Understanding Medicare Advantage Plans
Overview Overview of Medicare Advantage Plans Types of Medicare Advantage Plans Eligibility Requirements How Medicare Advantage Plans Work Enrollment Estimating the Cost
Medicare Advantage Plans 1997 Medicare Part C healthcare options, then called Medicare + Choice, created Also sometimes called Medicare Health Plans Medicare Advantage plans (MA) contract with Medicare Insurance provider is paid fixed amount monthly to provide Medicare benefits
Medicare Advantage Plans MA plans are: Approved and regulated by Medicare Run by private insurance companies Still part of the Medicare program Must cover all health services that Medicare Part A and Part B cover Most have limited geographical coverage area Not all options available in all parts of country
Medicare Advantage Plans May provide extra benefits Vision, hearing, dental and/or health and wellness program Many/most include prescription drug coverage Include Medicare rights and protections Appeal process Member services If plan leaves Medicare you can join another MA or return to Original Medicare
Advantage Plan Appeals Must say in writing how you can appeal if it Won t pay for a service Doesn t allow a service Stops or reduces course of treatment Can ask for expedited (fast) decision Plan must decide within 72 hours See plan membership materials
Types of MA Plans Health Maintenance Organization (HMO) Members can generally only go to doctors, specialists or hospitals that are part of the plan s network, except in an emergency. Preferred Provider Organization (PPO) Has a network of providers, but members can also use out-of-network providers for covered services, usually for a higher cost.
Types of MA Plans Private Fee For Service Plan (PFFS) Most have a network of providers, but members can also ask any Medicare approved provider if they will accept the coverage of the plan, usually at a higher cost to the member. Special Needs Plan (SNP) Type of MA plan in which enrollment is limited to certain groups of Medicare beneficiaries such as those living in a nursing home, those with both Medicare and Medicaid or those with certain chronic conditions
Types of MA Plans Medicare Medical Savings Account (MSA) Plan includes both a high deductible health plan and a bank account to help pay your medical costs. Plan deposits a certain amount of money each year, tax free if used for eligible expenses and remainder carries over to next year. Not include prescription drug coverage. Must purchase Part D - Drug plan Not currently available in Northern Kentucky and many parts of the country
Eligibility Requirements: Enrolled in Medicare Part A (Hospital Insurance) Enrolled in Medicare Part B (Medical Insurance) Must continue to pay the Part B monthly premium ($134.00 for most new in 2018) Live in plan service area Determined by zip code of residence Not have End-Stage Renal Disease at enrollment
How MA Plans Work Receive services through the plan Many plans function as: Medicare Part A Medicare Part B (still must pay monthly premium) Part D Prescription Drug Plan
How MA Plans Work Must provide Medicare covered services but can do so with different rules, costs and restrictions Must include a yearly limit on out-ofpocket expenses for Part A and B services Can t charge you more than Medicare for certain services like chemotherapy and dialysis
How MA Plans Work Can charge more for services like home health and inpatient hospital services Can provide additional benefits not covered by Original Medicare Dental, Hearing, Vision, Etc.
Medicare HMO Plans Provider List? Must choose a PC doctor? Need Referral to Specialists? Rx covered? Yes Generally must get care and services from providers in plan s network. In most cases. In most cases, yes. Certain services, like mammogram screening, do not require referral. In most cases, yes. Must check the plan.
Medicare HMO Plans What else you need to know If you get health care outside the plan s network, most likely will have to pay the full cost. Emergency care is covered even if at an out-ofnetwork provider. Check the plan for out-of-area urgent care coverage. Important to follow the plan s rules, like getting prior approval for certain services as required.
Medicare PPO Plans Provider List? Must choose a PC doctor? Need Referral to Specialists? Rx covered? Yes PPOs have a network of providers but can also use out-ofnetwork providers for covered services (usually for higher cost). No. In most cases, no. In most cases, yes. Check the plan.
Medicare PPO Plans What else you need to know If get health care outside the plan s preferred network, will have to pay a higher co-pay. PPO plans are not the same as Original Medicare or a Supplemental Insurance even though have expanded provider options. Important to follow the plan s rules.
Medicare PFFS Plans Provider List? Must choose a PC doctor? Need Referral to Specialists? Rx covered? Yes and No Will have a provider list but can go to any Medicare approved provider and ask them to accept the plan s payment terms. Not everyone will. May pay higher co-pay for nonnetwork providers. No. No. Sometimes. Check the plan. If no drug coverage can purchase a Part D plan.
Medicare PFFS Plans What else you need to know Plan decides how much you pay for services. Some have network of providers that will always treat you even if not seen them before. You need to make sure that all providers that treat you agree to and accept the plan s payment terms. In an emergency, all providers must treat you regardless of the terms of the plan.
Joining or Switching MA Plans Initial Enrollment Period (IEP) 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 Medicare Open Enrollment Period Open Enrollment October 15 th to December 7 th (each year) Coverage begins January 1 st
Joining or Switching MA Plans Special Enrollment Periods (SEP) have 63 days to obtain coverage Leaving or losing employer or union coverage (and have delayed Part B) You move out of the plan s service area Plan leaves Medicare program or reduces its service area You enter, live at, or leave a long-term care facility Other exceptional circumstances
Joining or Switching MA Plans 5-Star Special Enrollment Period (SEP) Can enroll in 5-Star Medicare Advantage (MA) or Prescription Drug Plan (PDP) any point during the year Once per year New plan starts first day of month after enrolled Star ratings given once a year in October Use Medicare.gov to see star ratings
Leaving MA Plans Medicare Open Enrollment Period Open Enrollment October 15 th to December 7 th (each year) Can leave MA Plan Switch to a different MA plan Leave MA and switch to Original Medicare Coverage begins January 1 st
Leaving MA Plans January 1 February 14 Can leave MA Plan Only switch to Original Medicare Coverage begins first day of month after switch May purchase Part D Drug Plan Drug coverage begins first day of month after enrolled May not join another MA Plan during this period
Leaving MA Plans Special Enrollment Period Trial Rights When join an MA Plan for the first time When first eligible at 65 or Leave Original Medicare Can dis-enroll during first 12 months Return to Original Medicare Have guaranteed issue rights for Medigap (Supplemental Insurance)
Evaluating the Benefits Offer extra benefits such as vision, hearing, dental and/or a health and wellness program? Extra cost for these benefits? Provider list meet your needs?
2018 MA Plan Costs Part B monthly premium - $134.00 MA Plan monthly premium Range from $0 - $163 (41017) Prescription Drug deductible Range from $0 - $360 Health Plan deductible Range from $0 - $1500 Extra Benefits rider Check the plan
MA Plan Costs Plan Service co-pays such as PC doctor visits Specialist visits In-patient hospitalization Outpatient services ER visit Etc. Each plan is different carefully review
MA Plan Costs Prescription Drug co-pays Drugs covered? Co-pay costs Mail Order and Preferred Pharmacy options Check Out-of-Pocket Spending Limit Range from $2,900 to $5,000 in-network Range from $3,400 to $10,000 for plans that allow out-of-network services
How to Evaluate Plans Consider these questions Are your preferred doctors in the network? Other preferred providers like hospital and home health agency in the network? Do your doctors recommend joining this plan? Will you need a referral from your PCP? What extra benefits are offered and what are the costs and the rules?
How to Evaluate Plans Consider these questions (continued) Are your prescriptions covered? What are the costs and are there any restrictions? Is your preferred pharmacy a network pharmacy? Will the plan cover you when you travel? What service area does the plan cover? What is the Star Rating for the plan and how long has it been in business?
How to Evaluate Plans Are you comfortable with: The costs of the plan (premium, deductible, co-pays)? The out-of-pocket maximum? The managed care concept and restrictions?
How to Evaluate Plans Go to www.medicare.gov For a step-by-step guide to using Medicare.gov go to: www.stelizabeth.com/primewise - Medicare Resources - Steps for Comparing Medicare Health (Advantage) Plans Make a list and call the company with your questions. Easy to contact and get answers?
Make Informed Decision! PrimeWise available to assist you (859) 301-5999 PrimeWise@stelizabeth.com Linking Adults 50+ to Health and Wellness