Medicare and Medicaid Week 3

Medicare Advantage – Part C Formerly known as Medicare + Choice (M+C) Program The managed care component of the Medicare program Each Medicare Advantage organization must provide the services currently available under Medicare Parts A & B May impose copayments & deductibles different from those under Parts A & B – if actuarially equivalent Must pass on a percentage of cost-savings in form of additional benefits or reduced premiums May offer supplemental benefits with separate premium Most have to offer at least one plan that offers RX drug coverage Must accept eligible beneficiaries without restriction. (Why is this important)?

Medicare Part C Eligibility Must be entitled to benefits under Part A and enrolled in Part B ESRD patients excluded Unless enrolled in plan when they develop ESRD; or Plan is MA Special Needs plan that covers ESRD Must reside in area served by the plan

Medicare Part C Enrollment Initial coverage election period – 7‑month period that starts 3 months before the month person turns 65, includes the month person turns 65, and ends 3 months after the month person turns 65. Medicare Open Enrollment Period For individuals already enrolled in a MA plan October 15th – December 7th of every year May enroll in MA plan, switch to different plan or return to traditional Medicare MA Disenrollment Period (January 1 – February 14) drop MA and return to the traditional Medicare program – plus add Part D prescription drug coverage. (Discussion for MADP). Before 2011, there was a three month open enrollment period, at the beginning of each year, when individuals enrolled in MA could change plans could change plans once – as long as they did not add or drop prescription drug coverage. Now, there is a 45 day disenrollment period during which individuals can only drop MA and return to the traditional Medicare program – plus add Part D prescription drug coverage.

Medicare Part C Enrollment Open enrollment periods Individual enrolled in Medicare Part A who but not yet enrolled in Part B, may enroll in Part B during 1st three months of year and then switch to Part C between April 1 and June 30. Special Enrollment Periods – apply if: Plan is terminated or is going out of business Individual moves out of service area of plan Individual demonstrates to CMS that the plan violated a provision of the contract or used misleading marketing

Medicare Part C - Advantages/Disadvantages No claims Emphasis on preventative care Comprehensive services No need for Medi-gap insurance Disadvantages Plan terminations Limitations on receiving specialized care Financial incentive to limit care Requirement to use Plan providers Out of area care limitations Possible higher co-pays and deductibles

Medicare Part C - Medicare Advantage Options Coordinated Care Plans Medicare Medical Savings Account (MSA) Health Savings Account Private Fee for Service Plans Religious Fraternal Benefit Society Plans Local and Regional Medicare Advantage Plans Specialized MA Plans for Special Needs Pts.

Medicare Part C - Medicare Advantage Options Coordinated Care Plans Must offer qualified Part D coverage that includes the requirements related to qualified prescription drug coverage Types of CCP’s HMO’s – Health Maintenance Organizations (staff-based facility of service providers and/or a group on independent practice associations) acting BOTH as an insurer and a provider Financed through capitated payments; copayments may apply

Medicare Part C - Medicare Advantage Options Types of CCP’s cont’d Provider Sponsored Organizations (PSO’s) created by health care providers to act as insurer for a defined group of enrollees, Physician-based or hospital-based models or a combination of service delivery models A managed care contracting and delivery organization consisting of a group of doctors, hospitals, and other health care providers who accept full risk for beneficiaries' lives. ( i.e. - provides its services in return for a fixed payment per month for each beneficiary). Owned and governed by health care providers such as physicians, hospitals, or allied health professionals and not by an insurance company.

Medicare Part C - Medicare Advantage Options Types of CCP’s cont’d Preferred Provider Organizations (PPO’s) managed care entities that contract with networks or panels of providers paid based upon contractually specified reimbursement

Medicare Part C - Medicare Advantage Options Medicare Medical Savings Account (MSA) not permitted to offer prescription drug coverage other than that required under Parts A & B combines the use of a health care savings account with a high deductible catastrophic health plan

Medicare Part C - Medicare Advantage Options Health Savings Account An individual opens a Health Care Savings Account (HSA) in connection with the purchase of high deductible private health insurance Advantages- considerable income tax savings; can carry over unspent balance from year to year; able to withdraw sums from the account to cover deductibles and other HC expenses; deposits are excluded from taxable income, earnings on the account are not taxable

Medicare Part C - Medicare Advantage Options Private Fee-for-Service Plans Plans may choose to offer qualified Part D coverage Provide: hospital , physician and other providers reimbursement does not vary rates for such a provider based on utilization does not restrict selection of providers

Medicare Part C Medicare Advantage Options Religious Fraternal Benefit Society Plans limits enrollment to members of the church, convention, or group with which it is affiliated Specialized MA Plans for Special Needs Patients (SNPs)