Medicare Advantage (Part C) Review 1
Medicare For people 65+ and under 65 with a disability 4 parts of Medicare Part A: Hospital Insurance Part B: Medical Insurance Part C: Medicare Advantage Plans Part D: Prescription Drug Coverage Part A & B called Original Medicare 3 Medicare Pays for reasonable and medically necessary services There are coverage gaps in Medicare including: Part A in-patient hospital deductible Part A daily co-payment for in-patient hospital days 61-90 Part A daily co-payment for in-patient hospital days 91-150 Part A daily co-payment for SNF days 21-100 Part B annual deductible Part B co-insurance (usually 20%) First three pints of blood Coverage outside the United States 4 2
Medicare 3 Enrollment Types Automatic: Already receiving Social Security benefits Voluntary: Don t have enough SS work credits, must purchase A+B Standard Enrollment: Eligible for SS and didn t take benefit before 65 3 Enrollment Periods Initial: 7 months surrounding 65 th birthday month Special: 8 months following loss of coverage from ACTIVE employment (individuals or spouses) General: Jan 1 st Mar 31 st of each year. July 1 st effective date 5 Medicare Can delay Part B enrollment if receiving health coverage through ACTIVE employment of individual or spouse 8 month SEP to join Part B once ACTIVE employment coverage has ended Late Enrollment Penalties Part A: Capped at 10% of premium and goes away after penalized for twice the length of time the person delayed enrollment For voluntary enrollees who don t enroll when initially eligible Part B: 10% of premium for each full 12 month period the individual delayed enrollment 6 3
Medicare Advantage (Part C) Overview Also known as Medicare Part C, MA Plan, MA-PD, or a Medicare Health Plan One option available for beneficiaries to get additional coverage to cover the gaps in Original Medicare Offered by a private company that contracts with Medicare to provide a beneficiary with their Part A & Part B benefits Is a replacement plan where beneficiary gets Part A & B coverage from MA Plan, not Original Medicare Must still pay Part B premium Most MA plans include prescription drug coverage (Part D) 8 4
Medicare Advantage Plans Must cover at least services covered under Original Medicare (Part A & Part B) Provide all the rights and protections guaranteed under Medicare Must offer extensive network of health care providers Plan must offer a plan with Part D drug coverage members who want drug coverage may only take drug plan offered by Medicare Advantage Plan If enroll in stand alone PDP, will be dis-enrolled from Part C and returned to Original Medicare Medicare Advantage HMO s and PPO s have different coverage, standards, etc. than regular HMO s and PPO s 9 Medicare Advantage Companies Companies are required to: Have package of benefits approved by Medicare Give beneficiaries written information about coverage, cost, and effective date Provide a quality of service which meets Medicare standards Give members information about appeal rights 10 5
Eligibility Eligibility requirements: Have Medicare Part A & Part B (must pay Part B premium) Cannot have ESRD (except if have coverage with a non-medicare plan from the same company prior to being diagnosed) Must live in the plan s service area Cannot be out of plan s service area for more than 6 consecutive months 11 Four Enrollment Periods Initial Enrollment Period (IEP) Open Enrollment Period (OEP) Special Enrollment Period (SEP) Medicare Advantage Disenrollment Period (MADP) 12 6
Initial Enrollment Period Same as Part B seven month enrollment period 3 months before 65 th birthday (or year of entitlement to Medicare for those under 65 with a disability), month of birthday, 3 months after birthday month Month earlier if birthday is the 1 st of the month 13 Open Enrollment Period October 15 th -December 7 th (effective Jan 1 st ) During this period a beneficiary may change from: Original Medicare to Medicare Advantage Plan Medicare Advantage Plan to Original Medicare Medicare Advantage Plan to another Medicare Advantage Plan Upgrade to include Medicare Prescription Plan coverage Downgrade to exclude Medicare Prescription Plan coverage 14 7
Special Enrollment Period Some qualifying events for SEP eligibility: Move out of plan s service area Leave employer coverage Nonrenewal or termination of plan Have or lose MassHealth Have Extra Help or Prescription Advantage Within trial period (first 12 months) of MA plan if enrolled into MA plan when first eligible for Medicare at age 65 In last 12 months, left a Medigap policy to join a MA plan for the first time FYI: There is NO SEP if a doctor leaves the plan network 15 Special Enrollment Period Special Enrollment Period How long beneficiary has to make new selection depends on event Once selection is made, the SEP is over If coverage is lost and no other selection is made, beneficiary returns to Original Medicare with no drug coverage If beneficiary is eligible and selects a stand alone Medicare drug plan, beneficiary will automatically be dis-enrolled from Medicare Advantage Plan Cannot have a stand alone Medicare Prescription Drug Plan along with a Medicare Advantage Plan 16 8
Medicare Advantage Disenrollment Period (MADP) Disenrollment Period: January 1 st February 14 th Can leave plan and return to Original Medicare Coverage begins the first of the month after disenrolling If switch to Original Medicare during this period, will have until February 14 th to also join a Medicare Prescription Drug Plan Coverage begins the first day of the month after the plan gets enrollment form. Cannot join another MA plan during this period 17 Changing MA plans Automatic disenrollment when changing Medicare Advantage Plans Beneficiaries don t need to call the plan they are leaving to dis-enroll Enrolling in the new MA plan will automatically alert the old plan 18 9
Plan Types Types of Medicare Advantage Plans HMO (Health Maintenance Organization) HMO-POS (HMO with Point-of-Service option) PPO (Preferred Provider Organization) SNP (Special Needs Plan) PFFS (Private Fee for Service) Not all plans are offered in all regions of the state 19 HMO Plans HMO (Health Maintenance Organization) Typically lower premium than other types of MA plans Most restrictive type of managed care plan Plan rules must be followed for services to be paid Members must use network providers Referrals from Primary Care Physician are required If plan does not pay, original Medicare will NOT pay as back-up Care outside the service area for emergencies and urgent care situations ONLY (notification rules apply) May include extra benefits like vision, hearing or dental 20 10
Advantages/Disadvantages to HMO Membership Advantages Quality of care enhanced due to coordination of services Easier to budget medical costs because premiums and co-pays are fixed amounts Other out-of-pocket expenses to enrollee minimal & predictable Less paperwork and no forms Extra benefits such as hearing, dental, routine exams, vision Health promotion and disease prevention Disadvantages Restriction on use of doctors, hospitals, health care providers Must have prior approval to see a specialist, have surgery, or obtain other medical services Enrollee may have to change from current physician HMO facilities may not be easily accessible Limitation on out-of-service area coverage Ongoing treatment of chronic conditions may not be covered while outside the service area 21 HMO-POS Plans HMO-POS (HMO with Point-of-Service option) POS benefit allows the enrollee to use doctors, hospitals, and other providers who are not in the HMO or other plan network May have to pay deductible and any other fee Medicare does not cover for services received through POS option Medicare Advantage Plans may offer a POS option as either: An additional benefit included in the plan s basic premium OR A mandatory or supplemental benefit for which the plan will charge a higher premium 22 11
PPO Plans PPO (Preferred Provider Organization) Can have a higher monthly premium Can go outside of network but will usually pay higher out-of-pocket costs Plan has network of providers (usually different than HMO network, even if same company) Generally does not require referrals from Primary Care Physician May include extra benefits like vision, hearing, dental 23 PFFS Plans (PFFS) Private Fee-For-Service Beneficiary can go to any provider that agrees to the terms of the plan No referrals needed for specialist May pay different amount for services under Part A & B but will get all the same services covered May pay extra for extra benefits 24 12
SNP Plans SNP (Special Needs Plan) Comprehensive program of medical care with membership limited to certain groups of people including: Those in certain institutions (like nursing homes) Those eligible for both Medicare & MassHealth (Duals) Those with certain chronic or disabling conditions Generally provides greater benefits to members including: Specialty care coordination Hospital case management Communication with caregivers Routine patient visits 25 Quick Reference: Pro s of Medicare Advantage Plans Medicare Advantage Plans tend to attract people who are not high utilizers of medical services. They also attract people who want a lower premium plan Pro s: Convenience of having only one plan (drug plan can be included) More choices available (HMO s, PPO s ) Lower premiums than Medigap plans Potential for better coordination of care (HMO s provide this) Additional benefits such as hearing, dental, vision and annual exams 26 13
Counseling Beneficiaries: Is Additional Coverage Needed? Does every Medicare beneficiary need additional Medicare coverage? Questions to ask beneficiary: Does she/he understand the gaps in Medicare coverage? Does she/he have other coverage to help pay for outof-pocket costs associated with Medicare? (Retiree Coverage, Medigap plan, MassHealth) Can she/he afford to purchase additional coverage? (screen for Public Benefit programs) 28 Medicare Advantage Review Review 1. What is a Medicare Advantage Plan? 2. What are the advantages of Medicare Advantage? 3. What are the disadvantages of Medicare Advantage? 4. Who can enroll in a Medicare Advantage Plan? 5. When can a person enroll? 6. What is the difference between an HMO and PPO? 28 14