Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)
Annual Notice of Change and Evidence of Coverage for Applicable Integrated Plans in States that Require Integrated Materials (CMS-10824)
ANOC
Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)
OMB: 0938-1444
<Material ID>
Instructions to Health Plans
[Plans can include the ANOC in the 2027 [insert name used: Evidence of Coverage/Member Handbook] or provide it to members separately.]
[States can choose to use the term Evidence of Coverage instead of Member Handbook and modify this term throughout all chapters.]
[Plans can modify the language in the ANOC, as applicable, to address Medicaid benefits and cost-sharing for its dual eligible population.]
[Plans must use the state-specific name for Medicaid in references to “Medicaid” in any plan-customized language throughout the ANOC.]
[Throughout the document update language based on how the integrated program is described in the state as instructed by the state (i.e. one name for the plan or matching Medicare and Medicaid plans, etc.).]
[Where the ANOC uses “medical care,” “medical services,” or “health care services” to explain services provided, plans can revise and/or add references to long-term services and supports and/or home and community-based services as applicable.]
[Plans can change references to terms such as “member,” “customer,” “beneficiary,” “enrollee,” “member services,” “care coordinator,” “primary care provider,” “prior authorization (PA)” as instructed by the state or based on plan preference and update them consistently throughout the ANOC.]
[Where the model material instructs inclusion of a plan phone number, plans must ensure it’s a toll-free number and include a toll-free TTY number and days and hours of operation.]
[Throughout the ANOC, plans must follow the applicable style rules of the state, if any. For instance, where the model material instructs inclusion of a date or time, plans must use the specific format requested by the state Medicaid program. Other items covered by a state-specific style guide or similar document should also be updated accordingly.]
[Plans should refer to the Member Handbook as needed using the appropriate chapter number and section letter. For example, "refer to Chapter 9, Section A." An instruction [insert reference, as applicable] appears with many cross references throughout the ANOC and Member Handbook. Plans can always include additional references to other sections, chapters, and/or member materials when helpful to the reader.]
[Plans must include the OMB approval information in the footer of the first page of the document as noted in this model.]
[Standardized materials must be used by all D-SNPs exactly as provided, unless otherwise indicated below and/or in the instructions within the EOC.
Permissible Alterations/Modifications or Deletions of Standardized Language:
Correct minor grammatical or punctuation changes, update/correct phone numbers, and/or references.
Recreate graphics and/or tables, add plan logos, correct formatting (e.g., font style, margins), provided changes meet regulations at 42 C.F.R. §§ 422 Subpart V and 423 Subpart V, the CMS Medicare Communications and Marketing Guidelines (MCMG), and other CMS and state guidance. The standardized text must be used in the same order as the standardized material.
Correct web addresses or URLs if inaccessible or broken.
Delete plan instructions in blue text when populating the materials.
Modify, or delete, as necessary, all references to primary care providers (PCP), referrals, etc. if the organization uses an open access model.
Modify language related to network providers, as necessary, to clarify when a POS benefit may furnish coverage.
Change any references to Member Services to the term used by the plan.
Change references to TTY to TDD or TTY/TDD to reflect the correct communication technology.
Create ANOCs specific to an enrollee’s plan and don’t combine multiple benefit packages in one ANOC.
Go to Appendix A for operational guidance.]
[Wherever possible, plans are encouraged to adopt good formatting practices that make information easier for English-speaking and non-English-speaking enrollees to read and understand. The following are based on input from beneficiary interviews:
Format a section, chart, table, or block of text to fit onto a single page. In instances where plan-customized information causes an item or text to continue on the following page, enter a blank return before right aligning with clear indication that the item continues (for example, similar to the Benefits Chart in Chapter 4 of the Member Handbook, insert: This section is continued on the next page).
Ensure plan-customized text is in plain language and complies with reading level requirements established in the three-way contract.
Break up large blocks of plan-customized text into short paragraphs or bulleted lists and give a couple of plan-specific examples as applicable.
Spell out an acronym or abbreviation before its first use in a document or on a page (for example, Long-term services and supports (LTSS) or low-income subsidy (LIS)). Plans can choose to spell out terms each time they’re used.
Include the meaning of any plan-specific acronym, abbreviation, or key term with its first use.
Avoid separating a heading or subheading from the text that follows when paginating the model.
Use universal symbols or commonly understood pictorials.
Draft and format plan-customized text and terminology in translated models to be culturally and linguistically appropriate for non-English speakers.
Consider using regionally appropriate terms or common dialects in translated models.
Include instructions and navigational aids in translated models in the translated language rather than in English.]
<Plan name> <plan type> offered by <sponsor name>
Annual Notice of Change for 2027
[Optional: insert member name]
[Optional: insert member address]
Introduction
[If there are any changes to the plan for 2027, insert: You’re currently enrolled as a member of our plan. Next year, there will be some changes to our [insert as applicable: benefits, coverage, rules, and costs]. This [insert as applicable: section or Annual Notice of Change] tells you about the changes and where to find more information about them. To get more information about costs, benefits, or rules please review the Member Handbook, which is located on our website at <URL>.] [If the plan has included a copy of the Member Handbook with the ANOC mailing, then the plan must insert the first sentence as applicable. However, if the plan isn’t mailing a copy the plan must insert the second sentence: You can also review the attached OR enclosed OR separately mailed Member Handbook. OR Call Member Services at the number at the bottom of the page to get a copy by mail.] Key terms and their definitions appear in alphabetical order in the last chapter of your Member Handbook.]
[If there are no changes whatsoever for 2027 (e.g., no changes to benefits, coverage, rules, costs, networks), insert: You’re currently enrolled as a member of our plan. Next year, there are no changes to our benefits, coverage, [insert if applicable: costs,] and rules. However, you should still read this [insert as applicable: section or Annual Notice of Change] to learn about your coverage choices. To get more information about costs, benefits, or rules please review the Member Handbook, which is located on our website at <URL>. Key terms and their definitions appear in alphabetical order in the last chapter of your Member Handbook.]
Additional resources
[Plans that meet the 5% alternative language or Medicaid required language threshold insert: This document is available for free in [insert the languages that meet the threshold].]
You can get this Annual Notice of Change for free in other formats, such as large print, braille, or audio. Call [insert Member Services toll-free phone and TTY numbers, and days and hours of operation]. The call is free.
[Plans also simply describe:
how they request a member’s preferred language other than English and/or alternate format,
how they keep the member’s information as a standing request for future mailings and communications so the member doesn’t need to make a separate request each time, and
how a member can change a standing request for preferred language and/or format.]
[Per the final rule CMS-4205-F released on April 4, 2024, §§ 422.2267(e)(31)(ii) and 423.2267(e)(33)(ii), plans must provide a Notice of Availability of language assistance services and auxiliary aids and services that, at a minimum, states that the plan provides language assistance services and appropriate auxiliary aids and services free of charge. The plan must provide the notice in English and at least the 15 languages most commonly spoken by individuals with limited English proficiency in <State> and must provide the notice in alternate formats for individuals with disabilities who require auxiliary aids and services to ensure effective communication.]
[Any plan that doesn’t include a particular section (e.g., Section C, Section F) deletes the section, orders all remaining sections and subsections sequentially, and updates the Table of Contents accordingly. Plans must update the Table of Contents to this document to accurately reflect where the information is found on each page after plan adds plan-customized information to this template.]
Table of Contents
B. Reviewing your Medicare and <Medicaid program name> (Medicaid) coverage for next year 8
B1. Information about <plan name> 8
C. Changes to our plan name 10
D. Changes to our network providers and pharmacies 10
E. Changes to benefits [insert if applicable: and costs] for next year 11
E1. Changes to benefits [insert if applicable: and costs] for medical services 11
E2. Changes to drug coverage 12
E3. Stage 1: “Initial Coverage Stage” 16
E4. Stage 2: “Catastrophic Coverage Stage” 21
H3. [Insert State-specific name for Ombudsperson Program] 29
H5. <Medicaid program name> 30
H7. [Insert additional resources if applicable] 31
[Plans must include all applicable disclaimers as required in federal regulations (42 CFR Part 422, Subpart V, and Part 423, Subpart V), and included in any state-specific guidance provided by <insert state>.] [Consistent with the formatting in this section, plans can insert additional bulleted disclaimers or state-required statements, including state-required disclaimer language, here.]
It’s important to review your coverage now to make sure it will still meet your needs next year. If it doesn’t meet your needs, you may be able to leave our plan. Refer to Section E for more information on changes to your benefits for next year.
If you choose to leave our plan, your Medicare [delete Medicare if the end date is the same for Medicare and Medicaid] membership will end on the last day of the month in which your request was made. [If there’s a different end date for Medicaid coverage enter a description here.] You’ll still be in the Medicare and <Medicaid program name> programs as long as you’re eligible.
If you leave our plan, you can get information about your:
Medicare options in the table in Section G2 [insert reference, as applicable].
[Insert name of Medicaid program and insert either: options and services or options] in Section G2 [insert reference, as applicable].
|
|
If you decide to stay with <plan name>: |
If you decide to change plans: |
If you want to stay with us next year, it’s easy – you don’t need to do anything. If you don’t make a change, you automatically stay enrolled in <plan name>. |
[Plans should revise this paragraph as necessary.] If you decide other coverage will better meet your needs, you may be able to switch plans (refer to Section G2 for more information). If you enroll in a new plan, or change to Original Medicare, your new coverage will begin on the first day of the following month. |
[Plans that aren’t changing the plan name, delete this section. Plans with an anticipated name change at a time other than January 1 can modify the date below as necessary.]
On January 1, 2027, our plan name changes from <2026 plan name> to <2027 plan name>.
[Insert language to inform members whether they’ll get new plan ID cards and how, as well as how the name change affects any other member communication.]
[Plans with no Part D copays can delete the following paragraph] Amounts you pay for your drugs depends on which pharmacy you use. Our plan has a network of pharmacies. In most cases, your prescriptions are covered only if they’re filled at one of our network pharmacies. [Insert if applicable: Our network includes pharmacies with preferred cost-sharing, which may offer you lower cost-sharing than the standard cost-sharing offered by other network pharmacies for some drugs.]
[Plans with no changes to network providers and pharmacies insert: We haven’t made any changes to our network of providers and pharmacies for next year.
However, it’s important that you know that we may make changes to our network during the year. If your provider leaves our plan, you have certain rights and protections. For more information, refer to Chapter 3 of your Member Handbook.]
[Plans with changes to provider and/or pharmacy networks, insert: Our [insert if applicable: provider] [and] [insert if applicable: pharmacy] network[s] [insert as applicable: has or have] changed for 2027.
Please review the 2027 Provider and Pharmacy Directory to find out if your providers (primary care provider, specialists, hospitals, etc.) or pharmacy are in our network. An updated Provider and Pharmacy Directory is located on our website at <URL>. You may also call Member Services at the numbers at the bottom of the page for updated provider information or to ask us to mail you a Provider and Pharmacy Directory. [If the plan has included a copy of the Provider and Pharmacy Directory in the envelope with the material delete the last half of the previous sentence stating, “or to ask us to mail you a Provider and Pharmacy Directory” and replace it with: Our current Provider and Pharmacy Directory is included in the envelope with this material.]
It’s important that you know that we may also make changes to our network during the year. If your provider leaves our plan, you have certain rights and protections. For more information, refer to Chapter 3 of your Member Handbook or call Member Services at the number at the bottom of the page for help.]
[If there are no changes in benefits or in cost-sharing, replace the rest of the section with: There are no changes to your benefits [insert if applicable: or amounts you pay] for medical services. Our benefits [insert if applicable: and what you pay for these covered medical services] will be the same in 2027 as they are in 2026.]
We’re changing our coverage for certain medical services [insert if applicable: and what you pay for these covered medical services] next year. The table below describes these changes.
[The table must include:
all new benefits that will be added or 2026 benefits that will end for 2027;
new or changing limitations or restrictions, including referrals, prior authorizations (PA), and step therapy for Part B drugs for benefits for 2027; and
all changes in cost-sharing for 2027 for covered medical services, including any changes to service category out-of-pocket maximums.]
|
2026 (this year) |
2027 (next year) |
<benefit name> |
[For benefits that weren’t covered in 2026, insert: <benefit name> isn’t covered.] [For benefits with a copay insert: You pay a $<2026 copay amount> copay [insert language as needed to accurately describe the benefit, e.g., “per office visit”].] |
[For benefits that won’t be covered in 2027, insert: <benefit name> isn’t covered.] [For benefits with a copay insert: You pay a $<2027 copay amount> copay [insert language as needed to accurately describe the benefit, e.g., “per office visit”].] |
<benefit name> |
[Insert 2026 cost or coverage, using format described above.] |
[Insert 2027 cost or coverage, using format described above.] |
[Plans that didn’t include a List of Covered Drugs in the envelope, insert: You’ll get a 2027 List of Covered Drugs in a separate mailing.]
[Plans that didn’t include a List of Covered Drugs in the envelope and won’t mail it separately unless requested, insert: An updated List of Covered Drugs is located on our website at <URL>. You may also call Member Services at the numbers at the bottom of the page for updated drug information or to ask us to mail you a List of Covered Drugs.]
[Plans that included a List of Covered Drugs in the envelope, insert: We sent you a copy of our 2027 List of Covered Drugs in this envelope.] The List of Covered Drugs is also called the Drug List.
[Plans with no changes to covered drugs, tier assignments, or restrictions can replace the rest of this section with: We haven’t made any changes to our Drug List at this time for next year. However, we’re allowed to make changes to the Drug List from time to time throughout the year, with approval from Medicare and/or the state. We update our online Drug List at least monthly to provide the most up to date list of drugs. If we make a change that will affect a drug you’re taking, we’ll send you a notice about the change. Refer to the 2027 Drug List for more information.]
We made changes to our Drug List, which could include removing or adding drugs, changing drugs we cover and changes to the restrictions that apply to our coverage for certain drugs [insert if the plan has cost-sharing tiers: or moving them to a different cost-sharing tier].
Review the Drug List to make sure your drugs will be covered next year and to find out if there are any restrictions [insert if the plan has cost-sharing tiers: or if your drug has been moved to a different cost-sharing tier].
Most of the changes in the Drug List are new for the beginning of each year. However, we might make other changes that are allowed by Medicare and/or the state that will affect you during the calendar year. We update our online Drug List at least monthly to provide the most up to date list of drugs. If we make a change that will affect a drug you’re taking, we’ll send you a notice about the change.
If you’re affected by a change in drug coverage, we encourage you to:
Work with your doctor (or other prescriber) to find a different drug that we cover.
You can call Member Services at the numbers at the bottom of the page [insert if applicable: or contact your care coordinator] to ask for a List of Covered Drugs that treat the same condition.
This list can help your provider find a covered drug that might work for you.
[Plans should include the following language if they have an advance transition process for current members:] Work with your doctor (or other prescriber) and ask us to make an exception to cover the drug.
You can ask for an exception before next year, and we’ll give you an answer within 72 hours after we get your request (or your prescriber’s supporting statement).
To learn what you must do to ask for an exception, refer to Chapter 9 of your Member Handbook or call Member Services at the numbers at the bottom of the page.
If you need help asking for an exception, contact Member Services [insert if applicable: or your care coordinator]. Refer to Chapters 2 and 3 of your Member Handbook to learn more about how to contact your care coordinator.
[Plans should include the following language if all current members won’t be transitioned in advance for the following year: Ask us to cover a temporary supply of the drug.]
In some situations, we cover a temporary supply of the drug during the first <number, must be at least 90> days of the calendar year.
This temporary supply is for up to <supply limit (must be the number of days in plan’s one-month supply)> days. (To learn more about when you can get a temporary supply and how to ask for one, refer to Chapter 5 of your Member Handbook.)
When you get a temporary supply of a drug, talk with your doctor about what to do when your temporary supply runs out. You can either switch to a different drug our plan covers or ask us to make an exception for you and cover your current drug.
[Plans can include additional information about processes for transitioning current enrollees to formulary drugs when your formulary changes relative to the previous plan year.]
[Include language to explain whether current formulary exceptions will still be covered next year or a new one needs to be submitted.]
[Plans implementing for the first time in 2027 the option to immediately substitute brand name drugs with its new generic equivalents or authorized generics or to immediately substitute biological products with interchangeable biosimilars or unbranded biosimilars, that otherwise meet the requirements, should insert the following: Starting in 2027, we can immediately remove brand name drugs or original biological products on our Drug List if, we replace them with new generics or certain biosimilars versions of the brand name drug or original biological product [insert if applicable: on the same or lower cost-sharing tier and] with the same or fewer rules. Also, when adding a new version, we can decide to keep the brand name drug or original biological product on our Drug List, but immediately [insert if applicable: move it to a different cost-sharing tier or] add new rules [insert if applicable: or both].
For example, if you take a brand name drug or biological product that’s being replaced by a generic or biosimilar version, you may not get notice of the change 30 days in advance, or before you get a month’s supply of the brand name drug or biological product. You might get information on the specific change after the change is already made.
Some of these drug types may be new to you. For definitions of drug types, please go to Chapter 12 of your [insert name used: Evidence of Coverage/Member Handbook]. The Food and Drug Administration (FDA) also provides consumer information on drugs. Go to the FDA website: www.fda.gov/drugs/biosimilars/multimedia-education-materials-biosimilars#For%20Patients. You can also call Member Services at the number at the bottom of the page or ask your health care provider, prescriber, or pharmacist for more information.]
Changes to drug costs [option for plans with two drug payment stages]
[Plans with two payment stages (i.e., those charging LIS cost-sharing in the initial coverage stage), should include the following information in the ANOC.]
[Only plans with two payment stages (i.e., those charging LIS cost-sharing in the initial coverage stage, etc.), include the following information in this section of the ANOC. Plans with one payment stage don’t include the information in this section and instead include the information in the section, “Changes to drug costs [option for plans with one drug payment stage].”]
[If there are no changes in drug costs, insert: There are no changes to the amount you pay for drugs in 2027. Read below for more information about your drug coverage.]
Because you’re eligible for <Medicaid program name>, you get Extra Help from Medicare to help pay for your Medicare Part D drugs. [Plans who have $0 cost-sharing for all Medicare Part D drugs should remove the remaining language in this paragraph.] We [insert as appropriate: have included or sent you] a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug coverage. If you don’t have this insert, please call Member Services and ask for the “LIS Rider.”
There are two payment stages for your Medicare Part D drug coverage under our plan. How much you pay depends on your level of Extra Help and which stage you’re in when you get a prescription filled or refilled. These are the two stages:
Stage 1 Initial Coverage Stage |
Stage 2 Catastrophic Coverage Stage |
During this stage, our plan pays part of the costs of your drugs, and you pay your share. Your share is called the copay. You begin this stage when you fill your first prescription of the year. |
During this stage, the plan pays all of the costs of your drugs through December 31, 2027. You begin this stage after you pay a certain amount of out-of-pocket costs. |
The Initial Coverage Stage ends when your total out-of-pocket costs for drugs reaches $<TrOOP amount>. At that point, the Catastrophic Coverage Stage begins. Our plan covers all of your drug costs from then until the end of the year. Refer to Chapter 6 of your Member Handbook for more information on how much you’ll pay for drugs.
Under the Manufacturer Discount Program, drug manufacturers pay a portion of our plan’s full cost for covered Part D brand name drugs and biologics during the Initial Coverage Stage and the Catastrophic Coverage Stage. Discounts paid by manufacturers under the Manufacturer Discount program don’t count toward out-of-pocket costs.
During the Initial Coverage Stage, our plan pays a share of the cost of your covered drugs, and you pay your share. Your share is called the copay. The copay depends on what cost-sharing tier the drug is in and where you get it. You pay a copay each time you fill a prescription. If your covered drug costs less than the copay, you pay the lower price.
[Insert if applicable: We moved some of the drugs on our Drug List to a lower or higher drug tier. If your drugs move from tier to tier, this could affect your copay. To find out if your drugs are in a different tier, look them up in our Drug List.]
The following table shows your costs for a one-month supply filled at a network pharmacy with standard copays in each of our <number of tiers> drug tiers. These amounts apply only during the time when you’re in the Initial Coverage Stage.
Most adult Part D vaccines are covered at no cost to you. For information about the costs of vaccines, or information about the costs [insert as applicable: for a long-term supply; or at a network pharmacy that offers preferred cost-sharing; or for mail-order prescriptions] go to Chapter 6, Section D of your Member Handbook.
[Plans must list all drug tiers in the following table and show costs for a one-month supply filled at a network retail pharmacy. Plans that have pharmacies that provide preferred cost-sharing must provide information on both standard and preferred cost-sharing using the second alternate chart. Plans without drug tiers can revise the table as appropriate.]
[Plans with pharmacies that offer standard and preferred cost-sharing can replace the chart above with the one below to provide both cost-sharing rates.]
The Initial Coverage Stage ends when your total out-of-pocket costs reach $<TrOOP amount>. At that point the Catastrophic Coverage Stage begins. [Insert as applicable: The plan covers all of your drug costs from then until the end of the year. If the plan covers excluded drugs under an enhanced benefit or Medicaid drugs with cost-sharing in this stage insert: The plan covers all of your Part D drugs until the end of the year. You may have cost-sharing for excluded drugs that are covered under [insert as applicable: our enhanced benefit or Medicaid].] Refer to Chapter 6 of your Member Handbook for more information about how much you pay for drugs.
When you reach the out-of-pocket limit $<TrOOP amount> for your drugs, the Catastrophic Coverage Stage begins and you pay nothing for your covered [insert if there are copays for Medicaid covered drugs or excluded drugs under an enhanced benefit: Part D] drugs. You stay in the Catastrophic Coverage Stage until the end of the calendar year. [Insert if applicable: You may have copays for Medicaid covered drugs or excluded drugs that are covered under our enhanced benefit.]
For more information about your costs in the Catastrophic Coverage stage, refer to Chapter 6 [insert reference, as applicable].
Changes to drug costs [option for plans with a single payment stage]
[Plans with one payment stage (i.e., those with no cost-sharing for all Medicare Part D drugs), include the following information.]
[If there are no changes in drug costs, insert: There are no changes to the amount you pay for drugs in 2027. Read below for more information about your drug coverage.]
[Insert if applicable: We moved some of the drugs on the Drug List to a lower or higher drug tier. [Insert if applicable: If your drugs move from tier to tier, this could affect your copay.] To find out if your drugs are in a different tier, look them up in the Drug List.]
The following table shows your costs for drugs in each of our <number of tiers> drug tiers.
[Plans must list all drug tiers in the following table.]
|
2026 (this year) |
2027 (next year) |
|---|---|---|
Drugs in Tier <Tier number> ([Insert short description of tier (e.g., generic drugs)]) Cost for a one-month supply of a drug in Tier <Tier number> that’s filled at a network pharmacy |
[Insert 2026 cost-sharing: Your copay for a one-month ([insert number of days in a one-month supply]-day) supply is $<XX>.] |
[Insert 2027 cost-sharing: Your copay for a one-month ([insert number of days in a one-month supply]-day) supply is $<XX>.] |
Drugs in Tier <Tier number> ([Insert short description of tier (e.g., generic drugs)]) Cost for a one-month supply of a drug in Tier <Tier number> that’s filled at a network pharmacy |
[Insert 2026 cost-sharing: Your copay for a one-month ([insert number of days in a one-month supply]-day) supply is $<XX>.] |
[Insert 2027 cost-sharing: Your copay for a one-month ([insert number of days in a one-month supply]-day) supply is $<XX>.] |
[Insert this section if applicable. Plans with administrative changes that impact members (e.g., change in contract or PBP number) can insert this section, include an introductory sentence that explains the general nature of administrative changes, and describe the specific changes in the table below. Plans that choose to omit this section should renumber the remaining sections as needed.]
|
2026 (this year) |
2027 (next year) |
[Insert a description of the administrative process/item that’s changing] |
[Insert 2026 administrative description] |
[Insert 2027 administrative description] |
[Insert a description of the administrative process/item that’s changing] |
[Insert 2026 administrative description] |
[Insert 2027 administrative description] |
[Plans that don’t have any Part D cost-sharing/copayments may delete this row] Medicare Prescription Payment Plan |
The Medicare Prescription Payment Plan is a payment option that began this year and can help you manage your costs for drugs covered by our plan by spreading them across the calendar year (January-December). |
If you’re participating in the Medicare Prescription Payment Plan and remain in the same plan, you don’t need to do anything to stay in the Medicare Prescription Payment Plan. |
We hope to keep you as a plan member. You don’t have to do anything to stay in our plan. Unless you sign up for a different Medicare plan or change to Original Medicare, you’ll automatically stay enrolled as a member of our plan for 2027.
[Plans should add any additional Medicaid information as directed by the state.] Most people with Medicare can end their membership during certain times of the year. Because you have <Medicaid program>, you can end your membership in our plan any month of the year.
In addition, you may end your membership in our plan during the following periods:
The Open Enrollment Period, which lasts from October 15 to December 7. If you choose a new plan during this period, your membership in our plan ends on December 31 and your membership in the new plan starts on January 1.
The Medicare Advantage (MA) Open Enrollment Period, which lasts from January 1 to March 31. If you choose a new plan during this period, your membership in the new plan starts the first day of the next month.
There may be other situations when you’re eligible to make a change to your enrollment. For example, when:
your eligibility for <Medicaid program name> or Extra Help changed, or
you recently moved into or are currently getting care in an institution (like a skilled nursing facility or a long-term care hospital). If you recently moved out of an institution, you can change plans or change to Original Medicare for two full months after the month you move out.
Your Medicare services
You have three options for getting your Medicare services listed below any month of the year. You have an additional option listed below during certain times of the year including the Open Enrollment Period and the Medicare Advantage Open Enrollment Period or other situations described in Section G2. By choosing one of these options, you automatically end your membership in our plan. [Insert additional option to change to another integrated program as directed by the state.]
1. You can change to: Another plan that provides your Medicare and most or all of your Medicaid benefits and services in one plan, also known as an integrated dual-eligible special needs plan (D-SNP) [insert the following if PACE offered in the state: or a Program of All-inclusive Care for the Elderly (PACE) plan, if you qualify.] |
Here is what to do: Call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. [Insert if applicable: For Program of All-inclusive Care for the Elderly (PACE) inquiries, call <PACE phone number>.] If you need help or more information:
OR Enroll in a new integrated D-SNP. You’ll automatically be disenrolled from our plan when your new plan’s coverage begins. |
2. You can change to: Original Medicare with a separate Medicare drug plan [Insert additional instructions regarding Medicaid as directed by the state.] |
Here is what to do: Call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you need help or more information:
OR Enroll in a new Medicare drug plan. You’ll automatically be disenrolled from our plan when your Original Medicare coverage begins. [Insert impact on Medicaid enrollment as directed by the state.] |
3. You can change to: Original Medicare without a separate Medicare drug plan [Insert additional instructions regarding Medicaid as directed by the state.] NOTE: If you switch to Original Medicare and don’t enroll in a separate Medicare drug plan, Medicare may enroll you in a drug plan, unless you tell Medicare you don’t want to join. You should only drop drug coverage if you have drug coverage from another source, such as an employer or union. If you have questions about whether you need drug coverage, call [Insert contact information regarding state SHIP program including name of program, phone number, days and hours of operation, TTY number and website address.] |
Here is what to do: Call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you need help or more information:
You’ll automatically be disenrolled from our plan when your Original Medicare coverage begins. [Insert impact on Medicaid enrollment as directed by the state.] |
4. You can change to: Any Medicare health plan during certain times of the year including the Open Enrollment Period and the Medicare Advantage Open Enrollment Period or other situations described in Section G2. |
Here is what to do: Call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. [Insert if applicable: For Program of All-Inclusive Care for the Elderly (PACE) inquiries, call <PACE phone number>.] If you need help or more information:
OR Enroll in a new Medicare plan. You’re automatically disenrolled from our Medicare plan when your new plan’s coverage begins. [Insert any additional information regarding the impact of Medicaid enrollment as directed by the state.] |
Your <Medicaid program name> services
For questions about how to get your <Medicaid program name> services after you leave our plan, contact [insert name of program as directed by the state, phone number, days and hours of operation, and TTY number and website if applicable]. Ask how joining another plan or returning to Original Medicare affects how you get your <Medicaid program name> coverage.
We’re here to help if you have any questions. Call Member Services at the numbers at the bottom of the page during the days and hours of operation listed. These calls are toll-free.
Read your Member Handbook
Your Member Handbook is a legal, detailed description of our plan’s benefits. It has details about benefits [insert if applicable: and costs] for 2027. It explains your rights and the rules to follow to get services and drugs we cover.
[If the ANOC is sent or provided separately from the Member Handbook, include the following: The Member Handbook for 2027 will be available by October 15.] [Insert if applicable: You can also review the <attached or enclosed or separately mailed> Member Handbook to find out if other benefit [insert if applicable: or cost] changes affect you.] An up-to-date copy of the Member Handbook is available on our website at <URL>. You may also call Member Services at the numbers at the bottom of the page to ask us to mail you a Member Handbook for 2027.
Our website
You can visit our website at <URL>. As a reminder, our website has the most up-to-date information about our provider and pharmacy network (Provider and Pharmacy Directory) and our Drug List (List of Covered Drugs).
You can also call the state health insurance program (SHIP). In <state> the SHIP is called the <SHIP program name>. <SHIP program name> can help you understand your plan choices and answer questions about switching plans. <SHIP program name> isn’t connected with us or with any insurance company or health plan. <SHIP program name> has trained counselors [insert in every county or locations] and services are free. <SHIP program name> phone number is <phone number>. [TTY phone number is optional.] For more information or to find a local <SHIP program name> office in your area, please visit <URL>.
[Insert this section if there’s an ombudsperson program in the state. Include a description of what the program can do, whether the services are free, and phone number. Please refer to an example of language below.]
[Optional language example: The Ombudsperson Program can help you if you have a problem with our plan. The ombudsperson’s services are free and available in all languages. The Ombudsperson Program:
works as an advocate on your behalf. They can answer questions if you have a problem or complaint and can help you understand what to do.
makes sure you have information related to your rights and protections and how you can get your concerns resolved.
isn’t connected with us or with any insurance company or health plan. The phone number for the Ombudsperson Program is [insert phone number].]
To get information directly from Medicare:
call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048
chat live at www.Medicare.gov/talk-to-someone
Medicare’s Website
You can visit the Medicare website (www.medicare.gov). If you choose to disenroll from our plan and enroll in another Medicare plan, the Medicare website has information about costs, coverage, and quality ratings to help you compare plans.
You can find information about Medicare plans available in your area by using Medicare Plan Finder on Medicare’s website. (For information about plans, refer to www.medicare.gov and click on “Find plans.”)
Medicare & You 2027
You can read the Medicare & You 2027 handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. This handbook is also available in Spanish, Chinese, and Vietnamese.
If you don’t have a copy of this booklet, you can get it at the Medicare website (www.medicare.gov/Pubs/pdf/10050-medicare-and-you.pdf) or by calling 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.
[Insert any additional sections as required by the state, such as the QIO or additional resources that might be available.]
[Insert a description of the state Medicaid program’s role and how to receive assistance from the state.]
The Medicare Prescription Payment Plan is a payment option that may help you manage your out-of-pocket costs for drugs covered by our plan by spreading them across the calendar year (January-December) as monthly payments. This payment option might help you manage your expenses, but it doesn’t save you money or lower your total out-of-pocket drug costs.
“Extra Help” from Medicare and help from your state’s pharmaceutical assistance program (SPAP) and the AIDS Drug Assistance Program (ADAP), for those who qualify, is more advantageous than participation in the Medicare Prescription Payment Plan. All enrollees are eligible to participate in this program, regardless of income level. To learn more about this program please contact us at the phone number at the bottom of this page or visit www.Medicare.gov.
[If applicable, insert a new section for each additional resource, including contact information and a description of their role.]
[Appendix A
Operational Guidance
Health Plan Management System (HPMS) Submission Instructions:
ANOCs must be submitted in HPMS.
Unpopulated materials may not be submitted into HPMS. The organization must submit an ANOC (if applicable) for each Contract/Plan Benefit Package (PBP) offered and must include all applicable premiums, cost-sharing, and benefit information in the material.
Note: Non-English language versions of previously submitted English language versions of the ANOC shouldn’t be submitted in HPMS. Please refer to the Submission, Review, and Distribution of Materials (42 C.F.R. §§ 422.2261 and 423.2261) section of the MCMG for additional information regarding non-English language and alternate format materials.
D-SNPs that have consolidated plans should include, in one “zipped” file, the ANOCs for both plans being consolidated. The zipped file should be uploaded under the remaining PBP. For example, H0001 is consolidating PBP 001 into PBP 002 for CY2025. One zipped file should be uploaded into HPMS under H0001 PBP 002. This zipped file should have the ANOC for PBP 001 and the ANOC for PBP 002. To help identify the zipped ANOCs, organizations must use the following naming convention for all zipped ANOC files: the Plan’s/Part D sponsor’s contract number, (“H” number) followed by an underscore; the PBP number followed by an underscore, any series of alpha numeric characters (Plan discretion) followed by an underscore; and an uppercase “M” for marketing materials (for example: H0001_001_efg456_M or H0001_002_abc123_M).
The “No Longer in Use” button shouldn’t be selected for ANOC submissions. Plans/Part D Sponsors must submit updated ANOCs via the material replacement function in HPMS.
Input of Actual Mail Dates:
D-SNPs must input the actual mail dates (AMDs) in HPMS within 15 days of mailing the ANOC. For instructions on technical aspects of submitting, refer to the Update AMD/Beneficiary Link/Function section of the Marketing Review Users Guide in HPMS. When entering the AMDs, please note the following requirements:
Enter AMDs only for ANOC mailings to existing enrollees.
If a renewing PBP has no existing enrollees, input the material submission date as the AMD and enter “1” for number of beneficiaries. HPMS doesn’t accept “0” in the “#Beneficiaries” field.
D-SNPs can’t enter AMDs that are prior to the material submission date or edit existing mail wave information that was previously entered for the material. Please contact your organization’s/sponsor’s Account Manager or Marketing Reviewer if edits to previously existing mail wave dates need to be made or if prior dates need to be entered.
Multiple ANOC Material Versions:
D-SNPs are permitted to upload different versions (not corrections) of ANOC materials with the original submission in one “zipped” file. For example, if a plan covers two states, the standalone ANOC for both states would be submitted in one “zipped” file as the original submission.
Material Replacements:
D-SNPs that change their current year ANOCs (e.g., error corrections, Medicare FFS rate updates, policy updates) must submit updated materials via the material replacement function in HPMS. Please refer to the MCMG, under “§§ 422.2261(d), 423.2261(d) – Standards for CMS Review,” and the HPMS Marketing Module User’s Guide for additional information regarding the material replacement function.
Note: Plans that submit updated ANOCs via the material replacement function to correct errors must also submit erratas for those errors in HPMS. Please refer to the HPMS Memo, “Contract Year 2024 Annual Notice of Change and Evidence of Coverage Submission Requirements and Yearly Assessment,” to determine when erratas should be submitted.
Note: Don’t submit errata sheets for updating Medicare fee-for-service (FFS) rates.
ANOC Mailing Requirements:
Plans may include the following in the ANOC mailing: a cover letter, a Notification of Availability of Electronic Materials, Summary of Benefits, Provider and Pharmacy Directory, Member Handbook (EOC), LIS Rider, the List of Covered Drugs (Formulary), Notice of Availability of language assistance services, a form allowing enrollees to “opt-in” to receiving their upcoming ANOC via e-mail, the annual Notice of Non-Discrimination, and an annual notification allowing enrollees to opt out of future calls regarding plan business as defined in 42 C.F.R. § 422.2264(b)(2). Unless otherwise directed, no additional plan communications may be included in the mailing.
Other than providing the SB with the ANOC, Plans may not highlight benefits or information regarding upcoming 2026 Plan activities in the ANOC, the EOC, or the notice.]
OMB Approval 0938-1444 (Expires: TBD)
If
you have questions, please call <plan name> at <toll-free
phone and TTY numbers>, <days and hours of operation>. The
call is free. For more information, visit <URL>.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | National Template for Dual Eligible Special Needs Plans Model Annual Notice of Changes |
| Subject | D-SNP CY 2027 NT ANOC |
| Author | CMS/MMCO |
| File Modified | 0000-00-00 |
| File Created | 2025-12-17 |
© 2025 OMB.report | Privacy Policy