MEDICARE ADVANTAGE PLANS OPTIONS AND DESCRIPTIONS Medicare Advantage (MA) plans are independent insurance companies that contract with Medicare to provide you with your Medicare benefits. MA plans are an alternative option for people receiving traditional Medicare benefits. If you enroll in a MA plan, you do not lose your Medicare benefits, instead you receive those benefits from the private insurance company rather than Medicare. Every MA plan is required by law to provide you with all of the benefits of traditional Medicare (hospital and medical benefits) as well as some benefits that traditional Medicare does not provide. You have the same care protections and appeal rights as you do through traditional Medicare. Medicare Advantage (MA) plans attempt to coordinate all health care services you receive. The plans generally use a limited network of health care providers and facilities and a system of "prior approval" from a primary care physician to achieve these goals. Most plans allow you to select a primary care doctor from those that are part of the plan. Generally, the doctor authorizes, arranges for, and coordinates your care, and decides what care is reasonable and necessary. With Medicare Advantage plans you still have to pay the Medicare Part B premium to the plan, but you do not pay traditional Medicare’s deductible or co-insurance as those are established by the individual MA plan. Most MA plans offer Rx coverage as well. These plans are called Medicare Advantage Prescription Drug Plans (MAPDs). With these plans you have hospital, medical AND prescription drug coverage through the one MA plan. The only time a someone can have a MA plan with one insurance company and their Part D coverage through another is if the you are enrolled in a Private Fee For Service Plan and the insurance company does not offer any Rx coverage. Otherwise, you are required to use the same insurance company as your MA plan for your prescription drug plan. Medicare Advantage Plan Options Health Maintenance Organizations (HMOs) Each plan has a network of providers operating through private practice offices. Generally speaking, you are required to receive all covered care from the doctors, hospitals, and other health care providers who are affiliated with the plan. Exceptions include emergency care and urgent care. This means that anyone considering a MA HMO should be certain that any and all doctors, hospitals, and care providers they wish to continue to see are within the network of the plan! Preferred Provider Organizations (PPOs) A PPO has a preferred network of service providers and medical facilities. Unlike an HMO, however, PPOs allow members to utilize out of network providers and facilities, usually at a higher cost than if you used in-network physicians and hospitals. Private Fee For Service (PFFS) PFFS plans set their own fees for services, not Medicare. PFFS plans determine how much they will pay for any covered Medicare service. Members of a PFFS may see any Medicare- approved physician who accepts the rates set by the plan. Physicians who accept the terms of a PFFS plan may not charge more than 115% of the contracted rate. Special Needs Plan (SNP) SNPs are designed to meet the needs of individuals in specific circumstances such as living in a nursing home, being eligible for both Medicare and Medicaid (dual eligible) or living with a chronic illness. SNPs often take the approach of coordinating care services to manage the health of clients in order to avoid hospitalization. Although any beneficiary may enroll in a Special Needs plans they are not the best option for beneficiaries who do not fall into one of the three categories listed above. It is a good idea to carefully review the plan’s network of providers before enrolling in an SNP as it can be costly to use out-of-network providers. Medicare Medical Savings Account Plan (MSA) MSAs are a new Medicare Advantage option available in CT in 2007. MSA plans combine traditional Medicare HMO plans with Medical Savings Accounts. This option has a high deductible that must be met before coverage begins for most services. This year Anthem BCBS is offering the only MSA option in NCAAA’s region and it is the “Smart Saver Plan”. Who Is Eligible to Enroll in a Medicare Advantage Plans? To enroll in a Medicare Advantage plan, an individual must: • Be enrolled in Medicare Parts A and B, and continue to pay the Part B premium; • Not be medically determined to have end-stage renal disease • Live within the geographic area served by the plan With the current exception of end-stage renal disease, you may not be denied membership due to poor health, disability, or other pre-existing condition. When Can Beneficiaries Enroll/Disenroll from Medicare Advantage Plans? Open Enrollment: January 1 through March 31 every year. During this time Medicare beneficiaries can enroll in, disenroll from, or change Medicare Advantage plans (individuals can not add or drop prescription drug coverage during this period). Enroll by the last day of the month and coverage is effective the first of the next month. Completed application must be reviewed and approved by the plan before a beneficiary is accepted into it. Be sure to receive the effective date in writing from the plan so that services will be covered when services are utilized. Annual Election Period: November 15 – December 31. During this time, a beneficiary can make any changes to their prescription drug coverage including enrolling in or disenrolling from a Medicare Advantage plan. The changes made will take effect on January 1. Initial Enrollment: For enrollment to be effective the first month in which a beneficiary is entitled to Medicare Parts A and B, he/she must enroll during the three months immediately before entitlement to both Medicare Part A and Part B begins. Special Enrollment: This is a period of time when beneficiaries can change plans outside of the other designated enrollment periods. Special Enrollment periods usually occur as a result of a qualifying event or special circumstance including, but not limited to moving out of the service area of the plan, enrolling in a plan because of false information provided by a sales agent. If a MA plan has a capacity limit as approved by the Centers for Medicare and Medicaid Services (CMS), then when the plan reaches that limit enrollment will be closed to all new enrollees, with only a few exceptions. Before completing any application for a MA plan, check with the plan to make certain that the plan is accepting new applications. Coverage usually begins on the first day of the month after an enrollment application has been received by the plan. Once a beneficiary has confirmation that his/her membership has been activated, they should notify all providers of their medical services of the new plan including the primary care physician and any specialists. How to Dis-Enroll from a Medicare Advantage Plan? If a beneficiary wishes to dis-enroll from an MA only plan (without drug coverage), he/she should state in writing that they want to withdraw from the plan and return to traditional Medicare coverage. This written statement should be sent to the plan’s administrative office or to the local Social Security Administration Office via certified mail. The beneficiary should also keep a copy of the letter sent. Sending the request to dis-enroll by certified mail provides the beneficiary with proof the plan received it. In any case, Social Security should be notified by calling 1-800-772-1213 to make sure the beneficiary is reentered in traditional Medicare. Beneficiaries may also dis-enroll by calling: 1-800-MEDICARE (1-800-633-4227) and asking for the Disenrollment Dept. Coverage under traditional Medicare will begin the first day of the month following receipt of your notification. If a beneficiary wishes to change from one Medicare Advantage plan (with or without drug coverage) to another, he/she may do so by enrolling in the other plan. This enrollment will automatically dis-enroll the beneficiary from the first plan. If a beneficiary in a MAPD plan wishes to return to Traditional Medicare with prescription drug coverage through a Part D plan, they can make the change by enrolling in a stand alone prescription drug plan (PDP). By enrolling in the Part D plan, Medicare will notify the MAPD of the disenrollment and return the beneficiary to Traditional Medicare with the new PDP for the 1st of the following month. Considering a Medicare Advantage Plan? Here are some Questions to ask: • Are ALL of my doctors, hospitals, and care providers covered in the plan’s network? • What local hospitals are in the network? • What will my financial responsibilities be? o Deductibles o Monthly Premium in addition to the $96.40 Part B Premium o Co-Pays to see my Primary Care Physician o Co-pays to see a specialist o Co-Payments for Hospital Admissions • Do I need a referral before I can see a specialist? • Are all of my medications covered? • What will my medication Co-Payments be? • Does the plan serve my geographic area? • If I am out of the geographic area, will I be covered? • Is there an out of network co-payment option? • If I have “Extra Help: through Social Security, how will that impart my out-of- pocket costs?
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