CY2024_8_PPO MA_ANOC_30 day PRA CLEAN

[Insert 2024 plan name] Annual Notice of Changes for 2024

1

[MA-only PPO models]
[2024 ANOC model]

[Insert 2024 plan name] ([insert plan type]) offered by [insert
MAO name] [insert DBA names in parentheses, as applicable,
after listing required MAO names]

Annual Notice of Changes for 2024
[Optional: insert member name]
[Optional: insert member address]
You are currently enrolled as a member of [insert 2023 plan name]. Next year, there will be
changes to the plan’s costs and benefits. Please see page 4 for a Summary of Important Costs,
including Premium.
This document tells about the changes to your plan. To get more information about costs,
benefits, or rules please review the Evidence of Coverage, which is located on our website at
[insert URL]. [Insert as applicable: You can also review the attached OR enclosed OR
separately mailed Evidence of Coverage to see if other benefit or cost changes affect you.] You
may also call Member Services to ask us to mail you an Evidence of Coverage.)
•

You have from October 15 until December 7 to make changes to your Medicare
coverage for next year.

What to do now
1. ASK: Which changes apply to you

 Check the changes to our benefits and costs to see if they affect you.
•

Review the changes to Medical care costs (doctor, hospital).

•

Think about how much you will spend on premiums, deductibles, and cost sharing.

 Check to see if your primary care doctors, specialists, hospitals and other providers
will be in our network next year.

 Think about whether you are happy with our plan.
2. COMPARE: Learn about other plan choices

 Check coverage and costs of plans in your area. Use the Medicare Plan Finder at
www.medicare.gov/plan-compare website or review the list in the back of your
Medicare & You 2024 handbook.

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 Once you narrow your choice to a preferred plan, confirm your costs and coverage on
the plan’s website.

3. CHOOSE: Decide whether you want to change your plan
•

If you don't join another plan by December 7, 2023, you will stay in [insert plan name].

•

To change to a different plan, you can switch plans between October 15 and December
7. Your new coverage will start on January 1, 2024. This will end your enrollment with
[insert plan name].

•

If you recently moved into, currently live in, or just moved out of an institution (like a
skilled nursing facility or long-term care hospital), you can switch plans or switch to
Original Medicare (either with or without a separate Medicare prescription drug plan) at
any time.

Additional Resources
•

[Plans that meet the 5% alternative language threshold insert: This document is
available for free in [insert languages that meet the 5% threshold].]

•

Please contact our Member Services number at [insert member services phone number]
for additional information. (TTY users should call [insert TTY number].) Hours are
[insert days and hours of operation]. This call is free.
[Plans must insert language about availability of alternate formats (e.g., braille, large
print, audio) as applicable.]

•
•

Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and
satisfies the Patient Protection and Affordable Care Act’s (ACA) individual shared
responsibility requirement. Please visit the Internal Revenue Service (IRS) website at
www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information.

About [insert 2024 plan name]
•

[Insert Federal contracting statement.]

•

When this document says “we,” “us,” or “our,” it means [insert MAO name] [insert Plan
in parentheses, as applicable, after listing required MAO names throughout this
document]. When it says “plan” or “our plan,” it means [insert 2024 plan name].

[Insert as applicable: [insert Material ID] CMS Approved [MMDDYYYY]
OR [insert Material ID]]

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Annual Notice of Changes for 2024
Table of Contents
Summary of Important Costs for 2024 ....................................................................... 4
SECTION 1

We Are Changing the Plan’s Name .................................................. 5

SECTION 1

Unless You Choose Another Plan, You Will Be
Automatically Enrolled in [insert 2024 plan name] in 2024 ............ 5

SECTION 2
Changes to Benefits and Costs for Next Year ................................. 6
Section 2.1 – Changes to the Monthly Premium ...................................................................... 6
Section 2.2 – Changes to Your Maximum Out-of-Pocket Amounts ........................................ 6
Section 2.3 – Changes to the Provider Network ....................................................................... 7
Section 2.4 – Changes to Benefits and Costs for Medical Services ......................................... 8
SECTION 3

Administrative Changes ................................................................... 9

SECTION 4
Deciding Which Plan to Choose ..................................................... 10
Section 4.1 – If you want to stay in [insert 2024 plan name] ................................................ 10
Section 4.2 – If you want to change plans .............................................................................. 10
SECTION 5

Deadline for Changing Plans .......................................................... 11

SECTION 6

Programs That Offer Free Counseling about Medicare ................ 11

SECTION 7

Programs That Help Pay for Prescription Drugs........................... 12

SECTION 8
Questions? ...................................................................................... 13
Section 8.1 – Getting Help from [insert 2024 plan name] ..................................................... 13
Section 8.2 – Getting Help from Medicare ............................................................................. 13

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Summary of Important Costs for 2024
The table below compares the 2023 costs and 2024 costs for [insert 2024 plan name] in
several important areas. Please note this is only a summary of costs.
[If using Medicare FFS amounts (e.g., Inpatient and SNF cost sharing) the plan must insert the

2023 Medicare amounts and must insert: These are 2023 cost-sharing amounts and may change
for 2024. [Insert plan name] will provide updated rates as soon as they are released. Member
cost-sharing amounts may not be left blank.]
Cost

2023 (this year)

2024 (next year)

Monthly plan premium
[Plans with no optional
supplemental benefits delete the
following.] (See Section [edit
section number as needed] 2.1 for
details.)

[Insert 2023 premium
amount]

[Insert 2024 premium
amount]

[Plans with no deductible may
delete this row.]
Deductible

[Insert 2023 deductible
amount]

[Insert 2024 deductible
amount] [If an amount
other than $0, add: except
for insulin furnished
through an item of durable
medical equipment.]

Maximum out-of-pocket amounts
This is the most you will pay
out-of-pocket for your covered
[insert if applicable:
Part A and Part B] services.
(See Section [edit section number
as needed] 2.2 for details.)

From network providers:
[insert 2023 in-network
MOOP amount]
From in-network and
out-of-network providers
combined: [insert 2023
combined MOOP
amount]

From network providers:
[insert 2024 in-network
MOOP amount]
From in-network and
out-of-network providers
combined: [insert 2024
combined MOOP amount]

Doctor office visits

Primary care visits:
[insert 2023 cost sharing
for PCPs] per visit
Specialist visits: [insert
2023 cost sharing for
specialists] per visit

Primary care visits: [insert
2024 cost sharing for
PCPs] per visit
Specialist visits: [insert
2024 cost sharing for
specialists] per visit

Inpatient hospital stays

[Insert 2023 cost sharing]

[Insert 2024 cost sharing]

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[If Section 1 does not apply, plans should omit it and renumber remaining sections as needed.]

SECTION 1 We Are Changing the Plan’s Name
[Plans that are changing the plan name, as approved by CMS, include Section 1, using the
section title above and the following text:
On January 1, 2024, our plan name will change from [insert 2023 plan name] to [insert 2024
plan name].
[Insert language to inform members if they will receive new ID cards and how, as well as if the
name change will impact any other member communication.]]

SECTION 1 Unless You Choose Another Plan, You Will Be
Automatically Enrolled in [insert 2024 plan name] in 2024
[If the member is being enrolled into another plan due to a consolidation or due to a transition
from a D-SNP look-alike plan under 42 CFR 422.514, include Section 1, using the section title
above and the text below. It is additionally expected that, as applicable throughout the ANOC,
every plan/sponsor that cross walks a member from a non-renewed plan to a consolidated
renewal plan or transitions a member from a D-SNP look-alike plan to a renewal plan meeting
the criteria in 42 CFR 422.514(e) will compare benefits and costs from that member’s previous
plan to the consolidated plan or the renewal plan. Every plan/sponsor that transitions a member
from a D-SNP look-alike plan to a renewal plan, as indicated above, is encouraged to include
language about the transition in a cover letter that accompanies the ANOC.]
On January 1, 2024, [insert MAO name] [insert Plan in parentheses, as applicable, after listing
required MAO names throughout this document] will be combining [insert 2023 plan name]
with one of our plans, [insert 2024 plan name]. The information in this document tells you about
the differences between your current benefits in [insert 2023 plan name] and the benefits you
will have on January 1, 2024 as a member of [insert 2024 plan name].
If you do nothing by December 7, 2023, we will automatically enroll you in our [insert 2024
plan name]. This means starting January 1, 2024, you will be getting your medical coverage
through [insert 2024 plan name]. If you want to change plans or switch to Original Medicare,
you must do so between October 15 and December 7. If you are eligible for “Extra Help,” you
may be able to change plans during other times.

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SECTION 2 Changes to Benefits and Costs for Next Year
Section 2.1 – Changes to the Monthly Premium
[Plans offering the following premiums must list separately in the table below: (1) Plan
premium; (2) optional supplemental benefit premiums (only plans offering optional supplemental
benefits during one or both of the comparison years); and (3) Part B premium reduction (only
plans with Part B premium reductions during one or both of the comparison years.]
Cost
Monthly premium
[If there are no changes from year to
year, plans may indicate in the column
that there is no change for the
upcoming benefit year. However, the
premium must also be listed.]

2023 (this year)

2024 (next year)

[Insert 2023 premium
amount]

[Insert 2024 premium
amount]

(You must also continue to pay your
Medicare Part B premium.)

Section 2.2 – Changes to Your Maximum Out-of-Pocket Amounts
[Plans that include the costs of supplemental benefits in the MOOP limit may revise this
information as needed.]
Medicare requires all health plans to limit how much you pay “out-of-pocket” for the year. These
limits are called the “maximum out-of-pocket amounts.” Once you reach this amount, you
generally pay nothing for covered [insert if applicable: Part A and Part B] services for the rest of
the year.

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Cost

2023 (this year)

2024 (next year)

In-network maximum
out-of-pocket amount

[Insert 2023 innetwork MOOP
amount]

[Insert 2024 in-network
MOOP amount]

Your costs for covered medical
services (such as copays [insert if
plan has a deductible: and
deductibles]) from network
providers count toward your innetwork maximum out-of-pocket
amount. [Plans with no premium
delete the following sentence.] Your
plan premium does not count toward
your maximum out-of-pocket
amount.
Combined maximum
out-of-pocket amount

[Insert 2023 combined
MOOP amount]

Once you have paid [insert
2024 in-network MOOP
amount] out-of-pocket for
covered [insert if applicable:
Part A and Part B] services
from network providers, you
will pay nothing for your
covered [insert if applicable:
Part A and Part B] services
from network providers for
the rest of the calendar year.
[Insert 2024 combined
MOOP amount]
Once you have paid [insert
2024 combined MOOP
amount] out-of-pocket for
covered [insert if applicable:
Part A and Part B] services,
you will pay nothing for your
covered [insert if applicable:
Part A and Part B] services
from in-network or out-ofnetwork providers for the
rest of the calendar year.

Your costs for covered medical
services (such as copays [insert if
plan has a deductible: and
deductibles]) from in-network and
out-of-network providers count
toward your combined maximum
out-of-pocket amount. [Plans with
no premium delete the following
sentence.] Your plan premium does
not count toward your maximum
out-of-pocket amount.
[If there are no changes from year
to year, plans may indicate in the
column that there is no change for
the upcoming benefit year. However,
the premium must also be listed.]

Section 2.3 – Changes to the Provider Network
[Insert if applicable: We included a copy of our current Provider Directory in the envelope with
this document.] Updated directories are [insert if applicable: also] located on our website at
[insert URL]. You may also call Member Services for updated provider information or to ask us
to mail you a Provider Directory, which we will mail within three business days.

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[Insert applicable section: For a plan that does not have changes in its provider network] There
are no changes to our network of providers for next year.
[Insert applicable section: For a plan that has changes in its provider network] There are
changes to our network of providers for next year. Please review the 2024 Provider Directory to
see if your providers (primary care provider, specialists, hospitals, etc.) are in our network.
[All plans must insert the following] It is important that you know that we may make changes to
the hospitals, doctors and specialists (providers) that are part of your plan during the year. If a
mid-year change in our providers affects you, please contact Member Services so we may assist.

Section 2.4 – Changes to Benefits and Costs for Medical Services
[If there are no changes in benefits or in cost sharing, revise heading to “There are no changes
to your benefits or amounts you pay for medical services” and replace the rest of this section
with: Our benefits and what you pay for these covered medical services will be exactly the same
in 2024 as they are in 2023.]
We are making changes to costs and benefits for certain medical services next year. The
information below describes these changes.
[The table must include: (1) all new benefits that will be added or 2023 benefits that will end for
2024, including any new optional supplemental benefits (plans must indicate these optional
supplemental benefits are available for an extra premium); (2) new/changing limitations or
restrictions, including referrals, prior authorizations, and Part B step therapy for CY2024 Part
C benefits; and (3) all changes in cost sharing for 2024 for covered medical services, including
any changes to service category, out-of-pocket maximums, and cost sharing for optional
supplemental benefits (plans must indicate these optional supplemental benefits are available for
an extra premium). Note that beginning July 2023, cost-sharing for insulin furnished through an
item of DME is subject to a coinsurance cap of $35 for one-month’s supply of insulin.]
[If using Medicare FFS amounts (e.g. Inpatient and SNF cost sharing) the plan must insert the
2023 Medicare amounts and must insert: These are 2023 cost-sharing amounts and may change
for 2024. [Insert plan name] will provide updated rates as soon as they are released. Member
cost-sharing amounts may not be left blank.]
[Instructions to plans offering VBID Model benefits: VBID Model participating plans should
update this section to reflect coverage for any new VBID Model benefits that will be added for CY
2024 benefits, and/or for previous CY 2023 VBID Model benefits that will end for CY 2024.
Specific to the VBID Model benefits, the table must include: (1) all new VBID Model benefits that
will be added for 2024, except for the hospice benefit component (which has separate ANOC
instructions to VBID participating plans), including mandatory supplemental benefits such as the
flexibility to Cover New and Existing Technologies or Food and Drug Administration (FDA)
approved Medical Devices or 2023 benefits that will end for 2024; and (2) all changes in cost
sharing for all VBID Model benefits for 2024.

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Cost
[Insert benefit name]

[Insert benefit name]

2023 (this year)

9

2024 (next year)

[For benefits that were
not covered in 2023
[Insert benefit name] is
not covered.]

[For benefits that are not
covered in 2024[Insert
benefit name] is not
covered.]

[For benefits with a
copayment insert: You
pay a $[insert 2023
copayment amount]
copay [insert language as
needed to accurately
describe the benefit (e.g.,
per office visit)].]

[For benefits with a
copayment insert: You
pay a $[insert 2024
copayment amount] copay
[insert language as
needed to accurately
describe the benefit (e.g.,
per office visit)].]

[For benefits with a
coinsurance insert: You
pay [insert 2023
coinsurance percentage]
% of the total cost [insert
language as needed to
accurately describe the
benefit (e.g., for up to one
visit per year)].]

[For benefits with a
coinsurance insert: You
pay [insert 2024
coinsurance percentage]
% of the total cost [insert
language as needed to
accurately describe the
benefit, e.g., for up to one
visit per year].]

[Insert 2023 cost/
coverage, using format
described above.]

[Insert 2024 cost/
coverage, using format
described above.]

SECTION 3 Administrative Changes
[Insert this section if applicable: Plans with administrative changes that impact members (e.g., a
change in options for paying the monthly premium, change in contract or PBP number) may
insert this section and include an introductory sentence that explains the general nature of the
administrative changes. Plans that choose to omit this section should renumber the remaining
sections as needed.]
Description
[Insert a description of the
administrative process/item that is
changing]

2023 (this year)
[Insert 2023
administrative
description]

2024 (next year)
[Insert 2024
administrative
description]

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Description
[Insert a description of the
administrative process/item that is
changing]

2023 (this year)
[Insert 2023
administrative
description]

10

2024 (next year)
[Insert 2024
administrative
description]

SECTION 4 Deciding Which Plan to Choose
Section 4.1 – If you want to stay in [insert 2024 plan name]
To stay in our plan, you don’t need to do anything. If you do not sign up for a different plan
or change to Original Medicare by December 7, you will automatically be enrolled in our [insert
2024 plan name].

Section 4.2 – If you want to change plans
We hope to keep you as a member next year but if you want to change plans for 2024 follow
these steps:
Step 1: Learn about and compare your choices
•

You can join a different Medicare health plan,

•

-- OR-- You can change to Original Medicare. If you change to Original Medicare, you
will need to decide whether to join a Medicare drug plan. If you do not enroll in a
Medicare drug plan, there may be a potential Part D late enrollment penalty.

To learn more about Original Medicare and the different types of Medicare plans, use the
Medicare Plan Finder (www.medicare.gov/plan-compare), read the Medicare & You 2024
handbook, call your State Health Insurance Assistance Program (see Section [edit section
number as needed] 6), or call Medicare (see Section [edit section number as needed] 8.2).
[Plans may choose to insert if applicable: As a reminder, [insert MAO name] [insert Plan in
parentheses, as applicable, after listing required MAO names throughout this document] offers
other [insert as applicable: Medicare health plans AND/OR Medicare prescription drug plans.
These other plans may differ in coverage, monthly premiums, and cost-sharing amounts.]]
Step 2: Change your coverage
•

To change to a different Medicare health plan, enroll in the new plan. You will
automatically be disenrolled from [insert 2024 plan name].

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o To change to Original Medicare with a prescription drug plan, enroll in the
new drug plan. You will automatically be disenrolled from [insert 2024 plan
name].
•

To change to Original Medicare without a prescription drug plan, you must either:
o Send us a written request to disenroll [insert if organization has complied with
CMS guidelines for online disenrollment: or visit our website to disenroll online].
Contact Member Services if you need more information on how to do so.
o – or – Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-4862048.

SECTION 5 Deadline for Changing Plans
If you want to change to a different plan or to Original Medicare for next year, you can do it
from October 15 until December 7. The change will take effect on January 1, 2024.
Are there other times of the year to make a change?
In certain situations, changes are also allowed at other times of the year. Examples include
people with Medicaid, those who get “Extra Help” paying for their drugs, those who have or are
leaving employer coverage, and those who move out of the service area.
If you enrolled in a Medicare Advantage plan for January 1, 2024, and don’t like your plan
choice, you can switch to another Medicare health plan (either with or without Medicare
prescription drug coverage) or switch to Original Medicare (either with or without Medicare
prescription drug coverage) between January 1 and March 31, 2024.
If you recently moved into, currently live in, or just moved out of an institution (like a skilled
nursing facility or long-term care hospital), you can change your Medicare coverage at any time.
You can change to any other Medicare health plan (either with or without Medicare prescription
drug coverage) or switch to Original Medicare (either with or without a separate Medicare
prescription drug plan) at any time.

SECTION 6 Programs That Offer Free Counseling about Medicare
[Organizations offering plans in multiple states: Revise this section to use the generic name
(State Health Insurance Assistance Program) when necessary, and include a list of names, phone
numbers, and addresses for all SHIPs in your service area.]
The State Health Insurance Assistance Program (SHIP) is an independent government program
with trained counselors in every state. In [insert state], the SHIP is called [insert state-specific
SHIP name].

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It is a state program that gets money from the Federal government to give free local health
insurance counseling to people with Medicare. [Insert state-specific SHIP name] counselors can
help you with your Medicare questions or problems. They can help you understand your
Medicare plan choices and answer questions about switching plans. You can call [insert statespecific SHIP name] at [insert SHIP phone number]. [Plans may insert the following: You can
learn more about [insert state-specific SHIP name] by visiting their website ([insert SHIP
website]).]

SECTION 7 Programs That Help Pay for Prescription Drugs
You may qualify for help paying for prescription drugs. [Plans in states without SPAPs, delete
the next sentence.] Below we list different kinds of help:
•

“Extra Help” from Medicare. People with limited incomes may qualify for “Extra
Help” to pay for their prescription drug costs. If you qualify, Medicare could pay up to
75% or more of your drug costs including monthly prescription drug premiums, annual
deductibles, and coinsurance. Additionally, those who qualify will not have a coverage
gap or late enrollment penalty. To see if you qualify, call:
o 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24
hours a day/7 days a week;
o The Social Security Office at 1-800-772-1213 between 8 am and 7 pm, Monday
through Friday for a representative. Automated messages are available 24 hours a
day. TTY users should call, 1-800-325-0778; or
o Your State Medicaid Office (applications).

•

[Plans without an SPAP in their state(s) should delete this bullet.] [Organizations
offering plans in multiple states: Revise this bullet to use the generic name (State
Pharmaceutical Assistance Program) when necessary, and include a list of names for all
SPAPs in your service area.] Help from your state’s pharmaceutical assistance
program. [Insert state name] has a program called [insert state-specific SPAP name]
that helps people pay for prescription drugs based on their financial need, age, or medical
condition. To learn more about the program, check with your State Health Insurance
Assistance Program.

•

[Plans without an ADAP in their state(s), should delete this bullet.] What if you have
coverage from an AIDS Drug Assistance Program (ADAP)? The AIDS Drug
Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS
have access to life-saving HIV medications. Medicare Part D prescription drugs that are
also covered by ADAP qualify for prescription cost-sharing assistance through the [insert
State-specific ADAP information]. Note: To be eligible for the ADAP operating in your
State, individuals must meet certain criteria, including proof of State residence and HIV
status, low income as defined by the State, and uninsured/under-insured status.

•

If you are currently enrolled in an ADAP, it can continue to provide you with Medicare
Part D prescription cost-sharing assistance for drugs on the ADAP formulary. In order to
be sure you continue receiving this assistance, please notify your local ADAP enrollment
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worker of any changes in your Medicare Part D plan name or policy number. [Insert
State-specific ADAP contact information.]
For information on eligibility criteria, covered drugs, or how to enroll in the program,
please call [insert State-specific ADAP contact information].

SECTION 8 Questions?
Section 8.1 – Getting Help from [insert 2024 plan name]
Questions? We’re here to help. Please call Member Services at [insert member services phone
number]. (TTY only, call [insert TTY number].) We are available for phone calls [insert days
and hours of operation]. [Insert if applicable: Calls to these numbers are free.]
Read your 2024 Evidence of Coverage (it has details about next year's benefits
and costs)
This Annual Notice of Changes gives you a summary of changes in your benefits and costs for
2024. For details, look in the 2024 Evidence of Coverage for [insert 2024 plan name]. The
Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your
rights and the rules you need to follow to get covered services and prescription drugs. A copy of
the Evidence of Coverage is located on our website at [insert URL]. [Insert as applicable: You
can also review the attached OR enclosed OR separately mailed Evidence of Coverage to see if
other benefit or cost changes affect you.] You may also call Member Services to ask us to mail
you an Evidence of Coverage.
Visit our Website
You can also visit our website at [insert URL]. As a reminder, our website has the most up-todate information about our provider network (Provider Directory).

Section 8.2 – Getting Help from Medicare
To get information directly from Medicare:
Call 1-800-MEDICARE (1-800-633-4227)
You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048.

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Visit the Medicare Website
Visit the Medicare website (www.medicare.gov). It has information about cost, coverage, and
quality Star Ratings to help you compare Medicare health plans in your area. To view the
information about plans, go to www.medicare.gov/plan-compare.
Read Medicare & You 2024
Read the Medicare & You 2024 handbook. Every fall, this document 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. If you don’t have a copy of this document, you can
get it at the Medicare website (https://www.medicare.gov/Pubs/pdf/10050-medicare-andyou.pdf) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048.

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