1. Medicare Advantage Plans & Other Medicare Plans with edits by Illinois SHIP - Module 11

2. 3/2/2014Medicare Advantage2 3/2/2014 Medicare Choices Original Medicare Medicare Advantage (MA) Plans Medicare drug plans –Medicare Prescription Drug Plans –Medicare Advantage Plans with prescription drug coverage

3. 3/2/2014Medicare Advantage3 Part A & B Some will include Part D Part – B Part – A Part – D or Secondary MedSup or Secondary Ways to receive Medicare Original Medicare Medicare Advantage (HMO, PPO, etc)

4. 3/2/2014Medicare Advantage4 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?

5. 3/2/2014Medicare Advantage5 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

6. 3/2/2014Medicare Advantage6 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)

7. 3/2/2014Medicare Advantage7 Medicare HMO Plans Generally must get care and services from plans 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 plans 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

8. 3/2/2014Medicare Advantage8 Medicare PPO Plans Have the option to use network providers or out-of-network providers that accepts Medicare Dont 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 PPOs 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

9. 3/2/2014Medicare Advantage9 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)

10. 3/2/2014Medicare Advantage10 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

11. 3/2/2014Medicare Advantage11 Special Needs Plans (SNPs) Designed to provide –Focused care management –Special expertise of plans providers –Benefits tailored to enrollee conditions Must include prescription drug coverage

12. 3/2/2014Medicare Advantage12 Special Needs Plans (continued) Three types of SNPs –Must limit membership to people With certain chronic or disabling conditions o Heart disease, diabetes, etc. Eligible for Medicare and Medicaid In certain institutions (confined to a nursing home) Available in some areas –Visit www.medicare.govwww.medicare.gov –Call 1-800-Medicare

13. 3/2/2014Medicare Advantage13 Who Can Join? Eligibility requirements –Live in plans 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 plans rules – Belong to only one Medicare Advantage plan at a time

14. 3/2/2014Medicare Advantage14 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.

15. 3/2/2014Medicare Advantage15 When you can Join or Switch MA Plans* Annual Election Period for 2011 and After October 15 – December 7 each year Coverage 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.

16. 3/2/2014Medicare Advantage16 When you can Join or Switch MA Plans New in 2011 Annual 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

17. 3/2/2014Medicare Advantage17 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

18. 3/2/2014Medicare Advantage18 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

19. 3/2/2014Medicare Advantage19 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

20. 3/2/2014Medicare Advantage20 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

21. 3/2/2014Medicare Advantage21 Comparing Plans Use on-line tool at www.Medicare.govwww.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

22. 3/2/2014Medicare Advantage22 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

23. 3/2/2014Medicare Advantage23 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

24. 3/2/2014Medicare Advantage24 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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