Health Insurance Agent Helper

Medicare Advantage (MA) plans are specialized health insurance plans, with special eligibility requirements and are regulated through the Federal Government. It is important for the health insurance agent to understand the government regulations before selling MA plans.

To enroll in a Medicare Advantage Plan, a beneficiary usually must: 1.) meet the Medicare Part A and Part B criteria; 2.) live in the service area of the plan; 3.) continue to pay the monthly Part B premium (unless paid for by Medicare); 4.) not have End Stage Renal Disease (ESRD); and 5.) must enroll during the enrollment periods set by the Center for Medicare Services (CMS).

A beneficiary must enter into a MA plan through an enrollment period. There are several different types of enrollment periods. The Initial Coverage Enrollment Period (ICEP) is the period of time, in which the beneficiary first becomes eligible. This window is 3 months before and 3 months after their eligibility date. When this 7 month window closes, the ICEP is over. Each beneficiary has only one Initial Coverage Enrollment Period. The Annual Enrollment Period (AEP) is from November 15th to December 31st of each year. Therefore, enrollment is effective January 1st of the following year. There is one AEP enrollment or disenrollment choice during this period.

There are Special Enrollment Periods (SEP) during which beneficiaries can enroll in a different MA plan. Reasons for enrollment include:

Beneficiary moves outside of the plan’s service

Beneficiary’s service contract with CMS is not renewed or is terminated

Beneficiary was enrolled in plan based on government error or wrong information

Beneficiary is inadequately informed of non-credible coverage

Beneficiary looses coverage

Beneficiary was diagnosed with a new disease (may enroll in a Special Needs Plan)

Beneficiary qualifies for a full or   partial Low Income Subsidy (LIS)

Open Enrollment Periods (OEP) applies to Medicare Advantage/Prescription Drug Plans only and the enrollment period is January 1st to March 31st. Enrollments during the OEP are limited to the type of coverage. For example, a beneficiary with Part D coverage must choose another Part D plan. A beneficiary without Part D coverage must choose another with Part D benefits.

Health insurance agents that sell Medicare Advantage plans are encouraged to understand enrollment periods and marketing ruless by reading the “Medicare and You” booklet provided by CMS. This updated publication describes updated Medicare guidelines and can be viewed at this site:

http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf

Health insurance agents should follow ethical guidelines related to presenting information appropriately, as to not confuse, mislead or pressure a prospective client. It is best to walk away from a potential sale and seek appropriate advice when potential confusion or a misunderstanding exists.