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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)
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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
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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
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