Navigating Medicare in 2020

Navigating Medicare in 2020
Carmen Irwin Health Insurance Specialist/ Rural Health Coordinator CMS Dallas Regional Office October 3, 2019

CMS Priorities and Strategic Initiatives
Current Topics July 2019 CMS Priorities and Strategic Initiatives We’re transforming the healthcare system to deliver better value and results for patients through competition and innovation. Lesson 1 provides information about the Centers for Medicare & Medicaid Services’ (CMS’) priorities and strategic initiatives. The goal is to transform the healthcare system into one that delivers better value to patients through competition and innovation.

CMS’ Strategic Initiatives
Current Topics CMS’ Strategic Initiatives July 2019 For 2019, CMS is focusing on 16 major initiatives. For the latest information on these initiatives, visit

CMS’ 16 Strategic Initiatives
Current Topics July 2019 CMS’ 16 Strategic Initiatives Each initiative has its own look and feel. There are many related projects within each initiative that help drive it forward. Next we'll focus on a few of the key projects impacting beneficiaries in For specific information on each initiative, visit CMS.gov/about-cms/story-page/focusing-on-results.html.

Current Topics July 2019

Current Topics Highlights July 2019 Expanded online self-service, including ability to print your own replacement Medicare card and make online premium payments Launched “What’s Covered” mobile app Launched a targeted campaign to encourage adoption of Medicare eResources instead of paper Redesigning Medicare.gov homepage and Medicare Plan Finder to improve user experience for next Open Enrollment Work underway to update and align individual tools for finding and comparing providers and facilities Last Fall, CMS announced a multi-year initiative that will empower patients and update Medicare resources to meet beneficiaries’ expectation of a more personalized customer experience. The eMedicare initiative will modernize the way beneficiaries get information about Medicare and create new ways to help them make the best decisions for themselves and their families. With 10K baby boomers new to Medicare each day, the expectations for a more modern information experience is greater than ever. However, for those who aren’t technically savvy, there are still non-electronic resources available. The eMedicare initiative’s goal is to provide a seamless online health care experience to meet the growing expectations for this generation of Medicare beneficiaries. CMS has a cohesive, multi-year strategy of consumer data integration and web product development to modernize Medicare.gov and improve access to personal health care data. The roadmap for this program will enhance opportunities to go digital, offer additional self-serve options, and create a seamless multi-channel customer service experience.

Blue Button Established in 2010 as a joint effort of CMS and the VA
Current Topics Blue Button July 2019 Established in 2010 as a joint effort of CMS and the VA Used by more than one million beneficiaries to download their CMS information as .txt or .pdf files, via the MyMedicare.gov portal Patients are increasingly using and sharing their data to improve health outcomes This drives the need for easier data interoperability The Blue Button service was established in 2010 as a joint effort of CMS and the Veteran’s Administration. Since that time, Blue Button has been used by more than one million beneficiaries to download their CMS information via the MyMedicare.gov portal. The current text and PDF downloadable files, while relatively easy to read, become challenging when handling large amounts of data, or converting the content into reusable data for further analysis. As digital health care evolves, data becomes an important resource that patients can use to improve health outcomes for themselves, and as part of research groups. This drives the need for easier data interoperability. Data interoperability addresses the ability of systems and services that create, exchange and consume data to have clear, shared expectations for the contents, context and meaning of that data. Interoperability may improve health by providing seamless access to the right information needed to more comprehensively understand and address the health of individuals and populations.

Current Topics July 2019 Blue Button 2.0 Enhances CMS’ current Blue Button service to provide a developer-friendly, standards-based data API Enables beneficiaries to connect to and share their Medicare claims data with the applications, services, and research programs they trust Contains 4 years of Medicare Part A, Part B and Part D data for 53 million Medicare beneficiaries Beneficiaries can find Blue Button 2.0 info and apps at Medicare.gov/manage-your- health/medicares-blue-button-blue-button-20 Identity and authorization controlled via MyMedicare.gov The mission of the Blue Button 2.0 project is to enhance CMS’ current Blue Button service to provide a developer-friendly, standards-based data Application Programming Interface (API) that enables beneficiaries to connect their Medicare claims data to the applications, services, and research programs they trust. Blue Button 2.0 from CMS is an API that contains 4 years of Medicare Part A, Part B, and Part D data for 53 million Medicare beneficiaries. This data reveals a variety of information about a beneficiary’s health, including type of Medicare coverage, drug prescriptions, primary care treatment and cost. Beneficiaries also have full control over how their data can be used and by whom, with identity and authorization controlled by MyMedicare.gov.

Proposed End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model
Current Topics July 2019 Proposed End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model Encourage greater use of kidney transplants and home dialysis for Medicare beneficiaries with ESRD Preserve or enhance quality of care Reduce Medicare expenditures Certain ESRD facilities and Managing Clinicians would be required to participate in the ETC Model based on their location in randomly selected geographic areas CMS is proposing the End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries with ESRD, while reducing Medicare expenditures and preserving or enhancing the quality of care furnished to beneficiaries with ESRD. Both of these modalities have support among health care providers and patients as preferable alternatives to in-center hemodialysis, but utilization has been less than in other developed nations. CMS proposes to achieve these goals by adjusting certain payments to nephrologists and other clinicians managing beneficiaries with ESRD (Managing Clinicians) and ESRD facilities selected to participate in the model. In particular, the proposed model would apply payment adjustments to the adjusted ESRD Prospective Payment System (PPS) per treatment base rate under the ESRD PPS to selected ESRD facilities, as well as the monthly capitation payment (MCP) to selected Managing Clinicians. These payment adjustments would offer the incentive to participating ESRD facilities and Managing Clinicians to work with beneficiaries and caregivers in the choice of treatment modality, and to provide additional resources to support greater utilization of home dialysis and kidney transplants. More information on the proposed model is available at: The ETC Model is part of a CMS proposed rule on specialty care models (CMS-5527-P), which can be viewed at For a fact sheet on the proposed mandatory Kidney Model (ETC) please visit choices-etc-mandatory-model.

Medicare Updates Program Enrollment New Medicare Card
Round 2021 of the Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program Income-Related Monthly Adjustment Amount (IRMAA) for 2019 2020 Medigap Changes Therapy Caps for 2019 Telehealth Services Lesson 2 provides information about changes in Medicare, including the following: Program Enrollment New Medicare Card Round 2021 of the Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program Income-Related Monthly Adjustment Amount (IRMAA) for 2019 2020 Medigap Changes Therapy Caps for 2019 Telehealth Services July 2019 Current Topics

Medicare Enrollment Numbers
Current Topics July 2019 Medicare Enrollment Numbers Year Month Original Medicare Medicare Advantage (MA) and Other Health Plans Total 2019 March 38,091,004 22,653,699 60,744,703 For historical information about Medicare enrollment, visit CMS.gov/Research- Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/Medicare- Enrollment/Enrollment%20Dashboard.html.

Medicaid Enrollment as of March 2019
Current Topics July 2019 Medicaid Enrollment as of March 2019 As of March 2019, there were 72,611,873 Medicaid/CHIP enrollees―65,949,108 in Medicaid and 6,662,765 in CHIP. Resource: Medicaid.gov/medicaid/program-information/medicaid-and-chip- enrollment-data/report-highlights/index.html.

New Medicare Card New Medicare Card mailing completed
Current Topics July 2019 New Medicare Card New Medicare Card mailing completed Medicare Beneficiary Identifier (MBI), not Social Security Number Can print copies from MyMedicare.gov Can use old card (number) until January 1, 2020 Claims filed without the MBI will be rejected New Medicare cards finished mailing early in The new cards no longer have the Social Security Number. Instead, there is a unique identifying Medicare number. To get your new number or to print out your official card, sign into your MyMedicare.gov account. Call MEDICARE ( ); TTY: if there is anything that needs to be corrected, like your mailing address. You can still use your old card to get health care services until January 1, 2020. MACRA

Current Topics July 2019 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP): Temporary Gap Period DMEPOS CBP contracts expired on December 31, 2018 As of January 1, 2019, there’s a temporary gap in the DMEPOS CBP Expected to last until December 31, 2020 During the temporary gap, any Medicare-enrolled DMEPOS supplier may furnish DMEPOS items and services to people with Medicare In most cases, people with Medicare won’t need to switch suppliers All Medicare Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) Competitive Bidding Program (CBP) contracts expired on December 31, Starting January 1, 2019, there will be a temporary gap in the DMEPOS CBP that CMS expects will last until December 31, During the temporary gap, any Medicare enrolled DMEPOS supplier may furnish DMEPOS items and services to people with Medicare. In most cases, people with Medicare won’t need to switch suppliers. BBA

Round 2021 Updates Competitive Bidding Areas (CBAs) Product Categories
Current Topics July 2019 Round 2021 Updates Competitive Bidding Areas (CBAs) CMS consolidated CBAs from round 2 Recompete and Round 1 – 2017, into a single round of competition for Round 2021 Total 130 CBAs Round 2021 contracts effective January 1, 2021, and extend to December 31, 2023 Product Categories Shifting some items to different, smaller product categories to accommodate the lead item pricing methodology 16 product categories in Round 2021 Items newly included are off-the-shelf (OTS) back braces, OTS knee braces, and non-invasive ventilators Round 2021 Updates - Competitive Bidding Areas (CBAs) - CMS consolidated the CBAs included in the Round 2 Recompete and Round into a single round of competition for Round 2021 for a total of 130 CBAs. Round contracts are scheduled to become effective on January 1, 2021, and extend through December 31, 2023. Product Categories - CMS is shifting some items to different, smaller product categories to accommodate the lead item pricing methodology. As a result, the 16 product categories listed below are included in Round Items newly included in the DMEPOS Competitive Bidding Program are off-the-shelf (OTS) back braces, OTS knee braces, and non- invasive ventilators. Commode Chairs Continuous Positive Airway Pressure (CPAP) Devices and Respiratory Assist Devices (RADs) Enteral Nutrition Hospital Beds Nebulizers Negative Pressure Wound Therapy (NPWT) Pumps Non-Invasive Ventilators OTS Back Braces OTS Knee Braces Oxygen and Oxygen Equipment Patient Lifts and Seat Lifts Standard Manual Wheelchairs Standard Power Mobility Devices Support Surfaces (Groups 1 and 2) Transcutaneous Electrical Nerve Stimulation (TENS) Devices Walkers BBA

DMEPOS—Round 2021 Updates (continued)
Current Topics July 2019 DMEPOS—Round 2021 Updates (continued) National Mail-Order (NMO) Not including a national mail-order program for diabetes testing supplies in Round 2021 Round 2021 Precluded Suppliers Precluded suppliers aren’t permitted to participate in Round 2021 Suppliers received a letter as a reminder that they are precluded from participating National Mail-Order (NMO) - As a result of Section of the Bipartisan Budget Act (BBA) of 2018, CMS isn’t including a national mail-order (NMO) program for diabetes testing supplies in Round 2021. Section of the BBA of 2018 mandates several changes to the NMO program, and CMS is working on making these required changes. Round 2021 Precluded Suppliers - Contract Suppliers whose contract for Round 2 Recompete, National Mail-Order Recompete and/or Round was terminated, and who were ultimately precluded from participation in the next round of bidding aren’t permitted to participate in Round 2021 of the DMEPOS Competitive Bidding Program. All precluded suppliers will get a letter from the Competitive Bidding Implementation Contractor before the opening of the bid window as a reminder that they are precluded from participating in Round 2021. BBA

File Individual Tax Return File Married & Separate Tax Return
Monthly Part B Standard Premium—Income-Related Monthly Adjustment Amount (IRMAA) for 2019 Current Topics July 2019 Chart is based on your yearly income in 2017 (for what you pay in 2019) File Individual Tax Return File Joint Tax Return File Married & Separate Tax Return In 2019 You Pay $85,000 or less $170,000 or less $135.50 Above $85,000 up to $107,000 Above $170,000 up to $214,000 See below $189.60 Above $107,000 up to $133,500 Above $214,000 up to $267,000 $270.90 Above $133,500 up to $160,000 Above $267,000 up to $320,000 $352.20 $160,000 and less than $500,000 Above $320,000 up to $750,000 Above $85,000 up to $415,000 $433.40 $500,000 and above $750,000 and above $415,000 and above $460.50 Since 2007, people with Medicare with higher incomes have paid higher Medicare Part B monthly premiums. These income‐related monthly premium rates affect roughly 5% of people with Medicare. The Bipartisan Budget Act of 2018, Sec. 402—Income-Related Premium Adjustment for Parts B and D: Beginning in 2018, this provision mandated adjustments to the current laws’ income-related premium policy. This provision adjusts the amounts of the income thresholds for determining Income-Related Monthly Adjustment Amounts (IRMAA). The total Medicare Part B premiums for people with higher income for 2019 are shown in the following table: For those whose income is $85,000 or less, and file an individual tax return, file a joint tax return with a yearly income of $170,000 or less, or who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses, the Part B premium is $ per month $85,000–$107,000, and file an individual tax return, file a joint tax return with a yearly income above $170,000 up to $214,000, the Part B premium is $ per month $107,000–$133,500, and file an individual tax return, file a joint tax return with a yearly income of above $214,000 up to $267,000, the Part B premium is $ per month $133,500–$160,000, and file an individual tax return, file a joint tax return with an income above $267,000 up to $320,000, the Part B premium is $ per month $160,000–$500,000, and file an individual tax return, file a joint tax return with an income above $320,000 up to $750,000, the Part B premium is $ per month Above $500,000, and file an individual tax return, file a joint tax return with an income above $750,000, the Part B premium is $ per month People with Medicare who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses with income greater than $85,000 and less than $415,000, the Part B premium is $ per month. In this same situation, if income is greater than $415,000, the Part B premium is $ per month. If you have to pay a higher amount for your Part B premium and you disagree (for example, if your income goes down), call Social Security at 1-800‑ ; TTY: 1‑800‑325‑0778. You may pay more if you have a have a Part B late enrollment penalty. NOTE: You may pay more if you have a Part B late enrollment penalty (LEP). BBA

July 2019 2020 Medigap Changes On or after January 1, 2020, Medigap carriers cannot sell policies that provide coverage of the Part B deductible Carriers are prohibited from selling standardized Plans C or F to people “newly eligible” for Medicare Turning 65 as of January 1, 2020, or later Entitled to Part A on the basis of age, disability, or ESRD as of January 1, 2020, or later A person who isn’t “newly eligible” for Medicare can apply with a carrier to purchase a Plan C or F and the carrier wouldn’t be precluded from selling the policy Carriers may sell Plans C or F to those getting Medicare retroactively with Part A start date before January 1, 2020 The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is bipartisan legislation signed into law on April 16, Section 1882 of the Social Security Act (42 U.S.C. 1395ss) is amended by Section 401 ‘‘Limitation on certain Medigap policies for newly eligible Medicare beneficiaries.” Plans C and F can no longer be sold as of January 1, 2020, to “newly eligible” Medicare beneficiaries, eliminating coverage of the Part B deductible in new policies available to those individuals. Existing policies may remain in force and Plans C and F can continue to be sold to individuals who aren’t “newly eligible” for Medicare. Carriers selling Medigap policies can't sell Plans C or F to people who turn 65 on January 1, 2020, or later, are entitled to Part B (due to age, disability, or ESRD) as of January 1, 2020, or later. An individual who isn’t a “newly eligible Medicare beneficiary” can apply with a carrier to purchase a Plan C or F and the carrier wouldn’t be precluded from selling the policy by the MACRA. Carriers may sell a Plan C or F to a person who gets Medicare Part A with a retroactive start date before January 1, 2020. MACRA Current Topics

2020 Medigap Changes (continued)
July 2019 2020 Medigap Changes (continued) Plans C and F will remain in force for people who already had them Plans C and F are guaranteed renewable Unless the premiums aren’t paid No federal guaranteed issue right to transfer from Plans C or F to other plan types Check with your state NOTE: Plans C and F may continue to be offered to people who became eligible for Medicare prior to January 1, 2020 Medigap Plans C and F will remain in force for those people who already had them; however, Plans C and F are guaranteed renewable for those who already have them. If the premiums aren’t paid, these plans would be lost and they generally won’t be able to get either of them back. There isn’t a federal guaranteed issue right for people with Plan C or F to change to other plan types. Check with your State Insurance Department about what rights you might have under state law. NOTE: Plans C and F may continue to be offered to people who became eligible for Medicare prior to January 1, 2020. MACRA Current Topics

Current Topics July 2019 Therapy Caps for 2019 Bipartisan Budget Act of 2018 repealed the therapy caps Annual dollar limit ($2,040 for 2019) for physical therapy and speech- language pathology combined $2,040 for occupational therapy The limit remains as a threshold above which claims must include the KX modifier as a confirmation that services are medically necessary (just as it was before) Retains the targeted medical review process, but at a lower threshold amount or $3,000 (instead of $3,700) through 2028 On February 9, 2018, President Trump signed into law the Bipartisan Budget Act of This new law includes several provisions related to Medicare payment. With regard to payment for outpatient therapy services, the law repeals application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record; and retains the targeted medical review process, but at a lower threshold amount ($3,000 instead of $3,700) through 2028. For more information, visit CMS.gov/Medicare/Billing/TherapyServices/index.html.

Telehealth Services for Substance Use Disorder Treatment
Current Topics July 2019 Telehealth Services for Substance Use Disorder Treatment The Recovery and Treatment (SUPPORT) for Patients and Communities Act removes the originating site geographic conditions and adds an individual’s home as a permissible originating telehealth services site for treatment of a substance use disorder or a co- occurring mental health disorder for services furnished on or after July 1, 2019 Requires that no originating site facility fee will be paid in instances when the individual’s home is the originating site Practitioners would be responsible for assessing whether individuals have an SUD diagnosis Medicare covers services like office visits, psychotherapy, consultations, and certain other medical or health services provided using an interactive, two-way telecommunications system (like real-time audio and video) by an eligible provider who isn’t at your location. These services are available in rural areas, under certain conditions, but only if you’re located at: a doctor’s office, hospital, critical access hospital, Rural Health Clinic, Federally Qualified Health Center, hospital-based dialysis facility, skilled nursing facility, or community mental health center. For most of these services, you’ll pay the same amount that you would if you got the services in-person. Section 2001(a) of the SUPPORT for Patients and Communities Act (Pub. L. 115–271, October 24, 2018) (the SUPPORT Act) makes several revisions to section 1834(m) of the Act. Known as the SUPPORT for Patients and Communities Act. It addresses the opioid epidemic, related to Medicare and Medicaid, including; Treatment, Prevention, Recovery, and Enforcement. It removes the originating site geographic requirements under section 1834(m)(4)(C)(i) for telehealth services furnished on or after July 1, 2019, for the purpose of treating individuals diagnosed with a substance use disorder (SUD) or a co-occurring mental health disorder. It ads the home of a patient as a permissible originating site for telehealth services furnished on or after July 1, 2019, to individuals with an SUD for purposes of treatment of an SUD or a co-occurring mental health disorder. No originating site facility fee will be paid in instances when the individual’s home is the originating site. Practitioners would be responsible for assessing whether individuals have an SUD diagnosis and whether it would be clinically appropriate to furnish telehealth services for the treatment of the individual’s SUD or a co-occurring mental health disorder. For more information on telehealth, view the fact sheet at CMS.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf. SUPPORT Act

Medicare Advantage (MA)
Current Topics July 2019 Medicare Advantage (MA) MA Update New MA Supplemental Benefits Medicare Advantage Open Enrollment Period (MA OEP) Plans with Low Enrollment Innovations in Health Plan Design CY 2020 Voluntary and Mandatory Maximum Out-of-Pocket (MOOP) Range Amounts by Plan Type End-Stage Renal Disease (ESRD) and Enrollment Lesson 3 provides information about changes in Medicare Advantage (MA) and Medicare Prescription Drug updates. MA Updates includes: New MA Supplemental Benefits Medicare Advantage Open Enrollment Period (MA OEP) Plans With Low Enrollment Innovations in Health Plan Design CY 2020 Voluntary and Mandatory Maximum Out-of-Pocket (MOOP) Range Amounts by Plan Type End-Stage Renal Disease (ESRD) and Enrollment

NEW Expanded Health Related Extra Benefits
Current Topics July 2019 NEW Expanded Health Related Extra Benefits Beginning calendar year 2019, CMS reinterpreted the meaning of “primarily health related” to consider an item or service as primarily health related if it is used to Diagnose, prevent, or treat an illness or injury Compensate for physical impairments Improve the functional/psychological impact of injuries or health conditions Reduce avoidable emergency and health care use Benefit must focus on enrollee’s health care needs and be recommended by a licensed medical professional as part of a care plan, if not provided by one Beginning in calendar year 2019, the Centers for Medicare & Medicaid Services (CMS) reinterpreted the meaning of “primarily health related” to consider an item or service as primarily health related if it is used to diagnose, prevent, or treat an illness or injury, compensate for physical impairments, acts to ameliorate (improve) the functional/ psychological impact of injuries or health conditions, or reduces avoidable emergency and health care utilization. A supplemental benefit isn’t primarily health related under the previous or new definition if it is an item or service that’s solely or primarily used for cosmetic, comfort, general use, or social determinant purposes. For CMS to approve a supplemental benefit, the benefit must focus directly on an enrollee’s health care needs and be recommended by a licensed medical professional as part of a care plan, if not directly provided by one. NOTE: CMS calls these “Extra benefits” rather than “Supplemental benefits” in consumer materials, to clearly distinguish from supplement insurance (Medigap).

NEW Allowable Extra Benefits
Current Topics July 2019 NEW Allowable Extra Benefits Adult Day Care Services Home-Based Palliative Care In-Home Support Services Support for Caregivers of Enrollees Medically-Approved Non-Opioid Pain Management Stand-alone Memory Fitness Benefit Home & Bathroom Safety Devices & Modifications Non-emergency Transportation Over-the-Counter (OTC) Benefits An Extra Benefit is defined as an item or service; (1) not covered by Original Medicare, (2) that is primarily health related, and (3) for which the MA Plans must incur a non-zero direct medical cost (Medicare Managed Care Manual (section 30.1). The list details allowable extra benefits resulting from CMS’ reinterpretation of the definition of “primarily health related” and summarizes where these new benefits should be entered and briefly described in the Plan Benefit Package (PBP). This list isn’t exhaustive. Adult Day Care Services: Services provided outside the home. Transportation to and from the adult day care facility may be provided. Home-Based Palliative Care: Home-based palliative care services to diminish symptoms of terminally ill members with a life expectancy of greater than 6 months. In-Home Support Services: In-home support services to assist individuals with disabilities and/or medical conditions in performing Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) within the home. Support for Caregivers of Enrollees: Respite care provided through a personal care attendant or the provision of short-term institutional-based care. Medically-Approved Non-Opioid Pain Management: Medically-approved non-opioid pain treatment alternatives, including therapeutic massage. Stand-alone Memory Fitness Benefit: Memory fitness benefit may be incorporated as a component of a health education benefit and/or offered as a standalone benefit. Home & Bathroom Safety Devices & Modifications: Non-Medicare-covered safety devices to prevent injuries in the home and/or bathroom. Transportation: Transportation to obtain non-emergent, covered Part A, Part B, Part D, and supplemental benefit items and services to accommodate the enrollee’s health care needs. For example, transportation for physician office visits. Over-the-Counter (OTC) Benefits: Health-related items and medications that are available without a prescription, and aren’t covered by Medicare Part A, Part B, or Part D.

NEW Expanded Health Related Extra Benefits (continued)
Current Topics July 2019 NEW Expanded Health Related Extra Benefits (continued) 12 parent organizations with 160 plans are providing enrollees with access to expanded health related extra benefits in 2019 More than 778,000 projected enrollees will have access to these benefits, with in- home support and support for caregivers being the most popular Adult-day care services Home-based palliative care In-home support services Support for caregivers of enrollees Therapeutic massage There are 20 states that have plans offering expanded health related extra benefits: AR, AZ, CT, GA, IL, IN, KY, MO, MS, NC, NJ, OR, RI, SC, TN, TX, VA, WA, WI and WV As a result of CMS’ expansion of the “primarily health related” definition, 12 parent organizations with 160 plans are providing enrollees with access to expanded health related extra benefits. More than 778,000 projected enrollees will have access to these benefits, with in- home support and support for caregivers being the most popular. Adult-day care services Home-based palliative care In-home support services Support for caregivers of enrollees Therapeutic massage There are 20 states that have plans offering expanded health related extra benefits: AR, AZ, CT, GA, IL, IN, KY, MO, MS, NC, NJ, OR, RI, SC, TN, TX, VA, WA, WI and WV. For more information about the expansion of health related supplemental benefits, visit CMS.gov/newsroom/fact-sheets/2019-medicare-advantage-and-part-d-rate- announcement-and-call-letter.

Current Topics July 2019 2019 Benefits at Reduced Extra Benefits/Cost-Sharing for Enrollees with Certain Health Conditions There are 19 parent organizations with 113 plans (717,000 projected enrollees) that have at least one supplemental benefits package for people with certain disease states Diabetes is the most popular disease state package offered, followed by Congestive Heart Failure Some plan-defined packages included Cardiovascular Disorders, Chronic Pain Syndrome, Chronic Kidney Disease, and Opiate Use Disorder There are 11 states that have plans offering benefits at reduced cost-sharing and additional benefits for enrollees with certain conditions: HI, ID, LA, MA, ME, MN, NE, NH, OK, PA and VT CMS reinterpreted the uniformity requirement so that MA Plans can offer reduced cost-sharing and extra benefits for specific enrollee populations based on health status or disease state in a manner that ensures that similarly situated individuals are treated uniformly. This flexibility helps MA Plans better manage health care services. There are 19 parent organizations with 113 plans (717,000 projected enrollees) that have at least one flexible benefits package. Diabetes is the most popular disease state offered, followed by Congestive Heart Failure. Some plan-defined packages included Cardiovascular Disorders, Chronic Pain Syndrome, Chronic Kidney Disease, and Opiate Use Disorder. There are 11 states that have plans offering benefits at reduced cost-sharing and extra benefits for enrollees with certain conditions: HI, ID, LA, MA, ME, MN, NE, NH, OK, PA and VT. For more information Uniformity Flexibility information, visit CMS.gov/newsroom/fact-sheets/2019-medicare-advantage-and-part-d-rate- announcement-and-call-letter.

NEW-2020 Non-Opioid Pain Management Extra Benefits
Current Topics July 2019 NEW-2020 Non-Opioid Pain Management Extra Benefits CMS encourages MA Plans to consider extra benefits that address medically-approved non-opioid pain management and complementary and integrative treatments Peer support services to facilitate recovery and assist in navigating health care resources as part of pain management treatment Psychosocial services/cognitive behavioral therapy can be included in counseling services Non-Medicare covered chiropractic services Acupuncture Therapeutic massage CMS encourages MA organizations to consider Part C benefit designs for extra benefits that address medically-approved non-opioid pain management and complementary and integrative treatments. For example, “peer support services” delivered by qualified individuals may be effective in facilitating recovery and assist in navigating health care resources. Peer support services and/or psychosocial services/cognitive behavioral therapy can be included in counseling services. In addition, non-Medicare covered chiropractic services, acupuncture, and therapeutic massage furnished by a state licensed massage therapist, may also be incorporated into plan designs. “Massage” shouldn’t be singled out as a particular aspect of other coverage (e.g., chiropractic care or occupational therapy) and must be ordered by a physician or medical professional to be considered primarily health related and not primarily for the comfort or relaxation of the enrollee. The non-opioid pain management item or service must treat or ameliorate the impact of an injury or illness (e.g., pain, stiffness, loss of range of motion).

NEW-2020 Special Benefits for the Chronically Ill
MA Plans may offer additional benefits that aren’t “primarily health-related” benefits only to enrollees who are “chronically ill enrollees” as defined by Medicare statute and only when the additional benefits have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee CMS won’t require extra benefits to be primarily health related when they are provided to chronically ill Special Supplemental Benefits for the Chronically Ill (SSBCI) - The Bipartisan Budget Act of 2018 (Public Law No ) amended section 1852(a) of the Social Security Act to expand the types of extra benefits that may be offered by Medicare Advantage (MA) plans to chronically ill enrollees. Includes benefits that aren’t primarily health related and may be offered non-uniformly to eligible chronically ill enrollees. Enable MA Plans to better tailor benefit offerings, address gaps in care, and improve health outcomes for the chronically ill population. The list on the following slide provides examples of non- primarily health related supplemental benefits for the chronically ill (SSBCI). BBA July 2019 Current Topics

Non-Primarily Health Related Items or Services Examples
“Non-primarily health related” item or service examples that may meet the criteria if the statute requirements are met Home-delivered meals, food and produce Complementary therapies Transportation for non-medical needs Services supporting self-direction Pest control Structural home modifications Indoor air quality equipment and services General supports for living Social needs benefits This list of special benefits for the chronically ill isn’t exhaustive: Meals (beyond limited basis): Meals may be offered beyond a limited basis as a non-primarily health related benefit to chronically ill enrollees. Food and Produce: Food and produce to assist chronically ill enrollees in meeting nutritional needs may be covered as SSBCI. Plans may include items like (but not limited to) produce, frozen foods, and canned goods. Tobacco and alcohol aren’t permitted. Transportation for Non-Medical Needs: Transportation to obtain non-medical items and services, like for grocery shopping, banking, and transportation related to any other SSBCI. Such transportation may be reimbursed, arranged, or directly provided by an MA Plan as a SSBCI. Pest Control: Pest eradication services that are necessary to ensure the health, welfare, and safety of the chronically ill enrollee. Services may include pest control treatment(s) or products that may assist the enrollee in the pest eradication (e.g., traps, pest control sprays, cleaning supplies). Indoor Air Quality Equipment and Services: Equipment and services to improve indoor air quality, like temporary or portable air conditioning units, humidifiers, dehumidifiers, High Efficiency Particulate Air filters, and carpet cleaning may be covered as SSBCI. Plans may also include installation and servicing of equipment as part of the benefit. Social Needs Benefits: Access to community or plan-sponsored programs and events to address enrollee social needs, like non-fitness club memberships, community or social clubs, park passes, and access to companion care, marital counseling, family counseling, classes for enrollees with primary caregiving responsibilities for a child, or programs or events to address enrollee isolation and improve emotional and/or cognitive function. Complementary Therapies: Complementary therapies offered alongside traditional medical treatment may be offered as non-primarily health related SSBCI. Complementary therapies must be provided by practitioners who are licensed or certified, as applicable, in the state in which they practice and are furnishing services within the scope of practice defined by their licensing or certifying state. Services Supporting Self-Direction: Services supporting self-direction allow enrollees to have the responsibility for managing all aspects of healthcare delivery in a person-centered planning process. Structural Home Modifications: Structural modifications to the home that may assist in the chronically ill enrollee’s overall function, health, or mobility are permitted if those items and services have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee (e.g., widening of hallways or doorways, permanent mobility ramps, easy use doorknobs and faucets). General Supports for Living: The benefit may include plan-sponsored housing consultations and/or subsidies for rent or assisted living communities. Plans may also include subsidies for utilities like as gas, electric, and water as part of the benefit. July 2019 Current Topics

NEW-2020 Physical Exam Extra Benefit for Special Needs Plans (SNPs)
Current Topics July 2019 NEW-2020 Physical Exam Extra Benefit for Special Needs Plans (SNPs) Beginning CY 2020, SNPs may offer the Physical Exam extra benefit Currently available to Non-SNP MA Plans Provide services beyond those services required to be provided in the Annual Wellness Visit Provide services beyond what is required as part of the SNP’s regular care coordination and disease management responsibilities The exam would be provided by a qualified physician or qualified non-physician practitioner Physical Exam Extra Benefit for Special Needs Plans (SNPs) Over the past several years, CMS has sought to improve care coordination and enhance the experience of care for beneficiaries, particularly those that are a part of the Special Needs Plans (SNP) population. We believe that specialized, targeted care through extra benefit offerings is one way to achieve this goal. Beginning CY 2020, SNPs may offer the Physical Exam extra benefit that is currently available to Non-SNP MA Plans. As discussed in section 30.1 of the Medicare Managed Care Manual, an extra physical exam benefit would provide services beyond and distinct from those services required to be provided in the Annual Wellness Visit (a basic benefit because it’s covered under Part B). Additionally, SNPs are still required to provide a higher level of care coordination and disease management as integral to the “special” care provided to their enrolled beneficiaries through the plan’s development and CMS’ approval of the SNP Model of Care (MOC) (42 C.F.R. § (g)). Therefore, the physical exam supplemental benefit would provide services beyond what’s required as part of the SNP’s regular care coordination and disease management responsibilities. To be considered an Annual Physical Exam that qualifies as a supplemental benefit by CMS, the exam must be provided by a qualified physician or qualified non-physician practitioner.

New Enrollment Changes
Current Topics July 2019 New Enrollment Changes Regulation CMS-4182-F, published April 16, 2018, included new enrollment provisions Impacts MA and Part D Plans Effective January 1, 2019 Subregulatory guidance issued July 31, 2018 Regulation CMS-4182-F was posted on April 16, 2018, included new enrollment provisions. It impacts enrollment in MA and Part D Plans. The changes we will discuss were effective January 1, Sub-regulatory guidance was issued on July 31, 2018 to implement these changes (see the Medicare Managed Care Manual, is in Chapter 2, section 30.5, and can be viewed at CMS.gov/Medicare/Eligibility-and-Enrollment/MedicareMangCareEligEnrol/Downloads/CY_2019_MA_Enrollment_and_Disenrollment_Guidance.pdf).

MA Open Enrollment Period
Current Topics July 2019 MA Open Enrollment Period MA Disenrollment Period ended 2018 Medicare Advantage Open Enrollment Period (MA OEP) began in 2019 January 1 – March 31 each year Must be in MA Plan on January 1 to use MA OEP New Medicare beneficiaries who enroll in MA during IEP have 3 months to use MA OEP to make a change To preserve beneficiary choice under MA, Section Preservation of Medicare beneficiary choice under MA, of the 21st Century Cures Act (Cures Act) discontinued the MA Disenrollment Period (MADP) and established the Medicare Advantage Open Enrollment Period (MA OEP), effective January 1, It’s held from January 1 to March 31 each year. In order to use the MA OEP, an individual must be in an MA Plan on January 1. In addition, newly MA-eligible individuals (those with Part A and Part B) who enroll in a MA Plan during their initial enrollment period, also have the opportunity to use the MA OEP during the first 3 months they have Medicare to make a change if they so choose. Cures Act

MA Open Enrollment Period (continued)
Current Topics July 2019 MA Open Enrollment Period (continued) People in an MA Plan on January 1 can use the MA OEP to do the following: Switch MA Plans (excluding MSA plans, Cost Plans, or PACE Plans) Leave MA to join Original Medicare There’s a coordinating Part D Special Enrollment Period (SEP), during which MA enrollees changing MA Plans or going to Original Medicare can add or drop Part D Can’t switch from one standalone PDP to another standalone PDP Can’t join MA if in Original Medicare During the MA OEP, MA Plan enrollees may switch plans or enroll in another MA Plan or disenroll from their MA Plan and return to Original Medicare. Individuals may add or drop Part D coverage during the MA OEP. Individuals enrolled in either Medicare Advantage Prescription Drug Plans (MA-PD) or MA-only plans can switch to MA-PD MA-only Original Medicare (with or without a stand-alone Part D plan) The OEP doesn’t provide an opportunity for an individual enrolled in Original Medicare to join an MA Plan. It also doesn’t allow for Part D changes for individuals enrolled in Original Medicare, including those enrolled in stand-alone Part D plans. The OEP isn’t available for those enrolled in Medicare Savings Accounts (MSAs) or other Medicare health plan types (like Cost Plans or Programs of All Inclusive Care for the Elderly (PACE)). Enrollments made using the OEP are effective the 1st of the month following the month in which the enrollment is made. People in an MA Plan on January 1 can use the MA OEP to do the following: Switch MA Plans (excluding MSA Plans) Leave MA to join Original Medicare There’s a coordinating Part D Special Enrollment Period (SEP), during which MA enrollees changing MA Plans or going to Original Medicare can add or drop Part D Can’t switch from one standalone PDP to another standalone PDP Can’t join MA if in Original Medicare

Plans With Low Enrollment
Current Topics July 2019 Plans With Low Enrollment Plans with low enrollment can’t renew for 2020 Non-SNPs that had fewer than 500 enrollees SNPs that had fewer than 100 enrollees In existence for 3 or more years as of March 2019 Excludes plans With low enrollment operating in service areas that don’t have a sufficient number of competing options Section 1876 Cost Plans, employer plans, or MSA plans Upon receipt of CMS notification, organizations Confirm each of the low enrollment plans identified by CMS will be eliminated or consolidated with another of the organization’s plans for CY 2020, or Provide a justification to CMS for renewal Plans with Low Enrollment - At the end of March 2019, CMS notified MA organizations that operate non-SNP plans that had fewer than 500 enrollees and SNP plans that had fewer than 100 enrollees and have been in existence for 3 or more years as of March 2019 (three annual election periods) of CMS’ decision not to renew these plans under 42 C.F.R. § (a)(4)(xv). Plans with low enrollment operating in service areas that don’t have a sufficient number of competing options of the same plan type (such that the low enrollment plan still represents a viable plan option for beneficiaries), as determined by CMS, don’t get this notification. Please note that 42 C.F.R. § is a minimum enrollment requirement that is applied at the contract level as part of the MA application process and is independent of this plan-level requirement. Upon receipt of this notification, organizations must either (1) confirm each of the low enrollment plans identified by CMS will be eliminated or consolidated with another of the organization’s plans for CY 2020, or (2) provide a justification to CMS for renewal. If CMS finds that the low enrollment justification is insufficient, CMS will instruct the organization to eliminate or consolidate the plan. Instructions and the timeframe for submitting justifications will be provided in CMS’ notification to the organization. These requirements don’t apply to Section 1876 Cost Plans, employer plans, or MSA plans. CMS recognizes there may be certain factors, like the specific populations served by and geographic location of the plan that led to a plan’s low enrollment. SNPs, for example, may justifiably have low enrollments because they focus on a subset of enrollees with certain medical conditions. CMS considers this information when evaluating whether specific plans should be non-renewed based on insufficient enrollment. MA organizations should follow CMS renewal/non-renewal guidance (see section 50 of Chapter 16B) to determine whether a low enrollment plan may be consolidated with another plan(s). Additional guidance regarding renewal options for 2020 was issued in April through HPMS Memo: Information about Renewal Options for 2020). CMS will continue to evaluate and implement low enrollment requirements on an annual basis.

Innovations in Health Plan Design
Current Topics July 2019 Innovations in Health Plan Design Value-Based Insurance Design (VBID) Model Test Tests whether the additional flexibilities provided under the model allow and incentivize plans to develop and offer interventions that improve health outcomes and lower expenditures MA enrollees Part D Enhanced Medication Therapy Management (MTM) Model Tests whether providing Part D sponsors with additional payment incentives and regulatory flexibilities will lead to improved outcomes and lower costs Part D Payment Modernization Model Tests the impact of a revised Part D program design and incentive alignment on overall Part D prescription drug spending and beneficiary out-of-pocket costs Innovations in Health Plan Design - The CMS Innovation Center is responsible for developing and testing new payment and service delivery models intended to lower costs while preserving or enhancing quality of care for Medicare, Medicaid, and CHIP beneficiaries. In the 2016 Call Letter, CMS indicated its intention to partner with private payers to test innovations in health plan design for CMS beneficiaries. In response to these efforts, the Value-Based Insurance Design (VBID) and the Part D Enhanced Medication Therapy Management (MTM) model tests began operations on January 1, The Part D Payment Modernization Model scheduled to begin on January 1, 2020 with applications currently being accepted. Each of these model tests is described below. Value-Based Insurance Design (VBID) Model Test - In CY 2020, the VBID model is testing whether the additional flexibilities provided under the model allow and incentivize plans to develop and offer interventions that improve health outcomes and lower expenditures for beneficiaries enrolled in participating MA organizations. Part D Enhanced MTM Model - The Part D Enhanced MTM model tests whether providing Part D sponsors with additional payment incentives and regulatory flexibilities will engender enhancements in the MTM program, leading to improved therapeutic outcomes, while reducing net Medicare expenditures. The model is an opportunity for stand-alone basic Part D plans to right-size their investments in MTM services, identify and implement innovative strategies to optimize medication use, improve coordination of care between plans and providers, and strengthen system linkages. For more information, visit innovation.cms.gov/initiatives. Part D Payment Modernization Model - The President’s Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs called on HHS to increase competition, improve negotiation, create incentives for lower list prices, and reduce out-of-pocket costs. Through the Part D Payment Modernization model, CMS is executing on the Blueprint and advancing President Trump’s commitment to lower prescription drug prices, with Medicare beneficiaries, Part D plans, and CMS all benefiting from a more aligned system. In January 2020, CMS’ Center for Medicare and Medicaid Innovation (Innovation Center) is scheduled to begin the Part D Payment Modernization model to test the impact of a revised Part D program design and incentive alignment on overall Part D prescription drug spending and beneficiary out-of-pocket costs. The model aims to reduce Medicare expenditures while preserving or enhancing quality of care for beneficiaries. The model is open to eligible standalone PDPs and MA-PDs that are approved to participate. For more information on the model, visit the model website at innovation.cms.gov/initiatives/part-d-payment-modernization- model.

Expansion of Telehealth Benefits
Current Topics July 2019 Expansion of Telehealth Benefits Starting in 2020, MA Plans can include “additional telehealth benefits” in their bids for basic benefits Beyond what Original Medicare allows MA enrollees may get Part B healthcare services from places like their homes Rather than a healthcare facility MA Plans have broader flexibility in how they pay and expand telehealth services Medicare Advantage Plans Offering Additional Telehealth Benefits - The Bipartisan Budget Act of 2018 allows MA Plans to include “additional telehealth benefits” (telehealth benefits beyond what Original Medicare allows) in their bids for the basic Medicare benefits, starting in plan year Under a final rule released on April 5, 2019, MA enrollees may have great opportunities to get healthcare services from places like their homes, rather than being required to go to a healthcare facility. MA Plans will now have broader flexibility than is currently available in how they pay for coverage of telehealth benefits to meet the needs of their enrollees. Patients in MA Plans have always been able to get more telehealth services than those in Original Medicare, and with the final rule there is an even greater likelihood that these patients will have access to telehealth services from more providers and in more parts of the country than before, whether they live in rural or urban areas. BBA

CY 2020 Voluntary and Mandatory Maximum Out-of-Pocket (MOOP) Range Amounts by Plan Type
July 2019 Plan Type Voluntary Mandatory HMO $0 - $3,400 $3,401 - $6,700 HMO POS $0 - $3,400 In-network $3,401 - $6,700 In-network Local PPO $0 - $3,400 In-network and $0 -$5,100 Combined $3,401 - $6,700 In-network and $3,401 - $10,000 Combined Regional PPO $0 - $3,400 In-network and $0 - $5,100 Combined PFFS (Full network) $0 - $3,400 Combined $3,401 - $6,700 Combined PFFS (partial network) PFFS (non network) Under 42 C.F.R. §§ (f)(4) and (5) and (d)(2) and (3), all MA Plans, including employer group plans and SNPs, must establish limits on enrollee out-of-pocket cost sharing (i.e., deductibles, coinsurance, and copayments) for Part A and Part B services that don’t exceed the annual limits set by CMS. In setting these limits under the regulation, CMS uses Medicare Fee-for-Service data to strike a balance between limiting maximum beneficiary out- of-pocket costs and potential changes in premium, benefits, and cost sharing, with the goal of ensuring beneficiary access to affordable and sustainable benefit packages. Local and regional Preferred Provider Organization (PPO) plans are required to have 2 Maximum Out-of-Pocket MOOP (MOOP) limits established by CMS, including (1) an in-network and (2) a catastrophic (combined) limit that includes both in-network and out-of-network items and services covered under Part A and Part B. HMO-Point of Service (POS) plans may offer out- of-network benefits as supplemental benefits, but aren’t required to have these services contribute to the in-network MOOP limit or to a combined in- and out-of-network MOOP limit. Although the MOOP requirement is for Part A and Part B services, an MA organization can include supplemental benefits as services that are subject to the MOOP. MA Plans may establish as their MOOP any amount within the ranges shown in table above. The table above displays the CY 2020 mandatory and voluntary MOOP amounts and the combined (catastrophic) MOOP amount limits applicable to Local PPOs and Regional PPOs. A plan’s adoption of a MOOP limit that qualifies as a voluntary MOOP ($0 - $3,400) results in greater flexibility for individual service category cost sharing. The possible ranges of the MOOP amount within each plan type are displayed in order to illustrate that MOOP limits may be lower than the CMS-established maximum amounts and what MOOP amounts qualify as mandatory and voluntary MOOP limits. In-network MOOP amount dictates the combined MOOP range for PPOs (i.e., PPOs aren’t permitted to offer a combined MOOP amount within the mandatory range, while having an in-network MOOP amount within the voluntary range). Current Topics

End-Stage Renal Disease (ESRD) and Enrollment
Current Topics July 2019 End-Stage Renal Disease (ESRD) and Enrollment Currently, most people with ESRD can’t join an MA Plan Effective January 1, 2021, people with ESRD will no longer be prohibited from enrolling in an MA Plan Cost of acquiring organs shift from the MA Plans to Original Medicare The 21st Century Cures Act, Section Allowing End-Stage Renal Disease (ESRD) beneficiaries to choose a Medicare Advantage Plan, eliminates the prohibition against individuals with End-Stage Renal Disease (ESRD) enrolling in an MA Plan after they have developed ESRD, effective for plan years beginning on or after January 1, Also beginning with plan year 2021, it transfers responsibility for the costs of acquiring organs for kidney transplants from MA Plans to the fee-for-service portion of Medicare. Payments to MA Plans will be adjusted to reflect that shift. Cures Act

Part D Updates Coverage Gap True Out-of-Pocket (TrOOP) Costs
Current Topics July 2019 Part D Updates Coverage Gap True Out-of-Pocket (TrOOP) Costs Income-Related Monthly Adjustment Amount (IRMAA) Formulary Changes The Preclusion List Elimination of Gag Clauses 2020 Specialty Tiers Threshold Low Enrollment Part D updates include: Coverage Gap True-Out-of-Pocket (TrOOP) Costs Income-Related Monthly Adjustment Amount (IRMAA) Formulary Changes The Preclusion List Elimination of Gag Clauses 2020 Specialty Tiers Threshold Low Enrollment

Improved Coverage in the Coverage Gap
July 2019 Year What You Pay for Covered Brand-Name Drugs in the Coverage Gap What You Pay for Covered Generic Drugs in the Coverage Gap 2019 25% 37% 2020 The Bipartisan Budget Act of 2018 accelerated the closure of the Coverage Gap for brand-name drugs. Once you reach the coverage gap in 2019, you pay 25% of the plan’s cost for covered brand-name prescription drugs. You get these savings if you buy your prescriptions at a pharmacy or order them through the mail. The discount will come off of the price that your plan has set with the pharmacy for that specific drug. In 2019, 95% of the price—the 25% you pay plus the 70% manufacturer discount payment—counts as out-of-pocket costs, which helps you reach the out-of-pocket cost threshold. What the drug plan pays toward the drug cost (5% of the price) and what the drug plan pays toward the dispensing fee (75% of the fee) aren't counted toward your out-of-pocket spending. In 2019, Medicare pays 63% of the price for generic drugs during the coverage gap. You pay the remaining 37% of the price. What you pay for generic drugs during the coverage gap reaches 25% in The coverage for generic drugs works differently from the discount for brand- name drugs. For generic drugs, only the amount you pay helps you move to the catastrophic phase of coverage. Visit Medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/costs-in-the- coverage-gap for examples of what you pay for generic or brand-name drugs. If you have a Medicare drug plan that already includes coverage in the gap, you may get a discount after your plan’s coverage has been applied to the price of the drug. The discount for brand-name drugs will apply to the remaining amount that you owe. BBA Current Topics

True Out-of-Pocket (TrOOP) Costs
July 2019 True Out-of-Pocket (TrOOP) Costs Expenses that count toward your out-of-pocket threshold ($5,100 in 2019) After threshold you get catastrophic coverage You pay only small copayment or coinsurance for covered drugs Explanation of Benefits (EOB) shows TrOOP costs to date TrOOP transfers if you switch plans mid-year True out-of-pocket (TrOOP) costs are the amounts you pay for covered Part D drugs that count toward your drug plan’s out-of-pocket threshold of $5,100 (for 2019). Your yearly deductible, coinsurance or copayments, and what you pay in the coverage gap all count toward this out-of- pocket limit. The monthly drug plan premiums you pay don’t count towards the out-of-pocket limit. TrOOP costs determine when your catastrophic coverage begins. Your drug plan will keep track of your TrOOP costs. Each month that you buy prescriptions covered by your plan, your drug plan will mail you an Explanation of Benefits (EOB) showing your TrOOP costs to date. For payments to count toward your TrOOP costs, you must make them or they must be made on your behalf, they can’t be covered by other insurance, and must be for certain types of costs according to your plan’s rules (for example, drugs on the plan’s formulary or filled at a pharmacy in the plan’s network). You can ask your pharmacist if a better price is available without going through your plan and your pharmacist can give you that information. However, Medicare recommends that you use your plan for every prescription so the plan can conduct proper safety checks and concurrent drug utilization reviews. If you do decide to pay out-of-pocket for your prescription, it’s your responsibility to submit documentation to your plan for TrOOP balance purposes. However, not all of these claims may be reimbursable. For more information, visit CMS.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Chapter- 14-Coordination-of-Benefits-v pdf. If you switch plans during the year, your TrOOP balance transfers to the new Medicare drug plan. Medicare has processes in place for transferring the TrOOP balance. The transfer begins when you disenroll and join a new plan. If you think there’s a mistake in the TrOOP balance that’s transferred, you may need to give a copy of your most recent EOB to the new plan to show the current TrOOP balance. Current Topics

Current Topics July 2019 Monthly Part D Standard Premium—Income-Related Monthly Adjustment Amount (IRMAA) for 2019 Chart is based on your yearly income in 2017 (for what you pay in 2019) File Individual Tax Return File Joint Tax Return File Married & Separate Tax Return You pay Income- related monthly adjustment amount + your plan premium $85,000 or less $170,000 or less $ YPP Above $85,000 up to $107,000 Above $170,000 up to $214,000 See below $12.40* + YPP Above $107,000 up to $133,500 Above $214,000 up to $267,000 $31.90* + YPP Above $133,500 up to $160,000 Above $267,000 up to $320,000 $51.40* + YPP Above $160,000 and less than $500,000 Above $320,000 and less than $750,000 Above $85,000 and less than $415,000 $70.90* + YPP $500,000 and above $750,000 and above $415,000 and above $77.40* + YPP The Bipartisan Budget Act of 2018, Section 402—Income-Related Premium Adjustment for Parts B and D: Beginning in 2018, this provision mandated adjustments to the current laws’ income-related premium policy. This provision adjusts the amounts of the income thresholds for determining IRMAA. In 2019, you pay only your plan premium if your yearly income in 2017 was $85,000 or less for an individual, or $170,000 or less for a married couple. For 2019, if you reported a modified adjusted gross income (MAGI) of more than $85,000 (individuals) or $170,000 (married individuals filing jointly) on your 2017 Internal Revenue Service (IRS) tax return (the most recent tax return information provided to Social Security by the IRS), you’ll have to pay the Part D IRMAA in addition to your monthly Medicare drug plan premium (YPP). It’s important to note that in 2018, the last income level for filing as an individual tax return was above $160,000, and filing a joint tax return was above $320,000. For 2019, an additional income level was added and the requirements changed for those who are married or separated and file separate tax returns. Above $160,000 up to $500,000, and file an individual tax return, file a joint tax return with an income above $320,000 up to $750,000, you pay YPP and IRMAA of $70.90 per month. IRMAA is adjusted each year. It is calculated on the annual beneficiary base premium. NOTE: If you’re married filing separately, but you lived with your spouse at any time during the taxable year, and your income is from $85,000 up to $415,000, you pay YPP and IRMAA of $70.90. If your income changes for certain reasons, like divorce or retirement, you may be able to reduce your IRMAA. Visit ssa.gov/forms/SSA-44-EXT.pdf to view and print a copy of the Medicare Income-Related Monthly Adjustment Amount – Life-Changing Event form. *IRMAA is adjusted each year. It is calculated on the annual beneficiary base premium.

NEW Formulary Changes A Medicare drug plan may
Remove a brand-name drug from its Part D formulary, or Change the brand-name drug's preferred or tiered cost-sharing, so long as a plan Adds a therapeutically equivalent generic drug to its formulary Couldn’t have previously included such drug on its formulary because such generic drug wasn’t yet available on the market Provides general notice to all current and prospective enrollees Provides advance general notice to CMS Starting with 2019 formularies, a Medicare drug plan may immediately remove a brand-name drug from its Part D formulary or change the brand-name drug's preferred or tiered cost-sharing without meeting the deadlines and refill requirements provided that the drug plan does all of the following: At the same time that it removes such brand-name drug or changes its preferred or tiered cost- sharing, it adds a therapeutically equivalent generic drug to its formulary on the same or lower cost- sharing tier and with the same or less restrictive utilization management criteria. The drug plan previously couldn’t have included such therapeutically equivalent generic drug on its formulary when it submitted its initial formulary for CMS approval because such generic drug wasn’t yet available on the market. Before making any permitted generic substitutions, the Part D plan provides general notice to all current and prospective enrollees in its formulary and other applicable enrollee communication materials advising them that Such changes may be made at any time when a new generic is added in place of a brand-name drug, and there may be no advance direct notice to the affected enrollees; If such a substitution should occur, affected enrollees will get direct notice including information on the specific drugs involved and steps they may take to request coverage determinations and exceptions. Before making any permitted generic substitutions, the Part D plan provides advance general notice to CMS and other specified entities. The drug plan provides notice of any such formulary changes to affected enrollees and CMS and other specified entities consistent with existing requirements. This would include direct notice to the affected enrollees. Visit ecfr.gov/cgi-bin/text- idx?SID=2d3b7366dd3d10f6be658cc29e27eff9&mc=true&node=pt &rgn=div5#se _11 20 (42 CFR ) to review the formulary changes. July 2019 Current Topics

NEW The Preclusion List
July 2019 NEW The Preclusion List List of individuals and entities currently revoked from Medicare, are under reenrollment bar, or could be revoked if they had been enrolled in Medicare because of OIG exclusions, felony convictions, and other misconduct, and if CMS determines that the underlying conduct that led to the revocation is detrimental to the best interest of the Medicare Program Individuals and entities are notified of their potential inclusion on the list and their applicable appeal rights One Preclusion List with subsequent updates - Initial list available January 1, 2019 Updates made every 30 days (first business day of each month) Visit CMS.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/PreclusionList.html for Preclusion List resources Medicare Advantage Plans and Part D plans must Reject claims or deny payments for Part D drugs and Medicare Advantage services and items prescribed or furnished by an individual or entity on the preclusion list Notify enrollees who got care in the last 12 months from a contracted provider or a prescription from a provider who’s included on the list The Preclusion List is a list of prescribers and individuals or entities who fall within any of the following categories: (1) Are currently revoked from Medicare, are under an active reenrollment bar, and CMS has determined that the underlying conduct that led to the revocation is detrimental to the best interests of the Medicare Program; or (2) Have engaged in behavior for which CMS could have revoked the prescriber, individual or entity to the extent applicable if they had been enrolled in Medicare, and CMS determines that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicare Program. Such conduct includes, but are not limited to, felony convictions and Office of Inspector General (OIG) exclusions ((422.2(1)(iii)). In the past, providers were on an exclusion list based on their actions in Medicare. This changed to allow for preclusion based on actions prior to becoming a Medicare provider. Prior to being added to a Preclusion List, providers will be notified by CMS of their potential inclusion on the Preclusion List and their applicable appeal rights. CMS will add a provider to the Preclusion List only if the provider’s appeal is denied at the CMS level or the timeframe for the provider to request a CMS level appeal has been exhausted. There is one Preclusion List with subsequent updates. CMS made the initial Preclusion List available to Medicare plans and Part D plans beginning January 1, 2019, on a secure website. Updates to the Preclusion List will be made available every 30 days, around the first business day of each month. Visit CMS.gov/Medicare/Provider-Enrollment-and- Certification/MedicareProviderSupEnroll/PreclusionList.html to review the “User Reference Guide for CMS Preclusion List” for instructions on how to access the list. Additional resources located on this site include, Preclusion List FAQs, a CMS Preclusion List File Layout, and a CMS List Sample File. Medicare plans must remove any contracted provider who’s included on the Preclusion List from their network as soon as possible. Medicare plans and Part D plans should review the Preclusion List for this purpose beginning January 1, 2019, and on a regular basis going forward. Medicare plans and Part D plans are required to immediately notify enrollees who’ve gotten care in the last 12 months from a contracted provider or a prescription from a provider who’s included on the Preclusion List. Current Topics

NEW The Preclusion List—Beneficiary Notice
July 2019 NEW The Preclusion List—Beneficiary Notice Medicare enrollees get 60-day advance notice before payment is denied or pharmacy claims are rejected Plans could begin payment denials and claims rejections on April 1, 2019, for the January 1, 2019, Preclusion List Allowing 30 days for plans to review the list and notify Medicare enrollees, but no later than 30 days from the posting of the list and an additional 60 days for enrollees to prepare Follow the same process for monthly updates to the Preclusion List as they did for the initial list CMS acknowledges that the relevant enrollee notification and claim adjudication timeframes in CMS F aren’t consistent within the preamble and regulation. A recent CMS proposed rule, if finalized, as part of 4185-F, 84 Fed. Reg (April, 16, 2019). For 2019, CMS recommends that Medicare plans and Part D plans furnish Medicare enrollees with at least a 60-day advance notice before they begin denying payment for a health care item or service furnished by a provider on the Preclusion List and rejecting a pharmacy claim (or denying the person’s request for reimbursement) for a drug that is prescribed by a provider on the Preclusion List. CMS suggests such payment denials and claims rejections begin on April 1, 2019, for the January 1, 2019, Preclusion List. This would allow 30 days for plans to review the Preclusion List and notify Medicare enrollees as soon as possible, but no later than 30 days from the posting of the list and an additional 60 days for people with Medicare to prepare. Medicare plans and Part D plans may not reimburse or make payment for claims (like, for covered items or services) or prescriptions associated with any providers on the initial Preclusion List for dates of service on or after April 1, CMS recommends that Medicare plans and Part D plans follow the same process for monthly updates to the Preclusion List as they did for the initial list. The plans will have 30 days to review the Preclusion List for updates and should notify the impacted enrollees as soon as possible, but no later than 30 days from the posting of the updated list. Medicare enrollees should be given at least 60 days’ advance notice before payment denials and claims rejections begin. Medicare plans and Part D plans may notify providers included on the Preclusion List by copying the provider on the notice sent to the enrollee or by other means. This will notify providers about their patients who are impacted by their preclusion from the Medicare Program. Current Topics

NEW Elimination of Gag Clauses
July 2019 NEW Elimination of Gag Clauses Know the Lowest Price Act of 2018 Prohibits PDPs, MA Plans, and MA-PDs from restricting or penalizing a pharmacy for disclosing price information to an enrollee Allows pharmacies to disclose difference between the negotiated price and a lower price without using any health insurance coverage Applies to plan years beginning on or after January 1, 2020 Enrollees pay cash at the pharmacy and submit claim to plan for reimbursement and TrOOP counting Gag clauses are provisions in contracts that insurance plans and their pharmacy benefit managers enter into with pharmacies. These clauses prevent pharmacists from telling customers when they could pay less for a drug by paying cash, instead of billing their insurance and paying the required copay or deductible. On May 17, CMS sent a letter to MA and Part D plans explaining that “gag clauses” that keep patients from knowing how to get the best deal are completely unacceptable, as part of the Administration-wide “American Patients First” initiative to lower prescription drug costs. On October 10, 2018, the ‘‘Know the Lowest Price Act of 2018’’ was signed into law. The law amends the Social Security Act by adding a prohibition on limiting certain information on drug prices. The law states that “a Medicare Prescription Drug Plan and a Medicare Advantage organization shall ensure that each prescription drug plan or Medicare Advantage Prescription Drug Plan (MA- PD) plan offered by the plan or organization doesn’t restrict a pharmacy that dispenses a prescription drug or biological from informing, nor penalize such pharmacy for informing, an enrollee in such plan of any differential between the negotiated price of, or copayment or coinsurance for, the drug or biological to the enrollee under the plan and a lower price the individual would pay for the drug or biological if the enrollee obtained the drug without using any health insurance coverage.’’ This law requirement applies to plan years beginning on or after January 1, 2020. The Drug Pricing final rule (May 2019), CMS finalized Part D regulations consistent with the statute. Specifically, CMS amended the pharmacy contracting requirements at § (a)(8) to provide that a Part D sponsor may not prohibit a pharmacy from, nor penalize a pharmacy for, informing a plan enrollee of the availability at that pharmacy of a prescribed medication at a cash price that is below the amount that the enrollee would be charged to obtain the same medication through the enrollee’s Part D plan. Although CMS believes that use of the Part D benefit is in the best interests of enrollees and the Medicare Program, the agency also recognizes there may be circumstances when a cash purchase is reasonable. For example, when the pharmacy offers discounted prices through “loyalty” programs or pharmacy coupon offers that aren’t subsidized by purchases of drugs covered by Part D—these prices may be lower than a Part D plan’s negotiated price. Enrollees may take advantage of such offers, but the receipt must reflect the actual price paid and the member must submit a request for reimbursement to the plan. In these cases, the plan’s reimbursement will be based on the amount paid for the covered Part D drug if purchased at either a network pharmacy or an out-of-network pharmacy. Resources: Congress.gov/115/bills/s2553/BILLS-115s2553enr.pdf Medicare Prescription Drug Benefit Manual Chapter 14 - Coordination of Benefits—Section 50.4 – Processing Claims and Tracking TrOOP (CMS.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Chapter-14-Coordination-of- Benefits-v pdf) Know the Lowest Price Act of 2018 Current Topics

2020 Specialty Tiers Threshold
Current Topics July 2019 2020 Specialty Tiers Threshold Part D sponsors may exempt a formulary tier from its tiering exceptions process Sponsor-negotiated price must exceed a dollar-per-month threshold established by CMS 2020 specialty tier threshold is $670 for the full cost of a 30-day supply Specialty Tiers Part D sponsors may exempt a formulary tier in which it places very high cost Part D drugs and biological product items from its tiering exceptions process, consistent with 42 C.F.R. § (a)(6)(iii). In order for a Part D drug to be placed on this specialty tier, the sponsor-negotiated price must exceed a dollar-per-month threshold established by CMS. Similar to past years, we analyzed CY 2018 prescription drug event (PDE) data to identify the percentage of monthly fills that exceed the current specialty tier threshold of $670. We believe that a threshold that identifies outlier claims is appropriate, to ensure that only the highest cost drugs are eligible for placement on the specialty tier. Historically, around 99% of monthly PDEs have been below the specialty tier threshold; however, the current year’s analysis indicated that this share has decreased, i.e., the percentage of 30-day equivalent fills that exceeded $670 was 1.2%. For CY 2020, we intend to maintain the specialty tier threshold at $670 in an effort to balance plan flexibility with beneficiary access.

Low Enrollment Plans (Stand-alone PDPs only)
Current Topics July 2019 Low Enrollment Plans (Stand-alone PDPs only) CMS will terminate low enrollment plans for 2020 Below 1,000 enrollees In the lowest 5th of enrollment within the specific PDP region For 3 consecutive years CMS notified affected low enrollment plans in the Spring of 2019 Option to consolidate or non-renew the plan May alternatively submit a strategic plan that describes how enrollment will be increased Low Enrollment Plans (Stand-alone PDPs only) CMS has the authority under 42 C.F.R. § (a)(4)(xiv) to terminate Part D plans (at the benefit package level) that don’t have a sufficient number of enrollees to establish that they are viable plan options. CMS evaluates plan enrollment at the PDP region level. Plans are deemed low enrollment plans if the plan enrollment is below 1,000, and the plan is in the lowest quintile of enrollment within the specific PDP region. Prior to taking additional action on a low enrollment plan, CMS considers relevant factors like: (1) whether the plan is a basic plan that is satisfying requirements set forth at 42 C.F.R. § (f)(2), and the organization’s enhanced plan doesn’t have low enrollment in the same region; (2) whether the plan has been in existence for 3 years or less; (3) whether the plan is offered nationally; (4) the total number of plan offerings in the applicable region; and (5) if the plan’s premium currently falls at or below the low income benchmark premium amount. We notified affected low enrollment plans that didn’t meet at least one of the 5 criteria above in the Spring of In these circumstances, the Part D sponsor has the option to consolidate or non-renew the plan, or they may alternatively submit a strategic plan that describes how enrollment will be increased for the upcoming plan year. We intend to terminate a plan if it continues to be low enrollment for a second consecutive year despite a strategic plan aimed at increasing enrollment. In this instance, notice will be provided no later than August 1 for a termination effective December 31 of the same year, in accordance with 42 C.F.R. § (a)(xiv). We will also notify Part D sponsors that meet low enrollment criteria (< 1,000 members and within the lowest quintile for a given PDP region) but possess one of the 5 relevant factors for informational purposes only. No action will be required for those sponsors that meet low enrollment criteria (< 1,000 members and within the lowest quintile for a given PDP region) but possess one of the five relevant factors for informational purposes only. No action will be required for those sponsors.

New Medicare Plan Finder

Medicare Communications & Marketing Guidelines (MCMG) Updates
Current Topics Medicare Communications & Marketing Guidelines (MCMG) Updates Clarifications/updates based on stakeholder feedback Overall 5-Star Rating Icon Plans may create their own gold star icon (or icon of distinction) so long as the icon isn’t misleading or confusing to beneficiaries 40.7 – Prohibition of Open Enrollment Period (OEP) Marketing During the OEP, Plans/Part D sponsors may include general information on their website about enrollment periods, including the Open Enrollment Period (OEP) 50.1 Educational Events Plans may conduct marketing/sales events immediately following an educational event in the same general location (e.g., same hotel) The 2020 Medicare Communications and Marketing Guidelines (MCMG) changes that are effective for the Medicare Open Enrollment Period 10/15/19-12/7/19, are largely clarifications of, or updates to existing policy and are based on feedback received from stakeholders. CMS instructed Medicare Advantage Organizations, Prescription Drug Plans, and Section 1876 Cost Plans to rely on contract year 2019 MCMG guidance, subject to the updated guidance provided an HPMS memorandum released 8/6/19. The following are some of the more notable clarifications and updates that people with Medicare and partners may want to be aware of: Overall 5-Star Rating Icon - Plans may now create their own gold star icon (or icon of distinction) so long as the icon isn’t misleading or confusing to beneficiaries, and aren’t required to solely use the CMS gold star icon in their marketing materials. 40.7 – Prohibition of Open Enrollment Period Marketing - During the OEP, Plans/Part D sponsors may include general information on their website about enrollment periods, including the Open Enrollment Period (OEP) 50.1 Educational Events - Plans may conduct marketing/sales events immediately following an educational event in the same general location (e.g., same hotel). This removes the previous prohibition of such activities.

Current Topics August 2019 Medicare Communications & Marketing Guidelines (MCMG) Updates (continued) Special Guidance for plans serving Long-Term Care Facilities The guidance in this subsection is no longer only applicable to Institutional Special Needs Plans (I-SNPs), but to marketing and communications for all health and drug plans contracted with CMS for beneficiaries in these facilities General Website Requirements Plans must ensure that their website “is updated within 30 days from notification of change” Appendix 2 – Disclaimers Remove: Federal Contracting Statement requirements for communications materials disclaimer, Benefits disclaimer, Non-English Translations disclaimer, Plan Online Enrollment disclaimer Special Guidance for plans serving Long-Term Care Facilities - The guidance in this subsection is no longer only applicable to Institutional Special Needs Plans (I-SNPs), but to marketing and communications for all health and drug plans contracted with CMS for beneficiaries in these facilities. General Website Requirements - Plans must ensure that their website “is updated within 30 days from notification of change.” This changes the previous requirement that plan websites are reviewed monthly and updated “as needed.” Plans should see the Prescription Drug Benefit Manual, Chapter 6 for information on updates and notice to beneficiaries regarding midyear formulary changes. Appendix 2 – Disclaimers - Remove: Federal Contracting Statement requirements for communications materials disclaimer (Past Example Text: “[Plan’s/Part D sponsor’s legal or marketing name] is a [plan type] with a Medicare contract. Enrollment in [Plan’s/Part D sponsor’s legal or marketing name] depends on contract renewal.”) Benefits disclaimer (Required Text: “This information is not a complete description of benefits. Call [insert customer service phone number/TTY] for more information.” Non-English Translations disclaimer (Past Required Text: “ATTENTION: If you speak [insert language], language assistance services, free of charge, are available to you. Call 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx- xxxx).") Plan Online Enrollment disclaimer (Past Required Text: “Medicare beneficiaries may also enroll in <plan name> through the CMS Medicare Online Enrollment Center located at To view the 2019 MCMG, visit CMS.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/CY2019- Medicare-Communications-and-Marketing-Guidelines_Updated pdf.

Marketplace Updates Periodic Data Matching (PDM) Notices
Current Topics Marketplace Updates Periodic Data Matching (PDM) Notices Equitable Relief from Late Enrollment Penalties Individual Shared Responsibility Payment Reduced to $0 Lesson 4 provides information about changes in Medicare, including the following: Periodic Data Matching (PDM) Notices Equitable Relief from Late Enrollment Penalties Individual Shared Responsibility Payment Reduced to $0

What’s Medicare Periodic Data Matching (PDM)?
Current Topics July 2019 What’s Medicare Periodic Data Matching (PDM)? A process that identifies whether you’re enrolled in Medicare Part A and Marketplace coverage by matching against Medicare enrollment data You’ll be notified by the Marketplace if you are found to have both Medicare and a Marketplace plan and are receiving premium tax credits and/or cost-sharing reductions Medicare PDM notices will include: Your name A recommendation that you should end your Marketplace coverage if you don’t wish to pay full cost for you Marketplace plan Instructions on how to end Marketplace coverage or Marketplace financial help if you’re enrolled in Medicare Part A or a Medicare Advantage (MA) Plan Where to find contact information to confirm if you’re enrolled or if you have any questions about Medicare “Medicare Periodic Data Matching (PDM)” is a process that identifies whether you’re enrolled in Medicare Part A (including a Medicare Advantage (MA) Plan since you must have Part A and Part B to join an MA Plan), and Marketplace coverage by matching Medicare enrollment data. You’re notified by the Marketplace if you’re getting premium tax credits and/or cost- sharing reductions and have Medicare and a Marketplace plan. If you’ve been determined eligible for, or are enrolled in Medicare, you’re generally not eligible to get financial help to pay for a Marketplace plan premium or for covered services. You should follow the instructions listed on your Medicare PDM notice.

Medicare Periodic Data Matching (PDM)— What’s New for 2019
Current Topics July 2019 Medicare Periodic Data Matching (PDM)— What’s New for 2019 The Federal Marketplace will now be able to end premium tax credits and/or cost-sharing reductions for you if you’re found to be enrolled in Medicare and the Marketplace The Federal Marketplace also added an attestation statement to the application for you to permit the Marketplace to act on your behalf and end coverage The Marketplace will now be able to end premium tax credits and/or cost-sharing reductions for you if you’re found to be enrolled in both Medicare and the Marketplace. The Marketplace also added an attestation statement to the application for you to permit the Marketplace to act on your behalf and end coverage. If allows you to agree that if anyone on your application enrolls in coverage through a Marketplace plan, but is later found to have other qualifying health coverage (including Medicare, Medicaid, and/or CHIP), the Marketplace may end their Marketplace coverage.

Medicare Periodic Data Matching (PDM)— New 2019 Process
Current Topics July 2019 Medicare Periodic Data Matching (PDM)— New 2019 Process Starting in 2019, if a PDM identifies you as having both Medicare and a Marketplace plan, you’ll have 30 days from the date of your PDM notice to return to the Marketplace to either end Premium tax credits/cost-sharing reductions, or Your Marketplace plan, if you so choose You’ll get specific instructions in your PDM notice based on your Medicare enrollment status The Medicare PDM process changed in 2019. If a PDM identifies you as having both Medicare and a Marketplace plan, you’ll have 30 days from the date of your PDM notice to return to the Marketplace to either end any premium tax credits or cost-sharing reductions, or end your Marketplace plan, if you so choose. You’ll get specific instructions in your PDM notice based on your Medicare enrollment status.

Medicare Periodic Data Matching (PDM)— New 2019 Process, continued
Current Topics July 2019 Medicare Periodic Data Matching (PDM)— New 2019 Process, continued You’ll also have the option to Disagree with the results of the Medicare PDM notice if you think you aren’t enrolled in Medicare, or Change your attestation response from agree to disagree if you no longer want the Marketplace to end your coverage If you don’t take any action, after the 30-day period ends, the Marketplace will either End premium tax credits/cost-sharing reductions, or End Marketplace coverage if you permitted the Marketplace to act on your behalf and end your Marketplace coverage if found to be enrolled in both Medicare and the Marketplace You’ll also have the option to either Disagree with the results of the Medicare PDM if you think you aren’t enrolled in Medicare; or if you return your application and resubmit it with an attestation that you don’t have Medicare, you may get a Medicare data matching issue (DMI) and will have 90 days to resolve. After the 90-day window, the Marketplace will take action to end premium tax credits or Marketplace coverage depending on your preference. Change your attestation response from agree to disagree if you no longer want the Marketplace to end your coverage. If you take back permission for the Marketplace to end coverage, the Marketplace will end premium tax credits/cost- sharing reductions after 30 days. If you don’t take any action, after the 30-day period ends, the Marketplace will either end premium tax credits/cost-sharing reductions, or end Marketplace coverage if you permitted the Marketplace to act on your behalf and end your Marketplace coverage if found to be enrolled in both Medicare and the Marketplace.

Equitable Relief from Late Enrollment Penalties
Current Topics July 2019 Equitable Relief from Late Enrollment Penalties If you have premium-free Part A, but not Part B, on or before September 30, 2019, and you get a PDM notice, you may have a special opportunity (called equitable relief) to sign up for Medicare Part B without a late enrollment penalty If you meet the eligibility criteria, you can request this equitable relief, up to September 30, 2019 Visit your local Social Security office or call the office at ; TTY: to request removal or reduction of their Medicare Part B penalty You must show your Medicare PDM notice or other forms of acceptable documentation If you have premium-free Part A, but not Part B, on or before September 30, 2019, and you get a PDM notice, you may have a special opportunity (called equitable relief) to sign up for Medicare Part B without a late enrollment penalty. If you meet the eligibility criteria, you can request this equitable relief, even after September 30, 2019. Visit your local Social Security office or call the office at ; TTY: to request removal or reduction of your Medicare Part B penalty You must show your Medicare PDM notice or other forms of acceptable documentation Marketplace Eligibility Determination Notice IRS Form 1095-A that demonstrates months of coverage and/or subsidy amounts Marketplace premium invoices Receipt of payment for Marketplace enrollment Other Marketplace notices confirming enrollment

Individual Shared Responsibility Payment Reduced to $0
Current Topics July 2019 Individual Shared Responsibility Payment Reduced to $0 Starting with the 2019 plan year (for which you’ll file taxes by April 2020), the payment for not having Minimum Essential Coverage (MEC) is reduced to $0, in most states Check with your state to find out if there’s a fee for not having health coverage You may still want to request a hardship or affordability exemption if you are 30 or older and want to apply for catastrophic coverage If you’re under 30, you can apply for catastrophic coverage without getting an exemption Starting with the 2019 plan year (for which you’ll generally file taxes by April 2020), the payment for not having Minimum Essential Coverage (MEC) is reduced to $0 in most states. (The fee is sometimes known as the health care “mandate” or “penalty.”) You may still want to request a hardship or affordability exemption if you are 30 or older and want to apply for catastrophic coverage. If you’re under 30, you can apply for catastrophic coverage without getting an exemption. A Catastrophic health plan offers lower-priced coverage that mainly protects you from high medical costs if you get seriously hurt or injured. For more information about Catastrophic coverage, visit healthcare.gov/choose-a-plan/catastrophic-health- plans.

CMS National Training Program (NTP)
To view all available NTP training materials, or to subscribe to our list, visit CMSnationaltrainingprogram.cms.gov. Stay connected. Contact us at or follow us @CMSGov #CMSNTP This training is provided by the CMS National Training Program (NTP). To view all available NTP materials, or to subscribe to our list, visit CMSnationaltrainingprogram.cms.gov. Contact us at Follow #CMSNTP.

Navigating Medicare in 2020

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