10/31/2025

Medicare Prescription Payment Plan (M3P) Phone number to M3P Dedicated Team: 866-845-1803 ▪ Goes live 9/15 ▪ Open 24 hours, 7 days a week ▪ Internal Transfer Number (DO NOT give to customer): 866-883-3177 ▪ TTY Users: 800-716-323

Extra Help Benefits - Low Income Subsidy (LIS)

Who qualified for Cost Sharing - Extra Help LIS? (refer to RDS QRT 5.1 > Extra Help Benefits / LIS)

1. Certain groups determined to be qualified for other federal programs automatically qualify for LIS

• those who get full Medicaid Benefits

•               get Supplemental Security Income (SSI)
  

•               have Medicaid helping in their Medicare Premiums
  

1. Beneficiaries auto=qualified for Extra Help are auto-enrolled unless

• Already in Part D plan
• Choose and join a plan on their own
• enrolled in employer/union plan receiving subsidy
• call the plan or 1-800-MEDICARE to opt out

How can a beneficiary submit a form for Extra Help

• can submit anytime Beneficiaries or someone on their behalf can submit Extra Help Application
• calling customer service (proactively offer to help by Member Service Advocates)
• written
• online
• local organizations If denied, beneficiaries can re-apply

How does extra help work?

1. EXTRA HELP LIS has different subsidy levels based on a review of beneficiaries' income, assets, and overall "net worth"
2. Subsidy Levels will have corresponding percentage of the monthly premium
3. All extra help qualifiers...
4. Plans are notified if Individuals qualify for Extra Help
5. Coverage for Extra Help is effective 2 months after this CMS notification
6. Plans refund the following costs back to effective date of Extra Help

• Deductibles/Premiums
• Cost-sharing assistance

Zero deductible-meaning they may not be required to pay the standard calendar year deductible out-of-pocket, this amounts are paid on behalf of beneficiaries by the government.

2025 LIS Chart (refer to RDS QRT 5.1 > Extra Help Benefits / LIS)

What term refers to a percentage of the cost of an insured service paid by insured individual

• coinsurance what term refers to a fixed fee
• copay Catastrophic Phase, customers are responsible for
• $0 In deductible customers are responsible for 100% of the drug cost out of pocket
• 100% What term refers to the amount paid for insurance coverage
• Premium

Sharepoint (Windows Button > apps > CignaPulseSharepoint)

• our digital platform; houses different support documents e.g. PDF, PPT, WORD, EXCEL
• Sharepoint houses all Critical Reference Materials
• Items like Job Aids, PHI Verification Grid, Plan Information (Per benefit year) Quick Reference Tool, Training Modules etc.

QRT 5.1 - For Next year's Plan Benefits QRT 4.6 - For this year's Plan Benefits Compliance Resources PHI GRID

(if no answer on QRT 5.1 > QRT 5.1 3RD PAGE > cigna active job aids link COMPREHENSIVE CABINET ACTION REVIEW (CCAR)

SHAREPOINT > PHI VERIFICATION > CIGNA PLUS VERIFICATION

QRT FEEDBACK

• to ensure tool is working to it's full capacity...

Content List (left side of sharepoint)

QRT - Miramar Access

MEDICARE AND CMS

Health Insurance

• a contract between company and consumer.
• company agrees to pay all or some of the insured person's healthcare costs in return for payment of amonthly premium

Health Insurance People Involved

• Agents and Brokers
• Plan Sponsors
• Providers
• Beneficiaries
• Members

Plan sponsors

• insurance company or federal state entity
• eg. medicare and medicaid

Providers Doctors, nurses etc

Agents

• an internal employee who is licensed to sell insurance products and does so on behalf of the plan sponsor

Members

• Beneficiaries who have signed up with the plan, are referred to internally as members

Beneficiaries

• Individuals who are eligible for various types of programs

Benefits

• gods or services provided by a plan sponsor

Effective Date

• January 1st upcoming plan year

Coverage

• list of goods and services for a maximum limit

Premium

• amount paid for health insurance

Deductible

• amount members must pay out of pocket

Copayment

• fixed amount

Coinusrance

• Percentage

Who administers Medicare? CMS - CENTER FOR MEDICAID AND MEDICARE SERVICES

MEDICARE FOR 65 YEARS OLD ABOVE; QUALIFYING DISABILITIES INSURANCE PROGRAM FUNDED BY THE GOVERNMENT

MEDICAID VARIES FROM STATE TO STATE FUNDED BY PAYROLL TAXES FOR PEOPLE WHO HAVE LOW INCOMES

YOU AUTOMATICALLY ENROLL TO MEDICARE WHEN YOU REACH 65

MEDICARE A (HOSPITAL INSURANCE) IN PATIENT CARE, HOSPITALIZATION SKILLED NURSING FACILITY CARE, HOSPICE CARE (HOME FOR THE AGED) HOME HEALTHCARE

B (MEDICAL INSURANCE) DOCTOR'S VISITS OUT PATIENT PREVENTIVE SERVICES WHEELCHAIR DURABLE MEDICAL EQUIPMENT WITH LATE ENROLLMENT PENALTY

MEDICARE PART D PRESCRIPTION ANTI SEIZURE ANTIDEPRESSANTS ANTIPSYCHOTICS CANCER DRUGS HIV/AIDS DRUGS IMMUNOSUPPRESSANT (MOST EXPENSIVE) DEPENDS ON THE PLAN

C MEDICARE ADVANTAGE (A+B) INCLUDES PART D EXTRA BENEFITS VISION DENTAL HEARING

Enrollment periods: IEP - Initial Enrollment Period the 7 month period that surrounds the month of medicare eligibility there is existing, proceed to AE

SEP - Special Election Period - based on specific predefined circumstances medicare allows for enrollment into Part D plans outside of the IEP or AEP A customer must meet the medicare mandated criteria to qualify for an SE

AEP Annual Enrollment Period - October 15th to December 7th every year for effective date of the following year (jan 1st) if there is existing, proceed to AEP

2 MONTHS TO GET C OR D TO AVOID GENERAL ENROLLMENT PERIOD (A & B) 7 month initial enrollment 3 months before 65 birth month 3 months after 65 birth month

Initial Coverage Enrollment Period Sept 25th 3 months before is June 3 months after is Dec

Personally Identifiable Information