medicare advantage plans & other medicare plans
DESCRIPTION
Medicare Advantage Plans & Other Medicare Plans. with edits by Illinois SHIP - Module 11. Medicare Choices. Original Medicare Medicare Advantage (MA) Plans Medicare drug plans Medicare Prescription Drug Plans Medicare Advantage Plans with prescription drug coverage. 9/23/2014. - PowerPoint PPT PresentationTRANSCRIPT
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Medicare Advantage Plans & Other Medicare Plans
with edits by Illinois SHIP - Module 11
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04/21/23 Medicare Advantage 204/21/23
Medicare Choices
• Original Medicare
• Medicare Advantage (MA) Plans
• Medicare drug plans– Medicare Prescription Drug Plans– Medicare Advantage Plans with prescription
drug coverage
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04/21/23 Medicare Advantage 3
Part A & B
Some will include Part D
Part – B
Part – A
Part – D or Secondary
MedSup
or
Secondary
Ways to receive Medicare
Original MedicareMedicare Advantage
(HMO, PPO, etc)
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04/21/23 Medicare Advantage 4
• 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
What Are Medicare Advantage (MA) Plans?
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04/21/23 Medicare Advantage 5
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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04/21/23 Medicare Advantage 6
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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04/21/23 Medicare Advantage 7
Medicare HMO Plans• Generally must get care and services from plan’s 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 plan’s 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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04/21/23 Medicare Advantage 8
Medicare PPO Plans• Have the option to use network providers or out-of-network
providers that accepts Medicare• Don’t 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 PPO’s 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
o Varies by plan
• May have higher deductible and/or premium than other PPOs
• May offer Medicare prescription drug coverage
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04/21/23 Medicare Advantage 9
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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04/21/23 Medicare Advantage 10
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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04/21/23 Medicare Advantage 11
Special Needs Plans (SNPs)
• Designed to provide– Focused care management– Special expertise of plan’s providers– Benefits tailored to enrollee conditions
• Must include prescription drug coverage
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04/21/23 Medicare Advantage 12
Special Needs Plans (continued)
• Three types of SNPs– Must limit membership to people
• With certain chronic or disabling conditionso 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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04/21/23 Medicare Advantage 13
Who Can Join?
• Eligibility requirements– Live in plan’s 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 plan’s rules– Belong to only one Medicare Advantage plan at a time
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04/21/23 Medicare Advantage 14
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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04/21/23 Medicare Advantage 15
When you can Join or Switch MA Plans*
Annual Election Period for 2011 and After
October 15 – December 7 each yearCoverage 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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04/21/23 Medicare Advantage 16
When you can Join or Switch MA Plans
New in 2011Annual Disenrollment Period
• Can leave an MA plan and switch to Original Medicare
• Between January 1–February 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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04/21/23 Medicare Advantage 17
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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04/21/23 Medicare Advantage 18
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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04/21/23 Medicare Advantage 19
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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04/21/23 Medicare Advantage 20
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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04/21/23 Medicare Advantage 21
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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04/21/23 Medicare Advantage 22
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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04/21/23 Medicare Advantage 23
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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04/21/23 Medicare Advantage 24
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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