What is Medicare Advantage

1
What is Medicare Advantage?

• Kelly R. Brantley
• Health Assistance Partnership

2
Background of MA

• New program with significant changes to replace
  Medicare Choice program
• Regional plans
• Expansion of plan options
• Increased range of benefit choices
• Limited enrollment period

3
Managed Care Concepts

• Medicare Advantage is managed care
• Medicare Medicare
• No health status limits
• Enrollment periods
• All Medicare services covered
• Extra benefits possible
• Network of providers
• Rules for certain services
• Appeals process

4
MA Costs in 2007

• Part A and B Premium 93.50 (and up, depending
  on income)
• MA Premium Varies from 0 and up (covers extra
  non-A and/or non-B benefits)
• Part D Premium Varies from 0 and up
• Part D Deductible Varies from 0 to 250
• Copayments for each health care service received
  (not coinsurance, like FFS Medicare)

5
Types of MA Plans

• Five types of MA plans
• Local Coordinated Care Plans (HMOs and PPOs)
• Regional Preferred Provider Organizations
• Private Fee-for-Service Plans
• Medical Savings Accounts
• Special Needs Plans

6
Local Coordinated Care Plans

• Most common type of MA plan
• Two varieties
• HMOs (Health maintenance organizations)
• All services must be in the network
• Some prior authorization requirements
• No coverage for out-of-network care (except
  emergencies)
• Some offer POS for out-of-network (at higher
  cost)
• PPOs (Preferred provider organizations)
• Lower costs for services in the network
• Higher costs for out-of-network care

7
Regional Preferred Provider Organizations

• New in 2006
• Offers network coverage throughout the region
• Combined A and B deductible
• Limit on out-of-pocket costs for covered services

8
Private Fee-for-Service

• Plan (not Medicare) decides reimbursement rate
  for physicians
• Enrollees may have higher out-of-pocket costs
• No network of providers providers must agree to
  plans terms for each patient and for each visit

9
Medical Savings Accounts

• Special savings account for Medicare to deposit
  set amount of money for covered services
• Partners with a high-deductible MA plan
• Deposit may not cover the plans deductible
• New to the market in 2007

10
Special Needs Plans

• Generally Coordinated Care Plans
• Limit enrollment to certain subsets of Medicare
  beneficiaries
• Institutionalized beneficiaries
• Full dual Medicare beneficiaries
• Beneficiaries diagnosed with certain chronic
  and/or disabling conditions

11
MA Enrollment

• Annual Election Period (11/15 to 12/31)
• Initial Coverage Election Period A B (7
  months around date of eligibility)
• Initial Enrollment Period D (7 months around
  date of eligibility)
• Open Enrollment Period (01/01 to 03/31)
• OEP for Institutionalized Individuals
  (continuous)
• Special Election Periods (similar to PDP SEPs)