coverage continuity and ease transitions to Medicare, the bill directs HHS to identify ways to align Medicare’s annual enrollment periods. HHS is to present these findings in a report to Congress by January 1, 2023.