NABIP Medicare cheat sheet

Medicare has four parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage), and Part D (prescription drug coverage).

Part A is generally premium-free with 40 or more quarters of Medicare-covered employment; fewer quarters means a monthly premium based on the number of quarters worked.

Part B is voluntary and requires a monthly premium; the standard premium is income-related, with higher-income beneficiaries paying an IRMAA surcharge based on modified adjusted gross income from two years prior.

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

The General Enrollment Period runs January 1 through March 31 each year; coverage begins the first day of the month after enrollment.

A Late Enrollment Penalty applies to Part B at 10% of the standard premium for each 12-month period enrollment was delayed, lasting for the life of the enrollment.

Medicare Advantage Open Enrollment Period runs January 1 through March 31; a beneficiary may make one change, such as switching MA plans or returning to Original Medicare.

Original Medicare is fee-for-service: Part A and Part B pay their share and the beneficiary is responsible for deductibles, coinsurance, and services Medicare does not cover.

Medicare Advantage (Part C) plans are approved private plans that provide Part A and Part B benefits and usually Part D; they may include extra benefits such as dental, vision, and hearing.

Medicare Supplement (Medigap) plans are sold by private insurers to fill gaps in Original Medicare; plans are standardized by letter, and Plans C and F are no longer available to newly eligible beneficiaries.

Medigap plans do not include prescription drug coverage; a beneficiary with Original Medicare and a Medigap plan generally needs a separate standalone Part D plan.

Part D plans are offered by private insurers with formularies, tiers, and pharmacy networks; the plan year deductible, copays, and coverage phases affect out-of-pocket cost.

Medicare Advantage plan types include HMO, PPO, PFFS, and SNP; HMOs generally require in-network care and referrals, while PPOs allow out-of-network care at higher cost.

Special Needs Plans (SNPs) serve specific populations: dual-eligible (D-SNP), institutionalized (I-SNP), and chronic condition (C-SNP) beneficiaries.

Part D late enrollment penalty is 1% of the national base beneficiary premium multiplied by the number of full uncovered months, rounded to the nearest ten cents.

A beneficiary cannot be enrolled in both a Medicare Advantage plan and a standalone Part D plan at the same time.

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 is practices inconsistent with sound fiscal or medical business.

Examples of fraud include billing for services not rendered, upcoding, phantom beneficiaries, and knowingly submitting false claims.

The False Claims Act imposes civil liability, including treble damages and per-claim penalties, for knowingly submitting false claims to federal health programs.

The Anti-Kickback Statute prohibits knowingly offering, paying, soliciting, or receiving remuneration to induce referrals for federally reimbursed services.

The Physician Self-Referral (Stark) Law prohibits certain physician referrals of designated health services to entities with which the physician has a financial relationship, subject to exceptions.

The Health Care Fraud Statute (18 U.S.C. § 1347) criminalizes knowingly executing a scheme to defraud a health care benefit program.

Compliance programs should include written policies, a designated compliance officer, training, communication lines, internal monitoring, and enforcement of standards.

Suspected FWA should be reported to the plan's compliance department, the HHS Office of Inspector General, or CMS; the OIG hotline and the Medicare.gov reporting tools accept tips.

The Annual Enrollment Period (AEP) runs October 15 through December 7; plan selections take effect January 1 of the following year.

The Medicare Advantage Open Enrollment Period runs January 1 through March 31; a beneficiary may make one change such as switching MA plans or returning to Original Medicare.

The Medicare Advantage and Part D marketing rules prohibit unsolicited door-to-door contact, cold calls, and approaching beneficiaries in common areas like parking lots or hallways.

Marketing materials must be submitted to CMS or the plan for review; agents may not use unapproved materials or alter approved materials.

A Scope of Appointment (SOA) must be completed and documented before a personal marketing appointment; the SOA must be plan-specific and signed by the beneficiary.

Agents may not offer gifts, meals, or incentives to induce enrollment; nominal gifts must be under the CMS value threshold and not conditioned on enrollment.

Agents must obtain permission before contacting a beneficiary and must not use lead lists that were not generated in compliance with CMS marketing rules.

The Medicare Communications and Marketing Guidelines (MCMG) govern agent conduct, including required disclosures, disclaimers, and call recording requirements.

Agents must complete required annual training and testing, including FWA and Medicare marketing training, before selling during the AEP.

Medicare eligibility generally begins at age 65 with citizenship or lawful permanent residency of at least five continuous years, or earlier with certain disabilities or ESRD/ALS.

The Initial Enrollment Period is 7 months long, beginning 3 months before the month of eligibility and ending 3 months after.

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

The Annual Enrollment Period runs October 15 through December 7, with coverage beginning January 1.

The Medicare Advantage Open Enrollment Period runs January 1 through March 31; a beneficiary may make one change.

A Special Enrollment Period (SEP) may be triggered by loss of employer coverage, moving out of the plan's service area, or other qualifying events.

Part B late enrollment penalty is 10% of the standard premium for each 12-month period of delayed enrollment, lasting for the life of the enrollment.

Part D late enrollment penalty is 1% of the national base beneficiary premium multiplied by the number of full uncovered months, rounded to the nearest ten cents.

Individuals with End-Stage Renal Disease (ESRD) may enroll in Medicare at any time after diagnosis and may have access to Medicare Advantage plans under certain conditions.

Medicare Advantage plans must provide all Part A and Part B benefits, but may use different cost-sharing and network rules than Original Medicare.

Medicare Advantage plans may offer extra benefits such as dental, vision, hearing, and fitness programs.

Part D plans must cover at least two drugs in each therapeutic category and class, and must have a formulary approved by CMS.

Part D plans have a coverage gap phase and a catastrophic phase; the coverage gap phase begins after the initial coverage limit is reached.

Medicare Advantage plans may not deny coverage for medically necessary services that are covered by Original Medicare.

Medicare Advantage plans must have a grievance and appeals process, and beneficiaries may appeal a denial of coverage.

Part D plans must provide a transition period for new enrollees to obtain non-formulary drugs.

Medicare Advantage plans must provide an Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) to beneficiaries before the plan year begins.

Medicare Advantage plans must comply with CMS marketing rules, including the prohibition on unsolicited contact and the requirement for a Scope of Appointment.

Beneficiaries have the right to appeal a denial of coverage or payment for a service, and may request a reconsideration.

The appeals process for Original Medicare includes redetermination, reconsideration, ALJ hearing, Medicare Appeals Council, and judicial review.

Medicare Advantage plans must provide a 60-day window for beneficiaries to file an appeal after a denial.

Beneficiaries may request an expedited appeal if a delay could seriously jeopardize their health.

The Medicare Ombudsman helps beneficiaries with complaints and appeals.

Beneficiaries may file a grievance with their plan or with Medicare.

The Quality Improvement Organization (QIO) reviews appeals of hospital discharges and certain quality-of-care complaints.

Beneficiaries may request a coverage determination for Part D drugs, including exceptions to formulary rules.

Medicare Advantage plans must provide a written denial notice that explains the appeal rights.

Medicare Secondary Payer (MSP) rules determine whether Medicare pays first or second when a beneficiary has other coverage.

Employer group health plans with 20 or more employees generally pay first for working beneficiaries aged 65 or older.

Employer group health plans with fewer than 20 employees generally pay second to Medicare.

Medicare generally pays first for beneficiaries with retiree coverage.

Medicaid may pay premiums and cost-sharing for dual-eligible beneficiaries, and Medicare pays first for most services.

Workers' compensation and no-fault insurance generally pay before Medicare for work-related injuries.

The MSP rules also apply to beneficiaries with ESRD and to those with disability coverage.

Beneficiaries should report other coverage to Medicare to ensure correct coordination of benefits.

Medicare Advantage plans must follow MSP rules when coordinating benefits.

Part D is voluntary and offered by private insurers; beneficiaries must actively enroll.

Part D plans have a deductible, initial coverage phase, coverage gap phase, and catastrophic phase.

The coverage gap phase begins after the initial coverage limit is reached; beneficiaries pay a share of drug costs until they reach the catastrophic threshold.

Part D plans must cover at least two drugs in each therapeutic category and class.

Beneficiaries may request an exception to a formulary rule if a drug is not covered or is subject to prior authorization.

Part D plans must provide a transition period for new enrollees to obtain non-formulary drugs.

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

Beneficiaries may qualify for Extra Help (Low-Income Subsidy) to reduce Part D costs.

Part D plans must provide a Summary of Benefits and a formulary to beneficiaries.

Agents may not cold call beneficiaries or engage in unsolicited door-to-door marketing.

Agents must complete a Scope of Appointment (SOA) before a personal marketing appointment.

Agents may not offer gifts or meals to induce enrollment.

Marketing materials must be approved by CMS or the plan before use.

Agents must not use lead lists that were not generated in compliance with CMS marketing rules.

Agents must complete annual training and testing, including FWA and Medicare marketing training.

Agents must disclose their relationship with the plan and provide required disclaimers.

Agents may not misrepresent the benefits or costs of a plan.

Agents must maintain records of marketing activities and SOAs.