1. Medicare and Medicaid
Week 3

2. 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)?

3. 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

4. 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.

5. 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

6. 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

7. 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.

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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)