Sonder Health Plans, Inc. Is an HMO with a Medicare contract.
Enrollment in sonder Heath Plans, inc. depends on contract renewal
Cy 2023 Agent and Broker Training
Today We’ll Cover
- Meet Sonder Health Plans
- Medicare 101
- Benefits at a Glance
- Enrollment Overview
- Important Contact Information
- Important Disclaimer Information
- CMS Mandatory Training
Meet Sonder Health Plans
Your Doctors, Your Neighbors, Your Friends.
Sonder Health Plan is Georgia’s leading local health plan that provides innovative Medicare Advantage benefit plans in the following Georgia counties: Cherokee, Clayton, Cobb, Coweta, Dekalb, Douglas, Fayette, Fulton, Gwinnett, Henry, Paulding and Rockdale. The Senior Leadership and the Employees are your neighbors and live and work in your community. Sonder Health Plans are “Georgians Caring for Georgians” working closely with the medical leadership in your community to provide comprehensive and quality care for our seniors.
Sonder Health Plans, Inc. is an HMO with a Medicare contract. Enrollment in Sonder Health Plans, Inc. depends on contract renewal.
Meet Sonder Health Plans
Your Doctors, Your Neighbors, Your Friends.
Our Mission
Improve the overall health and well-being of our members and being recognized as a valued and trusted partner in their healthcare journey.
Our Vision
To make healthcare simple, personal, and affordable by delivering on our commitments and holding ourselves accountable.
Being innovative by inventing the future and learning from the past. Eliminate the financial barriers for our members by offering cost effective plan choices.
Our Values
- Integrity
- Compassion
- Our Values
- Community Partner
- High Performance
- Diversity
Meet Sonder Health Plans
Your Doctors, Your Neighbors, Your Friends.
Sonder Health Plans has contracted with the leading hospital systems, including:
Emory Healthcare Hospitals
Grady Memorial Hospital
Northside Hospital
Piedmont Healthcare Hospitals
WellStar Health System Hospitals
Medicare 101
Options for Receiving Medicare
- Original Medicare only: includes Medicare Part A Hospital Insurance) and Part B Medical Insurance).
- Original Medicare with a stand-alone POP: Involves joining Original Medicare plus a separate Medicare drug plan to get Medicare drug coverage (Part D).
- Medicare Advantage and Prescription Drug (MA-PD): Medicare Advantage plan wart c that includes Medicare Part A Hospital insurance and Part B [Medical Insurance) plus Part D Prescription Drug coverage. Part D subsidizes the costs of brand-name and generic prescription drugs for Medicare beneficiaries.
- MA or Cost Plan without stand-alone PDP: Provides additional extra benefits that are not covered by Part A and Part B. A Cost Plan is similar to an MA plan as it provides enrollees with access to a network of doctors and hospitals, but unlike an MA plan enrollees can receive coverage outside of the network and have them paid through Original Medicare.
- Cost Plan with a stand-alone PDP: A stand-alone prescription drug plan is another term for a Part D prescription drug plan (PDPA PDP is often referred to as a “stand-alone prescription drug plan because it is a separate prescription drug coverage that Medicare beneficiaries can purchase – through private insurers – usually to supplement Oripinal Medicare.
- Private Fee-for-Service: Private fee-for-service plans are a type of MA plan that sometimes includes prescription drug coverage. some have provider networks, while others will allow a member to receive care from any hospital or doctor that accepts the plan’s coverage.
- Employer Group Plan: Employers may offer their Medicare-eligible employees the option to enroll with an MA Plan. MA organizations that offer MA plans to an employer or union may choose to accept voluntary enrollment requests directly from the employer or union may choose to accept voluntary enrollment requests directly from the employer or union (or its Third Party Administrator (TPA)) without obtaining a paper MA enrollment request form from each individual.
- Medicare-Medicaid Plans: unlike D-SPs, MMPs only serve full benefit dual (Medicare/Medicaid) eligible beneficiaries and some additional limitations may apply (such as state-specific requirements).
Medicare Benefits – Parts A & B
Medicare Part A
(Original Medicare – Hospital Insurance)
- Inpatient Hospital
- Home Health Care
- Skilled Hospice Care
- Nursing Rehabilitative Care
- Deductibles and Cost-sharing apply
- Most automatically enroll in Part A without paying a monthly premium as long as they have worked a minimum of 40 quarters or 10 years.
Medicare Part B
(Original Medicare – Hospital Insurance)
- Physician, Diagnostic, Preventive, and Outpatient Services
- Medical Equipment
- Some drugs
- Deductibles and Cost-sharing apply
- Monthly premium applied based on income level
- Beneficiaries must enroll into Part B and penalties may apply for late enrollment
Medicare Benefits – Parts C & D
Medicare Part C
Medicare Advantage Plans (MA)
- Includes benefits and services covered under Parts A & B
- HMO, PPO, PFFS or Cost Plans
- Offered through private insurance companies
- Often includes Prescription Drug coverage (MAPD)
- Other Part c options include Medicare supplements (or Medigap plans)
- Medicare supplement plans include deductibles. coinsurance, but not prescription drug coverage
- May have $0 premium, but member still pays Part B premium.
- If plan has premium, member may still pay that amount in addition to Part B premium and Part A (if Part A is not premium free)
Medicare Part D
Medicare Prescription Drug Coverage (PDP)
- Optional and offered to everyone with Medicare
- Can be offered as a stand-alone plan that goes with original Medicare
- May have additional monthly premium due to higher income
- Medicare Advantage (MA plans can offer medical and prescription benefits together as an MAPD plan
- Part D includes the mandatory use of a drug formulary
What’s the Advantage of Medicare Advantage?
- Often, MA Plans do not have deductibles.
- Low to no additional monthly premium.
- Out-of-pocket maximums allow for greater financial protection.
- Additional coverage may include dental, vision, hearing, a gym membership, transportation services or more. These benefits are not covered under Original Medicare.
Types of Medicare Advantage Coordinated Care Plans (CCPs)
WHAT ARE MEDICARE COORDINATED CARE PLANS (CCPS):
- CCs are the classification given to Medicare Advantage plans that are provided by private insurance companies.
- Medicare coordinated care plans include 4 main types:
- Health maintenance organizations (HMOS)
- Preferred Provider Organizations (PPOs)
- Special Needs Plans (SNPs)
- HMOs with a Point-of-Service (POS) option
- HMOs: In HMO Plans
- A beneficiary generally must select a primary care doctor and get his/her care and services from doctors, other health care providers, and hospitals in the plan’s network, except for Emergency care; out-of-area urgent care; Temporary out-of-area dialysis.
- Out-of-network services typically require a higher copayment or coinsurance. Prior approval (referral) required for some services, such as seempa specials
- Prescription drugs are usuallv covered
- PPOs: PPO Plans have network doctors, other health care providers, and hospitals.
- Beneficiary does not have to select PCP or obtain referrals, but pays less if he/she use doctors, hospitals, and other health care providers that belong to the plan’s network.
- Ability to use out-of-network providers for covered services, but usually at a higher cost.
- Provides coverage for emergency and urgent care
- Prescription drugs are usually covered.
Types of Medicare Advantage Coordinated Care Plans (CCPs)
- SNPs:
- SNPs are usually a good option for beneficiaries with a chronic health condition or if they are eligible for both Medicare and Medicaid. It may also be suitable for beneficiaries that live in a residential care home. All SNP beneficiaries must nominate a primary care doctor and a referral may be needed to see a specialist. SNPs provide the same coverage as Original Medicare and must come with Medicare Part D. Some plans offer additional benefits. such as vision.
- HMOs with POS (HMO-POS): HMO-POS are an optional add-on policy to some HMO plans. Beneficiaries choose a primary care doctor when they enroll on a POS plan, but their policy will also cover treatment from out-of-network providers. Out-of-network clinics generally cost more out-of-pocket. Some plans limit the amount you can claim for out-of-network treatment or limit coverage to particular services. Some POS providers cover specialist treatment without a referral, and others require a referral from a PCP. POS policies usually come with Medicare Part D
- Regional PPOs (RPPOs): Regional POs have coverage in one or more states. Beneficiaries are receive uniform coverage wherever
they receive care within the plan area. RPPOs are beneficial for beneficiaries that live in rural areas and have to travel outside their
locality to receive treatment
Types of Special Needs Plans (SNPs)
- CHRONIC CONDITION SNPs (C-SNPs):
- C-SNPs are SPs that restrict enrollment to special needs individuals with specific severe or disabling chronic conditions.
- Approximately two-thirds of Medicare enrollees have multiple chronic conditions requiring coordination of care among primary providers, medical and mental health specialists, inpatient and outpatient facilities, and extensive ancillary services related to diagnostic testing and therapeutic management.
- DUAL ELIGIBLE SNPs (D-SNPs):
- D-SNPs enroll individuals who are entitled to both Medicare (title XVIII) and medical assistance from a state plan under Medicaid (title XIX). States cover some Medicare costs, depending on the state and the individual’s eligibility.
- States may vary in determining their eligibility categories; therefore, there may be state-specific differences in eligibility levels.
- INSTITUTIONAL SNPS (I-SNPs):
- I-SNPs are SNPs that restrict enrollment to MA eligible individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a long-term care (LTC) skilled nursing facility (SNF), a LTC nursing facility (NF), a SNF/NF, an intermediate care facility for individuals with intellectual disabilities (ICF/IDD), or an inpatient psychiatric facility.
Medigap
- WHAT IS MEDIGAP? Medicare Supplement Insurance that helps fill “gaps” in Original Medicare and is sold by private companies.
- WHAT TYPES OF COSTS DOFS IT COVER?
- Copayments, Coinsurance, Deductibles
- some plans may cover medical care when an individual travels outside the U.S. (Original Medicare will pay Medicare Approved Amount first and then Medigap will pay remaining amount)
- IMPORTANT THINGS TO KNOW ABOUT MEDIGAP
- Individual must have Medicare Part A and Part B.
- A Medigap policy is different from a Medicare Advantage Plan, Those plans are ways to get Medicare benefits, while a Medigap policy only supplements an individual’s Original Medicare benefits.
- Individual pays the private insurance company a monthly premium for their Medigap policy. Individual pays this monthly premium in addition to the monthly Part B premium that he/she pays to Medicare.
- A Medigap policy only covers one person. If an individual and his/her spouse both want to Medigap coverage, they’ll each have to buy separate policies.
- An individual can buy a Medigap policy from any insurance company that’s licensed in his/her state to sell one.
- Any standardized Medigap policy is guaranteed renewable even if the individual has health problems. This means the insurance company can’t cancel an individual Medicap policy as long as he/she pays the premium.
- Some Medigap policies sold in the past cover prescription drugs. But, Medigap policies sold after January 1, 2006 aren’t allowed to include prescription drug coverage. If an individual wants prescription drug coverage, they can join a Medicare Prescription drug Plan (Part D). If an individual buys Medigap and a Medicare drug plan from the same company. he/she may need to make 2 separate premium payments.
- It’s Illegal for an agent/broker or anyone to sell a Medigap policy if an individual has a Medicare Advantage Plan, unless the individual switching back to Original Medicare
Medicare Medical Savings Account (MSA) Plans
- WHAT IS AN MSA? An MSA is similar to a Health Savings Account Plan that is available outside of Medicare. An individual can choose any health care service or provider as MSA plans usually don’t have a network or doctors. other health care providers. or hospitals.
- WHAT IS A MEDICARE MSA? Medicare MSA Plans are made up of both a high-deductible insurance plan and a medical savings account that an individual can use to pay for his/her health care costs.
- High-deductible health plan: The first part of an MSA is a special type of high-deductible Medicare Advantage Plan (Part C). The plan will only begin to cover costs once an individual meets a high yearly deductible, which varies by plan.
- Medical Savings Account (MSA): The second part of the MSA is a special type of savings account. The Medicare MSA Plan deposits money in a special Savings account for an individual to use to pay health care expenses. the amount of the deposit varies by plan. You can use this money to pay your Medicare-covered costs before you meet the deductible.
- WHAT DO MSA PLANS COVER?
- Medicare MSA plans cover the Medicare services that all Medicare Advantage Plans must cover.
- In addition, some Medicare MSA plans may cover some extra benefits like dental vision, and hearing services for an additional premium.
- Medicare MSA Plans don’t cover Medicare Part D prescription drugs.
Who is Eligible for Medicare Parts a and B?
Age 65 or older
Sonder Health Plans, Inc.
Social Security Disability for 24 consecutive months
Sonder Health Plans, Inc.
Diagnosed with End Stage Renal Disease (ESRD)
Sonder Health Plans, Inc.Who is Eligible for Medicare Part C (Medicare Advantage Plan)
In general, an Individual is eligible to elect an Ma plan when each of the following requirements is met :
- The individual is entitled to Medicare Part A and enrolled in Parts B, provided that he or she will be entitled to receive services under Medicare Part A and Part B as of the effective date of coverage under the plan (see exceptions described under $20.6);
- Effective for plan years beginning on or after January 1 , 2021, a beneficiary with ESRD can choose to join a MA plan;
- The individual permanently resides in the service area of the MA plan;
- The individual is a U.S. citizen or lawfully present in the United States;
- The individual or his/her legal representative completes an enrollment request and includes all the information required to process the enrollment or meets alternative conditions for enrollment specified by CMS:
- The individual is fully informed of and agrees to abide by the rules of the MA organization that were provided during the enrollment request; and
- The individual makes a valid enrollment request that is received by the plan during an election period, as described in Chapter 2 – MA Enrollment and Disenrollment Manual:
- For a special Needs Plan (SNP) additional requirements apply as described in $20 of the CMS Enrollment Manual.
- For an MSA plan, additional requirements apply as described in $20.10 of the CMS Enrollment Manual.
- For additional information on SNP eligibility criteria, see Chapter 16-B Spacial Needs plan
- See exceptions for permanent service area residency in $20.3 for persons living outside the service area at the time of the enrollment request
- See exceptions in $20 3.2 for persons unlawfully present at the time of the enrollment request
Who is Eligible for Medicare Part D (Prescription Drug Plan)
- GENERAL REQUIREMENTS: An individual is eligible to enroll in a Medicare prescription drug plan (PDP) if:
- The individual is entitled to Medicare Part A and/or enrolled in Part B, provided that he or she will be entitled to receive services under Medicare Part A and/or Part B as of the effective date of coverage under the plan;
- The individual has current Part D eligibility in CMS systems;
- The individual permanently resides in the service area of a PDP;
- The individual is a U.S. citizen or lawfully present in the United States.
- PART D LATE ENROLLMENT PENALTY (LEP):
- An amount added to the MA-PD plan premium of an individual who did not obtain creditable prescription drug coverage when s/he was first eligible for Part D or who had a break in creditable prescriotion drug coverage of at least 63 consecutive days.
- Members who qualify for Extra Help will not pay a penalty.
- If a beneficiary is found to be the subject of an LEP but, disagrees, he/she may request a “Reconsideration Request Form” from the plan.
- ADDITIONAL HELP WITH PRESCRIPTION DRUG COSTS:
- Beneficiaries with limited income may qualify for Extra Help. These beneficiaries may qualify for Extra Help from Medicare to pay prescription drug premiums, deductibles, and copayments.
- For more information about Extra Help. individuals may contact
- Their local Social Security Office or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
- Individuals can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp
- Beneficiaries may also call the Georgia Medicaid Office at 404-651-8681 or the toll-free at 877-423-4746.
- Reach Medicaid online at www.medicaid.georgia.gov
Beneficiary Grievance and Appeals Rights
- Beneficiaries of Original Medicare, Medicare Advantage Plans Part C) and Prescription Drug Plans Part D) have certain protections, such as filing a grievance or an appeal.
- Grievance vs Appeal: A grievance (complaint) is about the quality of care or services a beneficiary received or is receiving. A beneficiary can file an appeal it he/she has an issue with a plan’s refusal to cover a service, supply, or prescription.
- Grievances are complaints made by beneficiaries about the quality of care or services a beneficiary received or is receiving and could include Customer service; Access to specialists; Information from the Plan; Problems with an Appeal; Drug errors.
- The grievance must be filed by the beneficiary within a certain timeframe and the health plan must respond based on standard or expedited timeframe requirements. (Refer to Medicare Summary Notice for Original Medicare or directions provided by the Medicare Part C or D plan).
- What is an Appeal? An appeal is the action a beneficiary can take if he/she disagrees with a coverage or payment decision by Medicare or his/her Medicare plan. For example, a beneficiary can appeal if Medicare or his/her plan denies:
- A request for a health care service, supply, item, or drug the beneficiary thinks Medicare should cover.
- A request for payment of a health care service, supply, item, or drug the beneficiary already received.
- A request to change the amount a beneficiary must pay for a health care service, supply, item, or drug.
- Beneficiary may also appeal:
- If Medicare or his/her plan stops providing or paying for all or part of a health care service, supply, item, or drug the beneficiary thinks is still needed. An at-risk determination made under a drug management program that limits access to coverage for frequently abused drugs, like opioids and benzodiazepines.
- The appeal must be filed by the beneficiary within a certain timeframe and the health plan must respond based on standard or expedited timeframe requirements. (Refer to Medicare Summary Notice for Original Medicare or directions provided by the Medicare Part C or D plan)
Beneficiary Grievance and Appeals Rights
- Medicare Beneficiaries can also file complaints through these agencies
- The Medicare Beneficiary Ombudsman – Beneficiaries may call 1-800-MEDICARE (1-800-633-4227) or use the Medicare Complaint Form. The Medicare Beneficiary Ombudsman helps beneficiaries to address questions, complaints, their rights and protections. Beneficiaries may call 24 hours a day, 7 days per week, and help is available in both English and Spanish as well as for the hearing impaired (the TTY Medicare toll-free line is 1-877-486-2048).
- The Competitive Acquisition Ombudsman (CAO) – addresses complaints about durable medical equipment, prosthetics, orthotics and supplies.
- State Health Insurance Assistance Program (SHIP) – provides free, personalized counseling to people with Medicare about their rights, how to handle billing problems and complaints, find help paying for health care costs, and how Medicare works with other insurance.
- The Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) – assist beneficiaries with filing appeals; complaints (grievances); quality of care reviews; and medical necessity reviews
- State survey Agency – oversee health care facilities that participate in Medicare and Medicaid. They inspect health care facilities and investigate complaints to ensure these facilities meet health and safety standards.
Enrollment and Disenrollment
If not specified, references to MA Plans or MA Organizations throughout the rest of the presentation usually also relate to Part D plans
CMS Approved Enrollment Mechanisms/formats
CMS allow enrollment into Medicare via the following enrollment request mechanisms (formats). Plans/Part D sponsors must use an enrollment mechanism that complies with CMS Guidelines in format and content.
- Required Elements – In addition to the information collected on the enrollment request, the enrollment mechanism must include information indicating that the applicant acknowledges (1) The requirement to keep Part A and B; (2) That they will abide by the rules of the plan; (3) The release of information to Medicare and other plans. Information may be used to track enrollment and for other purposes, as allowed under federal law; (4) That enrollment in the plan automatically disenrolls him or her from any other Medicare health plan and prescription drug plan. Note: The model PFFS and MSA enrollment mechanisms provide language as appropriate; and (S) The right to appeal service and payment denials made by the organization.
- Paper Applications –
- Plan/Part D Sponsors must have, at minimum, a paper enrollment form process available for potential enrolees to request enrollment in Plan/Part D Sponsor, Specific model enrollment forms have been developed for MA coordinated care plans, MSA plans and PFFS plans and Employer group Health Plans(EGHP)
- Organizations can utilize CMS model enrollment forms or choose to develop their own materials using the CMS models as a guide. Materials are subject to the CMS review and approval of plan marketing material.
- A model short enrollment form (“short form”) and a model plan selection form allow for enrollment requests into another plan (PBP) offered by the same parent organization. For determining the appropriate use of the short form or model plan selection form, CMS defines parent organization as the contract numbers HM and legal entities that are owned and operated by a single organization in a single State. As a result, a short form or a model plan selection form may be used only for enrollment requests into another plan of the same type (Le., HMO to HMO, PPO to PPO, or PFFS to PFFS).
- Electronic Enrollment –
- Plan/Part D sponsors may offer electronic enrollment mechanisms via an electronic device or secure internet website. It must capture the same data as required on the CMS model enrollment form.
- Advise each individual at the beginning of the electronic enrollment process that he or she is completing an actual enrollment request to the Plan/Part Sponsor.
- Obtain an electronic signature from the applicant OR include a clear and distinct step that requires the applicant to activate an “Enroll Now,” or *1 Agree,” type of button or tool that indicates his or her intent to enroll.
CMS Approved Enrollment Mechanisms/formats
- Medicare Online Enrollment Center (OEC) – CMS offers an online enrollment center (OEC) through the Medicare.gov website and the 1-800-MEDICARE Call Center for enrollment into Medicare Advantage plans (except for MSA) and Medicare prescription drug plans.
- Enrollment via Telephone –
- Plan/Part D sponsors may accept requests for enrollment into their plans via an incoming (in-bound) telephone call to a plan representative or agent.
- Each telephonic enrollment request must be recorded audio and include a statement of the individual’s agreement to be recorded all required elements necessary to complete the enrollment per cms enrollment guidelines, and a verbal attestation of the intent to enroll. If the request is made by someone other than the beneficiary, the recording must include the attestation regarding the individual’s authority under State law to complete the request, in addition to the required contact information.
- All telephonic enrollment recordings must be reproducible and maintained in accordance with CMS guidelines.
- Default Enrollment Option for Medicaid Managed Care Plan Enrollees who are Newly Eligible for Medicare Advantage.
- Subject to prior CMS approval, MA Plans may automatically enroll newly eligible Medicare beneficiaries into a dual eligible special needs plan (D-SNP).
- Default enrollment is permitted only for individuals who: are newly eligible for Medicare Advantage; are currently enrolled in a Medicaid managed care plan offered by the MA organization for (or an entity under the same parent organization as the Ma organization) and will remain in the Medicaid managed care plan upon their conversion to Medicare.
- Auto and Facilitated enrollment
- AlI LIS eligible individuals who elect an MA plan without Medicare prescription drug benefits (“MA-only plan”) will be auto- or facilitated enrolled into an MA-PD plan in the same organization or into a pop oftered by the same organization unless the individual declines the enrollment.
- The MA organization’s auto- and facilitated enrollment processes will occur monthly.
The 365 Days of Medicare
It’s important to know when members can enroll and/or make a plan change.
- Initial Enrollment Period EPITOr MA
- This period begins 3 months immediately before the individual’s first entitlement to both Medicare Part A and Part B and ends on the later of:
- 1. The last day of the month preceding entitlement to both Part A and Part B, or;
- 2. The last day of the individual’s Part B initial enrollment period.
- The initial enrollment period for Part B is the 7-month period that begins 3 months before the month an individual meets the eligibility requirements for Part B and ends 3 months after the month of eligibility.
- This period begins 3 months immediately before the individual’s first entitlement to both Medicare Part A and Part B and ends on the later of:
- Initial Enrollment Period for Part D (IEP for Part D)
- The period during which an individual is first eligible to enroll in a Part D plan.
- In general, an individual is eligible to enroll in a Part D plan when he or she is entitled to Part A OR is enrolled in Part B, AND permanently resides in the service area of a Part D plan.
- Ultimately, CMS provides a part D eligibility effective date and maintains it in CMS systems.
- Open Enrollment Period for Institutionalized Individuals (OEPI)
- The OEPL is continuous for eligible individuals.
- For purposes of enrollment under the OEPI election period, an institutionalized individual is defined as an individual who moves into, resides in, or moves out of an institution. Also includes those meeting definition of MA SN for institutionalized individuals..
- The OEPI ends two months after the month the individual moves out of the institution.
- An MA eligible institutionalized individual can make an unlimited number of MA enrollment requests during the OEPI.
- An individual disenrolling from an MA-PD plan has an OEPI to enroll in a PDP.
- Lock in Period
- During this time a beneficiary cannot change his/her MA, MAPD, or PDP unless a special situation comes up which may allow you to qualify for a Special Enrollment Period (SEP).
- The lock-in period runs from April 1st to October 14th.
The 365 Days of Medicare
It’s important to know when members can enroll and/or make a plan change.
- Annual Election Period (AEP)
- AEP Is also referred to as the “fall Open Enrollment” season and the “Open Enrollment Period for Medicare Advantage AND Medicare prescription drug coverage”
- Occurs from October 15 through December 7 each year for January effective dates
- During the AEP, MA eligible individuals may enroll in or disenroll from an MA plan.
- The last enrollment request made, determined by the application date will be the enrollment request that takes eftect
- Open Enrollment Period (OEP)
- During the MA OEP, MA plan enrollees may enroll in another MA plan or disenroll from their MA plan and return to Original Medicare.
- Individuals may make only one election during the MA OEP
- Individuals enrolled in an MA plan may add or drop Part D coverage during the MA OEP. Individuals enrolled in either MA-PD or MA-only plans can switch to: MA-PD: MA-only: Original Medicare (with or without a stand-alone Part D plans
- Special Enrollment Period (SEP)
- Special election periods constitute periods outside of the usual IEP, AEP or OEP when an individual may elect a plan or change his or her current plan election.
- The SFP for the individual ends when the individual elects a new MA plan or when the SEP time frame ends whichever comes first, unless specified otherwise within an SEP
Special Enrollment Period (SEP) Examples
- 5-STAR SEP –
- An eligible individual may enroll in an MA plan offered by an MA organization with a Star Rating of S Stars during the year in which that plan has the 5-star overall performance rating, provided the enrollee meets the other requirements to enroll in that plan (e.g. living within the service area.)
- Individuals may use the 5-Star SEP to disenroll from a Medicare Advantage plan by enrolling in a 5-Star cost plan that is open for enrollment
- SEPS FOR CHANGES IN RESIDENCE – An SEP for a change in residence exists for these scenarios:
- Individuals who are no longer eligible to be enrolled in an MA plan due to a change in permanent residence outside of the service area:
- Individuals who were not eligible for MA because they were incarcerated and have now been released, or
- Individuals who will have new Medicare health or Part D plans available to them as a result of a permanent move.
- CHANGE IN LIS/DUAL STATUS – An SEP is provided for individuals who receive *Extra Help.” It includes those who:
- Become eligible for any type of assistance from the Title XIX program (including “partial duals” who receive cost-sharing assistance under Medicaid and individuals who qualify for LIS (but who do not receive Medicaid benefits);
- Lose eligibility for any type of assistance; and
- Have a change in the level of assistance they receive
- Examples: those who stop receiving Medicaid benefits, but still qualify for LIS; those who have a change in cost sharing or become eligible for additional Medicaid benefits.
- The SEP allows the individual one opportunity to make an election within three months of any of the changes noted above, or notification of such
a change, whichever is later. - The effective date for enrollments under this SEP is the first day of the month following receipt of the
enrollment request by the plan. - The SEP allows the individual one opportunity to make an election within three months of any of the changes noted above, or notification of such a change, whichever is later.
- The effective date for enrollments under this SEP is the first day of the month following receipt of the enrollment request oy the plan.
Special Enrollment Period (SEP) Examples
- SEP for Dual-eligible Individuals and Other LIS-Eligible Individuals
- There is an SEP for individuals who have Medicare Part A and Part B and receive any type of assistance from the Title XIX (Medicaid) program.
- This includes both “full benefit” dual eligible individuals as well as individuals often referred to as “partial duals” who receive cost sharing assistance under Medicaid (e.g. QMB-only, SLMB-only, etc.) and individuals who qualify for LIS (but who do not receive Medicaid benefits).
- This SEP begins the month the individual becomes dually-eligible and exists as long as he or she receives Medicaid benefits.
- Allows an individual to enroll in, or disenroll from, an MA plan once per calendar quarter during the first nine months of the year.
- This SEP can be used once during each of the following time periods: January – March, April – June, and July – September.
- It may not be used in the 4th quarter of the year (October – December).
- Limitation for “At-Risk” and “Potential At-Risk* Beneficiaries:
- At-Risk beneficiaries are those who are at risk for misuse or abuse of frequently abused drugs (FADs)
- Once an individual is identified by the MA-PD organization as a “potential at-risk” or “at-risk” beneficiary and the plan sponsor has sent written notice to the individual, he or she cannot use this SEP to change plans while this designation is in place.
- The notice to the individual explains that this SEP is no longer available.
- Duration of Limitation – This limitation starts as of the date on the initial notice provided to the “potential at-risk” beneficiary and ends based on the “situation” of the beneficiary as determined by the plan. (Refer to CMS Managed Care Manual – Chapter 2 for more information)
Enrollment Effective Dates
General Guidance for Enrollment Effective Dates
- With the exception of some SEPs and when election periods overlap, generally beneficiaries may not request their enrollment effective date.
- Except for EGHP enrollment requests, the effective date is generally not prior to the receipt of an enrollment request by the MA organization.
- An enrollment cannot be effective prior to the date the beneficiary or his/her legal representative completed the enrollment request.
- The effective date may not be earlier than the first day of the individual’s entitlement to both Medicare Part A and Part B
| Election Period | Effective Date of Coverage | Do MA organizations have to accept enrollment requests in this Election Preiod? |
|---|---|---|
| Initial Coverage Election Period and Initial Enrollment Period for Part D | First day of the month of entitlement a Medicare Part A and Part B-or-the first of the month following the month the enrollment request was made it after the entitlement has occurred. | Yes- unless capacity limit applies (see section 30.9 for capacity limit information). IEP for part D is applicable only to MA-PD enrollment request. |
| Open Enrollment Period for Institutionalized individuals (OEPI) | First day of the month after the month the MA organization receives an enrollment request. | No- the MA organization can choose to be “open” or “closed” for enrollments during this period |
| Annual Election Period | January 1 of the following vear | Yes- unless capacity limit applies |
| Special Election Period | First day of the month after the month the MA organization receives an enrollment request, Unless otherwise noted | Yes- unless capacity limit applies |
| Medicare Advantage open Enrollment Period (MA OEP) | First day of the month after the month the MA organization receives an enrollment request. | No- the MA organization can choose to be “open” or “closed” for enrollments during this period |
Section 1876 Cost Plan Open Enrollment
- DEEMED ENROLLMENT FOR SECTION 1876 COST PLANS:
- An individual who was enrolled on December 31, 1998, in an HMO with a risk contract under 1876 of the Social Security Act was deemed to be enrolled on January 1. 1999, in an MA plan offered by the same organization if he/she did not choose to disenroll from the organization effective on the latter date.
- This deemed enrollment apol even if the enrollee was not entitled to Medicare Part A or did not live in an MA plan service area or continuation area.
- However, if these individuals elect to disenroll from the MA organization, they are not eligible to enroll in any MA plan until or unless they meet all MA eligibility requirements.
- If enrollment in M are Part Bends for an individual, the individual may not continue as a member of the MA plan and must be disenrolled.
- ANNUAL PLAN REQUIREMENTS:
- The MA organization must identify all Medicare Part B-only “grandfathered* individuals and inform them of their status annually.
- The notice must inform these individuals that if they disenroll from the MA organization, they cannot elect another MA plan unless they become entitled to Medicare Part A /by enrolling in Medicare Part A at SSA and by paying the appropriate premium to CMS) and remain enrolled in Medicare Part-B.
- ENROLLMENT
- Grandfathered members may enroll in other MA plans in the same MA organization (within the same State).
- However, if grandfathered members disenroll from the MA organization (i.e., they switch to Original Medicare), they will not be eligible to enroll in any MA plan in any MA organization until or unless they meet all MA eligibility requirements.
- If the out of area erandfathered members disenroll from the MA organization (i.e., they switch to Original Medicare or attempt to enroll in another MA organization), they will only be able to enroll in other MA organizations if they meet all MA eligibility requirements, including, but not limited to, that of living in the service area of the MA plan.
Voluntary Disenrollment
- GENERAL REQUIREMENTS
- A Plan/Part D Sponsor may not either orally or in writing or by any action or inaction, request or encourage any member to disenroll.
- While an MA organization may contact members to determine the reason for disenrollment, the Plan/Part D Sponsor must not discourage members from disenrolling after they indicate their desire to do so.
- The disenrollment request must be dated when it is initially received by the MA organization.
- VOLUNTARY DISENROLLMENT METHODS – A member may request disenrollment from a Plan only during one of the CMS-approved election periods.
The member may disenroll by:- Enrolling in another plan (during a valid enrollment period);
- Giving or faxing a signed written notice to the MA organization or through his/her employer or union, where applicable;
- submitting a request a the Internet the MA organization (if the MA organization offers such an option); or
- Calling 1-800-MEDICARE.
- VERBAL REQUESTS: If a member verbally requests disenrollment from the Plan, the Plan must instruct the member to make the request in one of the ways described above. The MA orpanization may send a disenrollment form to the member upon request.
-
NOTICE REQUIREMENTS:
- After the member submits a request, the Plan must provide the member with a disenrollment notice within ten (10) calendar days of receipt of the request to disenroll.
-
EFFECTIVE DATE OF THE REQUEST:
- with the exception of some SEPs and when election periods overlap, beneficiaries may not choose their effective date.
- Instead, the Plan is responsible for assigning the appropriate effective date based on the election period,
Involuntary Disenrollment
- GENERAL REQUIREMENTS- The MA organization must disenroll a member from the Plan in the following cases. (Refer to CMS MA and Part D enrollment Manuals for exceptions.)
- A change in residence (includes incarceration – see below) makes the individual ineligible to remain enrolled in the plan;
- The member loses entitlement to either Medicare Part A or Part;
- The SNP enrollee loses special needs status and does not reestablish SNP eligibility prior to the expiration of the period of deemed continued eligibility;
- The member dies;
- The Plan’s contract is terminated, or the Plan reduces its service area to exclude the member. Some exceptions may apply. Refer to the CMS MA and Part D Enrollment Manuals);
- The member fails to pay his or her Part D-IRMAA to the government and CMS notifies the plan to effectuate the disenrollment; or
- The member is not lawfully present in the United States.
- OPTIONAL INVOLUNTARY DISENROLLMENTS – A Plan may disenroll a member from its Plan if:
- Premiums are not paid on a timely basis;
- The member enpages in disruptive behavior; or
- The member provides fraudulent information on an enrollment request, or if the member permits abuse of an enrollment card in the MA plan
- INCARCERATION -A member who is incarcerated resides outside the plan’s service area, even if the correctional facility is located within the plans service area
- NOTICE REQUIREMENTS – Disenrollment notices must be sent when:
- The individual has a change in residence and is determined to be out of the plan’s service area;
- CMS disenrolls the individual due to incarceration;
- The individual loses SP status and doesn’t regain eligibility within the period of continued deemed eligibility;
- The individual loses eligibility for enrollment due to contract termination or service area reduction by the MA organization; or
- CMS disenrolls the individual for non-payment of Part D-IRMAA.
Sonder Health Plans
Who is Eligible to Join Sonder Health Plans?
Medicare beneficiaries permanently residing in our service areas:
Cherokee, Clayton, Cobb, Coweta, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Henry, Pauling, and Rockdale
Medicare beneficiaries entitled to Medicare Parts A and B and meeting all other CMS requirements for enrollment
As of 2021, those Medicare beneficiaries with End Stage Renal Disease (ESRD) are now eligible to join.
Exploring Star Ratings
- Star Ratings are given by Medicare and shows how well a plan is performing in different categories.
- Medicare evaluates plans based on a 5-star rating system.
- Star Ratings are calculated each year and may change from one year to the next. This usually occurs after the kits are mailed. You may need to swap out the rating sheet when the updated ratings are given out.
- For more information on Plan Star Ratings go to www.Medicare.gov.
Because Sonder Health Plans is a new plan, we have not yet received any Star Rating.
Choosing Sonder Health Plans
Some of Our Sonder Plan Highlights
| $0 Monthly Plan Premium | $0 PCP & Specialist Visit Copays |
| $0 Copay for Tier One Generic Medications | Transportation Benefit |
| $0 Annual Deductible | Over the Counter (OTC) Allowance |
| $O Copay for all Brand & Generic Insulins (on Sonder Diabetes Wellness Plan only) | 24/7 Nurse Hotline |
| Dental, Vision and Hearing Benefits | Silver & Fit Membership |
Sonder Service Area
The Role of a Primary Care Physician (PCP)
A Member’s network Primary Care Provider coordinates all of his/her care including referrals and authorizations.
As the central point of care, a PCP will direct a members to services he/she needs, such as
- Hospital
- DME Supplies
- Wellness Services
- Ancillary
- Pharmacy
- Network Specialis
*If a member would like to change his/her PCP, he/she can simply call Member Services at 1 (888) 428-4440, TTY 711.
The Role of a
Primary Care Physician (PCP)
A Member’s network Primary Care Provider will provide him/her with the necessary authorizations and/or referrals so that he/she can access:
- Chiropractic Services
- Laboratory Services
- Dermatology Services
- Vision Exams/Glasses/Contacts
- Prescription Drugs
- Hospitals
- Behavioral Health Services
- Podiatry Services
- All Specialist Physicians
- Primary Care Services
- Dental Services
- Silver & Fit Memberships
- Hearing Aids/Hearing Exams
- Over-the-Counter Benefits
- Physical/Occupational/Speech Therapy Services
- Transportation Services
*A referral from a PCP is not required for emergency care or urgently needed care.
Exploring Our Plans
We offer four different plans
- HMO H1748-001
Sonder Complete Health MAPD Plan
For anyone eligible for Medicare Advantage - CSNP H1748-003
Sonder Diabetes Wellness Chronic Special Needs Plan
For those living with Diabetes Mellitus - CSNP H1748-004
Sonder Heart Healthy Chronic Special Needs Plan
For those living with a cardiovascular condition - DSNP H1748-005
Sonder Dual Complete Dual Eligible Plan
For those with both Medicare & Medicaid
Sonder Complete Health MAPD Plan (HMO H1748-001)
| Plan Costs | |
|---|---|
| Monthly Premium | $0 |
| Deductible | $0 |
| Max-Out-Of-Pocket (MOOP) | $6,000 |
| Inpatient Hospital Coverage | Cost Information |
|---|---|
| Days 1-6 | $295 copay |
| Days 7-90 | $0 copay |
| Outpatient Hospital Coverage | |
| Outpatient Hospital Services | $280 copay |
| Outpatient Hospital Observation | $75 copay |
| Ambulatory Surgical Centers (ASC) | $280 copay |
| Doctor Office Visits | |
| Primary Care Provider (PCP) | $0 copay |
| Specialists | $0 copay |
| Preventative Care | $0 copay |
| Emergency Care | |
| Emergency Room | $90 copay |
| Urgent Care | $40 copay |
| Diagnostic Services, Labs and Imaging | Cost Information |
|---|---|
| Diagnostic Radiology | $60-$290 copay |
| Lab Services(Non-Hospital) | $0 copay |
| Diagnostic Tests and Procedures | $55-$290 copay |
| Outpatient X-Rays | $60 copay |
| Therapeutic Radiology | $40 copay |
| Hearing Services- Per Year | |
| Hearing Exam | $40 copay |
| Hearing Aids | $849 copay, no quantity limit |
| Rehabilitation Therapy | |
| Physical Therapy | $40 copay |
| Occupational Therapy | $40 copay |
| Speech Therapy | $40 copay |
| Cardiovascular & Pulmonary Rehab | $30 copay |
| Vision Services – Per Year | |
| Routine Eye Exam(Annually) | $0 copay |
| Contact Lenses/Eyeglasses(frames & lenses) | $200 Annual Maximum |
| Foot Care (Podiatry Services) | |
| Foot Exams and Treatment | $30 copay |
| Routine Foot Care (Limited to Medicare covered services) | $30 copay |
Sonder Complete Health MAPD Plan (HMO H1748-001)
| Dental Services – Preventative & comprehensive – Per Year | Cost Information |
|---|---|
| Oral Exam | $0 copay 1 oral Exam Every 6 Months |
| Cleaning – Prophylaxis | $0 copay 1 Exam Every 6 Months |
| Fluoride Treatment | $0 copay 1 Treatment Exam Every 6 Months |
| Dental X-Rays | $0 copay 1 X-Ray Every 2 Years |
| Non-Routine Services | $0 copay |
| Restorative Services | $0 copay |
| Endodontics | $0 copay |
| Periodontics | $0 copay |
| Extractions | $0 copay |
| Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services( unless specified in Evidence of Coverage) | $0 copay |
| Dentures- Partial & implants | $0 copay |
| Combined Maximum Benefit | $1,000 |
| Mental Health Services | Cost Information |
|---|---|
| Impatient Hospital Psychiatric Services | |
| Day 1-5 | $295 |
| Day 6-90 | $0 |
| Outpatient Group Therapy Visit with a Psychiatrist | $40 copay |
| Outpatient Individual Therapy Visit with a Psychiatrist | $40 copay |
| Outpatient Group Therapy Visit with a Psychologist/Counselor | $40 copay |
| Outpatient Individual Therapy Visit with a Psychologist/Counselor | $40 copay |
| Skilled Nursing Facility | |
| Day 1-20 | $0 |
| Day 21-100 | $184 |
| Emergency Ambulance | |
| Ground Ambulance | $225 copay |
| Air Ambulance | $450 copay |
| Chiropractic Services (Medicare Covered Chiropractic Services) | |
| $20 copay | |
Sonder Complete Health MAPD Plan (HMO H1748-001)
| Home Health Care | Cost Information |
|---|---|
| $0 copay | |
| Medical Equipment/Supplies | |
| Durable Medical Equipment (DME) | 20% coinsurance |
| Medical Supplies | 20% coinsurance |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance |
| Diabetic Supplies | $0 copay |
| Therapeutic Shoes or Inserts | $0 copay |
| Transportation Services | |
| Non-Emergency Transportation | $0 copay 12 One-Way Trips |
| Outpatient Substance abuse | |
| $40 copay | |
| Renal Dialysis | |
| Renal Dialysis | 20% coinsurance |
| Fitness and Wellness | |
| Silver & Fit Fitness | $0 copay |
| Meals | Cost Information |
|---|---|
| 2 meals a day for 14 days provided immediately following each qualifying surgery or inpatient hospitalization. Up to 4 times per year | |
| Over-The-Counter | |
| $50 per quarter | |
| Grocery Card | |
| $55 Monthly Benefit | |
Sonder Complete Health MAPD Plan (HMO H1748-001)
| Cost Information | |
|---|---|
| Deductible | $0 |
| ICL | $4,660 |
| Tier 1 | |
| 1 Month Supply (up to 30-days) | $0 copay |
| 3 Month Supply (61-90 days) | $0 copay |
| $0 copay | |
| Tier 2 | |
| 1 Month Supply (up to 30-days) | $10 copay |
| 3 Month Supply (61-90 days) | $30 copay |
| $30 copay | |
| Tier 3 | |
| 1 Month Supply (up to 30-days) | $44 copay |
| 3 Month Supply (61-90 days) | $132 copay |
| $132 copay | |
| Tier 4 | Cost Information |
|---|---|
| 1 Month Supply (up to 30-days) | $95 copay |
| 3 Month Supply (61-90 days) | $285 copay |
| $285 copay | |
| Tier 5 | |
| 1 Month Supply (up to 30-days) | 33% coinsurance |
| 3 Month Supply (61-90 days) | 33% coinsurance |
| 33% coinsurance | |
Sonder Diabetes Wellness (CSNP H1748-003)
| Plan Cost | Cost Information |
|---|---|
| Monthly Premium | $0 |
| Deductible | $0 |
| Max-Out-Of-Pocket | $3,650 |
| Inpatient Hospital Coverage | |
| Days 1-6 | $350 copay |
| Days 7-90 | $0 copay |
| Outpatient Hospital Coverage | |
| Outpatient Hospital Services | $280 copay |
| Outpatient Hospital Observation | $275 copay |
| Ambulatory Surgical Centers (ASC) | $180 copay |
| Doctor Office Visits | |
| Primary Care Provider (PCP) | $0 copay |
| Specialists | $0 copay |
| Preventative Care | $0 copay |
| Emergency Care | |
| Emergency Room | $120 copay |
| Urgent Care | $25 copay |
| Diagnostic Services, Labs and Imaging | Cost Information |
|---|---|
| Diagnostic Radiology | $0-$275 copay |
| Lab Services (Non-Hospital) | $0 copay |
| Diagnostic tests and Procedures | $275 copay |
| Outpatient X-Rays | $0 copay |
| Therapeutic Radiology | 20% coinsurance |
| Hearing Services – Per Year | |
| Hearing Exam | $0 copay |
| Hearing Aids | $1000 Allowance, no quantity limit |
| Rehabilitation Therapy | |
| Physical Therapy | $40 copay |
| Occupational Therapy | $40 copay |
| Speech Therapy | $40 copay |
| Cardiovascula & Pulmonary Rehab | $0 copay |
| Vision Services – Per year | |
| Routine Eye Exam | $0 copay |
| Contact Lenses / Eyeglasses (frames & lenses) | $200 Annual Maximum |
| Foot Care (Podiatry Services) | |
| Foot Exams and Treatment Medical or Surgical treatment of injuries and routine foot care for certain medical conditions. | $40 copay |
Sonder Diabetes Wellness (CSNP H1748-003)
| Dental Services – Preventative & comprehensive – Per Year | Cost Information |
|---|---|
| Oral Exam | $0 copay 1 oral Exam Every 6 Months |
| Cleaning – Prophylaxis | $0 copay 1 Exam Every 6 Months |
| Fluoride Treatment | $0 copay 1 Treatment Exam Every 6 Months |
| Dental X-Rays | $0 copay 1 X-Ray Every 2 Years |
| Non-Routine Services | $0 copay |
| Restorative Services | $0 copay |
| Endodontics | $0 copay |
| Periodontics | $0 copay |
| Extractions | $0 copay |
| Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services( unless specified in Evidence of Coverage) | $0 copay |
| Dentures- Partial & implants | $0 copay |
| Combined Maximum Benefit | $1,500 |
| Mental Health Services | Cost Information |
|---|---|
| Impatient Hospital Psychiatric Services | |
| Day 1-5 | $350 |
| Day 6-90 | $0 |
| Outpatient Group Therapy Visit with a Psychiatrist | $40 copay |
| Outpatient Individual Therapy Visit with a Psychiatrist | $40 copay |
| Outpatient Group Therapy Visit with a Psychologist/Counselor | $40 copay |
| Outpatient Individual Therapy Visit with a Psychologist/Counselor | $40 copay |
| Skilled Nursing Facility | |
| Day 1-20 | $0 |
| Day 21-100 | $184 |
| Emergency Ambulance | |
| Ground Ambulance | $225 copay |
| Air Ambulance | $450 copay |
| Chiropractic Services (Medicare Covered Chiropractic Services) | |
| $20 copay | |
Sonder Diabetes Wellness (CSNP H1748-003)
| Home Health Care | Cost Information |
|---|---|
| $10 copay | |
| Medical Equipment/Supplies | |
| Durable Medical Equipment (DME) | 20% coinsurance |
| Medical Supplies | 20% coinsurance |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance |
| Diabetic Supplies | $0 copay |
| Therapeutic Shoes or Inserts | $0 copay |
| Transportation Services | |
| Non-Emergency Transportation | $0 copay 12 One-Way Trips |
| Outpatient Substance abuse | |
| $75 copay | |
| Renal Dialysis | |
| Renal Dialysis | 20% coinsurance |
| Fitness and Wellness | |
| Silver & Fit Fitness Program | $0 copay |
| Meals | Cost Information |
|---|---|
| 2 meals a day for 14 days provided immediately following each qualifying surgery or inpatient hospitalization. Up to 4 times per year | |
| Over-The-Counter | |
| $100 per quarter | |
| Grocery Card | |
| $52 Monthly Benefit | |
Sonder Diabetes Wellness (CSNP H1748-003)
| Cost Information | |
|---|---|
| Deductible | $0 |
| ICL | $4,660 |
| Tier 1 | |
| 1 Month Supply (up to 30-days) | $0 copay |
| 3 Month Supply (61-90 days) | $0 copay |
| $0 copay | |
| Tier 2 | |
| 1 Month Supply (up to 30-days) | $15 copay |
| 3 Month Supply (61-90 days) | $45 copay |
| $45 copay | |
| Tier 3 | |
| 1 Month Supply (up to 30-days) | $47 copay |
| 3 Month Supply (61-90 days) | $141 copay |
| $141 copay | |
| Tier 4 | Cost Information |
|---|---|
| 1 Month Supply (up to 30-days) | $100 copay |
| 3 Month Supply (61-90 days) | $300 copay |
| $300 copay | |
| Tier 5 | |
| 1 Month Supply (up to 30-days) | 33% coinsurance |
| 3 Month Supply (61-90 days) | 33% coinsurance |
| 33% coinsurance | |
| Tier 6 | |
| 1 Month Supply (up to 30-days) | $0 copay |
| 3 Month Supply (61-90 days) | $0 copay |
| $0 copay | |
Sonder Heart Healthy (CSNP H1748-004)
| Plan Cost | Cost Information |
|---|---|
| Monthly Premium | $0 |
| Deductible | $0 |
| Max-Out-Of-Pocket | $3,650 |
| Inpatient Hospital Coverage | |
| Days 1-6 | $350 copay |
| Days 7-90 | $0 copay |
| Outpatient Hospital Coverage | |
| Outpatient Hospital Services | $280 copay |
| Outpatient Hospital Observation | $275 copay |
| Ambulatory Surgical Centers (ASC) | $180 copay |
| Doctor Office Visits | |
| Primary Care Provider (PCP) | $0 copay |
| Specialists | $0 copay |
| Preventative Care | $0 copay |
| Emergency Care | |
| Emergency Room | $120 copay |
| Urgent Care | $25 copay |
| Diagnostic Services, Labs and Imaging | Cost Information |
|---|---|
| Diagnostic Radiology | $0-$275 copay |
| Lab Services (Non-Hospital) | $0 copay |
| Diagnostic Tests and Procedures | $275 copay |
| Outpatient X-Rays | $0 copay |
| Therapeutic Radiology | 20% coinsurance |
| Hearing Services – Per Year | |
| Hearing Exam | $0 copay |
| Hearing Aids | $1000 Allowance, no quantity limit |
| Rehabilitation Therapy | |
| Physical Therapy | $40 copay |
| Occupational Therapy | $40 copay |
| Speech Therapy | $40 copay |
| Cardiovascular & Pulmonary Rehab | $0 copay |
| Vision Services – Per year | |
| Routine Eye Exam | $0 copay |
| Contact Lenses / Eyeglasses (frames & lenses) | $200 Annual Maximum |
| Foot Care (Podiatry Services) | |
| Foot Exams and Treatment Medical or Surgical treatment of injuries and routine foot care for certain medical conditions. | $40 copay |
Sonder Heart Healthy (CSNP H1748-004)
| Dental Services – Preventative & comprehensive – Per Year | Cost Information |
|---|---|
| Oral Exam | $0 copay 1 oral Exam Every 6 Months |
| Cleaning – Prophylaxis | $0 copay 1 Exam Every 6 Months |
| Fluoride Treatment | $0 copay 1 Treatment Exam Every 6 Months |
| Dental X-Rays | $0 copay 1 X-Ray Every 2 Years |
| Non-Routine Services | $0 copay |
| Restorative Services | $0 copay |
| Endodontics | $0 copay |
| Periodontics | $0 copay |
| Extractions | $0 copay |
| Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services( unless specified in Evidence of Coverage) | $0 copay |
| Dentures- Partial & implants | $0 copay |
| Combined Maximum Benefit | $1,500 |
| Mental Health Services | Cost Information |
|---|---|
| Impatient Hospital Psychiatric Services | |
| Day 1-5 | $350 |
| Day 6-90 | $0 |
| Outpatient Group Therapy Visit with a Psychiatrist | $40 copay |
| Outpatient Individual Therapy Visit with a Psychiatrist | $40 copay |
| Outpatient Group Therapy Visit with a Psychologist/Counselor | $40 copay |
| Outpatient Individual Therapy Visit with a Psychologist/Counselor | $40 copay |
| Skilled Nursing Facility | |
| Day 1-20 | $0 |
| Day 21-100 | $184 |
| Emergency Ambulance | |
| Ground Ambulance | $225 copay |
| Air Ambulance | $450 copay |
| Chiropractic Services (Medicare Covered Chiropractic Services) | |
| $20 copay | |
Sonder Heart Healthy (CSNP H1748-004)
| Home Health Care | Cost Information |
|---|---|
| $10 copay | |
| Medical Equipment/Supplies | |
| Durable Medical Equipment (DME) | 20% coinsurance |
| Medical Supplies | 20% coinsurance |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance |
| Diabetic Supplies | $0 copay |
| Therapeutic Shoes or Inserts | $0 copay |
| Transportation Services | |
| Non-Emergency Transportation | $0 copay 12 One-Way Trips |
| Outpatient Substance abuse | |
| $75 copay | |
| Renal Dialysis | |
| Renal Dialysis | 20% coinsurance |
| Fitness and Wellness | |
| Silver & Fit Fitness Program | $0 copay |
| Meals | Cost Information |
|---|---|
| 2 meals a day for 14 days provided immediately following each qualifying surgery or inpatient hospitalization. Up to 4 times per year | |
| Over-The-Counter | |
| $100 per quarter | |
| Grocery Card | |
| $52 Monthly Benefit | |
Sonder Heart Healthy (CSNP H1748-004)
| Cost Information | |
|---|---|
| Deductible | $0 |
| ICL | $4,660 |
| Tier 1 | |
| 1 Month Supply (up to 30-days) | $0 copay |
| 3 Month Supply (61-90 days) | $0 copay |
| $0 copay | |
| Tier 2 | |
| 1 Month Supply (up to 30-days) | $15 copay |
| 3 Month Supply (61-90 days) | $45 copay |
| $45 copay | |
| Tier 3 | |
| 1 Month Supply (up to 30-days) | $47 copay |
| 3 Month Supply (61-90 days) | $141 copay |
| $141 copay | |
| Tier 4 | Cost Information |
|---|---|
| 1 Month Supply (up to 30-days) | $100 copay |
| 3 Month Supply (61-90 days) | $300 copay |
| $300 copay | |
| Tier 5 | |
| 1 Month Supply (up to 30-days) | 33% coinsurance |
| 3 Month Supply (61-90 days) | 33% coinsurance |
| 33% coinsurance | |
| Tier 6 | |
| 1 Month Supply (up to 30-days) | $0 copay |
| 3 Month Supply (61-90 days) | $0 copay |
| $0 copay | |
Sonder Dual Complete (DSNP H1748-005)
| Plan Cost | Cost Information |
|---|---|
| Monthly Premium | $0 |
| Deductible | $0 |
| Max-Out-Of-Pocket | $3,650 |
| Inpatient Hospital Coverage | |
| Days 1-6 | $0 copay |
| Days 7-90 | $0 copay |
| Outpatient Hospital Coverage | |
| Outpatient Hospital Services | $0 copay |
| Outpatient Hospital Observation | $0 copay |
| Ambulatory Surgical Centers (ASC) | $0 copay |
| Doctor Office Visits | |
| Primary Care Provider (PCP) | $0 copay |
| Specialists | $0 copay |
| Preventative Care | $0 copay |
| Emergency Care | |
| Emergency Room | $120 copay |
| Urgent Care | $25 copay |
| Diagnostic Services, Labs and Imaging | Cost Information |
|---|---|
| Diagnostic Radiology | $0 copay |
| Lab Services (Non-Hospital) | $0 copay |
| Diagnostic Tests and Procedures | $0 copay |
| Outpatient X-Rays | $0 copay |
| Therapeutic Radiology | $0 copay |
| Hearing Services – Per Year | |
| Hearing Exam | 20% coinsurance |
| Hearing Aids | $1000 Allowance, no quantity limit |
| Rehabilitation Therapy | |
| Physical Therapy | $40 copay |
| Occupational Therapy | $40 copay |
| Speech Therapy | $40 copay |
| Cardiovascular & Pulmonary Rehab | $0 copay |
| Vision Services – Per year | |
| Routine Eye Exam | $0 copay |
| Contact Lenses / Eyeglasses (frames & lenses) | $300 Annual Maximum |
| Foot Care (Podiatry Services) | |
| Foot Exams and Treatment Medical or Surgical treatment of injuries and routine foot care for certain medical conditions. | $40 copay |
Sonder Dual Complete (DSNP H1748-005)
| Dental Services – Preventative & comprehensive – Per Year | Cost Information |
|---|---|
| Oral Exam | $0 copay 1 oral Exam Every 6 Months |
| Cleaning – Prophylaxis | $0 copay 1 Exam Every 6 Months |
| Fluoride Treatment | $0 copay 1 Treatment Exam Every 6 Months |
| Dental X-Rays | $0 copay 1 X-Ray Every 2 Years |
| Non-Routine Services | $0 copay |
| Restorative Services | $0 copay |
| Endodontics | $0 copay |
| Periodontics | $0 copay |
| Extractions | $0 copay |
| Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services( unless specified in Evidence of Coverage) | $0 copay |
| Dentures- Partial & implants | $0 copay |
| Combined Maximum Benefit | $3,500 |
| Mental Health Services | Cost Information |
|---|---|
| Impatient Hospital Psychiatric Services | |
| Day 1-5 | $0 copay |
| Day 6-90 | $0 copay |
| Outpatient Group Therapy Visit with a Psychiatrist | $0 copay |
| Outpatient Individual Therapy Visit with a Psychiatrist | $0 copay |
| Outpatient Group Therapy Visit with a Psychologist/Counselor | $0 copay |
| Outpatient Individual Therapy Visit with a Psychologist/Counselor | $0 copay |
| Skilled Nursing Facility | |
| Day 1-20 | $0 copay |
| Day 21-100 | $0 copay |
| Emergency Ambulance | |
| Ground Ambulance | $0 copay |
| Air Ambulance | $0 copay |
| Chiropractic Services (Medicare Covered Chiropractic Services) | |
| $0 copay | |
Sonder Dual Complete (DSNP H1748-005)
| Home Health Care | Cost Information |
|---|---|
| $0 copay | |
| Medical Equipment/Supplies | |
| Durable Medical Equipment (DME) | $0 copay |
| Medical Supplies | $0 copay |
| Prosthetics (e.g., braces, artificial limbs) | $0 copay |
| Diabetic Supplies | $0 copay |
| Therapeutic Shoes or Inserts | $0 copay |
| Transportation Services | |
| Non-Emergency Transportation | $0 copay 36 One-Way Trips |
| Outpatient Substance abuse | |
| $0 copay | |
| Renal Dialysis | |
| Renal Dialysis | $0 copay |
| Fitness and Wellness | |
| Silver & Fit Fitness Program | $0 copay |
| Meals | Cost Information |
|---|---|
| 2 meals a day for 14 days provided immediately following each qualifying surgery or inpatient hospitalization. Up to 4 times per year | |
| Over-The-Counter | |
| $400 per quarter | |
| Grocery Card | |
| $60 Monthly Benefit | |
Sonder Dual Complete (DSNP H1748-005)
| Cost Information | |
|---|---|
| Deductible | $0 |
| ICL | $4,660 |
| Tier 1 | |
| 1 Month Supply (up to 30-days) | $0 copay |
| 3 Month Supply (61-90 days) | $0 copay |
| $0 copay | |
| Tier 2 | |
| 1 Month Supply (up to 30-days) | $20 copay |
| 3 Month Supply (61-90 days) | $60 copay |
| $60 copay | |
| Tier 3 | |
| 1 Month Supply (up to 30-days) | $47 copay |
| 3 Month Supply (61-90 days) | $141 copay |
| $141 copay | |
| Tier 4 | Cost Information |
|---|---|
| 1 Month Supply (up to 30-days) | $95 copay |
| 3 Month Supply (61-90 days) | $285 copay |
| $285 copay | |
| Tier 5 | |
| 1 Month Supply (up to 30-days) | 25% coinsurance |
| 3 Month Supply (61-90 days) | 25% coinsurance |
| 25% coinsurance | |
Our Prescription Drug Coverage
• Tier 1 generic prescriptions are covered 100%
• Different out-of-pocket costs may apply for members who:
◦ Have limited incomes
◦ Live in long term care facilities
◦ Access to American Indian/Alaskan Native providers
• Some medications may have quantity limits or they may need authorizations from a medical provider
• Sonder Health Plans offers national in-network prescription coverage
• We also offer a mail order option for prescriptions for all of our plans
*A member can also ask the plan to make an exception to the coverage rules by asking for a Formulary Exception.
Our comprehensive formulary can also be found at
www.sonderhealthplans.com/pharmacy
Our Prescription Drug Coverage
• Members pay a copay for approved prescriptions until the total years drug costs (paid by the Sonder member & Sonder Health Plans) equals $4,130.
• After $4,130 in total prescription costs are reached and the coverage gap begins, members will still have all Tier 1 generics 100% covered. Other approved medications are discounted during the coverage gap.
◦ Other approved medications are discounted during the coverage gap.
• With discounts included, members will generally pay no more than 25% of the plan’s costs for brand and generics drugs until the yearly out-of-pocket drug costs reach $6,550.
Our comprehensive formulary can also be found at
www.sonderhealthplans.com/pharmacy
Exploring the Tiers of Part D
• Transitioning to Sonder Health Plans: A newly eligible member who is switching plans or is experiencing a change in his/her level of health care can receive a one time 30-day supply of their current medication(s). Members in long term care will receive a 31-day supply.
• Some drugs have prior authorization, quantity limited and/or Step Therapy requirements
Our comprehensive formulary can also be found at www.sonderhealthplans.com/pharmacy
Becoming a Member
No matter which enrollment option a beneficiary chooses, each application will go through the following procedure for approval:
- Once the application has been submitted, it will be reviewed for completeness.
- CMS will confirm Medicare eligibility.
- Members who enroll through an agent will be contacted within 10 days of application receipt to verify receipt of a completed enrollment request and to provide effective date of coverage
- If everything is in order, the member will receive a letter in the mail confirming his/her plan selection and participation. This letter can be used as proof of insurance until ID cards arrive.
Becoming a Member
Once someone becomes a Sonder Health Plans Member, he/she will receive the Sonder Health Plans Welcome Kit in the mail. Welcome kits includes:
- Evidence of Coverage (EOC) – members should carefully read over their EOC, which explains the terms and conditions of benefits.
- Sonder Member ID Card – this should be carried at all times. Once enrolled, members should show this card instead of the Original Medicare card.
- Sonder Quick Find Guide – this guide is for easy navigation of the www.sonderhealtdev.wpengine.com to find any important information.
- Sonder Multi-Language Insert
- Advance Directives
- Non-Discrimination Statement
Becoming a Member
Members can access some important plan information and documents on our website www.sonderhealtdev.wpengine.com/docsandforms Members can access the following on our site:
- The Evidence of Coverage (EOC)
- Annual Notice of Change (ANOC)
- Explanation of Benefits (EOB)
- Comprehensive Formulary
- Provider Directory
Members can request paper versions of each document from Member Services at 1 (888) 428-4440 at any time.
Contact Sonder Health Plans
The Sonder Health Plans team is standing by to assist members in the following ways:
Customer Service – 1 (888) 428-4440
We are available to members 365 days a year from 8 am to 8 pm.
Members can also visit us at our Sonder Health Plans office at:
6190 Powers Ferry Road
Suite 5320
Atlanta, GA 30339
Member Rights and Safeguards
- As a Sonder Health Plans member, a will always have the right to appeal any denial of coverage or payment for benefits or services you believe should be covered.
- You can file a grievance if you are not satisfied with our benefits or services.
- Your agent will review Member Rights and the Appeals & Grievances process at the conclusion of this presentation.
Please refer to Sonder Health Plans’ Evidence of Coverage (EOC) or contact our Member Customer Service team for more detailed information.
Plans may not discriminate based on race, ethnicity, religion, gender, sexual orientation, disability, health status, or geographic location within the service area. All items and services of a plan are available to all eligible beneficiaries in the service area with the following exceptions: Certain products and services may be made available to enrollees with certain diagnoses (e.g., medication therapy management program for individuals with chronic illnesses or medically necessary coverage provisions).
Enrollment in the low-income subsidy (LIS), as there may be additional eligibility standards. A Plan may not engage in discriminatory practices including:
- Targeting marketing to beneficiaries from higher income areas;
- Stating or otherwise implying that plans are available only to seniors rather than to all Medicare beneficiaries
- Only organizations offering SPs may limit enrollment to dual-eligible, institutionalized individuals, or individuals with severe or disabling chronic conditions and or may target items and services to corresponding categories of beneficiaries.
The Fine Print
- Sonder Health Plans, Inc. is a Medicare Advantage organization with a Medicare contract. The benefit information provided is a brief summary, not a complete description of benefits.
- Limitations, co-payment, and restrictions may apply.
- Benefits, formulary, pharmacy network, premium and/or co-payments/coinsurance may change on January 1 of each year. Each beneficiary must continue to pay his/her Medicare Part B premium.
- This information is available for free in other languages. Our Member Services line is open 365 days a year from 8 am to 8 pm at 1 (888) 428-4440 or TDD/TTY relay 711. If you call after hours, you can leave a message and we’ll return your call the next business day.
- From October 15th to April 1st from, our prospective members can contact a licensed agent at (888) 217-7110, 7 days a week, from 8 am to 6 pm.
- Other Pharmacies, Physicians and Providers are available in our network. Plan performance Star Ratings are assessed each year and may change from one year to the next. Medicare beneficiaries may also enroll in Sonder Health Plans, Inc. through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
Communications and Marketing Requirements and Regulations
HIPAA Privacy
- KEY TERMS
- HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT of 1996 (HIPAA) – a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. It’s comprised of the HIPAA Privacy Rule and the HIPAA Security Rule.
- PROTECTED HEALTH INFORMATION – Protected health information includes all individually identifiable health information, including demographic data, medical histories, test results, insurance information, and other information used to identify a patient or provide healthcare services or healthcare coverage. ‘Protected’ means the information is protected under the HIPAA Privacy Rule.
- PERSONALLY IDENTIFIABLE INFORMATION (PII) – defined as information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual.
- HIPAA PRIVACY TAKEAWAYS FOR AGENTS AND BROKERS
- Agents and Brokers may not use or disclose protected health information, except either: (1) as the Privacy Rule permits or requires; or (2) as the individual who is the subject of the information (or the individual’s personal representative) authorizes in writing.
- HIPAA requires an individual’s written authorization before a use or disclosure of his or her protected health information can be made for marketing.
- Agents and Brokers may not sell protected health information to a business associate or any other third party for that party’s own purposes.
- Agents and Brokers may not sell lists of patients or enrollees to third parties without obtaining authorization from each person on the list.
- Agents and brokers may only collect, use, or disclose PII to the extent necessary to carry out authorized functions, such as enrolling a Medicare beneficiary or performing marketing functions as defined by the HIPAA Privacy Rule.
TRAINING DISCLAIMER: Nothing in this training creates an exemption or exception to HIPAA or other applicable laws.
RESOURCE: https:///www.hhs.cov/hipaa/for-professionals/privacy/guidance/marketing/index.html
Agent, Broker, and Other Third -Party Requirements 42 CFR §§ 422.2274, 423.2274
Agent/Broker Requirements
- Agents and brokers who represent Plan/Part D Sponsors must follow these requirements:
- Be licensed and appointed under state law (if required under applicable state law).
- Be trained and tested annually as required under paragraph (C)(4) of this section and achieve an 85 percent of nigher on all forms of testing.
- Secure and document a Scope of Appointment prior to meeting with potential enrollees
- REPRESENTATION Includes selling products (including Medicare Advantage plans, Medicare Advantage Prescription Drug plans, Medicare Prescription Drug plans, and section 1876 cost plans) as well as outreach to existing or potential beneficiaries and answering or potentially answering questions from existing or potential beneficiaries.
- PLAN OVERSIGHT. Plans /Part D sponsors must oversee first-tier downstream, and related entities that represent the Plan/Part D sponsor to ensure agents and brokers abide by all applicable State and Federal laws, regulations, and requirements. Plans Part D sponsors must do all of the following:
- As required under applicable State law, employ as marketing representatives only individuals who are licensed by the State to conduct marketing (as defined in this subpart) of health insurance in that State, and whom the MA organization has informed that State it has appointed, consistent with the appointment process for agents and brokers provided for under State law.
- As required under applicable State law, report the termination of an agent or broker to the State and the reason for termination.
- Report to CMS all enrolments made by unlicensed agents or brokers and for-cause terminations of agents or brokers.
Please note that Plans/Part D sponsors have additional oversight requirements. This list is limited to employment and Reportine requirements for CMS
Potential Consequences of Inappropriate Behavior
- Potential Consequences of Engaging in Inappropriate or Prohibited Communication and Marketing Activities
- Report requirements-
- As required under applicable State law, Plan/Part D sponsors must report the termination of an agent or broker to the State and the reason for termination.
- Plan/Part D sponsors must report to CMS all for-cause terminations of agents or brokers
- Disciplinary actions
- Termination
- Forfeiture of future compensation
- Report requirements-
- Prohibited activities, include, but not limited to (Refer to additional activities in this presentation)
- Conducting health screenings,
- Providing cash or monetary rebates
- Making unsolicited contact
Communications and Marketing Definitions 42 CFR §§ 422.2260, 423.2260
- COMMUNICATIONS means activities and use of materials created or administered by the plans or any downstream entity to provide information to current and prospective enrollees.
- All activities and materials aimed at prospective and current enrollees, including their caregivers, are “communications within the scope of the applicable regulations.
- Note: Where the term enrollee is used, whether a current or prospective enrollee, the term encompasses representatives of the enrollee who are authorized to act on the enrollee’s behalf.
- MARKETING is a subset of communications and includes materials and activities that meet both the following standards for intent and content:
- Intended to do any of the following:
- Draw a beneficiary’s attention to a MA plan or plans.
- Influence a beneficiary’s decision-making process when making a MA plan selection.
- Influence a beneficiary’s decision to say enrolled in a plan (that is, retention-based marketing.)
- In evaluating the intent of an activity or material, cis will consider obfectave information inducing but not limited to, the audience of the activity or material, other information communicated by the activity or material, timing, and other context of the activity or material and is not limited to the MA organization’s stated intent.
- Include or address content regarding any of the following:
- The plan’s benefits, benefits structure, premiums, or cost-sharing
- Measuring or ranking standards (for example, star Raunes or plan comparisons).
- Rewards and incentives as defined under s 422.134 a).
- Intended to do any of the following:
- The MCMG discusses requirements applicable to all communication activities and materials, as well as additional requirements only applicable to marketing activities and materials. a marketing. unless otherwise noted, must adhere to the communication requirements.
General Communications Materials and Activities Requirements 42 CFR §§ 422.2262 (a), 423.2262 (a)
General Rules
- MA organizations may not mislead, confuse, or provide materially inaccurate information to current or potential enrollees
- PROHIBITED. Plan/Part D Sponsors may not do any of the following
- Provide information that Is inaccurate or misleading.
- Make unsubstantiated statements, except when used in logos or taglines.
- Engage in activities that could mislead or confuse Medicare beneficiaries or misrepresent the Plan/Part D sponsor.
- Engage in any discriminatory activity such as attempting to recruit Medicare beneficiaries from higher income areas without making comparable efforts to enroll Medicare beneficiaries from lower income areas or vice versa.
- Target potential enrollees based on income levels, unless it is a dual eligible special needs plan or comparable plan as determined by the Secretary.
- Target potential enrollees based on health status, unless it is a special needs plan or comparable plan as determined by the Secretary.
- State or imply plans are only available to seniors rather than to all Medicare beneficiaries.
- Employ Plan/Part D sponsor names that suggest that a plan is not available to all Medicare beneficiaries unless it 15 a special needs plan or comparable plan as determined by the Secretary. This prohibition does not apply to MA plan names in effect prior to July 31, 2000.
- Display the names or logos or both of co-branded network providers on the organization’s member identification card, unless the provider names or logos or both are related to the member selection of specific provider organizations [for example, physicians or hospitals).
- Use a plan name that does not include the plan type. The plan type should be included at the end of the plan name, for example, “Super Medicare Advantage (HMO).” MA organizations are not required to repeat the plan type when the plan name is used multiple times in the same material.
General Communications Materials and Activities Requirements 42 CFR §§ 422.2262 (a), 423.2262 (a)
General Rules(Continued)
- PROHIBITED. Plan/Part D Sponsors may not do any of the following
- Claim they are recommended or endorsed by CMS. medicare, the secretary. or HHS.
- Convey that a failure to pay premium will not result in disenrollment, except for tactually accurate descriptions of the MA organization’s policies adopted in accordance with $422.74 (b)(1) and (d)(1)of this chapter.
- Use the term “free to describe a SO premium, any type of reduction in premium, reduction in deductibles or cost-sharing, low-income subsidy, or cost-sharing pertaining to dual eligible individuals.
- Imply that the plan operates as a supplement to Medicare.
- State or imply a plan is available only to or is designed for beneficiaries who are dually eligible for Medicare and Medicare unless it is a dual-eligible special needs plan or comparable plan as determined by the Secretary.
- Market a non-dual eligible special needs plan as if it were a dual-eligible special needs plan.
- Target marketing efforts primarily to dual eligible individuals, unless the plan is a dual eligible special needs plan or comparable plan as determined by the Secretary.
- Claim a relationship with the state Medicaid agency, unless a contract to coordinate Medicaid services for enrollees in that plan is in place.
- PERMISSIBLE. Plans/Part D Sponsors organizations may do any of the following:
- State that the MA organization is approved to participate in Medicare programs or is contracted to administer Medicare benefits or both
- Use the term “Medicare-approved” to describe benefits or services in materials or both.
- Use the term “free” in conjunction with mandatory, supplemental, and preventative benefits provided at a zero cost share for all enrollees
General Communications Materials and Activities Requirements 42 CFR §§ 422.2262 (b), 423.2262 (b)
Product Endorsements/Testimonials
- FORMS. Product endorsements and testimonials may take any of the following forms:
- Television or video ads
- Radio ads
- Print ads
- Social media ads. In cases of social media, the use of a previous post, whether or not associated with or originated by the Plan/Part D Sponsor, is considered a product endorsement or testimonial.
- Other types of ads
- REQUIREMENTS. Plan/Part D Sponsors may use individuals to endorse the Plan/Part D Sponsor’s product provided the endorsement or testimonial adheres to the following requirements:
- The speaker must identify the Plan/Part D Sponsor’s product or company by name.
- Medicare beneficiaries endorsing or promoting the Plan/Part D Sponsor’s must have been an enrollee at the time the endorsement or testimonial was created.
- The endorsement or testimonial must clearly state that the individual was paid for the endorsement or testimonial, if applicable.
- If an individual is used (for example, an actor) to portray a real or fictitious situation, the endorsement or testimonial must state that it is an actor portrayal.
General Communications Materials and Activities Requirements 42 CFR §§ 422.2262 C), 423.2262 (C)
Requirements When Including Certain Telephone Numbers in Materials
- REQUIREMENTS. Plan/Part D Sponsors must adhere to the following requirements for including certain telephone numbers in materials:
- When a Plan/Part D Sponsor includes its customer service number, the hours of operation must be prominently included at least once
- When a Plan/Part D Sponsor includes its customer service number, it must provide a toll-free TTY number in conjunction with the customer service number in the same font size.
- On every material where 1-800-MEDICARE or Medicare TTY appears, the Plan/Part D Sponsor must prominently include, at least once, the hours and days of operation for 1-800-MEDICARE (that is, 24 hours a day/7 days a week).
- EXEMPTIONS. The following advertisement types are exempt from these requirements:
- outdoor advertising
- Banners or banner- like ads
- Radio advertisements and sponsorships
Websites 42 CFR §§ 422.2265, 423.2265
Required Posted Materials
- REQUIRED POSTED MATERIALS. Plan/Part D websites must provide access to the following materials, in a printable format, within the timeframes specified the applicable communications and marketing regulations.
- The following materials for each plan year must be posted on the website by October 15 prior to the beginning of the plan year:
- Evidence of Coverage.
- Annual Notice of Change (for renewing plans).
- summary or Benefits.
- Provider Director
- Provider/Pharmacy Directory.
- The following materials must be posted on the website throughout the year and be updated as required:
- Prior Authorization Forms for physicians and enrollees.
- When applicable, Part D Model Coverage Determination and Redetermination Request Forms
- Exception request forms for physicians (which must be posted by January 1 for new plans).
- CMS Star Ratings document, which must be posted within 21 days after its release on the Medicare Plan Finder.
Websites 42 CFR §§ 422.2263, 423.2263
Displaying CMS-issued Star Ratings
- DISPLAYING STAR RATINGS. The following requirements apply to how MA organizations must display CMS-issued Star Ratings:
- References to individual Star Rating measure(s) must also include references to the overall Star Rating for MA-PDs and the summary rating for MA-only plans.
- May not use an individual underlying category, domain, or measure rating to imply overall higher Star Ratings.
- Must be clear that the rating is out of 5 stars.
- Must clearly identify the Star Ratings contract year.
- May only market the Star Ratings in the service area(s) for which the Star Rating is applicable, unless using Star Ratings to convey overall MA organization performance (for example, “Plan X has achieved 4.5 stars in Montgomery, Chester, and Delaware Counties in which case the MA organization must do so in a way that is not confusing or misleading.
- CMS also has requirements for 5 Star and Low Pertormine contracts.
- As a new plan, sonder Health Plans has no Star Rating and is not required to provide the Star Ratings Document until when it has been issued by CMS
Required Materials and Content 42 CFR § 423.2267(D)(2)
Electronic Communications
- Plan/Part D Sponsors must mail required materials in hard copy or provide them electronically, following the requirements in paragraphs 42 CFR § 423.2267 (d)(1) and (2) of 42 CFR § 423.2267.
- With prior authorization from the enrollee, MA organizations may provide any required material or content electronically.
- To do so, Plan/Part D Sponsors must:
- Obtain prior consent from the enrollee. The consent must specify both the media type and the specific materials being
provided in that media type - Provide instructions on how and when enrollees can access the materials
- Have a process through which an enrollee can request hard copies be mailed, providing the beneficiary with
- The option of a one-time request or a permanent request (which must stay in place until the enrollee chooses to receive electronic materials), and
- With the option of requesting hard copies for all or a subject of materials.
- Hard copies must be mailed within 3 business days of the request
- Have a process for automatic mailing of hard copies when electronic versions or the chosen media type is undeliverable.
- Obtain prior consent from the enrollee. The consent must specify both the media type and the specific materials being
Required Materials and Content 42 CFR § 423.2267(D)(2)
Electronic Communications
- Without prior authorization from the enrollee, MA organizations may mail new and current enrollees a notice informing enrollees how to electronically access the following required materials:
- Evidence of Coverage, Provider and Pharmacy Directories, and Formulary.
- The following requirements apply:
- The MA organization may mail one notice for all materials or multiple notices.
- Notices for prospective year materials may not be mailed prior to September 1st of each year our must be sent in time for an enrollee to access the specified materials by October 15 of each year.
- The MA organization may send the notice throughout the year to new enrollees.
- The notice must include the website address to access the materials, the date the materials will be available if not currently available, and a phone number to request that hard-copy materials be mailed.
- The notice must provide the enrollee with the option to request hardcopy materials. Requests may be material specific and must have the option of a one-time request or a permanent request that must stay in place until the enrollee chooses to receive electronic materials again.
- Hard copies of requested materials must be sent within three business days of the request.
Beneficiary Contact 42 CFR §§ 422.2264, 423.2264
Unsolicited Contact
- Unsolicited contact is subject to the rules for contact for plan business in 422.2264 (b) and apply when materials or activities are given or supplied to a beneficiary or their caregiver without prior request by the MA organization or its agents and brokers.
- Updated marketing guidelines do not support unsolicited contacts of prospective beneficiaries.
- Permissible Activities. Plans/Part D Sponsors may make unsolicited direct contact with a beneficiary or a beneficiary’s caregivers using the following methods:
- Conventional mail and other print media (e.g., advertisements and direct mail)
- Email, provided all emails contain an opt-out function
- Prohibited Activities. MA organizations may not do any of the following if unsolicited:
- Use door-to-door solicitation, including leaving information of any kind, except that information may be left when an appointment is pre scheduled but the beneficiary is not home.
- Approach enrollees in common areas such as parking lots, hallways, and lobbies.
- Send direct messages from social media platforms
Beneficiary Contact 42 CFR §§ 422.2264, 423.2264
Unsolicited Contact (Telephonic)
- Prohibited Activities. MA organizations may not do any of the following if unsolicited:
- Use telephone solicitation (that is, cold calling), robocalls, text messages, or voicemail messages, including, but not limited to, the following:
- Calls based on referrals.
- Calls to former enrollees who have disenrolled or those in the process of disenrolling, except to conduct disenrollment surveys for quality improvement purposes.
- Calls to beneficiaries who attended a sales event, unless the beneficiary gave express permission to be contacted.
- Calls to prospective enrollees to confirm receipt of mailed information.
- Use telephone solicitation (that is, cold calling), robocalls, text messages, or voicemail messages, including, but not limited to, the following:
- Permitted Activities.
- Calls are not considered unsolicited if the beneficiary provides consent or initiates contact with the plan.
- For example, returning phone calls or calling an individual who has completed a business reply card requesting contact is not considered unsolicited.
- Calls are not considered unsolicited if the beneficiary provides consent or initiates contact with the plan.
Beneficiary Contact 42 CFR §§ 422.2264, 423.2264
Contact for Plan Business (Telephonic)
- Permissible. MA organizations may contact current, and to a more limited extent, former members, including those enrolled in other products offered by the parent organization, to discuss plan business, in accordance with the Following requirements:
- An MA organization may conduct the following activities as plan business:
- Call current enrollees, including those in non-Medicare products, to discuss Medicare products. Examples of such calls include, but are not limited to the following:
- Enrollees acing into Medicare from commercial products.
- Existing enrollees, including Medicaid enrollees, to discuss other Medicare products or plan benefits.
- Members in a Part D plan to discuss other Medicare products.
- Call beneficiaries who submit enrollment applications to conduct business related to enrollment.
- with prior CMs approval, call Lis enrollees that a plan is prospectively losing due to reassignment. CMS decisions to approve calls are for limited circumstances based on the following:
- The proximity of cost of the losing plan as compared to the national benchmark: and
- The selection of plans in the service area that are below the benchmark.
- Agents brokers calling clients who are enrolled in other products they may sell such as automotive or home insurance
- Call current enrollees, including those in non-Medicare products, to discuss Medicare products. Examples of such calls include, but are not limited to the following:
- When reaching out to a beneficiary regarding plan business, as outlined in this section, MA organizations must offer the beneficiary the ability to opt out of future calls regarding plan business.
- Prohibited. MA organizations may not make unsolicited calls about other lines of business as a means of generating leads for Medicare plans.
Annual Election Period Marketing
42 CFR 422.66; 42 CFR 423.32
- Special Rule for the Annual Election Period (AEP):
- •Plan/Part D sponsors may not solicit submission of paper enrollment forms or accept telephone or on-line enrollment requests prior to the beginning of the AEP
- Brokers and agents under contract to Plan/Part D sponsors may not accept or solicit submission of paper enrollment forms prior to the start of the AEP,
- Plan/Part D sponsors and their brokers and agents also should remind beneficiaries that they cannot submit enrollment requests prior to the start of the AEP.
- CMS recognizes that Plan/Part D sponsors may receive unsolicited paper enrollment forms prior to the start of the AEP, given that marketing activities may begin prior to this date.
- To be considered unsolicited, the Plan/Part D sponsor must have received the paper AEP enrollment request directly from the applicant and not through a sales agent or broker.
- Other enrollment request mechanisms may not be accepted prior to the actual start of the AEP.
- Paper AEP enrollment requests received prior to the start of the AEP for which there is indication of sales agent or broker involvement in the submission of the request (i.e., the name or contact information of a sales agent or broker) must be investigated by the organization for compliance with the requirements in the Medicare Communications and Marketing Guidelines
Annual Election Period Marketing
42 CFR 422.66; 42 CFR 423.32
- If a Plan/Part D sponsor receives unsolicited paper enrollment forms on or after October 1st but prior to the start of the AEP, it must retain and process them as follows:
- Within 7 calendar days of the receipt of a paper enrollment request, the Plan/Part D sponsor must provide the beneficiary with a written notice that acknowledges receipt of the complete enrollment request and indicates that the enrollment will take effect on January 1 of the following year (refer to applicable CMS model notices).
- For AEP enrollment requests received prior to the start of the AEP the MA organization must submit all transactions to CMS systems (MARx) on the first day of the AEP with an “application date” of the same date.For example, unsolicited AEP paper enrollment requests received October 1 through October 14 must be submitted on October 15th with an “application date” of October 15th of the current year in the appropriate data field on the enrollment transaction. If a beneficiary has submitted more than one AEP paper enrollment request prior to the start of the AEP, the beneficiary will be enrolled in a plan based on the first application that is processed.
- Once the Plan/Part D sponsor receives a MAR DTRR from CMS indicating whether the individual’s enrollment has been accepted or rejected, it must meet the remainder of the requirements (e.g., sending a notice of the acceptance or rejection of the enrollment within 10 calendar days following receipt of the DTRR from CMS) provided in the applicable enrollment guidance.
- Note: If organizations receive incomplete unsolicited AFP paper enrollment requests prior to the start of the AEP they must follow existing guidance for working with beneficiaries to complete the application.
- Again, this policy applies only to the receipt of unsolicited paper enrollment forms prior to the beginning of the AEP. To help ensure a successful AEP season, it is imperative that organizations follow these steps and submit valid enrollment transactions promptly as directed
General Marketing Requirements 42 CFR §§ 422.2263(B)(7), 423.2263(B)(7)
Open Enrollment Period Marketing
- Permissible Activities. During the OP, Plans/Part D sponsors may:
- Conduct marketing activities that focus on other enrollment opportunities including but not limited to marketing to age-ins (who have not vet made an enrollment decision).
- Conduct marketing of their 5-star plan continuous enrollment special election period (SEP) and marketing to dual-eligible and LIS beneficiaries who, in general may make changes once per calendar quarter during the first 9 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
- At the beneficiary’s request, provide information on the OP through the call center
- Include educational information, excluding marketing, on the Plan/Part D sponsor’s website about the existence of OEP.
- The OEP is from January 1 to March 31 annually
- For more information on the OP, refer to Chapter 2 (Medicare Advantage Enrollment and Disenrollment) of the Medicare Managed Care Manual
General Marketing Requirements
42 CFR §§ 422.2263(b)(7), 423.2263(b)(7)
Open Enrollment Period Marketing
- Permissible Activities.
- Plans/Part D sponsors are prohibited from knowingly targeting or sending unsolicited marketing materials to any MA enrollee or Part D enrollee during the continuous Open Enrollment Period (OEP) (January 1 to March 31).
- During the OEP, Plans/Part D sponsors may not:
- Send unsolicited materials advertising the ability or opportunity to make an additional enrollment change or referencing the ОЕР;
- Specifically target beneficiaries who are in the OP because they made a choice during Annual Enrollment Period (AEP) by purchase of mailing lists or other means of identification;
- Engage in or promote agent or broker activities that intend to target the OP as an opportunity to make further sales
- Call or otherwise contact former enrollees who have selected a new plan during the AFP
- Marketing messages aimed at generating interest or leads during the OP are generally prohibited, unless as permitted in the MCMG.
- For example, a generic marketing line of “not happy with your plan, change now” would be considered inappropriate marketing.
- “Knowingly takes into account the intended recipient as well as the content of the message.
- For example, if messaging specifically calling out the OP is sent, it would be knowingly targeting.
- Likewise, if a plan was aware that an individual had already made an AEP enrollment decision, sending unsolicited marketing materials to that individual, even if the OP was not mentioned, would be considered “knowingly targeting.”
Marketing of Rewards and Incentives (RI) Programs
42 CFR §§ 422.134, 42 CF §§ 422.2260, 423.2260
- As part of its marketing efforts MA Plans:
- May include information about R&I Programs in marketing materials if those communications are provided to all current and prospective enrollees without discrimination
- May not offer reward and/or incentive “Items” to potential enrollees under any circumstances
- Additional Guidelines:
- Plans may not use R&I programs to target potential enrollees
- Nominal gifts that are part of marketing activity are different from rewards and incentives
- The target activity in an R&l program must not do any of the following:
- Be related to Part D benefits. Part D plans are not permitted by CFR o 42.134 to develop or use rewards and incentives
plans, so Part D sponsors may not market reward and incentive programs. - Discriminate against enrollees. To ensure that anti-discrimination requirements are met, an MA organization, in providing a rewards and incentives program, must comply with all fraud and abuse laws, all MA program anti-discrimination prohibitions, and must not design a program based on the achievement of a health status measurement.
- Be related to Part D benefits. Part D plans are not permitted by CFR o 42.134 to develop or use rewards and incentives
Note:
For information regarding RI program marketing requirements, see Chapter 4 of the Medicare Managed Care Manual, Section 100.6.
Events With Beneficiaries
42 CFR 55 422.2264(c)(1), 423.2264(c)(1)
Educational Events
- Plans/Part D sponsors and their agents or brokers may hold educational events to meet with Medicare beneficiaries, either face-to-lace or virtually
- Educational events must be advertised as such and be designed to generally inform beneficiaries about Medicare, including Medicare Advantage, Prescription Drug programs, or any other Medicare program.
- Permissible Activities. Plan/Part D sponsors holding or participating in educational events may –
- Distribute communications materials
- Answer beneficiary-Initiated questions pertaining to Plan/Part D sponsor
- Set up future personal marketing appointments
- Distribute business card
- Obtain beneficiary contact information, including Scope of Appointment forms
- Schedule appointments with residents of long-term care facilities (for example, nursing homes, assisted living facilities, board and care homes) upon a resident’s request. If a resident did not request an appointment, any visit by an agent or broker is prohibited as the unsolicited door-to-door marketing
- Prohibited Activities. Plan/Part D sponsors holding or participating in educational events may not:
- Market specific plans or benefits
- Conduct sales or marketing presentations or distribute or accept plan applications
Beneficiary Contact 42 CFR § 423.2264(C)(2), 423.2264(C)(2)
Marketing/sales Events
-
- Definition. Marketing or sales events are group events that fall within the definition of marketing at § 422.2260.
- Requirements:
- If a marketing event directly follows an educational event, the beneficiary must be made aware of the change and given the opportunity to leave prior to the marketing event beginning.
- Permissible. MA organizations holding or participating in marketing events may do any of the following:
- Provide marketing materials.
- Distribute and accept plan applications.
- Collect scope of Appointment forms for future personal marketing appointments
- Conduct marketing presentations
- Prohibited. MA organizations holding or participating in marketing events may not do any of the following:
- Require sign-in-sheets or require attendees to provide contact information as a prerequisite for accending an event
- conduct activities, including health screenings. health surveys, or other activities that are used for or could be viewed as being used to target a subset of members (that is, “cherry-picking“)
- use information collected for raffles or drawings for any purpose other than raffles or drawings.
-
- Note: Plans are reminded that other laws – such as the HIPPA privacy rules -may limit the use of information gathered from other sources or in connection with other products offered by the plan. Nothing in this guidance creates an exemption or exception to other applicable laws.
Beneficiary Contact 42 CFR § 423.2264(c)(3), 423.2264(c)(3)
Personal Marketing Appointments
- Definition. Personal marketing appointments are those appointments that are tailored to an individual or small group (for example, a married couple). Personal marketing appointments are not defined by the location
- Requirements:
- Prior to the personal marketing appointment beginning, the MA plan or agent or broker, as applicable) must agree upon and record the scope of Appointment with the beneficiary (ies).
- Permissible. Plan/Part D Sponsors holding a personal marketing appointment may do any of the following:
- Provide marketing materials.
- Distribute and accept plan applications.
- Conduct marketing presentations.
- Review the individual needs of the beneficiary including, but not limited to, health care needs and history, commonly used medications, and financial concerns.
- Prohibited. MA organizations holding a personal marketing appointment may not do any of the following:
- Market any health care related product during a marketing appointment beyond the scope agreed upon by the beneficiary, and documented by the plan, prior to the appointment.
- Market additional health related lines of plan business not identified prior to an individual appointment without a separate Scope of Appointment identifying the additional lines of business to be discussed.
- Market non-health related products, such as annuities.
Customer Service Call Center Hours of Operations
42 CFR §§ 422.111(H)(1)(1), 423.128(D)(1)(1)
- Plans/Part D sponsors must have mechanisms for providing specific information on a timely basis to current and prospective
enrollees soon request. - Plans/Part D sponsors must have a toll-free customer service call center that meets the following requirements:
- Is open during usual business hours.
- For coverage beginning on and after January 1, 2022, is open at least from 8:00 a.m. to 8:00 p.m. in all service areas served by the Part C/D plan with the following exceptions:
- From October 1 – March 31 of the following year, a customer call center may be closed on Thanksgiving Day and Christmas Day so long as the interactive voice response (IVR) system or similar technology records messages from incoming callers and such messages are returned within one (1) business day.
- From April 1 – September 30, a customer call center may be closed any Federal holiday, Saturday, or Sunday, so long as the interactive voice response VR system or similar technology records messages from incoming callers and such messages are returned within one (1) business day.
Activities With Healthcare Providers or in the Healthcare Setting 42 CFR §§ 422.2266(e) and 423.2266(e)
Plan/part D Sponsor Activities in the Healthcare Setting
- DEFINITION.
- Plan/Part D sponsor activities in the health care setting are those activities, including marketing activities that are conducted by MA organization staff or on behalf of the Plan/Part D sponsor, or by any downstream entity, but not by a provider.
- All marketing must comply with the requirements in (a) and (b) of 42 CFR §§ 422.2266 AND 423.2266
- PERMISSIBLE ACTIVITIES. During Plan/Part D Sponsor activities, the following is permitted:
- Accepting and collecting Scope of Appointment forms.
- Accepting enrollment forms
- Making available, distributing, and displaying communications materials, including in areas where care is being delivered.
- Provide or make available marketing materials and enrollment forms in common areas.
Activities With Healthcare Providers or in the Healthcare Setting 42 CFR §§ 422.2266 (a) and b) AND 423.2266 (a) and (b)
Marketing Activities
- PROHIBITED LOCATIONS. Marketing activities and materials are not permitted in areas where care is being administered, including but not limited to the following:
- Exam rooms
- Mosolra batient rooms
- Treatment areas where patients interact with a provider and clinical team (including such areas in dialysis treatment facilities)
- Pharmacy counter areas
- PERMISSIBLE LOCATIONS. Marketing activities and materials are permitted in common areas within the health care setting, including the following:
- Common entryways
- Vestibules
- waiting rooms
- Hospital or nursing home cafeterias
- Community, recreational, or conference rooms
Activities With Healthcare Providers or in the Healthcare Setting 42 CFR §§ 422.2266 (c) AND 423.2266 (c)
Provider-Initiated Activities
- DEFINITION.
- Provider-initiated activities are activities conducted by a provider at the request of the patient, or as a matter of a course of treatment, and occur when meeting with the patient as part of the professional relationship between the provider and patient.
- Provider-initiated activities do not include activities conducted at the request of the MA organization or pursuant to the network participation agreement between the MA organization and the provider and fall outside of the definition of marketing in §422.2260.
- PERMISSIBLE PROVIDER-INITIATED ACTIVITIES include:
- Distributing unaltered, printed materials created by CMS, such as reports from Medicare Plan Finder, the “Medicare & You” handbook, or “Medicare Options Compare” (from https://www.medicare.gov), including in areas where care is delivered.
- Providing the names of MA organizations with which they contract or participate or both.
- Answering questions or discussing the merits of a MA plan or plans, including cost sharing and benefit information, including in areas where care is delivered.
- Referring patients to other sources of information, such as State Health Insurance Assistance Program (SHIP) representatives, plan marketing representatives, State Medicaid Office, local Social Security Offices, CMS’ website at https://www.medicare.gov, or 1-800-MEDICARE.
- Referring patients to MA plan marketing materials available in common areas.
- Providing information and assistance in applying for the LIS.
- Announcing new or continuing affiliations with MA organizations, once a contractual agreement is signed. Announcements may be made through any means of distribution.
Activities With Healthcare Providers or in the Healthcare Setting 42 CFR §§ 422.2266 (d) and 423.2266 (d)
Plan Initiated Provider Activities
- DEFINITION.
- Plan-initiated provider activities are those activities conducted ov a provider at the request of an MA organization. During a plan-initiated provider activity, the provider is acting on behalf of the MA organization. For the purpose of plan-initiated activities, the MA organization is responsible for compliance with all applicable regulatory requirements.
- PROHIBITED PLAN-INITIATED PROVIDER ACTIVITIES include:
- Accepting or collecting Scope of Appointment forms.
- Accepting Medicare enrollment applications.
- Making phone calls or direct, urge, or attempt to persuade their patients to enroll in a specific plan based on financial or any other interests of the provider.
- Mailing marketing materials on behalf of the MA organization.
- Offering inducements to persuade patients to enroll in a particular MA plan or organization.
- Conducting health screenings as a marketing activity.
- Distributing marketing materials or enrollment forms in areas where care is being delivered.
- Offering anything of value to induce enrollees to select the provider.
- Accepting compensation from the MA organization for any marketing or enrollment activities performed on behalf of the MA organization.
- PERMISSIBLE PLAN-INITIATED PROVIDER ACTIVITIES include:
- Making available, distributing, and displaying communications materials, including in areas where care is being delivered.
- Providing or making available marketing materials and enrollment forms in common areas.
Activities With Healthcare Providers or in the Healthcare Setting 42 CFR §§ 422.2266 (f)
Activities of Institutional Special Needs Plans (I-SNPS) Serving Long-term Care Facility Residents
- Depending on the context of a given situation, I-SNP contracted with a long-term care facility can be viewed as both a provider and a plan.
- I-SNPs may use staff operating in a social worker capacity to provide information, including marketing materials (excluding enrollment forms), to residents of a long-term care facility.
- Social workers of the ISNP whether employees, agents, or contracted providers may not accept or collect a scope of appointment or enrollment form on behalf of the I-SNP
- Unless the beneficiary or the beneficiary authorized representative initiates additional contact with or by the plan. all other marketing and outreach activities in the beneficiary’s room must follow the requirements for beneficiary contact under §422.2264*
- All other activities with healthcare providers or in the healthcare setting must comply with §9 422.2266 a). (b), (c). d), and (e)
Note: Applicable regulatory references are included in this presentation. Use search function to locate.
Required Materials and Content 42 CFR §§ 422.2262, 422.2267, 423.2262, 423.2267
- Non-English and alternate format materials. based on previously created materials. may have the same standardized material
identification SMID as the material on which they are based - Standards for required materials and content. All required materials and content, regardless of categorization as standardized or
model must meet the following:- Be in a 12pt font, Times New Roman or equivalent.
- For markets with a significant non-English speaking population, be in the language of these individuals. Specifically, MA organizations must translate required materials into any non-English language that is the primary language of at least 5 percent of the individuals in a plan benefit package (PBP) service area.
- Be provided to the beneficiary within CMS’s specified timeframes.
- ID cards are exempt from the translation requirements for markets with a significant non-English speaking population described at §§ 422.2267(a)(2) and 423.2267(a)(2).
- Plans/Part D sponsors are not required to resubmit non-English language materials that are based on an English version. If a Plan/Part D sponsor creates a material to be used only in a non-English language, the Plan/Part D sponsor must submit an English translation to HPMS.
- Plans/Part D sponsors are not required to submit alternate format versions of a previously submitted standard material.
Required Materials and Content 42 CFR §§ 422.2262, 422.2267, 423.2262, 423.2267
Multi Language Insert (MLI)
- Description. The Multi-Language Insert is a standardized communications material which states, “We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at (1-xxx-xxx-xxxx.
Someone who speaks (language] can help you. This is a free service.” in the following languages: Spanish, Chinese, Tagalog, French, Vietnamese, German, Korean, Russian, Arabic, Italian, Portuguese, French Creole, Polish, Hindi, and Japanese. - Specifications:
- Additional languages that meet the 5-percent service area threshold must be added to the MLI used in that service area. A plan may also opt to include in the MLI any additional language that do not meet the 5-percent service area threshold, where it determines that this inclusion would be appropriate.
- The MLI must be provided with all required materials under paragraph (e) of 42 CFR 55 422.2267 and 423.2267
- The MLI may be included as a part of the required material or as a standalone material in conjunction with the required material
- When used as a standalone material, the MLI may include organization name and logo.
- When mailing multiple required materials together, only one ML is required.
- The MLI may be provided electronically when a required material is provided electronically as permitted under electronic communications guidelines of 42 CF §§ 422.2267 and 423.2267
General Marketing Requirements 422.2263(b)(2), 423.2263(b)(2)
Nominal Gifts
- CMS’s regulations governing marketing prohibit plans from offering gats to beneficiaries unless the gins are of nominal value.
- CMS’ Interpretation of the terms “nominal gifts” and “cash equivalents,” aligns with HHS OIG’s interpretations.
- The following rules apply to nominal gifts:
- Nominal Value limits – no more than $15 per item or $75 In the aggregate, per person, per year.
- Nominal gifts must be offered to similarly situated beneficiaries without discrimination and without regard to whether the beneficiary enrolls in a plan.
- Nominal gifts may not be in the form of cash, including cash-equivalents, or other monetary rebates.
- CMS is adopting OlG’s interpretation of cash equivalents.
- OlG has interpreted the term “cash equivalents” to encompass items convertible to cash (such as a check) or items that can be used like cash (such as a general-purpose debit card, but not a gift card that can be redeemed only for certain categories of items or services, like a fuel-only gift card redeemable at gas stations). See 85 Fed. Reg. 77,684, 77,789-90 (Dec. 2, 2020), 81 Fed. Reg. 88,368, 88,393 n. 19 (Dec. 7, 2016). CMS’s interpretation of “cash equivalents” for the purposes of this regulation mirrors OlG’s interpretation subject to the following, additional guidance.
- A general gift card that is not restricted to specific retail chains or to specific items and categories would fall under those types that would be considered a cash equivalent (e.g. Visa gift card).
- Gift cards for retailers or online vendors that sell a wide variety of consumer products would also fall under this prohibition (e.g., Walmart and Amazon).
- A gift card that can be used for a more limited selection of items or food, would not be considered a cash equivalent (e.g. Starbucks or a Shell Gas gift card).
General Marketing Requirements 422.2263(b)(2), 423.2263(b)(2)
Exclusion of Meals As A Nominal Gift
- Plans/Part D Sponsors may not provide meals to potential enrollees regardless of value as part of a marketing event.
- Additional Guidance per the MCMG:
- Refreshments and light snacks are not considered “meals.”
- Plans should ensure that items provided could not be reasonably considered a meal and/or that multiple items are not being “bundled” and provided as if a meal.
- Meals may be provided at educational events that meet MS’s regulations and other events that would fall under the definition of communications.
General Marketing Requirements 42 CFR §§ 422.2263, 423.2263
- Marketine is a subset or communications and therefore must rollow the requirements outlined in §423.2262 as well as 42 CFR §§422.2263 Marketing (as defined in § 423.2260) must additionally meet the following requirements:
- Plans/Part D sponsors may begin marketing prospective plan ear offerings on October 1 of each year for the following contract year. Plans/Part D Part D sponsors may market the current and prospective year simultaneously provided materials clearly indicate what year is being discussed
- Prohibited Activities. In marketing, MA organizations may not do any of the following:
- Provide cash or other monetary rebates as an inducement or enrollment or otherwise
- Offer gifts to beneficiaries, unless the gifts are of nominal value as governed by guidance published by the hiS OlG) are offered to similarly situated beneficiaries without regard to whether or not the beneficiary enrolls and are not in the form of cash or other monetary rebates
- Provide meals to potential enrollees regardless of value
- Market non health care related products to prospective enrollees during any MA sales activity or presentation. This is considered cross-selling and is prohibited
- Compare their plan to other plans, unless the information is accurate, not misleading, and can be supported by the MA organization making the comparison.
- Display the names or logos or both of provider co-branding partners on marketing materials, unless the materials clearly indicate via a disclaimer or in the body that “Other providers are available in the network.”
- Knowingly target or send unsolicited marketing materials to any MA enrollee during OEP.
Agent, Broker, and Other Third-party Requirements 42 CFR §§ 422.2274, 423.2274
Compensation Terms
- COMPENSATION
- Includes monetary or non-monetary remuneration of any kind relating to the sale or renewal of a plan or product offered by an MA organization including, but not limited to the following: Commissions, Bonuses, Gifts, Prizes or Awards.
- Does not include any of the following:
- Payment of fees to comply with State appointment laws, training, certification, and testing costs.
- Reimbursement for mileage to, and from, appointments with beneficiaries.
- Reimbursement for actual costs associated with beneficiary sales appointments such as venue rent, snacks, and materials.
- INITIAL ENROLLMENT YEAR means the first year that a beneficiary is enrolled in a plan versus subsequent years (c.f., renewal year) that a beneficiary remains enrolled in a plan.
- LIKE PLAN TYPE means one of the following:
- PDP replaced with another PDP.
- MA or MA-PD replaced with another MA or MA-PD.
- Cost plan replaced with another cost plan.
- RENEWAL ENROLLMENT YEAR means all years following the initial enrollment year in the same plan or in different plan that is a like plan type.
- UNLIKE PLAN TYPE means one of the following:
- An MA or, MA-PD plan to a PDP or Section 1876 Cost Plan.
- A PDP to a Section 1876 Cost Plan or an MA or MA-PD plan.
- A Section 1876 Cost Plan to an MA or MA-PD plan or PDP.
Agent, Broker, and Other Third-party Requirements 42 CFR §§ 422.2274, 423.2274
Compensation Overview
COMPENSATION REQUIREMENTS. Plans/Part D Sponsors must ensure they meet regulatory requirements of this section in order to pay compensation. These compensation requirements only apply to independent agents and brokers.
GENERAL RULES.
- Plans may only pay agents or brokers who meet the following requirements.
- Licensed and appointed under State law if required under applicable State law).
- Trained and tested annually as required and achieve an 85 percent or higher on all forms of testing.
- Secure and document a Scope of Appointment prior to meeting with potential enrollees.
- Plans may determine, through their contracts, the amount of compensation to be paid, provided it does not exceed limitations outlined in this section.
- Plans may determine their payment schedule (for example, monthly or quarterly). Payments (including payments for AEP enrollments) must be made during the year of the beneficiary’s enrollment.
- Plans may only pay compensation for the number of months a member is enrolled.
ADDITIONAL GUIDANCE
- Compensation year is Jan. 1 through Dec. 31, regardless of beneficiary enrollee date. This is called the “Plan Year” and “Enrollment Year”.
- Initial members are paid either a pro-rated amount or the full compensation
- Payment must be pro-rated for mid-year renewals
- Recoupment must occur for months a member is not in the plan
- Recoupment for rapid disenrollment. Rapid Disenrollment is when a beneficiary makes any plan change (regardless of the parent organization) within the first three months of enrollment.
Agent, Broker, and Other Third-party Requirements 42 CFR §§ 422.2274, 423.2274
Compensation
These compensation requirements only apply to independent agents and brokers.
Employed agents. (agents/brokers who only sell for one Plan/Part D sponsor) are exempt from compensation requirements,
INITIAL ENROLLMENT YEAR COMPENSATION. For each enrollment in an initial enrollment year, Plans may pay compensation at or below FMV.
- Plans may pay either a full or pro-rated initial enrollment var compensation for:
- A beneficiary’s first year of enrollment in any plan; or
- A beneficiary’s move from an employer group plan to a non-employer group plan (either within the same parent organization or between parent organizations).
- MA organizations must pay pro-rated initial enrollment year compensation for:
- A beneficiary’s plan changes) during their initial enrollment year.
- A beneficiary’s selection of an “unlike plan type change. In that case, the new plan would only pay the months that the beneficiary is enrolled, and the previous plan would recoup the months that the beneficiary was not in the plan.
RENEWAL COMPENSATION. For each enrollment in a renewal year, MA plans may pay compensation at an amount up to 50 percent of FMV.
- MA plans may pay compensation for a renewal year:
- In any year following the initial enrollment year the beneficiary remains in the same plan; or
- When a beneficiary enrolls in a new “like plan tune”
PAYMENTS FOR REFERRALS.
- Payments may be made to individuals for the referral (including a recommendation, provision, or other means of referring beneficiaries) to an agent broker or other entity for potential enrollment into a plan.
- The payment may not exceed $100 for a referral into an MA or MA-PD plan and $25 for a referral into a POP plan.
Agent, Broker, and Other Third-party Requirements 42 CFR §§ 422.2274, 423.2274
Third Party Marketing Organization (TPMO)
DEFINITION-
Third Party Marketing Organization (TPMO) means organizations and individuals Including independent agents and brokers, who are compensated to perform lead generation, marketing, sales, and enrollment related functions as a part of the chain of enrollment (the steps taken by a beneficiary from becoming aware of an MA plan or plans to making an enrollment decision).
TPMOs may be a first tier, downstream or related entity (FDRs), as defined under $ 422.2, but may also be entities that are not FDRs but provide services to an MA plan or an MA plan’s FDR
TPMO OVERSIGHT. In addition to any applicable FOR requirements, when doing business with a TPMO, either directly or indirectly through a downstream entity. Ma plans must implement the following as a part of their oversight of TPMOs:
- when a TPMO is not otherwise an FDR, the MA organization is responsible for ensuring that the TPMO adheres to any requirements that apply to the MA plan
- Contracts, written arrangements, and agreements between the TPMO and a Plan/Part D Sponsor, or between the TPMO and a Plan/Part D sponsor’s FDR, must ensure the TPMO:
- Discloses to the Plan/Part D Sponsor any subcontracted relationships used for marketing, lead generation, and enrollment.
- Records all calls with beneficiaries in their entirety including the enrollment process,
- Reports to plans monthly any staff disciplinary actions or violations of any requirements that apply to the Plan/Part D sponro associated with beneficiary interaction to the plan.
- Uses the TPMO disclaimer as required under applicable guidance.
- Ensure that the TPMO, when conducting lead generating activities, either directly or indirectly for an MA organization, must, when applicable:
- Disclose to the beneficiary that his or her information will be provided to a licensed agent for future contact.This disclosure must be provided as follows:
- Verbally when communicating with a beneficiary through telephone.
- In writing when communicating with a beneficiary through mail or other paper.
- Electronically when communicating with a beneficiary through email, online chat, or other electronic messaging platform.
- Disclose to the beneficiary that he or she is being transferred to a licensed agent who can enroll him or her into a new plan.
- Disclose to the beneficiary that his or her information will be provided to a licensed agent for future contact.This disclosure must be provided as follows:
Appendix a: Regulatory References/resources
| Content | References |
|---|---|
| Original Medicare Basics |
|
| Medicare Advantage Basics |
|
| Part D Basics |
|
| 1876 Cost Plans and Other Plan Types |
|
| Extra Help |
|
| Election Periods |
|
| Enrollment and Disenrollment Process |
|
Appendix a: Regulatory References/resources
| Content | References |
|---|---|
| Beneficiary Protections |
|
| Part C Organizational Determinations and Appeals, Part D Coverage Determinations and Redeterminations, and Grievances |
|
| Overview of Marketing |
|
| Overview of Marketing Materials Requirements |
|
| Agent/Broker Compensation |
|
| Marketing Event Requirements |
|
| Marketing Event Type |
|
Important Compliance Reminder
You have completed the required MS Agent and Broker Compliance Training section for Sonder Health Plans.
Be sure to complete all required certifications and other clearances before performing any sales and marketing functions.
If you have any further questions, we are here to help!
Thank you!