New Medical Law: What You Need to Know

June 13, 2022


Author :

Bradley Zeller

Have you heard about the recent medical law put in place to expand access to Medicare Advantage and Part D plans through improved consumer protections? Are you unsure of what that means for your agency? Do you want to learn more about these changes and how they affect you?

Over twenty-seven million beneficiaries receive services through Part D and Medicare Advantage plans, and an increasing number of beneficiaries are dually eligible for Medicaid and Medicare. All these plans have confusing information that can quickly become misleading if improperly advertised. To learn more about this new medical law and what you can do to ensure compliance, continue reading below.

New Medicare Medical Law Passed

The final rule of the Medicare Advantage Plan and Part D regulation changed the marketing and communications method used to solicit these plans. This is due in part because many seniors complained of the confusing and misleading information provided to them about these Medicare plans and what they even offer. This is a growing issue because state insurance regulators are not required to exercise their oversight authority in advertising and marketing these Medicare plans.

Marketing and Communications Oversight

As mentioned above, several seniors complain of receiving misleading or confusing information about Medicare plans. This new medical law protects Medicare beneficiaries by making sure that they receive the correct information about their Medicare coverage. It also allows them access to this information. These changes include strengthening oversight of specific third-party organizations to prevent and detect the use of spreading misleading or confusing information. Additional changes to the marketing and communications oversight:

  • Providing information about available interpreter services
  • Codifying enrollee ID card standards
  • Instructions on how to appoint a representative
  • Disclaimers for limited access to preferred cost-sharing pharmacies

The new medical law also requests for websites to post clear information on how to enroll and provides access to the necessary forms.

Lowering Beneficiary Cost-Sharing

Recently, more Part D plans have entered into specific arrangements with pharmacies that pay less money to dispense drugs if the pharmacy does not meet specific criteria. The negotiated price is typically reported to the Centers for Medicare & Medicaid Services at the point of sale to then calculate the cost the beneficiary must pay. These types of payment arrangements provide higher cost savings for Medicare beneficiaries and faster advancement through Part D plans. With this new policy, beneficiaries have lower out-of-pocket costs, improving price transparency.

Network Adequacy

As mentioned earlier, this new medical law improves network adequacy, explicitly strengthening the oversight and application standards. The Centers for Medicare & Medicaid Services requires that Medicare advantage plus applicants prove that they have a sufficient network of contracted providers to provide care for their beneficiaries. They must provide this information before the Centers for Medicare & Medicaid Services will approve their expanded or new Medicare Advantage Plus plans. Requiring applicants to demonstrate this shows compliance with network adequacy standards and strengthens oversight of a specific organization's ability to provide adequate resources to their enrollees.

Maximum Out-Of-Pocket Policy

Medicare Advantage plans must set a limit on how much a beneficiary pays for their share of Medicare Part A and B services before the program starts to pay for 100% of their services. The final rule of this law specifies that the maximum out-of-pocket that a beneficiary plays is to be calculated based on the accrual of all Medicare cost-sharing paid by the beneficiary, other secondary insurance, or Medicaid. It is projected that this new change will save state Medicaid agencies approximately two billion over the course of ten years while increasing payments to providers who serve dually eligible beneficiaries. It is projected to provide an additional eight billion dollars to these providers.

Simplifying D-SNP Enrollee Materials

Most dually eligible beneficiaries don't have the proper literacy to navigate their health plans. Compared to non-dually eligible beneficiaries, dually eligible beneficiaries have a more complex system of coverage to digest and understand. Before the new law, D-SNP candidates received two different packages of materials, one for Medicare and Medicaid benefits. The new law now integrates important information together so that enrollees can better understand their coverages.

Updates for HIDE SNPs and FIDE SNPs

A candidate can receive their Medicare coverage in several different ways, including through HIDE SNPs and FIDE SNPs. HIDE SNPs, which stands for highly integrated dual eligible special needs plans, and FIDE SNPs, which is short for fully integrated dual eligible special needs plans, both have complex language that the general public and health insurance professionals who support these plans have a hard time understanding. There wasn't any clear indication about the unique benefits of a particular program or what a beneficiary could expect from the plan. The new rule requires that all fully integrated dual eligible special needs plans to cover Medicaid home health, behavioral health services, and durable medical equipment through a capitated contract with the state's Medicaid agency. This rule requires this to happen by 2025 and for all following years.

Stay Compliant and Get Better Leads

With this new medical law, you will want to ensure that you properly follow the listed protocols and stay compliant. As more people take on Medicare or Medicaid coverages, they need to be fully aware of their benefits and the cost-sharing associated with their plans. If you are ready to generate Medicare leads or you need help creating the best strategy for your agency, contact us now. We here at Zeller Media are leading experts in generating exclusive Medicare leads and creating a custom marketing plan that works best for your business.

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