Community Health Centers

1
Community Health Centers Medicare Advantage

• Susan Vega
• Senior Advocate
• Alivio Medical Center

2
Community Health Centers

• Community Health Centers (CHCs) also known as
  Federally Qualified Health Centers
• Serve medically underserved communities
• Have periodically renewable designation with
  federal government
• Receive higher reimbursement rate
• Have mission to serve uninsured and underinsured
• Have mandates for developing specific programs /
  services, reporting measures, board composition
  and more

3
Medicare Advantage - MA

• Originally known as Medicare Plus Choice
  Medicare Part C
• Created by the Balanced Budget Act of 1997
• Trend has been for larger co-pays and fewer extra
  services covered
• Often limits consumer choice of providers
• Can include lots of complicated rules and
  exclusions
• Can also be a good choice especially for people
  in Medicare because of disabilities

4
How MA Plans Work

• Usually get all Medicare Part A and Part B
  services through the plan
• May have to use ONLY providers that belong to the
  plan in order to be covered
• May get extra benefits
• May get vision, hearing, dental services
• May get prescription drug coverage
• Still in Medicare program
• Get all Part A and Part B services
• Have Medicare rights and protections

5
Background

• Some Community Health Centers have had contracts
  with Medicare Advantage plans for years
• Most CHCs that have MA contracts have large
  numbers of 65 and / or patients with
  disabilities

6
Medicare Advantage Options

• Medicare HMOs
• Medicare HMOs with Point of Service (POS) options
• Special Needs Plans (SNP)
• Institutional
• Chronic or disabling condition
• Private Fee For Service (PFFS)
• Preferred Provider Organizations (PPO)
• Local
• Regional
• Medical Savings Account
• Medicare Advantage plans may be available with
  or without prescription drug coverage (Medicare
  Part D)

7
CHC Upsides and Downsides

• CHCs accepting MA plans generally get enhanced
  reimbursement
• This does NOT apply for Medicare patients who are
  also eligible for Medicaid
• CHCs do not get Medicaid co-pay from state since
  there is no contract between state and MA plan

8
Patient Upsides and Downsides

• Need to understand the rules
• Many plans have limited networks
• Sometimes can find hospitals but not primary care
  physicians or specialists
• Patients may have to make choice between plan and
  provider
• Sometimes can save significant money over
  traditional Medicare supplements

9
Note to Providers and Consumers

• Proceed with caution
• Understand all the rules
• Understand reimbursement, referral process
• Consider most important needs
• Choice of doctors, specialists, hospitals,
  healthcare needs, including extra services
• Get good impartial advice

10
Resources

• Providers
• Illinois Primary Health
• Care Association
• Medicare

• Consumers
• Start with your Health Care Provider
• Medicare website
• www.medicare.gov
• Senior Health Insurance Program
• 1-800-548-9034