Marketing for 2021 Annual Enrollment Period - Reminder
The 2021 Annual Enrollment Period (AEP) is just around the corner, starting on October 15th and ending on December 7th 2020. It is important to remember that The Centers for Medicare & Medicaid Services (CMS) do not allow any marketing for AEP to take place before October 1st. "Marketing" includes the following examples:
Contacting consumers to solicit an appointment.
Completing an enrollment application.
Hosting or advertising an event where 2021 plans will be discussed.
Talking about 2021 plan rates, options or benefits over the phone or during an appointment.
Obtaining a 2021 Scope of Appointment.
Sharing content regarding AEP on social media or via email.
Rule of thumb: If the purpose of the marketing activity is to eventually solicit an appointment for AEP, per CMS, it is NOT acceptable before October 1st 2020. If an agent is found to be marketing for AEP before October 1st, the agent could be penalized from the insurance carrier being marketed, or from CMS.
It is a good idea for agents to take this time before October 1st to work on certifications and becoming Ready to Sell for the 2021 AEP season. Save all marketing efforts for after October 1st.
The cost-sharing chart below covers what beneficiaries with Medicare Part D will pay for prescription coverage in each phase in 2021. This includes:
A deductible of up to $445 (this deductible varies by plan).
25% of the costs of their prescription drugs in the Initial Coverage Period (or up to $1,032.50 if they are in a plan with no deductible).
Up to $6,550 out-of-pocket expenses before the beneficiary reaches the Catastrophic Benefits Period. Once they hit this threshold, the Medicare beneficiary will pay either 5% coinsurance or $3.70 copay for generic medications, and $9.20 for brand-name drugs.
*Most Part D plans are not standard plans. This means calculating TrOOP costs during the initial deductible and ICP varies by plan. Source: 2021 Call Letter (p. 71) at: 2021 Call Letter.
CMS launched a remodeled website Thursday that consolidates its eight online consumer tools to one platform.
The redesigned site is an attempt by CMS to give users a more streamlined experience using its platform, called Compare tools.
CMS has published information online about healthcare providers and care settings for Medicare beneficiaries and their caregivers for more than 15 years. One of the elements for the hospital version to convey quality, the star ratings, has come under fire for producing inconsistent results and CMS recently proposed changes to the methodology as a result.
The eight different interfaces representing each care setting was confusing and cumbersome for users, according to CMS Administrator Seema Verma during a press call Wednesday. "The information will now be displayed in a modern streamlined design to make it as helpful as possible to users," Verma said.
The remodeled site, available on Medicare.gov, can now access users' location and a drop-down menu allows the consumer to select what type of provider they are looking for. Options are hospitals, nursing homes, home health, dialysis centers, long-term care hospitals, inpatient rehabilitation, physicians and hospice groups. A user can compare up to three providers using information about costs, location and quality data. The site is also compatible for use on smartphone and tablets.
CMS is seeking feedback from users about the upgraded platform. There is an online survey available on Medicare.gov for users. CMS will also seek feedback from provider stakeholders who treat Medicare beneficiaries.
Trump Administration Issues Call to Action Based on New Data Detailing COVID-19 Impacts on Medicare Beneficiaries
Today, under the leadership of President Trump, the Centers for Medicare & Medicaid Services (CMS) is calling for a renewed national commitment to value-based care based on Medicare claims data that provides an early snapshot of the impact of the coronavirus disease 2019 (COVID-19) pandemic on the Medicare population. The data shows that older Americans and those with chronic health conditions are at the highest risk for COVID-19 and confirms long-understood disparities in health outcomes for racial and ethnic minority groups and among low-income populations.
“The disparities in the data reflect longstanding challenges facing minority communities and low income older adults, many of whom face structural challenges to their health that go far beyond what is traditionally considered ‘medical’,” said CMS Administrator Seema Verma. “Now more than ever, it is clear that our fee-for-service system is insufficient for the most vulnerable Americans because it limits payment to what goes on inside a doctor’s office. The transition to a value-based system has never been so urgent. When implemented effectively, it encourages clinicians to care for the whole person and address the social risk factors that are so critical for our beneficiaries’ quality of life.”
The data released today includes the total number of reported COVID-19 cases and hospitalizations among Medicare beneficiaries between January 1 and May 16, 2020. The snapshot breaks down COVID-19 cases and hospitalizations for Medicare beneficiaries by state, race/ethnicity, age, gender, dual eligibility for Medicare and Medicaid, and urban/rural locations. The new data show that more than 325,000 Medicare beneficiaries had a diagnosis of COVID-19 between January 1 and May 16, 2020. This translates to 518 COVID-19 cases per 100,000 Medicare beneficiaries. The data also indicate that nearly 110,000 Medicare beneficiaries were hospitalized for COVID-19-releated treatment, which equals 175 COVID-19 hospitalizations per 100,000 Medicare beneficiaries.
Blacks were hospitalized with COVID-19 at a rate nearly four times higher than whites. The disparities presented in the snapshot go beyond race/ethnicity and suggest the impact of social determinants of health, particularly socio-economic status.
Other key data points:
End-stage renal disease (ESRD) patients (individuals with chronic kidney disease undergoing dialysis) had the highest rate of hospitalization among all Medicare beneficiaries, with 1,341 hospitalizations per 100,000 beneficiaries. Patients with ESRD are also more likely to have chronic comorbidities associated with increased COVID-19 complications and hospitalization, such as diabetes and heart failure.
The second highest rate was among beneficiaries enrolled in both Medicare and Medicaid (also known as “dual eligible”), with 473 hospitalizations per 100,000 beneficiaries.
Among racial/ethnic groups, Blacks had the highest hospitalization rate, with 465 per 100,000. Hispanics had 258 hospitalizations per 100,000. Asians had 187 per 100,000 and whites had 123 per 100,000.
Beneficiaries living in rural areas have fewer cases and were hospitalized at a lower rate than those living in urban/suburban areas (57 versus 205 hospitalizations per 100,000).
The snapshot also shows that besides higher hospitalization rates, beneficiaries enrolled in both Medicaid and Medicare have a higher infection rate of COVID-19, with 1,406 cases per 100,000 beneficiaries. By comparison, the coronavirus infection rate for beneficiaries enrolled only in Medicare is 325 cases per 100,000. The rate of COVID-19 cases for dual eligible individuals is higher across all age, sex, and race/ethnicity groups. Previous research has shown that these individuals experience high rates of chronic illness, with many having long-term care needs and social risk factors that can lead to poor health outcomes.
Given the complexity of these disparities, any solution requires a multi-sectoral approach that includes federal, state, and local governments, community based organizations, and private industry. One piece of this is the increased implementation of a value-based system that rewards providers for keeping patients healthy and gives consumers the information about disease prevention and outcomes needed to help make healthcare choices on the basis of quality. Additionally, CMS is encouraging states to double down on efforts to protect low income seniors and look at the data and determine what resources are available, both locally and federally, to improve this disparity of health outcomes. CMS has identified a range of operational opportunities for states to improve care for dually eligible individuals and a variety of models that states can participate in that focus on improving the quality and cost of care for individuals who are concurrently enrolled in Medicaid and Medicare.
The Center for Medicaid and Children’s Health Insurance Program (CHIP) Services is developing guidance for states on new opportunities to adopt innovative, value-based payment design and implement strategies to address social determinants of health for their beneficiaries, including those who are dually-eligible for Medicare and Medicaid. In addition to these ongoing efforts and programs, the CMS Office of Minority Health will be holding a series of listening sessions with key stakeholders responsible for providing care to racial and ethnic minorities. These listening sessions are intended to help refine the ongoing outreach and work by CMS to improve future efforts on this issue.
CMS typically releases Medicare claims information on an annual basis when there are more complete claims and encounter data. However, as part of the agency’s efforts to provide data transparency during the pandemic and ensure the public has this vital information as soon as it is available, CMS is releasing this preliminary data now. The data will be updated on a monthly basis as more claims and encounter records are received. CMS anticipates releasing similar information on Medicaid beneficiaries in the future.
President Trump Announces Lower Out of Pocket Insulin Costs for Medicare’s Seniors
Across the nation, 88 Part D Sponsors applied to the Part D Senior Savings Model to offer enhanced plans with a maximum $35 copay for a broad set of insulins beginning in 2021.
Today, under President Trump’s leadership, the Centers for Medicare & Medicaid Services (CMS) announced that over 1,750 standalone Medicare Part D prescription drug plans and Medicare Advantage plans with prescription drug coverage have applied to offer lower insulin costs through the Part D Senior Savings Model for the 2021 plan year. Across the nation, participating enhanced Part D prescription drug plans will provide Medicare beneficiaries access to a broad set of insulins at a maximum $35 copay for a month’s supply, from the beginning of the year through the Part D coverage gap. The model follows on the Trump Administration’s previously announced 13.5 percent decline in the average monthly basic Part D premium since 2017 to the lowest level in seven years.
Currently, Part D sponsors may offer prescription drug plans that provide lower cost-sharing in the coverage gap; however, when they do, the Part D sponsor accrues costs that pharmaceutical manufacturers would normally pay. These costs are then passed on to beneficiaries in the form of higher premiums. The new insulin model directly addresses this disincentive by doing two things: 1) allowing manufacturers to continue paying their full coverage gap discount for their products, even when a plan offers lower cost-sharing; and 2) requiring participating Part D sponsors’ plans, in part through applying manufacturer rebates, to lowering cost-sharing to no more than $35 for a month’s supply for a broad set of insulins.
Under President Trump’s leadership, for the first time, CMS is enabling and encouraging Part D plans to offer fixed, predictable copays for beneficiaries rather than leaving seniors paying 25 percent of the drug’s cost in the coverage gap. Both manufacturers and Part D sponsors responded to this market-based solution in force and seniors that use insulin will reap the benefits.
Based on CMS’s estimates, beneficiaries who use insulin and join a plan participating in the model could see average out-of-pocket savings of $446, or 66 percent, for their insulins, funded in part by manufacturers paying an estimated additional $250 million of discounts over the five years of the model. With a robust voluntary response from Part D sponsors, CMS anticipates beneficiaries will have Part D plan options in all 50 states, the District of Columbia, and Puerto Rico, through either a standalone prescription drug plan (PDP) or a Medicare Advantage plan with prescription drug coverage. Beneficiaries will be able to enroll during Medicare open enrollment, which is from October 15, 2020 through December 7, 2020, for Part D coverage that begins on January 1, 2021.
“President Trump has forged partnerships with pharmaceutical manufacturers and plans to deliver lower priced insulin to our nation’s seniors,” said CMS Administrator Seema Verma. “This market-based solution, in which insulin manufacturers and Part D sponsors compete to provide lower costs and higher quality for patients, will allow seniors to choose a Part D plan that covers their insulin at an average 66 percent lower out-of-pocket cost throughout the year.”
The Part D Senior Savings Model – which was announced on March 11, 2020 – is a voluntary model that tests the impact on insulin access and care by participating Part D enhanced alternative plans offering lower out-of-pocket costs, at a maximum $35 copay for a month’s supply, for a broad range of insulins.
Part D sponsors that participate in the model will offer beneficiaries Part D prescription drug plans that provide supplemental benefits for a broad range of insulins, including both pen and vial dosage forms for rapid-acting, short-acting, intermediate-acting, and long-acting insulins. Participating pharmaceutical manufacturers will continue to pay their current 70 percent discount in the coverage gap for their insulins that are included in the model, and based on the model’s waiver of current regulations, those manufacturer discount payments will be calculated before the application of supplemental benefits under the model – which will reduce the out-of-pocket cost of insulin for Medicare beneficiaries.
One in every three Medicare beneficiaries has diabetes, and over 3.3 million Medicare beneficiaries use one or more of the common forms of insulin. For some of these beneficiaries, access to insulin is a critical component of their medical management, with gaps in access increasing risk of serious complications, ranging from vision loss to kidney failure to foot ulcers to heart attacks. Unfortunately, the costs of insulin can be a major barrier to appropriate medical management of diabetes.
A beneficiary’s out-of-pocket costs for insulin in Medicare’s Part D prescription drug benefit can fluctuate from one month to the next, in part due to the different rules applying for each phase of the Part D benefit. This can be challenging for beneficiaries when budgeting for their drug costs. These challenges can in turn lead to beneficiaries not being able to afford their medicine or resorting to medication rationing, resulting in worse health outcomes over time. The model aims to address this with stable, predictable costs for insulin that beneficiaries know up front by staying in or choosing a model-participating plan during open enrollment.
Part D sponsors that applied must submit their calendar year 2021 plan benefits to CMS by June 1, 2020 to designate their participation in the model. CMS anticipates releasing the premiums and costs for specific Medicare health and drug plans for the 2021 calendar year in September 2020, including final information on the model.
Beneficiaries will be able to find a Part D plan participating in the Part D Senior Savings Model in the 2021 plan year through the Medicare Plan Finder on Medicare.gov during the annual open enrollment period, which begins on October 15, 2020 and ends December 7, 2020. CMS will enhance the Medicare Plan Finder to include a filter to identify plans that will offer capped out-of-pocket costs for insulin in the model so beneficiaries can easily find those plans during open enrollment in the Fall. The Medicare Plan Finder, which was upgraded for the first time in a decade last year, is the most used tool on Medicare.gov and allows users to shop and compare Medicare Advantage and Part D plans.
The Part D Senior Savings Model builds on steps the Trump Administration has already taken to strengthen Medicare and improve the quality of care for patients with diabetes. CMS has taken the following actions to address the needs of beneficiaries with diabetes:
Providing coverage for therapeutic continuous glucose monitors (CGM) for patients who synchronize their insulin devices with their smartphones, when used in conjunction with a durable CGM receiver.
Allowing Medicare Advantage plans to offer a broader range of supplemental benefits tailored to a patient’s chronic disease. For an enrollee living with diabetes for example, a plan could provide transportation to a doctor’s appointment, diabetes education programs, or time with a nutritionist.
To respond to the coronavirus disease 2019 (COVID-19) public health emergency, CMS has taken additional actions to ensure that beneficiaries with diabetes have access to treatment and care by:
Implementing statutory requirements for Medicare Part D prescription drug sponsors and MA plans with a prescription drug benefit to allow enrollees to obtain prescription fills or refills of covered Part D drugs—including insulin—for up to a three-month supply in most instances.
Providing additional flexibility to Part D sponsors to give beneficiaries more options for delivery of their medications – including their diabetes supplies -- such as mail or home delivery through retail pharmacies.
Expanding telehealth so that people with diabetes, nationwide, can still maintain access to their doctor.
Expanding access to therapeutic continuous glucose monitors for patients with diabetes as determined medically appropriate by practitioners. Previously, patients were required to meet certain clinical criteria to qualify for coverage of a therapeutic continuous glucose monitor under Medicare. During the COVID-19 public health emergency, CMS will not enforce the clinical indications in Local Coverage Determinations for therapeutic continuous glucose monitors in an effort to give practitioners the flexibility to allow more of their diabetic patients to better monitor their glucose and adjust insulin doses from home.