Medicare Advantage Plans

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Medicare Advantage Plans Other Medicare Plans

• with edits by Illinois SHIP - Module 11

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Medicare Choices

• Original Medicare
• Medicare Advantage (MA) Plans
• Medicare drug plans
• Medicare Prescription Drug Plans
• Medicare Advantage Plans with prescription drug
  coverage

10/27/2013
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Ways to receive Medicare
Medicare Advantage (HMO, PPO, etc)
Original Medicare
Part B
Part A B
Part A
Part D or Secondary
MedSup or Secondary
Some will include Part D
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What Are Medicare Advantage (MA) Plans?

• Health plan options approved by Medicare
• Run by private insurance companies
• Part of the Medicare program
• Sometimes called Part C or Medicare Health
  Plans
• Provides Medicare-covered benefits
• May cover extra benefits, e.g. vision or dental

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How MA Plans Work

• You are still in the Medicare program
• You receive Medicare-covered services through the
  plan
• All Part A and Part B covered services
• Some plans may provide additional benefits
• Most plans include prescription drug coverage
• You may need to use network doctors or hospitals
• MA plans may be different than Original Medicare
• Benefits and cost-sharing
• If the plan leaves Medicare
• You can join another MA plan
• You can return to Original Medicare
• You still have Medicare rights and protections

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Types of Medicare Advantage Plans

• Medicare Health Maintenance Organization (HMO)
• Medicare Preferred Provider Organization (PPO)
• Medicare Private Fee-for-Service (PFFS)
• Medicare Special Needs Plan (SNP)

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Medicare HMO Plans

• Generally must get care and services from plans
  network
• Use doctors and hospitals that belong to the plan
  
• May need to choose primary care doctor
• Usually need a referral to see a specialist
• Doctors can join or leave
• Copayment amounts set by plan
• May have to pay in full for care outside plans
  network
• Covered if emergency or urgently needed care
• May include prescription drug coverage
• If signing up for Part D, must take coverage with
  same plan
• Some plans may offer a Point-of-Service (POS)
  option
• May allow you to get some services out-of-network
• You may have to pay a higher cost share for these
  services

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Medicare PPO Plans

• Have the option to use network providers or
  out-of-network providers that accepts Medicare
• Dont need referral to see specialist
• Copayment and coinsurance amounts set by plan
• Will usually pay more for out-of-network care
• There are two types of PPOs offered
• Local PPOs
• Can service one county or multiple counties
• Regional PPOs
• Coverage can be a region such as, an entire
  state or a multi-state coverage area
• Have annual limit on out-of-pocket costs
• Varies by plan
• May have higher deductible and/or premium than
  other PPOs
• May offer Medicare prescription drug coverage

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Medicare PFFS Plans

• Can see any Medicare-approved doctor or hospital
  that accepts the plan
• Can get services outside service area
• Plan sets copayment amounts
• For PFFS network rules see individual plan info
• If offered, can get Medicare prescription drug
  coverage
• If not offered, can join a stand-alone Medicare
  Prescription Drug Plan (PDP)

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Changes in Access Requirements for PFFS Plans
By 2011

• Medicare PFFS
• If two or more network-based MA Plans (such as
  HMOs and PPOs) exist in a service area they must
  offer a network
• Employer PFFS
• Must have contracts with networks of providers

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Special Needs Plans (SNPs)

• Designed to provide
• Focused care management
• Special expertise of plans providers
• Benefits tailored to enrollee conditions
• Must include prescription drug coverage

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Special Needs Plans (continued)

• Three types of SNPs
• Must limit membership to people
• With certain chronic or disabling conditions
• Heart disease, diabetes, etc.
• Eligible for Medicare and Medicaid
• In certain institutions (confined to a nursing
  home)
• Available in some areas
• Visit www.medicare.gov
• Call 1-800-Medicare

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Who Can Join?

• Eligibility requirements
• Live in plans service area
• Entitled to Medicare Part A
• Enrolled in Medicare Part B
• Not have End-Stage Renal Disease (ESRD) at
  enrollment
• Some exceptions
• To join an MA plan, a person must also
• Agree to provide the necessary information to the
  plan
• Agree to follow the plans rules
• Belong to only one Medicare Advantage plan at a
  time

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When You Can Join or Switch MA Plans When You Can Join or Switch MA Plans
Initial Coverage Election Period 7 month period begins 3 months before the month you turn 65 Includes the month you turn 65 Ends 3 months after the month you turn 65
Annual Election Period for 2010 November 15 December 31 Coverage begins January 1, 2011
Plan must be allowing new members to join.
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When you can Join or Switch MA Plans When you can Join or Switch MA Plans
Annual Election Period for 2011 and After October 15 December 7 each year Coverage begins Jan. 1 of following year
MA Open Enrollment Period Was January 1 March 31 each year Eliminated in 2011
Special Election Period Move from the plan service area and cannot stay in the plan Plan leaves Medicare program Other special situations
Plan must be allowing new members to join.
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When you can Join or Switch MA Plans When you can Join or Switch MA Plans
New in 2011 Annual Disenrollment Period Can leave an MA plan and switch to Original Medicare Between January 1February 14 Coverage begins the first of the month after you switch If you make this change you also may join a Medicare Prescription Drug Plan to add drug coverage Between January 1-February 14 Drug coverage begins the first of the month after the plan gets enrollment form
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MA Plan Cost

• Must still pay Part B premium
• Some people may be eligible for state assistance
• Medicare Savings Program (MSP)
• May pay an additional monthly premium to plan
• You pay deductibles, coinsurance and copayments
• Different from Original Medicare
• Varies from plan to plan
• Costs may be higher if you go out of network

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Monthly Premiums- 2011

• Starting January 1, 2011 Part D monthly premiums
  may be higher based on income
• Includes PDP and MA-PD plans
• If income is above
• 85,000 filing individual tax return
• 170,000 filing a joint tax return
• Additional monthly adjustments will be charged in
  addition to part D premiums
• SSA will be contacting those who have to pay
  higher premiums in November

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Non-renewing MA plans Guaranteed Options

• Plan must send notification of non-renewal 90
  days prior to last day of coverage
• Affected Members have a Special Enrollment
  Period-SEP
• Can pick up a new MA plan
• October 1, 2010 to January 31, 2011
• Effective dates of either
• January 1 or February 1, 2011 (depending on
  application date)
• If another MA plan is not selected
• Beneficiary will be defaulted to Original
  Medicare on effective date of termination
• 63 days to join a PDP
• 63 days for a guaranteed issue Medicare
  Supplement policies A, B,C,F, K, L

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Medicare Advantage Trial Right Special Election
Period

• People who join an MA plan for the first time
• When first eligible for Medicare at age 65 or
• Leave Original Medicare and drop Medigap policy
• Can disenroll from MA plan during first 12 months
• Join Original Medicare
• Have guaranteed issue for Medigap policy

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Comparing Plans

• Use on-line tool at www.Medicare.gov
• Choose the Health and Drug Plans tab
• Compare, Review, and Enroll
• Make sure MA plan services your area
• If seeking MA plan with drug coverage make sure
  the plan has needed drugs in formulary
• Call the plan or Visit their website

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Rights in All Medicare Plans

• People with Medicare have certain guaranteed
  rights
• To get the health care services they need
• To receive easy-to-understand information
• To have their personal medical information kept
  private
• Access to health care providers
• Know how doctors are paid
• Fair, efficient, and timely appeals process
• Fast appeals in certain health care settings

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Appeals in MA

• Plan must say in writing how to appeal if
• Will not pay for a service
• Does not allow a service
• Stops or reduces a course of treatment
• Can ask for fast (expedited) decision
• Plan must decide within 72 hours
• See plan's membership materials
• Include instructions on how to file an appeal or
  grievance

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Required Notices

• After every
• Adverse determination
• Adverse appeal
• Include
• Detailed explanation of why services denied
• Information on next appeal level
• Specific instructions

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