AHIP Medicare cheat sheet

Medicare is federal health insurance for people age 65+, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD).

Part A covers inpatient hospital, skilled nursing facility, hospice, and some home health care; most beneficiaries pay no premium if they or their spouse paid Medicare taxes for 40+ quarters.

Part B covers physician services, outpatient care, durable medical equipment, and preventive services; the premium is income-related and generally deducted from Social Security benefits.

Part A and Part B together are Original Medicare (fee-for-service); beneficiaries may see any provider that accepts Medicare assignment.

The Initial Enrollment Period (IEP) is a 7-month window: the 3 months before the month of 65th birthday, the birthday month, and the 3 months after.

The General Enrollment Period runs January 1 through March 31 each year, with coverage effective the first of the month after enrollment.

A Medicare Advantage Open Enrollment Period runs January 1 through March 31, allowing one change from MA back to Original Medicare or to another MA plan.

The Annual Election Period (also called the Medicare Open Enrollment Period) runs October 15 through December 7, with coverage effective January 1.

Late enrollment penalties: Part B adds 10% of the premium for each 12-month period without creditable coverage; Part D adds 1% of the national base beneficiary premium per month.

Medicare Advantage (Part C) plans are offered by private insurers approved by CMS and must provide all Part A and Part B benefits, except hospice care.

MA plan types include HMO, PPO, PFFS, SNP (Special Needs Plans), and MSA (Medical Savings Account); network rules differ by type.

HMO plans generally require in-network providers except for emergencies and out-of-area urgent care; PPO plans allow out-of-network care at higher cost sharing.

MA plans may offer extra benefits such as dental, vision, hearing, and fitness programs, and often include Part D prescription drug coverage (MA-PD).

Special Needs Plans serve three groups: institutionalized beneficiaries (I-SNP), those dually eligible for Medicare and Medicaid (D-SNP), and those with chronic conditions (C-SNP).

Beneficiaries generally cannot enroll in an MA plan while in hospice, and MA plans may not restrict care during a hospice election.

Cost-sharing in MA plans cannot exceed Original Medicare cost sharing for certain services such as chemotherapy, renal dialysis, and skilled nursing facility care.

The 5-star special enrollment period allows beneficiaries to switch to a 5-star rated MA plan or PDP once per year between December 8 and November 30.

Part D is optional outpatient prescription drug coverage delivered through standalone Prescription Drug Plans (PDPs) or Medicare Advantage Prescription Drug plans (MA-PDs).

Plans must cover at least two drugs per therapeutic class and all drugs in six protected classes: antipsychotics, antidepressants, antiretrovirals, antineoplastics, immunosuppressants, and anticonvulsants.

The Part D benefit includes a deductible (capped annually), an initial coverage phase, and an out-of-pocket threshold after which catastrophic coverage applies with reduced cost sharing.

The coverage gap (donut hole) has been phased down; under the Inflation Reduction Act, the annual out-of-pocket cap on Part D spending is $2,000 starting in 2025.

The Part D late enrollment penalty is 1% of the national base beneficiary premium multiplied by the number of full uncovered months, added to the plan premium.

The Low-Income Subsidy (Extra Help) reduces or eliminates Part D premiums, deductibles, and copayments for qualifying beneficiaries.

Plans use formularies and tiering; exceptions and appeals processes allow beneficiaries to request coverage of non-formulary drugs or lower cost sharing.

Insulin cost sharing is capped at $35 per month per prescription under the Inflation Reduction Act, and recommended adult vaccines are covered at no cost.

CMS prohibits marketing activities that are misleading, high-pressure, or that discriminate based on health status; plans may not use the Medicare name or logo in a misleading way.

Unsolicited contact is restricted: cold-calling, door-to-door solicitation, and approaching beneficiaries in common areas such as parking lots or pharmacies are prohibited.

Marketing materials must be submitted to CMS for review (generally 45 days prior to use) and must be approved before distribution.

Agents must obtain a scope of appointment (SOA) before a personal marketing appointment and document it; the SOA cannot be used to expand into other product types without consent.

Call recording requirements apply to telephonic enrollment; permission must be obtained before recording, and the recording must be retained for 10 years.

Enrollment applications must be completed and submitted accurately; agents may not enroll a beneficiary without their knowledge or consent.

Business reply cards and lead-generating materials must include required CMS disclaimers and may not imply that the plan is endorsed by Medicare.

Marketing must be conducted in a manner that accommodates beneficiaries with limited English proficiency and disabilities, and TTY/TDD numbers must be included.

Fraud is intentional deception or misrepresentation that the individual knows or should know could result in unauthorized benefit; waste is overutilization or misuse of resources.

Abuse involves practices that are inconsistent with sound fiscal, business, or medical practices and result in unnecessary cost or improper payment.

Examples of fraud include billing for services not rendered, upcoding, identity theft, and kickbacks for referrals.

The False Claims Act imposes liability for knowingly submitting false claims and includes qui tam (whistleblower) provisions.

The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving remuneration to induce referrals for items or services covered by federal health care programs.

The Stark Law prohibits physician self-referral for designated health services when a financial relationship exists, unless an exception applies.

The Health Care Fraud and Abuse Control (HCFAC) program, funded by the Medicare Trust Funds, supports enforcement efforts.

Agents and plans must report suspected fraud, waste, and abuse to CMS or the plan's compliance department; noncompliance can result in civil monetary penalties or exclusion.

Medicare is federal health insurance for people age 65+, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD).

Part A covers inpatient hospital, skilled nursing facility, hospice, and some home health care; most beneficiaries pay no premium if they or their spouse paid Medicare taxes for 40+ quarters.

Part B covers physician services, outpatient care, durable medical equipment, and preventive services; the premium is income-related and generally deducted from Social Security benefits.

Part A and Part B together are Original Medicare (fee-for-service); beneficiaries may see any provider that accepts Medicare assignment.

The Initial Enrollment Period (IEP) is a 7-month window: the 3 months before the month of 65th birthday, the birthday month, and the 3 months after.

The General Enrollment Period runs January 1 through March 31 each year, with coverage effective the first of the month after enrollment.

A Medicare Advantage Open Enrollment Period runs January 1 through March 31, allowing one change from MA back to Original Medicare or to another MA plan.

The Annual Election Period (also called the Medicare Open Enrollment Period) runs October 15 through December 7, with coverage effective January 1.

Late enrollment penalties: Part B adds 10% of the premium for each 12-month period without creditable coverage; Part D adds 1% of the national base beneficiary premium per month.