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3. Medigap & Medicare Advantage |
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3.1 2007 Choosing A
Medigap Policy: A Guide To Health Insurance For People With Medicare |
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3/07 |
56 |
CMS |
Beneficiary |
02110 |
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This booklet explains Medigap (Medicare Supplemental Insurance) policies. It helps the person with Medicare: 1. Decide if you want to buy a Medigap policy. 2. Understand when you can buy a Medigap policy. 3. Choose the Medigap policy that best meets your needs. 4. Understand how Medigap policies have changed since Medicare prescription drug coverage started. 5. Know where to go if you have questions. See an update/latest notice – a CMS announcement of 2007 Deductible Amount for Medigap Plans F & J, updated each year based on the August CPI-U figures released by the Bureau of Labor Statistics. |
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Spanish (2006) |
Braille |
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Large Print (English) |
Audiotape (English) |
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3/07 |
2 |
CMS |
Partner |
Notice |
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This notice reminds plan sponsors that in accordance with our coordination of benefit requirements of the Medicare Prescription Drug Manual, plans must accept premium payments made by supplemental payers, like State Pharmaceutical Assistance Programs (SPAPs), on behalf of their Part D enrollees. Part D plans are required to work directly with SPAPs, or the other payers, to systematically coordinate and accept premium payments in accordance with the guidelines. |
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3/07 |
104 |
Partner |
CMS |
Training |
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The Medicare Preventive Services PowerPoint presentation is an instructor-led presentation that provides attendees with an overview of covered Medicare preventive services as well as background and other information on preventive services. The presentation discusses the “prevention gap” and explores ways to close the gap by making sure Medicare beneficiaries take advantage of the preventive services available to them. This is available on the Medicare Learning Network - Preventive Services Web site. |
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3.4 Quick Facts
about Medicare's New Coverage for Prescription Drugs for people with a
Medigap (Medicare Supplement Insurance) policy |
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Web Address |
Pub Date |
No. of Pages |
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Pub Number/ Type |
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2/07 |
3 |
CMS |
Beneficiary |
11120 |
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This fact sheet provides guidance to people who have drug coverage as part of their supplemental plan in determining what prescription drug coverage might be best for them. |
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3.5 Marketing Guidance |
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Web Address |
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http://www.cms.hhs.gov/PrescriptionDrug |
9/06 |
N/A |
CMS |
Partner |
Link |
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This site, web page, or URL contains guidance describing plan marketing rules and regulations, including model documents. |
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3.6 Creditable
Coverage Guidance for Medigap Issuers |
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Web Address |
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http://www.cms.hhs.gov/CreditableCoverage/Downloads/ |
2/07 |
3 |
CMS |
Partner |
Link |
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This site, web page, or URL provides guidance documents relating to Creditable Coverage and Medigap policies and model notices, including links to the Creditable Coverage Disclosure Form to CMS. The MMA requires both Employers and Medigap issuers whose policies include prescription drug coverage to notify policyholders whether their drug coverage is or is not creditable coverage. MMA imposes a late enrollment penalty on individuals who do not maintain Creditable Coverage for a period of 63 days or longer following their initial enrollment period for the Medicare prescription drug benefit. |
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3.7 Managed Care Manual: Chapter 1 - General Provisions |
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Web Address |
Pub Date |
No. of Pages |
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Rev 68 9/05 |
16 |
CMS |
Partner |
100-16 |
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3.8 Managed Care
Manual: Chapter 2 - Medicare Advantage Enrollment and Disenrollment |
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Web Address |
Pub Date |
No. of Pages |
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Pub Number/ Type |
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Rev 70 9/05 |
170 |
CMS |
Partner |
100-16 |
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3.9 Managed Care
Manual: Chapter 4 - Benefits and Beneficiary Protections |
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Web Address |
Pub Date |
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Rev 72 9/05 |
78 |
CMS |
Partner |
100-16 |
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3.10 Managed Care Manual: Chapter 5 - Quality Assessment |
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Pub Date |
No. of Pages |
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Rev 78 1/06 |
82 |
CMS |
Partner |
100-16 |
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3.11 Managed Care Manual: Chapter 6 - Relationships with Providers |
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Pub Date |
No. of Pages |
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Rev 67 8/05 |
22 |
CMS |
Partner |
100-16 |
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3.12 Managed Care Manual: Chapter 7 - Payment to Medicare + Choice Organizations |
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Web Address |
Pub Date |
No. of Pages |
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Rev 57 8/04 |
123 |
CMS |
Partner |
100-16 |
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3.13 Managed Care Manual: Chapter 8 - Premiums and Cost-Sharing |
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Web Address |
Pub Date |
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Rev 25 6/03 |
41 |
CMS |
Partner |
100-16 |
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3.14 Managed Care Manual: Chapter 10 - MA Organization Compliance with State Law and Preemption by Federal Law |
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Rev 76 10/05 |
5 |
CMS |
Partner |
100-16 |
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3.15 Managed Care Manual: Chapter 11 - Medicare Advantage Application Procedures and Contract Requirements |
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Web Address |
Pub Date |
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Rev 79 2/06 |
45 |
CMS |
Partner |
100-16 |
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3.16 Managed Care Manual: Chapter 12 - Effect of Change of Ownership |
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Rev 69 9/05 |
9 |
CMS |
Partner |
100-16 |
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3.17 Managed Care Manual: Chapter 13 - Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and Health Care Prepayment Plans (HCPPs), (collectively referred to as Medicare Health Plans) |
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Rev 80 3/06 |
95 |
CMS |
Partner |
100-16 |
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3.18 Managed Care Manual: Chapter 14 - Contract Determinations and Appeals |
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Rev 69 9/05 |
9 |
CMS |
Partner |
100-16 |
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3.19 Managed Care Manual: Chapter 15 - Intermediate Sanctions |
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Web Address |
Pub Date |
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Rev 73 9/05 |
5 |
CMS |
Partner |
100-16 |
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3.20 Managed Care
Manual: Chapter 19 - Enrollment and Payment Guide |
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No. of Pages |
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2/07 |
N/A |
CMS |
Partner |
100-16 |
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This site takes you to links containing Plan Communications Users Guide v.1.4 August 11, 2006; Plan Communications Users Guide Appendices v.1.4 August 11, 2006; Enrollment and Payment Guide - Chapter 19; and MARx Monthly Processing Schedule – 2006. |
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3.21 Managed Care Manual: Chapter 20 - Managed Care and MA Business Requirements |
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Web Address |
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No. of Pages |
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2/06 |
N/A |
CMS |
Partner |
100-16 |
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This site takes you to links containing: Plan Communications Users Guide v.1.1 Nov 7, 2005, Plan Communications Users Guide Appendices v.1.1 Nov 7, 2005, Enrollment and Payment Guide - Chapter 19, MARx Monthly Processing Schedule – 2006 |
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3.22 Announcement of Calendar Year (CY) 2007 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies |
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Web Address |
Pub Date |
No. of Pages |
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Pub Number/ Type |
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http://www.cms.hhs.gov/States/Downloads/ |
6/06 |
2 |
CMS |
Partner |
Notice |
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This notice or fact sheet is an overview of CY 2007 MA capitation rates and Medicare Advantage and Part D payment Policies. Learn more about Medicare Advantage (historical M+C) announcements and advance notice of methodological changes. |
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3.23 Medicare Marketing Guidelines |
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Web Address |
Pub Date |
No. of Pages |
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Appropriate |
Pub Number/ Type |
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http://www.cms.hhs.gov/PrescriptionDrugCovContra/ |
7/06 |
179 |
CMS |
Partner |
Reference |
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This reference provides in depth Medicare Marketing Guidelines for: Medicare Advantage Plans (MA); Medicare Advantage Prescription Drug Plans (MA-PDs); Prescription Drug Plans (PDPs); and 1876 Cost Plans. Compare to November 2005 document (173 pages). |
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3.24 Part D Marketing Guideline – Historical Update |
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Web Address |
Pub Date |
No. of Pages |
Published By |
Appropriate |
Pub Number/ Type |
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11/05 |
24 |
CMS |
Partner |
Notice |
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This 2005 notice contains corrections and clarifications to the Medicare Marketing Guidelines for Medicare Advantage, Medicare Advantage Prescription Drug Plans, Prescription Drug Plans, and 1876 Cost Plans. |
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3.25 Part D Marketing Guidance |
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Web Address |
Pub Date |
No. of Pages |
Published By |
Appropriate |
Pub Number/ Type |
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http://www.cms.hhs.gov/PrescriptionDrugCovContra/07_RxContracting_Marketing.asp |
9/06 |
N/A |
CMS |
Partner |
Link |
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This site, web page, or URL specifically designed for plan sponsors contains information on Part D marketing guidelines and associated model materials. CMS has combined the marketing guidance for Medicare Advantage and Prescription Drug Plans. The guidelines allow organizations that offer both Medicare Advantage and Prescription Drug Plans the ability to reference one single-source document. Plans that use model marketing materials (sample, model letter, mailing or notice) without modification will be eligible for File and Use Certification or a 10-day review. Update! Co-branding relationships with pharmacies are permitted in 2007, but may not be designated on member ID cards. As in 2006, plans are required to submit their member ID cards for review by CMS before distributing to beneficiaries. |
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3.26 Your Guide
to Medicare’s Preferred Provider Organization Plans-CURRENTLY IN DEVELOPMENT |
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Web Address |
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No. of Pages |
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Pub Number/ Type |
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TBD |
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CMS |
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11152 |
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This publication is a guide to Medicare’s Preferred Provider Organization (PPO) Plans |
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3.27 Train-the-Trainer Module 11: Medicare
Advantage and Other Medicare Health Plans
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Web Address |
Pub Date |
No. of Pages |
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Pub Number/ Type |
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http://www.cms.hhs.gov/NationalMedicareTrainingProgram/TL/list.asp |
2/07 |
42 |
CMS |
Partner |
Classroom |
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Classroom training Module is designed for Medicare partners, trainers, and other information intermediaries and explains what Medicare Advantage Plans are, who is eligible and when they can join or switch plans, how the plans work, and the differences between types of plans. PowerPoint slides and speaker’s notes. Visit the Training Library for updates. |
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3.28 Quick Facts
about Medicare’s New Coverage for Prescription Drugs for people with a
Medicare Health Plan with prescription drug coverage |
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Web Address |
Pub Date |
No. of Pages |
Published By |
Appropriate |
Pub Number/ Type |
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2/07 |
2 |
CMS |
Beneficiary |
11135 |
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This fact sheet provides basic information about Medicare's new prescription drug coverage for people with a Medicare health plan with prescription drug coverage. |
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3.29 Medicare
Demonstrations |
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Web Address |
Pub Date |
No. of Pages |
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Appropriate |
Pub Number/ Type |
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3/07 |
N/A |
CMS |
Partner |
Link |
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This library provides a list of links to current Medicare demonstrations. CMS conducts and sponsors a number of innovative demonstration projects to test and measure the effect of potential program changes. Demonstrations study the likely impact of new methods of service delivery, coverage of new types of service, and new payment approaches on beneficiaries, providers, health plans, states, and the Medicare Trust Funds. Evaluation projects validate research and demonstration findings and help monitor the effectiveness of Medicare, Medicaid, and the State Children's Health Insurance Program (SCHIP). |
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Web Address |
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Pub Number/ Type |
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http://www.cms.hhs.gov/NationalMedicareTrainingProgram/TL/list.asp |
4/07 |
65 |
CMS |
Partner |
Classroom |
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This classroom training module explains Medigap, supplemental insurance policies that pay certain beneficiary health care costs not covered under Medicare. This module is designed for presentation to trainers and other information givers who already have a basic knowledge of Medicare and includes PowerPoint slides and speaker’s notes. Visit the Training Library for updates. |
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Web Address |
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No. of Pages |
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Pub Number/ Type |
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http://www.cms.hhs.gov/partnerships/downloads/ |
10/06 |
2 |
CMS |
Partner |
11227 |
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This tip sheet explains that some Medicare drug plan or Medicare Advantage Plan premiums for people with Medicare were erroneously withheld from monthly Social Security benefit payments or were not withheld at all. The people affected will get one letter based on their situation that explains how Medicare and Social Security are resolving this issue. |
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3.32 Medigap Policies - The Basics |
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Web Address |
Pub Date |
No. of Pages |
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Appropriate |
Pub Number/ Type |
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5/03 |
2 |
CMS |
Beneficiary |
10209 |
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This fact sheet contains basic information about Medigap policies and protections. |
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Web Address |
Pub Date |
No. of Pages |
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Appropriate |
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3/07 |
N/A |
CMS |
Partner |
Link |
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This is a site, web page, or URL with information regarding Special Needs Plans. It includes a fact sheet for Special Needs Plans (February 2006; 3 pages), reports, and maps (November 2005) showing location of SNP across the country. Under the Medicare Modernization Act of 2003 (Section 231), Congress created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs. Special needs individuals (SNP) identified by Congress are: 1) institutionalized; 2) dually eligible; and/or 3) individuals with severe or disabling chronic conditions. |
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3.34 Health Plans - Medicare Cost Plans |
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Appropriate |
Pub Number/ Type |
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12/05 |
N/A |
CMS |
Partner |
Link |
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This is a site, web page, or URL with information regarding Medicare Cost Plans. A Cost Contract provides the full Medicare benefit package. Payment is based on the reasonable cost of providing services. Beneficiaries are not restricted to the HMO or CMP to receive covered Medicare services, i.e. services may be received through non-HMO/CMP sources and are reimbursed by Medicare intermediaries and carriers. See also job aid, visual aid, or tool – a comparison chart of Medicare Cost vs. Medicare Advantage Programs (zipped file, 23 pages). |
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3.35 2005 Monitoring Guide for Medicare Advantage Organizations |
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Pub Date |
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Appropriate |
Pub Number/ Type |
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http://www.cms.hhs.gov/HealthPlansGenInfo/29_ManCarMon_02_MonGuide.asp |
12/05 |
N/A |
CMS |
Partner |
Reference |
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This reference set of multiple zipped files (881KB) describes what CMS uses to monitor plan compliance. It has 7 chapters. MAO contractors are required to meet all statutory, regulatory, and program requirements that govern the Medicare Advantage program for MAOs. The Review Guide is one way that CMS determines the compliance of MAOs with these federal requirements. |
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3.36 Medicare
Options Compare |
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Web Address |
Pub Date |
No. of Pages |
Published By |
Appropriate |
Pub Number/ Type |
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3/07 |
N/A |
CMS |
Partner |
Tool |
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Medicare Options Compare, previously called the Medicare Personal Plan Finder (MPPF) is a consumer-oriented online tool available for people with Medicare to learn more about Medicare plan options. The Medicare Options Compare will help people with Medicare view 2006 and 2007 plan information, compare out-of-pocket costs, compare plans based on price and benefit structure, sort plans based on estimated annual cost or narrow the search based on what is important to the user (for example, premium or drug coverage), and narrow plans down by state and preference, such as drug plans with no coverage gap or with low premiums. Please see this fact sheet to view Enhancements to Plan Finder Tools |
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12/05 |
N/A |
CMS |
Partner |
Link |
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This is a site, web page, or URL with basic information regarding the Program of All-Inclusive Care for the Elderly (PACE). It includes a listing of existing PACE organizations and information for State partners regarding program administration. The PACE model was developed to address the needs of long-term care clients, providers, and payers. For most participants, the comprehensive service package permits them to continue living at home while receiving services instead of being institutionalized. Capitated financing allows providers to deliver all services participants need rather than be limited to those reimbursable under the Medicare and Medicaid fee-for-service systems. Participants must be at least 55 years old, live in the PACE service area, and be certified as eligible for nursing home care by the appropriate State agency. The PACE program becomes the sole source of services for Medicare and Medicaid eligible enrollees. See PACE fact sheet (13 pages). |
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3.38 Evidences of Coverage |
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Pub Date |
No. of Pages |
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Pub Number/ Type |
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http://www.cms.hhs.gov/ManagedCareMarketing/02_EvidencesofCoverage.asp |
12/05 |
N/A |
CMS |
Partner |
Link |
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This is a sample or model letter, mailing or notice. This library provides the model templates all plans use to develop member handbooks. The Evidences of Coverage (EOC) are intended for use by all Medicare Advantage Organizations, (HMO, PPO, PFFS; includes MA/MA-PD), and 1876 Cost Plans to explain how the plan works, covered benefits and related cost-sharing responsibilities. Model EOC is provided for industry review and comment prior to CMS releasing final versions. |
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No. of Pages |
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Appropriate |
Pub Number/ Type |
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http://www.cms.hhs.gov/PrescriptionDrugCovContra/ |
3/07 |
N/A |
CMS |
Partner |
Library |
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This library of latest notices provides a complete list of all Medicare prescription drug (Part D) guidance materials distributed by CMS to plans via the Health Plan Management System (HPMS). These items are useful for caseworkers or partners processing Part D casework. |
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3.40 CMS Notices to
Plans – HPMS Systems/Data Notice History |
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Pub Date |
No. of Pages |
Published By |
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Pub Number/ Type |
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http://www.cms.hhs.gov/PrescriptionDrugCovContra/HPMSSD/list.asp |
3/07 |
N/A |
CMS |
Partner |
Library |
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This library of latest notices provides a complete list of all Medicare prescription drug (Part D) systems and other data notices distributed by CMS to plans via the Health Plan Management System (HPMS). Useful for caseworkers or partners processing Part D case work. |
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3.41 CMS Health Plan Reports |
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Web Address |
Pub Date |
No. of Pages |
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Pub Number/ Type |
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http://www.cms.hhs.gov/HealthPlanRepFileData/01_Overview.asp |
1/06 |
N/A |
CMS |
Partner |
Reference |
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This reference library contains high-level reports presenting aggregate Medicare Advantage (MA) enrollment, and Original Medicare eligible counts. A Medicare Advantage plan is a health insurance plan offered by a managed care organization of some type: Risk, Cost, Pace, PFFS etc. The reports are periodic and historical, that is, they are published at regular intervals and are archived. The reports differ in the period of publication (quarterly, monthly).The reports also differ in how they are aggregated. CMS privately distributes quarterly enrollment and eligible files, which aggregate data by state, county, Organization, zip code, gender and age group. Contact, Joanne Weller, (Joanne.Weller@cms.hhs.Gov) if you are interested in purchasing these files. |
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1/07 |
N/A |
CMS |
Partner |
Link |
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This site, web page, or URL gives an overview and has detailed information regarding the appeals process, downloadable appeals forms, and appeals of Local Coverage Determinations. |
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3.43 2007 Annual Notice of Change Model Letters/Forms |
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Web Address |
Pub Date |
No. of Pages |
Published By |
Appropriate |
Pub Number/ Type |
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8/06 |
N/A |
CMS |
Partner |
Reference |
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This is a sample or model letter, mailing, or notice. This reference library contains approved Annual Notice of Change models for Medicare Advantage Organizations, Demonstrations, 1876 Medicare Cost Plans and Prescription Drug Plans. The templates include specific changes in Medicare and plan benefits, plan premiums and plan rules effective January 1, 2007. In particular, the model ANOCs contains information specific to the Medicare Part D benefit, open enrollment period limitations and important information for beneficiaries receiving extra help. |
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3.44 Guidance for Medicare Advantage
Medical Savings Account (MSA) Demonstration Plans |
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Web Address |
Pub Date |
No. of Pages |
Published By |
Appropriate |
Pub Number/ Type |
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7/06 |
7 |
CMS |
Partner |
Tool |
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FAQ tool providing guidance in the form of answers to questions (Q&A, or QA) about Medicare Advantage Medical Savings Account (MSA) Demonstration Plans. Learn more. For additional clarification, contact James.Mayhew@cms.hhs.gov. |
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3.45 NAIC
Model Standards for Regulation of Medicare Supplement Insurance |
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No. of Pages |
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Pub Number/ Type |
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http://a257.g.akamaitech.net/7/257/2422/01jan20051800/ |
3/05 |
112 |
CMS |
Partner |
Notice |
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This latest notice or regulation published in Volume 70, No. 57 of the Federal Register describes changes made by the MMA to section 1882 of the Social Security Act that governs Medicare supplemental insurance, or Medigap. This notice recognizes the Model Regulation adopted by the National Association of Insurance Commissioners (NAIC) in September 2004 as the applicable NAIC Model. |
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