CMS guidelines prohibit marketing materials that are misleading or confusing. Using disproportionate formatting (like a much larger font) to emphasize favorable information, even if the data is accurate, can distort a beneficiary’s perception and is considered misleading. The rule focuses on the overall impression, not just strict formatting parity.

For a beneficiary with specific, ongoing health needs, the adequacy of the provider network and coverage for necessary services (like Part B drugs) is the most critical factor. A low premium is irrelevant if the plan doesn’t cover their essential treatment. MA plans bundle Part A, B, and often D, so replacing Original Medicare and a standalone Part D requires careful analysis of medical and drug coverage.

The fundamental structural difference is that Medigap plans work alongside Original Medicare to pay for costs like copays, coinsurance, and deductibles. In contrast, Medicare Advantage Plans (Part C) are a private insurance alternative that takes the place of Original Medicare and provides Part A and B benefits, often with additional services.

Original Medicare with a Medigap plan (particularly Plan G or N) offers the greatest nationwide portability, as providers who accept Medicare assignment will accept her coverage anywhere in the U.S. This provides the predictable costs she values and eliminates the network restrictions she would face with most Medicare Advantage plans while traveling.

CMS strictly prohibits using meals or other gifts as an inducement to attend an educational event or to enroll in a plan. While modest refreshments may be allowed at educational events, marketing the event around a “Birthday Celebration” with food could be seen as an inducement. Promotional materials must focus on the educational content, not the meal.

The Low-Income Subsidy (Extra Help) significantly reduces out-of-pocket costs for Part D. Beneficiaries who qualify for full LIS typically pay $0 premium (if they choose a benchmark plan), $0 deductible, and very low fixed copays for prescriptions throughout the year, including in the coverage gap. Medicaid coverage for drugs transitions to Part D when Medicare eligibility begins.

Individuals who have creditable health coverage through current employment (their own or a spouse’s) when first eligible for Medicare at 65 qualify for a Part B Special Enrollment Period (SEP). This SEP lasts for 8 months after the employment or group coverage ends, allowing them to enroll in Part B without a late enrollment penalty. Their ICEP for Part C and D is tied to this Part B enrollment.

When a plan makes a negative change to its formulary (like moving a drug to a higher cost-sharing tier), affected members have the right to request a formulary exception. The plan must have a process for members or doctors to request an exception to cover the drug at a lower cost-sharing level if medically necessary. They cannot switch MA plans mid-year solely for this reason unless they qualify for a different SEP.

CMS requires a Scope of Appointment (SOA) form to be completed and documented before any plan-specific marketing meeting or enrollment discussion. This form outlines what types of plans will be discussed and obtains the beneficiary’s consent. It must be completed prior to the appointment (for scheduled meetings) or at the beginning of an unscheduled meeting, and before any plan-specific details are discussed or an application is taken.

CMS guidelines prohibit marketing materials that are misleading or confusing. Using disproportionate formatting (like a much larger font) to emphasize favorable information, even if the data is accurate, can distort a beneficiary’s perception and is considered misleading. The rule focuses on the overall impression, not just strict formatting parity.0