Medicare Open Enrollment 2025 and Medicare Advantage Plans OIG Involvement

Medicare Open Enrollment

2025

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Medicare Open Enrollment Annual 2025:

Gentle reminder to the industry about the Medicare Open Enrollment Annual 2025.  This is a critical element of operating a healthcare organization.  Providers must ensure that staff are educated and have systems to properly implement.  This is an important foundation for Program Development. 

Parts of Medicare A, B, C, D

•    Medicare Part A (Hospital Insurance)
•    Medicare Part B (Medical Insurance)
•    Medicare Part C (Medicare Advantage)
•    Medicare Part D (Drug Coverage)

Video: https://youtu.be/MlNw4LovNjE

(This is a great video for staff to watch and learn the different types of Medicare.)

Part A (Hospital Insurance)
Medicare Part A helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care.

Part B (Medical Insurance)
Medicare Part B helps cover:

•    Services from doctors and other health care providers.
•    Outpatient care.
•    Home Health care.
•    Durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment).
•    Many preventive services (like screenings, shots or vaccines, and yearly “Wellness” visits).

Part C (Medicare Advantage)

•    Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D.
•    In most cases, an individual will need to use doctors who are in the plan’s network.
•    Plans may have lower out-of-pocket costs than Original Medicare.
•    Plans may offer some extra benefits that Original Medicare does not cover — like vision, hearing, and dental services.

Part D (Drug Coverage)

Medicare Part D helps cover the cost of prescription drugs (including many recommended shots or vaccines). You join a Medicare drug plan in addition to Original Medicare, or you get it by joining a Medicare Advantage Plan with drug coverage. Plans that offer Medicare drug coverage are run by private insurance companies that follow rules set by Medicare.

Medicare Supplemental Insurance (Medigap)

Extra insurance an individual can buy from a private company that helps pay an individual’s share of costs in Original Medicare. Policies are standardized, and in most states named by letters, like Plan G or Plan K. The benefits in each lettered plan are the same, no matter which insurance company sells it.

Medicare Options

When an individual first signs up for Medicare and during certain times of the year, they choose from two primary options for receiving Medicare coverage. These two options provide different ways to receive Medicare services, with Original Medicare offering more flexibility in choosing providers and Medicare Advantage bundling services into a managed care plan with possible different benefits.

1.    Original Medicare:

o    Part A (Hospital Insurance): Covers hospital stays, skilled nursing facility care, hospice, and some home health services.
o    Part B (Medical Insurance): Covers doctor visits, outpatient care, medical supplies, and preventive services.
o    With Original Medicare, individuals can choose any doctor or hospital that accepts Medicare anywhere in the U.S.
o    This option does not include prescription drug coverage (Part D), so individuals need to enroll in a separate Medicare drug plan if they want it.
o    To help cover out-of-pocket costs like coinsurance, individuals can buy Medigap (Medicare Supplement Insurance) or have other types of coverage from a former employer, union, or Medicaid.

2.    Medicare Advantage (Part C):

o    These are Medicare-approved private plans that bundle Part A, Part B, and usually Part D (prescription drug coverage).
o    Medicare Advantage plans often include additional benefits such as dental, vision, or hearing coverage.
o    However, individuals must use doctors and hospitals within the plan's network, which may be limited to specific geographic areas.

Medicare Versus Medicaid

Medicare is federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions. 

Medicaid is a joint federal and state program that provides health coverage for some people with limited income and resources.  Medicaid offers benefits, like nursing home care, personal care services, and assistance paying for Medicare premiums and other costs.
Medicare Open Enrollment refers to the annual period during which Medicare beneficiaries can make changes to their Medicare coverage. This period allows individuals to review their current health and prescription drug coverage and adjust as needed. 

1.    Dates:

The Medicare Open Enrollment period runs from October 15th to December 7th every year. During this time, beneficiaries can make changes to their coverage for the upcoming year.

2.    Coverage Options:

•    Medicare (Part A and Part B) Original provides hospital and medical insurance.
•    Medicare Advantage Plans (Part C) are private health plans that include coverage from both Part A and Part B, often with additional benefits.
•    Medicare (Part D) offers prescription drug coverage and can be added to Original Medicare or included in many Medicare Advantage Plans.

3.    Changes Allowed:

•    Switch from Original Medicare to a Medicare Advantage Plan.
•    Switch from a Medicare Advantage Plan back to Original Medicare.
•    Switch from one Medicare Advantage Plan to another.
•    Join a Part D prescription drug plan or switch from one drug plan to another.

4.    Medicare Handbook:

•    https://www.medicare.gov/publications/10050-medicare-and-you.pdf

5.    Medicare Part B Application Links For Enrollment/Changes:

•    Application Link:
o    https://secure.ssa.gov/mpboa/medicare-part-b-online-application/
•    Create an Account:
o    1-800-MEDICARE or Medicare.gov.
•    Part B Only: 
o    https://www.ssa.gov/medicare/sign-up/part-b-only

6. Review Current Coverage:

•    It is important to review the beneficiary’s current health and prescription drug coverage to ensure it meets their needs for the upcoming year. Plans can change, and the beneficiary’s health needs may evolve.

7.    Special Enrollment Periods:

•    Some individuals may qualify for Special Enrollment Periods outside of the Annual Open Enrollment period. This could be due to life events such as moving, changes in income, or other qualifying circumstances. If a resident is under 65 years of age and disabled for 2 years or greater, they become eligible for Medicare.

8.    Medigap Policies:

•    Open Enrollment primarily focuses on Medicare Advantage and Medicare Part D plans, but it doesn't typically apply to Medigap (Medicare Supplement Insurance) policies. Medigap policies may have a separate enrollment period.

The Medicare Annual Election Period = Open Enrollment Period.  It occurs from: October 15, 2024, through December 7, 2024.

During this period, current Medicare beneficiaries can make changes regarding:

•    Medicare Traditional (Original),
•    Medicare Advantage, and
•    Medicare Part D for Calendar Year 2025.

Beneficiaries can switch from Original (Traditional) Medicare to Medicare Advantage plans or vice versa during this period. Beneficiaries can also switch from one Medicare Advantage plan to another. 

Medicare

•    Premiums,
•    Deductibles, and 
•    Coinsurance Rates,

are adjusted every year at this time.

More to come on this subject matter.  Video discusses Medicare Advantage risks and OIG involvement. 

Downloads/Attachments  To Follow:   (Or please email me and I will send.)

1.a. PPT CMS Medicare Open Enrollment 2025 Day One 9.25.2024.
1.b. PPT CMS Medicare Open Enrollment 2025 Day Two 9.26.2024.
2. Medicare Handbook CMS 2025.
3. PPT Medicare for those Under 65 years of age Webinar 3-15.
4. Medicare Prescription Payment Plan CMS Q and A September 2024.

Medicare Advantage Plans:

5. Special Report CMA - The Real Impact of Medicare Advantage for Beneficiaries & Medicare Funding.
6. Medicare Advantage Overpayments PNP 2022: “Our Payments Their Profits”.
7. OIG Audit August 2024.
8. Medicare Communications and Marketing Guidelines 2.9.2022.
9. Strategic Plan OIG Managed Care for Medicare and Medicaid August 2023.
10. Medicare Advantage Plans 9.26.2024 (Word and PDF).
11. Open Enrollment Annual 2025 9.29.2024 (Word and PDF).
12. Open Enrollment Provider and Resident Tracking Tool 9.26.2024.
13. Medicare Part A and B CMS-10797-508C Special Enrollment Form.
14. Medicare Part B Enrollment Form CMS-40B.

15. Video Medicare Advantage OIG and CMA Special Report Inserts 9.29.2024.

Sincerely,

Kris

Kris B. Harmony OTR/L, LNHA, MBA