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Key Changes for DSNP Plans in 2025

Key Changes for DSNP Plans in 2025

by | Dec 18, 2024 | Blog | 0 comments

Key Changes for DSNP Plans in 2025
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Jeff Palo

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The Centers for Medicare & Medicaid Services (CMS) has announced some big changes in their final rule that will affect DSNP plans and the special election period (SEP) for 2025.

 If you’re a producer working on new business or managing a large portfolio, you’ll need to understand these upcoming changes and what they mean for you.

How Producers Will Be Affected These changes might present both hurdles and chances for producers dealing with dual-eligible plans. While some modifications are limited, others are clarified, altering the landscape for those deeply involved with dual-eligible clients.

Access to Resources

We know you’ve got questions about how to watch our webinars, and we’re here to make it simple. All our webinars, including the latest ones, are available on our YouTube channel, Pinnacle Financial Services. By subscribing, you’ll never miss out—you’ll get notifications about new content and stay updated weekly.

Key Changes Overview

The CMS final rule introduces considerable adjustments affecting full dual eligible beneficiaries, partial dual eligible beneficiaries, and LIS-only members. These changes will be effective from January 1, 2025, and apply during the annual period when you are writing new businesses.

Quarterly Update Elimination: The quarterly election period for full duals, partial duals, and LIS-only members will be removed, transitioning to a more structured framework moving forward.

New Monthly SEPs: A significant shift is the introduction of monthly SEPs. These will enable beneficiaries to make specific changes more frequently:

  • Disenrollment Options: Beneficiaries can disenroll from an MAPD to revert to original Medicare and enroll in a standalone drug plan.
  • Drug Plan Adjustments: Monthly adjustments are allowed for standalone drug plan changes within the year.
  • DSNP Plan Changes: Full dual eligibles can change to an integrated DSNP plan, emphasizing the need to identify integrated and aligned DSNPs.

Emphasizing DSNP Plan Integration Levels

These changes necessitate understanding DSNP integration levels. Full dual eligibles can migrate to fully integrated Dual Eligible Special Needs Plans (FI-SNP), Highly Integrated Dual Eligible Special Needs Plans (HIDE-SNP), or other applicable integrated plans (AIP).

Alignment and Future Considerations

Aligned enrollments will become increasingly critical, potentially restricting DSNP enrollments to aligned options by 2027. Understanding the relationship between Medicaid managed care organizations (MCOs) and DSNPs is vital, as these affiliations will determine eligible enrollment.

State-Specific Dynamics

Producers should be aware that the availability of eligible dual plans may vary significantly across states. Many states primarily offer coordination-only plans, limiting election use for full duals if integrated options aren’t available.

Conclusion

As we move into 2025, it’s vital to stay on top of the new regulations and understand all the nuances. Producers need to keep updated on the status of DSNP plans and make the most of the existing SEPs and resources to maximize dual enrollment and retention strategies.

If you have any questions or need further clarification, give us a call at 1-800-772-6881. And don’t forget to check out our YouTube channel for the latest updates. Stay informed and prepared as we head into 2025 to maintain your edge in the insurance industry.

For more information, contact a Pinnacle Financial Services representative today 1 (800) 772-6881 x7731 | sales@pfsinsurance.com
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Jeff Palo

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Social Security Increase and Medicaid

Social Security Increase and Medicaid

by | Feb 8, 2023 | Blog | 0 comments

Social Security Increase and Medicaid
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Jeff Palo

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Social Security Increase and Medicaid by the Numbers.

In October 2022, the Social Security Administration announced an 8.7% Cost of Living (COLA) increase in Social Security payments.  These annual increases are determined by the increase in the Consumer Price Index for Urban Wage Earners and Clerical Workers (CPI-W).

 They are designed to help Social Security beneficiaries keep pace with inflation.  The idea is for benefits to not lose value over time.  This 8.7% increase is the largest COLA increase since 2009.  It’s set to go into effect on March 1st, 2023.  Social Security is a Federal program, whereas Medicaid is administered through individual state programs.  Medicaid rules are complex and vary greatly, so it’s important to be specific with every individual.  A good rule of thumb is, if you make less than 100% to 200% of the federal poverty level (FPL) and are pregnant, elderly, disabled, a parent/caretaker, or have a child, there’s likely a program for you.

Social Security Increase and Medicaid Eligibility.

There have been mixed reactions to the recent COLA increase.  Some beneficiaries have rejoiced at the increase in their monthly checks, while others are worried about how it will impact their Medicaid eligibility. Medicaid is a need-based program that provides health coverage to people with limited income and resources. In many states, beneficiaries with income above a certain threshold are not eligible for Medicaid.  Social Security income is considered “countable” income in regard to Medicaid eligibility. As an example, someone’s countable income was $1,000 per month before the increase and is now $1,087 per month.  This could make them ineligible for Medicaid.  

Remember, not all states will be affected by this increase in the same way.  There can be more generous or strict income thresholds. some states have “spend-down” provisions, allowing for medical expenses to drop an individual’s income below the threshold.  Asset, marital status, and living situation are also factors in determining Medicaid eligibility. It’s always best to have clients speak with a Social Security representative or Medicaid specialist to understand how changes impact their eligibility.

Social Security Increase and Medicaid Conclusion.

It’s always important to stay informed about any changes coming from the government, such as new CMS marketing rules.  Many Medicare Advantage carriers now offer tools to help determine Medicaid eligibility in real-time when sitting with a potential client.  In certain states, there are State Pharmaceutical Assistance Programs (SPAP) designed to help with costs, which also create a Special Election Period for Medicare Advantage.  Some carriers offer plans that cater to those beneficiaries with partial dual eligibility.  It’s important to have the proper quoting tool that shows all plans that are available to you as an agent in your area, such as Connect4Medicare.  Be sure to take advantage of the tools available to help your clients make the best decision for their health and finances.

Be sure to subscribe to our posts to receive information in real-time.

For more information on Medicare OEP and one-on-one support, click here to contact your Sales Director.

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Understanding Medicare OEP Rules

Understanding Medicare OEP Rules

by | Dec 13, 2022 | Blog | 0 comments

Understanding Medicare OEP Rules
j

Jeff Palo

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The Medicare Open Enrollment Period (OEP) occurs each year between January 1st and March 31st.  It is important to understand the Medicare OEP rules.  A client must be on a Medicare Advantage plan to take advantage of the OEP opportunity.  If your client is currently on a Medicare Advantage plan, they can either make a one-time switch to a different Medicare Advantage Plan or go back to their Original Medicare and enroll in a stand-alone Prescription Drug Plan.  The new plan would be effective the first of the month following the submission of the enrollment.

It is important to remember that, while the client may drop their MA plan and go back to Original Medicare and a PDP, they will NOT automatically be Guarantee Issue Acceptance for a Medicare Supplement plan.  They would need to follow that state/carrier rules regarding plan acceptance.  Using the OEP enrollment selection does not disqualify a client from using their quarterly Special Election period for a Dual Special Needs Plan if they have both Medicare and Medicaid.

Medicare OEP “Do’s and Dont’s”?

CMS has specific marketing guidelines that must be followed during OEP.  Agents may not knowingly target or send unsolicited marketing materials to any MA or Part D for the purpose of using their OEP option to change plans.  “Knowingly” takes into account the intended recipient as well as the content of the message. 

Do Not

  • Send unsolicited materials advertising the ability/opportunity to make an additional enrollment change or referencing the OEP;
  • Specifically, target beneficiaries who are in the OEP because they made a choice during the Annual Enrollment Period (AEP) by the purchase of mailing lists or other means of identification;
  • Engage in or promote agent/broker activities that intend to target the OEP as an opportunity to make further sales; or
  • Call or otherwise contact former enrollees who have selected a new plan during the AEP.

Do 

  • Marketing to age-ins (who have not yet made an enrollment decision);
  • Marketing by 5-star plans regarding their continuous enrollment SEP;
  • Marketing to dual-eligible and LIS beneficiaries who, in general, may make changes once per calendar quarter during the first nine months of the year;
  • Send marketing materials when a beneficiary makes a proactive request;
  • At the beneficiary’s request, have one-on-one meetings with a sales agent; and
  • At the beneficiary’s request, provide information on the OEP through the call center

Medicare OEP Training

We hold webinars multiple times throughout the week covering a variety of topics, including Medicare OEP and other marketing opportunities.  Be sure to always check the Enrollment Period Guide if you have questions on eligibility.  Reach out to our support team for training calendars from each carrier in your area.

For more information on Medicare OEP and one-on-one support, click here to contact your Sales Director.

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The new CMS Recording Rule (Final Rule)

The new CMS Recording Rule (Final Rule)

by | Jul 8, 2022 | Blog | 0 comments

The new CMS Recording Rule (Final Rule)
j

Jeff Palo

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On April 29, 2022, the Centers for Medicare & Medicaid Services (CMS) released what they call 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.”

  • Marketing and Communication Oversight
  • Lowering Beneficiary Pharmacy Costs
  • Verifying Past Plan Performance
  • Strengthening Network Adequacy
  • Creating Transparency in Medical Loss Ratio
  • Part C and D Quality Rating System
  • Enrollee Input in DSNP Operations
  • Social Determinants of Health and Special Needs Plan Health Risk Assessments
  • Simplified Appeals and Grievance Processes
  • New Pathways to Have Star Ratings Specific to the Performance of the Local D-SNP
  • New Pathways to Simplify D-SNP Enrollee Materials
  • Maximum Out-of-Pocket Policy for Dually Eligible Beneficiaries
  • Technical and Definitional Updates for FIDE SNPs and HIDE SNPs

The latest episode of Connect4Insurance has a more in-depth discussion on the full regulations.

How does the new CMS Recording Rule affect agents?

The National Association of Health Underwriters (NAHU), the leading advocate for health insurance agents, released an update as they continue to fight for change within the rule.  As it currently stands, beginning on October 1st, 2022, all field agents will be required to record all phone calls with beneficiaries.  There is also now a disclaimer that all agents must provide: verbally within the first minute of a sales phone call, electronically when communicating by email or other electronic means, or displayed on any third-party marketing materials or websites.  The disclaimer reads:

“I/We do not offer every plan available in your area. Please contact medicare.gov or 1-800-MEDICARE to get information on all your options”

What can an agent do to prepare or fight the new CMS Recording Rule?

There is a petition founded by Medicare agents trying to reach lawmakers within CMS to explain why the recording rule, while admirable, will negatively affect the wrong people.  According to the Federal Registry for 2022, CMS reported that there were only 39,617 “complaints to Medicare” out of 29,000,000 enrollments.  This equates to 0.0013661% of enrollments.  Most of the complaints were geared toward misleading television ads created by third-party marketing organizations that provide leads to call centers.  Sign the petition and register for your local NAHU chapter to make sure your voice is heard.

If the rule stands as-is, you need to be prepared.  We will have multiple options for recording calls, storing data, and identifying beneficiaries.  This is all provided at no cost.  Schedule a call with our National Sales Trainer, Rob Valincius, for more information on the technology available to you.

Be sure to subscribe to our posts to receive information in real-time.

For more information on Medicare OEP and one-on-one support.

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Medicare Advantage Commissions 2021

Medicare Advantage Commissions 2021

by | Feb 6, 2021 | Blog | 0 comments

Medicare Advantage Commissions 2021
j

Jeff Palo

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What are Medicare Advantage Commissions 2021?  This depends on the state in which you write business, as well as the effective date of the policy. CMS creates a standard amount as a maximum allowed that most carriers use as their commission amount for that year.  The commission amount will change from year to year, typically increasing, but you’ll want to check every year to ensure you’re being paid Fair Market Value (FMV). 

Where to Find your Medicare Advantage Commissions 2021

Every carrier will release its commission schedule for the upcoming AEP sometime in July or August.  You can contact your Sales Director for a copy of your commission schedule for each carrier.  Some carriers will require you to sign an amendment every year, while others will simply notify you of the change. It’s important to note how the carrier differentiates payment for those who are New to Medicare, changing from one Medicare Advantage plan to another, and internal plan changes.  You may receive a higher commission when enrolling a client electronically in some situations.

What are New-to-Medicare Commissions?

A Medicare beneficiary (potential Medicare client) is someone who is receiving their Part B for the first time.  This entitles you to the First Year (initial) commission for that client.  This is the only time that the first-year commission is paid.  This will be paid in two lump sums.  Your first payment amount will always be as if the client was not New to Medicare.  After CMS verifies the person is in fact new, they notify the company, who then pays you the remainder of the commission.  Renewal commissions for these plans are paid monthly, at the renewal amount, starting in January the following year.

What are the Changes to Medicare Advantage Commissions 2021?

CA and NJ

  • Initial MA commissions increased from $636/member/year to $672/member/year.
  • Renewal commissions increased from $318/member/year to $336/member/year.

CT, DC, and PA

  • Initial MA commissions increased from $574/member/year to $607/member/year.
  • Renewal commissions increased from $287/member/year to $304/member/year.

Puerto Rico and the U.S. Virgin Islands

  • Initial MA commissions increased from $350/member/year to $370/member/year.
  • Renewal commissions increased from $175/member/year to $185/member/year.

In all other states, initial MA commissions increased from $510/member/year to $539/member/year. Renewal commissions increased from $255/member/year to $270/member/year.

2021 Medicare Advantage Commission Chart

Initial Renewal
Product Region 2020 2021 2020 2021
MAPD National $510 $539 $255 $270
CT, PA, & DC $574 $607 $287 $304
CA & NJ $636 $672 $318 $336
Puerto Rico & U.S. Virgin Islands $350 $370 $175 $185
PDP National $78 $81 $39 $41

For more information on Medicare Advantage Commissions 2021 and one-on-one support, click here to contact your Sales Director.

For more information, contact a Pinnacle Financial Services representative today

1 (800) 772-6881 x7731 | sales@pfsinsurance.com

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Jeff Palo

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“

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support@pfsinsurance.com

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