2022 hmo plans - anthem.cmpsystem.com

Y0114_22_130619_I_C 06/24/2021

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Medicare AdvantageHealth Maintenance Organization (HMO) Plans

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This presentation contains proprietary information. It is intended for use only by our contracted brokers and employer groups. Any redistribution or other use is strictly forbidden. The benefit descriptions are intended to be a brief overview of some benefits available to plan members. For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.

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Introduction

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Welcome to the Medicare Advantage: Health Maintenance Organization (HMO) course.

The overall goal of this course is to help you learn and understand the basic structure of the Medicare Advantage HMO plans offered for enrollment.

A course is considered completed with a passing score of 90% or higher on the product certification test for this module. Once you have successfully completed this module, you will see a completion checkmark on your online training list.

This module may also be used for agent re-education, if necessary, in the event of a sales inquiry. Note: You may return to this module at any time for a refresher on HMO product training.


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Learning Objectives

• Understand the typical HMO benefits and their components such as coverage and general benefit-related costs

• Explain the differences between HMO and other plan types

• Define general eligibility criteria for HMO plans

• List the rules on premium rates

• Explain service area and the impact to member cost if services are received out of network

• Describe general HMO plan structure

• Explain the difference between MA-only and MA-PD plans and the impacts of enrolling in MA-only and PDP plans

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Medicare Advantage Overview

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The Medicare Advantage (MA) Program, sometimes called “Part C”, combines coverage for Parts A & B benefits and is administered by private health plans.

Private health plans contract with CMS to administer benefits on behalf of CMS including HMOs, PPOs, Special Needs Plans (SNP), and Private Fee-for-Service (PFFS) plans.

• Medicare pays a fixed amount for the beneficiary’s care every month to the companies offering MA Plans.

• An organization offering MA plans must offer at least one MA plan with prescription drug coverage (known as MA-PD plan) in every service area.


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Eligibility Criteria

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The enrollee must:

• Be entitled to Part A and enrolled in Part B• Reside in the MA plan’s service area• Not have End Stage Renal Disease *

*NOTE: The 21st Century Cures Act amended the Social Security Act to allow all Medicare-eligible individuals with ESRD to enroll in MA plans beginning January 1, 2021.

For enrollment rules prior to this date, individuals who develop ESRD while enrolled in a health plan (e.g., a commercial or group health plan, or a Medicaid plan) are eligible to enroll during their initial enrollment period in a MA plan offered by the same organization.


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Rules on Rates

• Rates are according to service area and vary by plan selection

• Rates are the same, regardless of gender or age

• Rates are for individuals; there are no spouse or household discounts• Rates are subject to annual review

Remind the beneficiary any plan premium they pay is in addition to the Medicare Part B premium.

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Definition of HMO Plans

Our Medicare Advantage HMO plans (or Part C plans) take the place of Medicare Part A and Part B and may offer more benefits than Original Medicare.

HMO plans have a defined service area and require services be performed by in-network providers, except in an emergency.

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HMO Service Area

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HMO plans have a defined service area and beneficiaries must reside in the plan’s service area in order to be eligible to enroll.

In most cases, enrollees can only go to doctors, specialists, or hospitals in the plan’s network except in an emergency.

If enrollees get care out-of-network without prior approval from the plan, they may have to pay the full cost.

It is very important for enrollees to fully understand the need to work with their primary care provider (PCP) to coordinate their health care; as well as the potential financial impact of receiving services from providers who are out of the HMO network.


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HMO Plan Structure – General

• Some HMO Plans include Part D prescription coverage while others do not

• When you are marketing a HMO plan, be certain to confirm whether or not the beneficiary wants drug coverage

NOTE: Agents wishing to sell HMO plans with drug coverage (MA-PD) are also required to take the Part D module as part of their certification.

• At a minimum, plans must cover all services covered under Medicare, but can also provide extra benefits not covered by traditional Medicare, such as:

— Routine vision and hearing exams— Fitness benefits— Dental benefits

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HMO Plan Structure – Specific

• Enrollees choose a PCP (Primary Care Physician), unless not required in their state

• Most services must be given or coordinated by the PCP

• Some services may require a referral by the PCP

• Enrollees must use doctors, specialists, or hospitals in the plan’s network except in an emergency

• HMOs can be sold with drug coverage (MA-PD), or without drug coverage as medical-only (MA-only)

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HMO Plan Structure – Plan Costs for the Beneficiary

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In addition to the monthly premium, beneficiaries choosing HMO plans will have additional costs. You must clearly explain and ensure the beneficiary fully understands these costs:

• Premium• Deductible• Copays• Coinsurance• Non-Covered Services• Out-of-Network expenses

Show the beneficiary where these details can be found in the sales materials you give to them.


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HMO Plan Structure – Deductible

Certain covered services may be subject to an annual deductible.

A deductible is a fixed dollar amount that an insured pays before the insurer starts to make payments for covered medical services.

Please refer to the plan’s Summary of Benefits document for more information on the covered services subject to the annual deductible.

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HMO Plan Structure – Copayments and Coinsurance

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Certain services may be subject to a copayment.

• A Copayment (or Copay) is a fixed amount to be paid each time the member receives a medical service

Some services may be subject to coinsurance.

• Coinsurance is a percentage of the total cost of a medical service to be paid by the member

Beneficiaries must have an understanding of this cost-sharing feature.

Providers may request copayment or coinsurance amounts from the member when the service is provided.


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HMO Plan Structure – Maximum Out of Pocket Limits

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There is a limit as to how much a member will pay out of-pocket for covered health care services each calendar year. The annual maximum out-of-pocket limit is the highest or total amount the plan requires members to pay towards the cost of their health care.

If during the year, costs for certain services reach the annual out-of-pocket limit amount, the member will not pay any further costs for these network provided covered services for the remainder of the calendar year.


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In addition to the overall out-of-pocket maximum, some plans specifically limit the amount a member will pay out-of-pocket annually for inpatient hospital care, which also includes inpatient mental health care.

These out-of-pocket costs also apply to the overall out-of-pocket maximum.

This protection provides members stability for the unknown future medical costs.



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Prescription drug costs under Part D do not apply toward the medical out-of-pocket maximum. There are separate limits on prescription drug costs.

Expenses for the following services and supplies do not apply to the out-of-pocket maximum, even when they are covered:

• Non-Medicare covered Eye Exams

• Non-Medicare covered Eye Wear

• Non-Medicare covered Hearing Exams

• Hearing Aids

• Prescription Drug Costs under Part D



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Covered Benefits

The Summary of Benefits is a helpful tool when explaining the benefits and features of the plan to the enrollee.

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Primary Care Provider (PCP)

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A PCP must be selected by the enrollee (unless not required by the plan) at the time of enrollment. A PCP will provide and arrange for medical care. Referrals from the PCP are not required for some services, including emergency care or urgently needed care.

Please refer to the provider online directory to find providers eligible to be selected as a PCP.


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Referrals for Specialist Care

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In most situations, the PCP must give approval in advance before the member can see other providers in the plan's network. This is called a referral. The referral can be requested but may be at the discretion of the PCP and is usually based on medical necessity.

Referrals from the PCP are not required for emergency care or urgently needed care.

The Summary of Benefits provides more detailed information on which services require a PCP referral.


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In-Network and Out-of-Network

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This plan has formed a network of doctors, specialists, and hospitals. Members can only use doctors who are part of our network.

The member must use in-network providers except in emergency or urgent care situations.

Note: If the member obtains preventive care and screening tests from out-of-network providers, neither Medicare nor the HMO plan will be responsible for the costs. The member will be responsible for the costs in this case. Be certain you explain this, and the member fully understands.

Preventive care can include care such as:

• Routine / Annual Exams• Pap Smears / Pelvic Exams• Prostate Cancer Screening

• Colorectal Screening• Bone Mass Measurements• Mammography Screening


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In-Network and Out-of-Network – Emergency Care

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Members can receive emergency care from a non-network provider. A medical emergency is defined as “when you believe that your health is in serious danger.” This could include severe pain, a bad injury, a sudden illness or a medical condition that is quickly getting much worse.

Emergency care can be received from both an in network and a non-network provider anywhere in the United States or its territories. In addition, as long as the member obtains prior authorization, benefits will be provided when going to non-network providers for covered services in the following limited cases:

• When a member receives urgently needed care when network providers are not available

• When a member receives out-of-service-area dialysis

If a member receives non-emergency care from non-network providers without prior authorization, the member must pay the entire cost.

For more information, please see the Summary of Benefits for this product.This presentation contains proprietary information. It is intended for use only by our contracted brokers and employer groups. Any redistribution or other use is strictly forbidden. The benefit descriptions are intended to be a brief overview of some benefits available to plan members. For agent/broker use only. Not for distribution to the general public; nor for solicitation purposes.

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MA-only vs. MA-PD HMO Plans

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MA-only plans do not include Part D prescription coverage.

MA-PD plans have Part D prescription coverage integrated into the benefits.

Agents wishing to sell HMO plans with drug coverage (MA-PD) are also required to take the Part D module as part of their certification.

Note: it is important to know the consequences your client may experience, if you do not understand the following rule:

If a beneficiary is enrolled in a MA-only HMO and they also sign up for a PDP plan, they will be automatically dropped from their MA plan.


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MA-only vs. MA-PD HMO Plans (cont.)

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For a beneficiary who enrolled in a MA-only plan during the Annual Election Period, he or she will not be able to enroll in a plan that offers prescription drug coverage until the following Annual Election Period.

EXCEPTION: The beneficiary chooses to use their one-time election during the Open Enrollment Period or qualifies for a Special Election Period.


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Optional Supplemental Benefits

Optional Supplemental Benefits (OSB) packages are an additional offering to members that can be purchased to enhance selected Medicare Advantage plans.

There are different levels of packages that may be obtained, including such supplemental benefits as dental and vision.

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Optional Supplemental Benefits – Package Summary

Package offerings may include:

• Preventive Dental Package

• Dental and Vision Package

• Enhanced Dental and Vision Package

Members can disenroll from the optional supplemental benefits (OSB) throughout the year but may not change their “base” health plan. If a member disenrolls, they may not re-enroll in the OSB until the following annual election period.

Please refer to your marketing materials to determine if any plans in your area offer OSB and what package levels might be available for purchase.

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HMO Assessment

Now it is time to put together all the elements covered throughout this course.

An assessment will be given to test your knowledge on the information presented. A score of 90% or above on the assessment is required to successfully pass this module. If a score of 90% is not obtained, the assessment can be attempted again immediately.

Please click the link to access the assessment.

After completing the assessment for this course, refer to your online training summary for your certification progress.

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CLICK HERE FOR ASSESSMENT

https://anthem.uat.coursestage.com/course/view.php?id=43&pageid=51

2022 hmo plans - anthem.cmpsystem.com

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