Docstoc

Medicare Costs For Medicare Advantage Plan

Document Sample
Medicare Costs For Medicare Advantage Plan Powered By Docstoc
					       Medicare & Advantage Plan
                                                                                                     Medicare Costs for 2011
           Updates for 2012                                                                   • Part A $1,132 deductible per benefit period
                                                                                                   • Copayment $283/day for hospital days 61-90
                                                                                                   • Copayment $566/day for hospital days 91-150
For professionals who assist Medicare beneficiaries in
                                                                                                   • Copayment $141/day for SNF days 21-100
Wisconsin -- A Training in Three Parts
                                                                                              • Part B
Developed and presented by Peg Nugent, Ph.D.,                                                      • Multiple premiums rates because of no Social
Medicare Trainer and Counselor for the Greater                                                       Security COLA as well as higher income premiums
Wisconsin Agency on Aging Resources, Inc. (GWAAR)                                                  • Many still have 2009 premium of $96.40
Final section on Medicare Supplements by Vicki                                                     • Others may be $110.50 (2010) or $115.50 (2011)
Buchholz, Lead Counselor of the Medigap Helpline,                                             • Part C (Advantage Plans) or Part D (Drugs only)
Wisconsin Board on Aging and Long Term Care                                                        • Vary with the plan and can change each year
                                                                                                   • More increases seen in PDPs only than in MAPDs for
                                                                                                     2012

         October 2011 Medicare and Medicare Advantage Plan Updates for 2012   1                       October 2011 Medicare and Medicare Advantage Plan Updates for 2012      2




                                                                                                         From the HIGHS . . .
        Medicare Costs in 2012                                                      Based on Yearly individual Modified                  2010-2011 Part B premiums were
                                                                                  Adjusted Gross Income from two                         “held harmless” for most . Higher
May be small Cost of Living Increase for Social                                   years prior. These thresholds are                      incomes, folks still not taking SS
                                                                                  frozen until 2020                                      retirement, or if premium is paid by
Security -- but Part B Premium may increase to                                                                                           Medicaid paid higher amount
absorb it all for those whose premiums have held                                  $85,000 or lower per person                            $96.40 if on Medicare before 2010
constant in recent years.                                                         (i.e. $170,000 for a couple)                           $110.50 if joined Medicare in 2010
                                                                                                                                         $115.50 if joined Medicare in 2011
Any changes in deductibles for Part A and Part B                                  $85,001-$107,000                                       $154.70 in 2010
not yet announced.                                                                $107,001-$160,000                                      $221.00 in 2010
Individuals with incomes over $85,000 pay                                         $160,001-$214,000                                      $287.30 in 2010
higher premiums for Part B and Part D                                             Above $214,000                                         $353.60 in 2010
                                                                                  Part D premiums will also be a percentage of the national base premium higher for those
Premium changes not yet announced for 2011                                        at these income levels – the same dollar amount regardless of the actual premium for
          for those who will get an increase.                                     their Part D source.
                                                                                  Remember that you can appeal to remove this premium increase if there has been a
         October 2011 Medicare and Medicare Advantage Plan Updates for 2012   3                        October 2011 Medicare and Medicare Advantage Plan Updates for 2012 4
                                                                                  significant reduction in income since the year on which SSA bases its calculations.




       Those With Higher Incomes                                                                               To the LOWS. . .
        also pay more for Part D                                                          Medicare Savings Programs (MSPs) can pay
                                                                                          Part B costs for those with limited incomes and
The extra charge is paid to Social Security, not to                                       assets.
the Part D Plan                                                                           Can also help folks get on to Part B without a
Note that if you are on Medicare because over                                             penalty if they have dropped or never took Part B
age 65 but not yet claiming Social Security                                               when they could.
Retirement, you also have to pay Social Security
                                                                                          Even helpful for permanent residents over 65
directly for your Part B Premium if you enrolled in
                                                                                          who have had legal status for 5 years to allow
it.
                                                                                          them to receive premium free Medicare if they
                                                                                          qualify for the MSP.

         October 2011 Medicare and Medicare Advantage Plan Updates for 2012   5                       October 2011 Medicare and Medicare Advantage Plan Updates for 2012      6
          Medicare Savings Programs                                                              Many Entitled Have Never Applied
    These programs pay the Medicare Part B premium and                                         • QMB (Qualified Medicare Beneficiary)
    automatically qualify you for “Extra Help” for Medicare                                       – Payment of Medicare Part A monthly premiums (when applicable).
    Part D                                                                                        – Payment of Medicare Part B monthly premiums and annual
                                                                                                    deductible.
    Those with very low incomes may have deductibles                                              – Payment of coinsurance and deductible amounts for services under
    and copays virtually covered for them                                                           both
    An individual must have income below $1,225.13 per                                              Medicare parts A and B.
    month and liquid assets below $6,680.00                                                    • SLMB (Specified Low-Income Medicare Beneficiary)
    A couple must have income below $1,654.88 and liquid                                          – Payment of the Medicare Part B premium only.
    assets below $10,020.00                                                                    • SLMB+ / QI (Qualified Individual Program)
                                                                                                  – Payment of the Medicare Part B premium only.
                                                                                                                    Only about 40% of those who are eligible
                                                                                                                     are receiving this important support

            October 2011 Medicare and Medicare Advantage Plan Updates for 2012            7                October 2011 Medicare and Medicare Advantage Plan Updates for 2012   8




2011 Medicare Savings Program Eligibility Limits
                                                                                                  If in Doubt – Refer or Help Apply
          QMB                     SLMB                      SLMB+                With
                                                                                 Count-       The higher
                                                                                 able         asset limits
                                                                                 Assets       have helped
                                                                                 below        thousands
                                                                                              more
Single    < $907.50               $907.50 to                $1,089 to            $6,680       Wisconsinites
net                               $1,089                    $1,225.13                         to benefit from
monthly
                                                                                              the MSPs
income

Married   <$1,225.83              $1, 225.83                $1,471 to            $10,020
                                  to $1,471                 $1,654.88
            October 2011 Medicare and Medicare Advantage Plan Updates for 2012            9                October 2011 Medicare and Medicare Advantage Plan Updates for 2012   10




      If in Doubt – Refer or Help Apply
                                                                                                          Affordable Care Act
    The first $20 of unearned income each month
    does not count                                                                                        Changes to Medicare
    Disregards for earned income are even greater --                                           Open Enrollment Period Oct. 15th – Dec. 7th
    $65 and then half of the remaining earnings each                                           Annual Disenrollment Period - Jan 1st- Feb 14th
    month                                                                                      End overpayments to Advantage Plans but pay
    If in doubt, apply – but try to assure that the                                               more for improved quality
    needed assistance is given to complete the full                                            Open Enrollment Period Oct. 15th – Dec. 7th
    Medicaid application with needed documentation                                                (So important it bears repeating!)
    Also remind them about annual recertification


            October 2011 Medicare and Medicare Advantage Plan Updates for 2012        11                   October 2011 Medicare and Medicare Advantage Plan Updates for 2012   12
      Efforts to Improve Quality                                                                 How IS Quality Measured?
• Bonus payment for quality -- If an overall 4 or 5
  Medicare Advantage – % more per member                                                         Criteria for Health Plan ratings include
• 5 Star Special Enrollment Period created                                                       • Managing chronic conditions effectively
  (more in next section of training) % weighted by enrollment                                    • Responsiveness and care of providers
                                                                                                 • Complaints and Appeals
  2011 Quality Rating           All MAPDs in Nation                   All PDPs in Nation
                                                                                                 • Provision of preventive services and focus on
        5 stars                             1%                                   6.4%
                                                                                                   health maintenance
        4 stars                           23.2%                                  9.3%
                                                                                                 • Customer satisfaction with call center.
        3 stars                           60.4%                                  6.4%

           Plans rating lower than 3 for three consecutive years will receive
                    a “poor performance” rating and symbol on Plan Finder.
            October 2011 Medicare and Medicare Advantage Plan Updates for 2012          13              October 2011 Medicare and Medicare Advantage Plan Updates for 2012   14




More Changes to Advantage Plans                                                                 Making the Most of Preventive
    from Health Care Reform                                                                           Health Benefits!
 Uniform exceptions and appeals process for all                                               Welcome to Medicare Exam
    drug plans (PDP & MA-PD)                                                                  Annual Wellness Visit
 Cannot charge more than Original Medicare for                                                Various screenings and preventive services
    Chemo, Dialysis, SNF, and some other services                                             Almost all with no Part B
 Cannot have copays for preventive services with                                                 deductible or co-insurance because of ACA
    no charge under Original Medicare                                                         Know what to ask for
 Must have Maximum Out of Pocket cost (at least                                              and how to benefit most
          for in-network)
      Overpayments ending – bonuses for quality
            October 2011 Medicare and Medicare Advantage Plan Updates for 2012          15              October 2011 Medicare and Medicare Advantage Plan Updates for 2012   16




     Welcome to Medicare Exam                                                                     Welcome to Medicare Exam
                                                                                             • Must be scheduled within first 12 months of
      • Available to Medicare beneficiaries within                                             effective date of Part B.
        the first 12 months of enrolling in Medicare
        Part B.                                                                              • NOT a routine physical/checkup (G0402)
      • Affordable Care Act eliminated any costs for                                         • Does not include any lab tests -- although if
                                                                                               Cardiovascular screening is ordered as Medicare preventive
        beneficiaries after January 1, 2011.                                                   service, covered every 5 years
      • Evaluate your vision, blood pressure, body                                           • Exam must contain 7 Medicare-specific
        mass index, health history, plan for                                                   components to be covered.
        preventive screenings, and provide referrals
                                                                                             • Beneficiary must specifically call and schedule
        if needed
                                                                                               it by name (Medicare does not cover physicals).

            October 2011 Medicare and Medicare Advantage Plan Updates for 2012          17              October 2011 Medicare and Medicare Advantage Plan Updates for 2012   18
     What is the Wellness Visit?                                                         When Might You Get a Bill?

• Basic measurements of height, weight, blood                                       These are not the same as routine check-ups
  pressure                                                                          and have special codes that must be used.
• Review of medications being taken                                                 Lab work, EKGs etc. that MD may order as a
                                                                                    result of these visits may have copays,
• Record of various medical providers involved
                                                                                    coinsurance, and deductibles.
• Review of family medical history and risk factors
                                                                                    If you bring up specific medical complaints, you
• Basic cognitive assessment                                                        may be billed for a separate “Evaluation and
• Development of preventive screenings plan                                         Management” office visit.
• Must be coded properly by provider G0438 initial
                visit and G0439 for subsequent AWVs
          October 2011 Medicare and Medicare Advantage Plan Updates for 2012   19           October 2011 Medicare and Medicare Advantage Plan Updates for 2012   20




    Then Why Use These Services?                                                     Resources to Understand Better
 If you have some of the screenings, like a                                         – http://www.medicare.gov/share-the-health/
 colonoscopy, and they biopsy a suspicious                                          – National Center for Benefits Outreach & Enrollment
 polyp, you will pay 20%.                                                             Quick Reference: Medicare’s Preventive Benefits
 Early detection from such screenings may save                                      – http://www.centerforbenefits.org under Core Benefits
                                                                                      – Original Medicare
 your life.
                                                                                    – http://www.medicareinteractive.org/ and type
 Early detection may mean easier or better                                            Preventive Services in the search box
 treatment options and so lower costs in the long                                   – Medicare Learning Network provider
 run.                                                                                 manual www.cms.gov/MLNProducts/downloads/PSGUID.pdf



          October 2011 Medicare and Medicare Advantage Plan Updates for 2012   21                                                                                22
                                                                                            October 2011 Medicare and Medicare Advantage Plan Updates for 2012




Covered Screening & Preventive Services                                                A Few Special Considerations
Abdominal aortic             Glaucoma tests                                                on Some Screenings
aneurysm screening*          Hepatitis B shots                                       Abdominal aortic aneurysms ultrasound
Bone mass                    HIV Screening                                           screening -- only if referred at IPPE
measurement                  Mammograms (screening)
Cardiovascular disease Pap test/pelvic exam/                                        The following are covered periodically if risk
screenings                   clinical breast exam                                    factors exist
Colorectal cancer            Prostate cancer screening                               Bone Mass Measurement
screenings                   Pneumococcal shots                                      Diabetes Screening
Diabetes screenings          Smoking cessation                                       Glaucoma Screening
EKG Screening*     *When referred during Welcome to Medicare
   Flu shots       physical exam.                                                   There may be copayments for the facility,
                                Medicare Advantage plans must cover in               especially in an outpatient setting
                                network w/out copays if Original Medicare does.
                                           i                                                October 2011 Medicare and Medicare Advantage Plan Updates for 2012
          October 2011 Medicare and Medicare Advantage Plan Updates for 2012   23                                                                                24
                              Colorectal Cancer Screening 
  Test and 
Requirements         Covered Once Every…                                       You Pay 
Fecal Occult    12 months                                 No cost for the test. No deductible or          Pap Test and Pelvic Exam
Blood Test                                                copayment                                       with Clinical Breast Exam
Age 50 or older
                                                                                                    Covered for all women with Medicare
Flexible          48 months or 120 months                 Doctor’s service –No deductible or        – Once every 24 months
Sigmoidoscopy     after a previous screening              copayment – Deductible still waived 
 Age 50 or        colonoscopy for those not at            even if becomes diagnostic and            – Once every 12 months if
 older            high risk                               surgical services are performed same        • At high risk for cervical or vaginal cancer
                                                          day as test.                                • Childbearing age and abnormal Pap test in the past 36 mo.
Colonoscopy 120 months (generally) (high  No deductible or copayment
No minimum  risk every 24 months) or 48                                                             In Original Medicare you pay
age         months after a previous                                                                 – Nothing for Pap lab test
            flexible sigmoidoscopy
                                                                                                    – No Part B deductible
Barium Enema 48 months (high risk every  You pay 20% of the Medicare‐approved 
Age 50 or older 24 months) when used                    amount for the doctor’s services. In a      – No copayment
                instead of a sigmoidoscopy  hospital outpatient setting, you pay a 
                                                                                                            October 2011 Medicare and Medicare Advantage Plan Updates for 2012
                or colonoscopy                          copayment. 
                   October 2011 Medicare and Medicare Advantage Plan Updates for 2012     25                                                                                      26




                                                                                                        Prostate Cancer Screening
        Cervical & Vaginal Cancer Screen
                                                                                                    Covered
                                                                                                     – For all men with Medicare
    • Denial Reasons:
                                                                                                     – Beginning the day after 50th birthday
    • Beneficiary not at high risk received test
                                                                                                    Tests include
         within past 2 years.
                                                                                                     – Digital rectal exam
    • Beneficiary who is high risk received                                                          – PSA blood test
         screening Pap during past year.                                                                • Prostate-specific antigen
    • High risk pap must be coded differently                                                       In Original Medicare you pay
         than low risk person.                                                                       – Nothing for the PSA blood (lab) test
                                                                                                     – 20% after Part B deductible for digital rectal exam

                                                                                                             October 2011 Medicare and Medicare Advantage Plan Updates for 2012
                    October 2011 Medicare and Medicare Advantage Plan Updates for 2012      27                                                                                    28




                   Screening Mammogram                                                                    Diagnostic Mammogram
        Covered for all women with Medicare                                                         Used when there are clinical findings
          – One baseline mammogram age 35 to 39                                                      – On physical exam
          – Once a year starting at age 40                                                           – lump or other symptom found
        In Original Medicare you pay                                                                 – Abnormal screening mammogram
          – No deductible or copayment if doctor accepts                                            Medicare covers as many as needed
            assignment                                                                               – Requires referral by MD to be covered
          – If in Advantage Plan, you may be charged if you go                                       – Also covered for men
            outside the network (same as with other preventive
            services)
                                                                                                    Deductible and coinsurance/ copayments will
                                                                                                             apply
                     October 2011 Medicare and Medicare Advantage Plan Updates for 2012
                                                                                                            October 2011 Medicare and Medicare Advantage Plan Updates for 2012
                                                                                            29                                                                                    30
                                                                                                      Influenza (“Flu”) Shot
          How About a Shot?                                                              Flu viruses are always changing
                                                                                            – Shot updated for most current flu viruses
                                                                                         Flu shot covered for all people with Medicare
                                                                                         Once each flu season protects for about a year
                                                                                         Covered under Part B
                                                                                         Generally no deductible or copayment
                                                                                                 Advantage Plans may charge office visit copay
                                                                                         Watch for those on Medicare Advantage Plans
                                                                                         if offering a “clinic” – can you bill them?


         October 2011 Medicare and Medicare Advantage Plan Updates for 2012    31                     October 2011 Medicare and Medicare Advantage Plan Updates for 2012   32




  Pneumococcal Pneumonia Shot                                                                            Hepatitis B Shots
   Pneumonia is inflammation in the lungs                                                 Serious disease (virus attacks the liver)
    – Caused by bacteria (streptococcus pneumoniae)                                          – Can cause lifelong infection, cirrhosis (scarring) of
   One shot could be all you ever need                                                         the liver, liver cancer, liver failure, or death

   All people with Medicare are eligible                                                  Covered for medium to high risk
                                                                                             – End-stage renal disease and hemophilia
   Covered by Part B so not an issue in doctor’s
                                                                                             – Condition that lowers resistance to infection
   office
                                                                                          Part B covers – series of 3
   You pay no deductible or copayment
                                                                                             – No deductible or copayment


          October 2011 Medicare and Medicare Advantage Plan Updates for 2012

                                                                               33   06/08/2010                         Medicare Preventive Services
                                                                                                     October 2011 Medicare and Medicare Advantage Plan Updates for 2012    34




                                                                                                 A Few More Changes of Note
              Shingles Vaccine
• Herpes Zoster vaccine IS covered by Medicare -                                        Affordable Care Act also increased authority of
  - but through Part D coverage for administration                                      Secretary of HHS over Medicare Advantage
  and drug                                                                              Plans
• Must obtain vaccine from a pharmacy in your                                              – Can deny bids with significant increases in cost
                                                                                             sharing
  Part D network for greatest savings.
                                                                                           – Or significant decreases in benefits
• Some pharmacies will actually administer
                                                                                        Careful attention to Medicare Complaint System
  vaccines.
                                                                                        Pilots to reduce costs -- Bundled Payments
• If received in MD office – you may be charged
  much more than the Part D Plan will reimburse.                                        Coordination of care to Duals –
  – You CAN submit your MD bill to the Part D Plan.                                        – Medicare-Medicaid Coordination Office
                                                                                                 •       Wisconsin received a grant for a project
         October 2011 Medicare and Medicare Advantage Plan Updates for 2012    35                    October 2011 Medicare and Medicare Advantage Plan Updates for 2012    36
        Mental Health Benefits:                                                   Durable Medical Equipment -- DMEPOS
         Moving Toward Parity
                                                                                   In many sections of the country where Snowbirds fly,
• Authorized by MIPPA legislation in 2008
                                                                                   now required to use providers registered as DMEPOS
• Continuing toward parity in Part B                                               with CMS
  coinsurance for outpatient Mental health                                         Requires competitive bidding to help reduce costs – and
  treatment (you pay 45% in 2010 & 2011,                                           fraud
   40% in 2012, 35% in 2013, and 20% in 2014)                                      Starting Jan. 1, 2012 expanded to most Milwaukee and
                                                                                   Waukesha zip codes
• Benzodiazepines and barbiturates can be                                          For oxygen supplies, mail order diabetes supplies, power
   covered by all Part D Plans in 2013.                                            wheelchairs and scooters, hospital beds , CPAP,
  (It’s getting closer!)                                                           walkers, and enteral nutrition needs.


        October 2011 Medicare and Medicare Advantage Plan Updates for 2012   37             October 2011 Medicare and Medicare Advantage Plan Updates for 2012   38




                                                                                     Part II: Medicare Health Plans
                                              Or Break Time
                                                                                    Medicare Advantage Plans & how they work
                                                                                    Medicare Cost Plans -- in select areas
                                                                                    Important changes for 2012

                   s                                                                Marketing considerations
                                                                                    Medicare Resources for Professionals




        October 2011 Medicare and Medicare Advantage Plan Updates for 2012   39             October 2011 Medicare and Medicare Advantage Plan Updates for 2012   40




  Your Medicare Coverage Options:
                                                                                                  Medicare Advantage Plans
        A Review in Cheese
                                                                                                    are NOT Supplements
            Original Medicare has holes like Swiss                                                          •Advantage Plan Medicare has smaller
                                                                                                             holes -- but more of them (Swiss Lace)
            Part A - Hospital deductible
                                                                                                            •Holes are coinsurance or copays.
                       per benefit period and co-                                                           •Sometimes have a premium in addition
              insurance for longer hospital stays                                                            to the Part B premium.
            Part B - Deductible + 20%                                                                       •Provide a Maximum Out of Pocket for
                  coinsurance on most services                                                               Medicare A & B covered services.
            No out of pocket maximum.                                                                       •Often include Rx coverage.
                                                                                                            •May require you to use network doctors
            Need a separate source of Rx coverage
                                                                                                            •Can change or cancel every year.

        October 2011 Medicare and Medicare Advantage Plan Updates for 2012   41             October 2011 Medicare and Medicare Advantage Plan Updates for 2012   42
    Traditional Medicare Supplements                                                      What Are Medicare Advantage Plans?
    Original Medicare with a traditional                                                        Health plan options approved by Medicare
     Medicare Supplement (Medigap)                                                              Run by private companies
     is like brick cheese.
                                                                                                Part of the Medicare program
    Once Medicare has paid its part,
                                                                                                 – Sometimes called “Part C”
     the Medigap pays your coinsurance.
    Premium increases with age
                                                                                                Available in many areas of the country
    but the coverage is guaranteed                                                              Provide Medicare-covered benefits
    to stay the same.                                                                            – May cover extra benefits, e.g.; vision or dental
    More costly, but leaves you with less
           risk of unplanned costs.

             October 2011 Medicare and Medicare Advantage Plan Updates for 2012   43                     October 2011 Medicare and Medicare Advantage Plan Updates for 2012   44




   When You Can Join or Switch MA Plans*                                                          When you can Join or Switch MA Plans
Initial               7 month period begins 3 months before                            New in 2011      Can leave an MA or MAPD plan
Coverage              the month you turn 65                                            Annual         and switch to Original Medicare
Election                –Includes the month you turn 65                                                 Between January 1–February 14
                                                                                       Disenrollment 
                                                                                                        – Coverage begins the first of the month after
Period                  –Ends 3 months after the month you                             Period             you switch
                         turn 65                                                                                If you make this change you also may join a
                                                                                                                Medicare Prescription Drug Plan to add drug
Annual                Oct. 15 – Dec. 7, 2011                                                                    coverage
Election              Coverage begins January 1, 2012                                                           – Between January 1-February 14
Period for            STRESS THAT FOLKS CAN’T WAIT                                                              – Drug coverage begins the first of the month
2011                  UNTIL THE END OF THE YEAR!                                                                   after the plan gets enrollment form

      *Plan must be allowing new members to join.
                                                                                       Special Election  Move from the plan service area
                                                                                                                  –and cannot stay in the plan
                                                                                       Period                 Plan leaves Medicare program
             October 2011 Medicare and Medicare Advantage Plan Updates for 2012   45                 October 2011 Medicare and Medicare Advantage Plan Updates for 2012 46
                                                                                                              Other special situations




    Expert’s Quiz – Where can all the
            SEPs be found?
                                                                                          Remember the 5-Star SEP?
       To Check all SEPs                                                                   Won’t know until Oct. 15th if we have 5-Star plans
 Medicare Managed Care Manual                                                              Not the same star rating found in Medicare & You
                                                                                           Begins December 8 and can only be used one time
           Section 30.4                                                                   in the next 12 months
                                                                                           Can enroll in any 5-Star plan (MA, MAPD, PDP)
                                                                                              any time – (opens the “lock”)
https://www.cms.gov/manuals/iom/                                                           New plan starts first of next month


             October 2011 Medicare and Medicare Advantage Plan Updates for 2012   47                     October 2011 Medicare and Medicare Advantage Plan Updates for 2012   48
    Medicare Advantage Trial Right                                                            The Other Federal
    Special Election Period (SEP 65)                                                    Medicare Advantage Trial Right
  People who join an MA plan for the first time                                      People who drop a traditional Medicare
   – When first eligible for Medicare A & B at age 65 or                             Supplement in order to try Medicare
  Can disenroll from MA plan during first 12                                         Advantage for the FIRST TIME.
  months                                                                             12 month trial period to disenroll, return to
   – Join Original Medicare                                                          Original Medicare, and return to old
   – Have guaranteed issue for Medigap policy                                        Supplement
   – This does not apply to disabled people                                          Sometimes other supplements will accept you
   – Nor to those who did not take Part B originally                                 If supp no longer being sold, you can choose
     during their original Open Enrollment Period
                                                                                     another with guaranteed issue
   – Nor to folks who have been on Medicare awhile

         October 2011 Medicare and Medicare Advantage Plan Updates for 2012   49            October 2011 Medicare and Medicare Advantage Plan Updates for 2012   50




                      Expert’s Quiz
                                                                                       The Special Wisconsin Option
What is the special Medicare                                                                    Insurance Code 3.39 (34)
                                                                                   • Use a Federal SEP to leave an Employer
 Advantage Trial Period only in                                                      Group Health Plan and enroll into Advantage
 Wisconsin – and what is it good                                                     Plan
 for?                                                                              • If within 12 months, they disenroll using a
                                                                                     Federally approved disenrollment period,
                                                                                     they have a WI guaranteed issue right to
                                                                                     purchase a Medigap Supplement


         October 2011 Medicare and Medicare Advantage Plan Updates for 2012   51            October 2011 Medicare and Medicare Advantage Plan Updates for 2012   52




            How MA Plans Work                                                         How Do Medicare Advantage Plans
  You get Medicare-covered services through the
                                                                                               Work? (continued)
  plan and ONLY through that plan                                                    You are still in Medicare program – but do not
   – All Part A and Part B covered services                                          use your Original Medicare Card
   – Some plans may provide additional benefits                                      Only Original Medicare is nationwide – some
  Most plans include prescription drug coverage                                      MA plans allow for coverage if you travel
   – Part D
                                                                                     outside of their service area and follow their
                                                                                     rules.
  You may have to go to network doctors or
  hospitals                                                                          You still have Medicare rights and protections
  MA may be different than Original Medicare                                         If the plan leaves Medicare
                                                                                      – You can join another MA plan
   – Benefits and cost-sharing
                                                                                      – You can return to Original Medicare
         October 2011 Medicare and Medicare Advantage Plan Updates for 2012   53            October 2011 Medicare and Medicare Advantage Plan Updates for 2012   54
               Medicare Advantage Costs
                                                                                               Types of Medicare Advantage Plans
        Must still pay Part B premium
          – Some people may be eligible for state assistance                                      • Medicare Health Maintenance Organization
        May pay an additional monthly premium to plan                                               (HMO) 70% Nationally
          – 52% Nationally have no premium
                                                                                                  • Medicare Preferred Provider Organization (PPO)
        May cost less than a free-standing drug plan for drug
        coverage.                                                                                 • Medicare Private Fee-for-Service (PFFS)
        Note: You CAN be in SeniorCare and an Advantage                                           • Medicare Special Needs Plan (SNP)
        Plan
        You pay deductibles, coinsurance and copayments                                           • Point of Service Plan (POS)
          – Different from Original Medicare                                                      • NOTE: There are also Employer Group Health
          – Varies from plan to plan                                                                Advantage Plans that may be same or different
          – Costs may be higher if you go out of network


                     October 2011 Medicare and Medicare Advantage Plan Updates for 2012   55   10/4/2011   October 2011 Medicare and Medicare Advantage Plan Updates for 2012   56




                       Medicare Special Needs (SNP) Plan
Can you get your 
health care from 
                         You generally must get your care and services from doctors or 
                         hospitals in the plan’s network (except emergency care, out‐of‐
                                                                                                       Initiatives to Encourage More
any doctor or            area urgent care, or out‐of‐area dialysis).                                          (and better) SNPs
hospital?
Are prescription         Yes. All SNPs must provide Medicare prescription drug coverage          • Seeking to improve coordination of care
drugs covered?           (Part D). 
                                                                                                   for Medicare and Medicaid members.
Do you need to           Generally, yes. 
choose a primary                                                                                 • Requiring contracts with State Medicaid
care doctor?                                                                                       Office so fewer issues with providers
Do you need a            In most cases, yes. Certain services like yearly screening 
referral to see a        mammograms don’t require a referral.                                    • Disenrolling those who do not meet the
specialist?                                                                                        Special Needs criteria (SEP same as for
What do you need       A plan must limit plan membership to :                                      non-renewing plans – Dec. 8 – Last day of
to know about this  1)People who live in certain institutions (like a nursing home) 
type of plan?         or who require nursing care at home, or                                      February
                      2)People who are eligible for both Medicare and Medicaid, or 
                      3)People who have specific chronic or disabling conditions
                  October 2011 Medicare and Medicare Advantage Plan Updates for 2012                       October 2011 Medicare and Medicare Advantage Plan Updates for 2012   58
                                                                                          57




        Medicare Cost Plans – Who & Where?                                                                      Medicare Cost Plans
      Different from Medicare Advantage Plans, but                                                               Sort of a Hybrid
      included in many of the same materials.                                                   • Listed in the Landscape with Medicare Advantage Plans
       – DeanCare Gold in Central Wisconsin                                                       because they have federal contract with CMS
       – HealthPartners in Northwestern Wisconsin                                               • This year also on Plan Finder and can enroll online
                                                                                                • They can include Part D coverage
       – Medica in Northwestern Wisconsin – larger area
                                                                                                • If you receive services in their facilities, they must cover –
       – Medicare Associates Clinic Health Plan in                                                but may have copays
         Southwestern WI                                                                        • Can be similar to Med Supps – listed in “Yellow Book”
      “Cost plans fill a unique niche by providing a Medicare managed care
      option in rural and other areas that traditionally had few or no MA plans.”               • Enhanced plans include Wisconsin Med Supp Mandates
      GAO Report, December 2009 “MEDICARE MANAGED CARE:
                     Observations about Medicare Cost Plans”

                     October 2011 Medicare and Medicare Advantage Plan Updates for 2012   59               October 2011 Medicare and Medicare Advantage Plan Updates for 2012   60
             Medicare Cost Plans
                        Sort of a Hybrid
• May have premiums similar to Med Supps – but easier to
  purchase without underwriting                                                                            Changes to Medicare
• Not locked in like Advantage Plans                                                                        Advantage and Cost
• Unlike with Advantage Plans, you still retain Original A & B                                                 Plans in 2012
  coverage and can use it with providers outside of the
  network -- even out of the plan area
• Efforts are repeatedly made to eliminate them, but
  extensions keep being approved.


            October 2011 Medicare and Medicare Advantage Plan Updates for 2012   61               October 2011 Medicare and Medicare Advantage Plan Updates for 2012   62




                                                                                      Changes In Medicare Advantage
      Trends in Wisconsin Plans
                                                                                           Plans in Wisconsin
• Slightly more plans than last year.                                                 • Very few plans cancelling compared to last year
• Still a fair number with no Rx to accommodate                                       • Pay attention to quality ratings
  those who use VA, SeniorCare, or some other                                         • Read your Annual Notice of Coverage to find out
  source for medications.                                                               about other changes
• Only 18 PFFS plans remain after last year’s                                         • If you are in a plan that is ending, check with your
  exodus – and 14 of these are Today’s Options.                                         Benefit Specialist or the
• Remember the potential risk of PFFS plans as                                          Medigap Helpline for important options
  well as fact that Universal American was under                                             1(800)242-1060
  sanction and not allowed to sell most of this year.


                                                                                                                                                                       64
            October 2011 Medicare and Medicare Advantage Plan Updates for 2012   63               October 2011 Medicare and Medicare Advantage Plan Updates for 2012   64




         Ending WI Advantage Plans
                          (as of Dec. 31, 2011)                                         Options if Your Advantage Plan
 • Several Anthem Smart Value (PFFS)                                                             is Cancelling
 • Secure Horizons PFFS plans in two counties                                          • Return to Original Medicare (effective January 1st, 2012)
                                                                                         – be sure to have drug coverage if the terminating plan
 • Universal American Corp.                                                              was a MAPD
    – Three Today’s Health HMO plans                                                   • Select another Advantage Plan
    – Several Today’s Options PFFS in various counties                                 • Have a Special Enrollment Period (SEP) to elect a new
                                                                                         Advantage Plan or just PDP from Dec. 8 through end of
 • Some plans “mapping” individuals into other plans                                     Feburary. Will take effect Jan. 1 (or first day of next
                                                                                         month if enrolled in January or February)
    – Especially Medica Cost plans
                                                                                       • OR Guaranteed Issue right into a traditional Medicare
    – Also some Today’s Options                                                          Supplement until March 4, 2011
                                                                                       • NOTE: Different timetable for SEPS v. Supps

                                                                                                                Medicare Advantage Plans and Other
            October 2011 Medicare and Medicare Advantage Plan Updates for 2012   65   10/4/2011   October 2011 Medicare and Medicare Advantage Plan Updates for 2012   66
                                                                                                                  Medicare Plans - Nugent/Buchholz
                                                                                        If Your Plan is Dropping . . .
   How to help folks looking at                                                      Consider your age, health status, and economic
                                                                                     situation as you decide what to do.
           Med-Supps
                                                                                     Do you need a new source of drug coverage?
                                                                                     If you have chronic or serious health problems you
 • For a presentation by Vicki Buchholz, watch the                                   would normally be uninsurable by a traditional
   final part of the Oct. 11th Webinar.                                              supplement --
 • Recording should be posted by Oct. 15th on                                        So this could be a chance at comprehensive
   DHS Media Site. (Search on Buchholz)                                                   coverage -- Medicare Supplement
 • Powerpoint will be linked to webinar.

         October 2011 Medicare and Medicare Advantage Plan Updates for 2012   67           October 2011 Medicare and Medicare Advantage Plan Updates for 2012   68




        Know Your Coverage!
• The Annual Disenrollment Period means                                                  Marketing Regulations
  members only have 6 weeks to try out their
  Advantage Plan and decide whether it will work
  for them.
• Make sure your clients check their cards to know
  what they have – and also read their plan
  documents!
• Remember that if people can prove that they
  were misled by a sales person and thought they
  were signing up for a PDP but got into an
  Advantage Plan instead, they may qualify for a
  Special Enrollment Period to change later.
         October 2011 Medicare and Medicare Advantage Plan Updates for 2012   69           October 2011 Medicare and Medicare Advantage Plan Updates for 2012   70




     Disclosure of Plan Information for                                               Watch for Marketing Abuses
       New and Renewing Members
                                                                                   Unsolicited Contacts
                                                                                    Extends existing prohibition on door-to-door
                                                                                    solicitation to other instances, e.g.;
                                                                                        – Outbound marketing calls
                                                                                        – In common areas like parking lots, hallways,
                                                                                          lobbies
                                                                                        – Calls/visits after attendance at sales event
                                                                                        – Unless express permission given
                                                                                        – Unsolicited emails


         October 2011 Medicare and Medicare Advantage Plan Updates for 2012   71           October 2011 Medicare and Medicare Advantage Plan Updates for 2012   72
    Promotional Activity Reminders
                                   (continued)
  Cross Selling
   Prohibited during any MA or Part D sales                                          Scope of Appointments
   activity or presentation                                                           Must specify types of products to be discussed
                                                                                       – Prior to marketing and/or in-home appointment
   Cannot market non-health care related                                                 • e.g.; Medigap, MA, or PDP
   products
                                                                                       Additional products can only be discussed
     – e.g.; annuities, life insurance
                                                                                       – On beneficiary request at a separate appointment
    Allowed on inbound calls when requested by
    beneficiary


           October 2011 Medicare and Medicare Advantage Plan Updates for 2012   73             October 2011 Medicare and Medicare Advantage Plan Updates for 2012   74




         Tips for Professionals                                                      Resources for Professionals Now
  • Ask to see ALL their cards – help them understand
    what kind of coverage they actually have.                                        • CMS FAQ question bank
  • Remind them to save and READ their plan                                            https://questions.cms.hhs.gov/app/home
    documents.                                                                       • Wisconsin BOALTC website
  • Screen for possible benefits such as MSP, Extra                                  dhs.wisconsin.gov/aging/boaltc/medigap.htm
    Help                                                                             • GWAAR Website - Google “GWAAR Medicare”
  • Help assure that consumer protections are                                        • Office of the Commissioner of Insurance website
    honored                                                                            especially consumer publications
  • Watch for potential marketing abuses and                                                           http://oci.wi.gov/
    REPORT
                                                                                     • Wisconsin Administrative Code (Ins. 3.39)
           October 2011 Medicare and Medicare Advantage Plan Updates for 2012   75             October 2011 Medicare and Medicare Advantage Plan Updates for 2012   76




       Resources for Future                                                           Medicare.gov Resource Locator
    Decisions – Focus on Quality
•Medicare has many tools to help healthcare options
            •Check www.Medicare.gov

                      •www.medicare.gov/caregivers
                      •www.hospitalcompare.hhs.gov



           October 2011 Medicare and Medicare Advantage Plan Updates for 2012   77             October 2011 Medicare and Medicare Advantage Plan Updates for 2012   78
             Medicare.gov                                                        Or Manage Your Medicare
         Facilities and Doctors
                                                                                 Claims @ MyMedicare.gov
        even more comparisons




       October 2011 Medicare and Medicare Advantage Plan Updates for 2012   79     October 2011 Medicare and Medicare Advantage Plan Updates for 2012   80




Learn A Lot On the Internet: If you don’t
  use it, have a friend or relative help!                                                                                Or Break Time

www.medicare.gov to compare Health and Drug
Plans and for lots of other info
http://oci.wi.gov/pub_list.htm for a range of
publications for consumers. Scroll down to the
section on Medicare Supplements
                                                                                              s
www.healthcare.gov for information on all
    aspects of health care reform and health
           insurance
       October 2011 Medicare and Medicare Advantage Plan Updates for 2012   81     October 2011 Medicare and Medicare Advantage Plan Updates for 2012   82

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:6
posted:10/2/2012
language:English
pages:14