Medicare Advantage Plans and Other Medicare

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					            Medicare Advantage Plans
            and OtherMedicarePlans

            National Medicare Training Program
            Module 11 with edits by Illinois SHIP




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                    Medicare Choices

      Original Medicare
      Medicare Advantage Plans
      Other Medicare Plans
      Medicare drug plans
            – Medicare Prescription Drug Plans
            – Medicare Advantage Plans and other Medicare
              plans with prescription drug coverage




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             Ways to receive Medicare
                                                   Medicare Advantage
Original Medicare                                          (HMO, PPO, etc)



                     Part – B
                                                            Part A & B
       Part – A



       MedSup       Part – D or
                    Secondary
            or                                             Some will include
                                                               Part D
      Secondary




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                What are Medicare
              Advantage (MA) Plans?

       Health plan options approved by Medicare
       Run by private companies
       Part of the Medicare program
            – Sometimes called “Part C”




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            Medicare Advantage Plans


  Medicare Health Maintenance Organization
   (HMO) (HMO with POS)
  Medicare Preferred Provider Organization (PPO)
  Medicare Private Fee-for-Service (PFFS)
  Medicare Special Needs Plan (SNP)
  Medicare Medical Savings Account (MSA)



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                Medicare HMO Plans
   Copayment amounts set by plan
   Usually must use network doctors and hospitals
   May pay in full for care outside plan’s network
       – Covered if emergency or urgently needed care
       – POS option allows visits to “out-of-network” providers> may pay
         more for going out of network
   May need to choose primary care doctor
       – Usually need a referral to see a specialist
       – Doctors can join or leave
   May include prescription drug coverage
       – Must take Drug coverage with same plan

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                   Medicare PPO Plans

     Can see any doctor or provider that accepts
      Medicare
            – Don’t need referral to see specialist
            – Don’t need referral to see out-of-network provider
            – Copayment and coinsurance amounts set by plan
               • Will usually pay more for out-of-network care
     May include Medicare prescription drug
      coverage
            – Must take drug coverage with same plan

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            Medicare PPO Plans (cont’d)

 Regional PPOs

     – Available in most areas of the country
     – Have annual limit on out-of-pocket costs
        • Varies by plan
     – May have higher deductible and/or premium than
       other local PPOs




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              Medicare PFFS Plans


   Can see any Medicare-approved doctor or
    hospital that accepts the plan
       – Can get services outside service area
       – Don’t need referral to see a specialist
       – Plan sets copayment amounts
   If Drug coverage is offered through the plan,
    Must take it from same plan.
       – If Drug coverage is not offered, can join a stand
         alone Medicare Prescription Drug Plan


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             Changes in Access (MIPPA)
            Requirements for PFFS Plans
   Some employer and non-employer PFFS Plans
    may use new access requirements in 2010:

       – Through a contracted network of providers
         that meets CMS requirements

       – By paying not less than the Original Medicare
         payment rate

       – Having providers deemed (accepting) to be
         contracted as providers

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                Changes in Access
            Requirements for PFFS Plans
   Employer PFFS plans must meet access
    requirements by 2011
       – Must have contracts with a sufficient number
         and range of providers


   Non-employer PFFS
       – If two or more network-based MA Plan
         exist in a service area. Plans must have contracts
         with a sufficient number and range of providers


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            Special Needs Plans (SNPs)

      Designed to provide
            – Focused care management
            – Special expertise of plan’s providers
            – Benefits tailored to enrollee conditions


      Must include prescription drug coverage




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            Special Needs Plans (cont’d)

 Three types of SNPs
     – May limit all or most of membership to people
        • With certain chronic or disabling conditions
             – Heart disease, diabetes, etc.
        • Eligible for Medicare and Medicaid
        • In certain institutions (such as nursing home confined)
 Available in some areas
     – Visit www.medicare.gov
        • Plans in your area search
     – Call 1-800-Medicare


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                       MSA Plans
  Similar to Health Savings Account plans
  Have two parts
      – Medicare Advantage Plan with high deductible
         • Pays covered costs after annual deductible is
           met (In Illinois ded. range is $2,700-$4,000)*
      – Medical Savings Account
         • Medicare deposits money
            – Member can only use money to pay health care
              costs, any balance rolls over year-to-year


 *2009 DATA

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                    Who Can Join?
 Eligibility requirements

     –   Live in plan’s service area
     –   Entitled to Medicare Part A
     –   Enrolled in Medicare Part B
     –   Not have End-Stage Renal Disease (ESRD) at time of
         enrollment
          • Some exceptions (SNP’s with ESRD as chronic
            condition)


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            When Can People Join?

 A person can join a Medicare Advantage Plan or
  other Medicare plan
     – When first eligible for Medicare
     – During specific enrollment periods
        • Annual Election Period
        • Medicare Advantage Open Enrollment Period
        • Special Enrollment Periods




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             When Can People Switch?

      Annual Election Period (AEP)
      MA Open Enrollment Period (MA-OEP)
      Special Enrollment Period (SEP)
            – Move out of the plan’s service area OR move and
              have new MA or Part D options available
            – Plan leaves Medicare program
            – Other special situations




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               Non-renewing MA plans
                 Guarantee Options
 If enrolled in a
     – HMO, PPO, PFFS and plan terminated
        • Including MA or MA-PD
 Have guaranteed issue of;
     – Medicare Supplement Policy, or
     – Medicare Prescription Drug plan
         • PDP or MA-PD
     – If purchased within 63 days of when coverage ends
 Can elect new plan by Dec. 31, 2009
     – Coverage to begin on Jan. 1, 2010
 Includes Aged and Medicare Disabled beneficiaries

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                 MA Trial Right SEP

    People who join an MA plan for the first time
        – When first eligible for Medicare at age 65 or
        – Leave Original Medicare and drop a
          Medigap policy
    Can disenroll from MA plan during first 12 months
        – Can go back to Original Medicare
        – Have guaranteed issue for Medigap policy




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            Annual Election Period

 November 15 – December 31
     – Can choose new plan
        • Medicare Advantage Plan
        • Medicare Prescription Drug Plan
        • Original Medicare
     – New plan starts January 1




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            MA Open Enrollment Period

     January 1 – March 31
     Same period each year
     Change effective first day of following month
     Cannot be used to start or stop Medicare drug
      coverage
     May only make one change during this time
      period



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   MA Open Enrollment Period Limits
If coverage is                   Can use OEP to get             Cannot use OEP to get

Medicare Advantage               A different MA-PD or           MA-only or Original Medicare only
with prescription drug           Original Medicare + PDP or     (cannot drop drug coverage)
coverage (MA-PD)                 MA-PFFS + PDP

Medicare Advantage               A different MA-only or         MA-PD or Original Medicare +
with no prescription drug        Original Medicare only         PDP       (cannot add drug
coverage (MA-only)                                              coverage)

MA-only PFFS + PDP               MA-PD or different             MA-only or Original Medicare only
                                 MA-only PFFS and same          (cannot drop drug coverage)
                                 PDP or Original Medicare
                                 and same PDP

Original Medicare and a          MA-PD or MA-PFFS               MA-only or A different PDP to use
prescription drug plan (PDP)     and the same PDP               with Original Medicare
                                                                (cannot drop drug coverage)

Original Medicare only           MA-only                        MAPD or Original Medicare + PDP
                                                                (cannot add drug coverage)

MSA                              N/A                            The MA OEP does not apply to
    4/13/2010                  Understanding Medicare Advantage enroll into or disenrollment 22
                                                                Plans
                                                                from an MSA plan
              Comparing Plans
   Use on-line tool at www.Medicare.gov
   Choose “Compare Health Plans” in the Health
    and Drug Plans box
   Input your state in the “Learn More About
    Health Plans and Medigap Plans in Your Area”
   Can view copays for all services online
   Call the plan or visit plan’s website
   If seeking drug coverage with the plan, find out
    if current drugs are on the formulary list
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            Rights in All Medicare Plans

 People with Medicare have certain guaranteed
  rights
     – To get the health care services they need
     – To receive easy-to-understand information
     – To have their personal medical information kept
       private
     – Access to health care providers
     – Know how doctors are paid
     – Fair, efficient, and timely appeals process
     – Fast appeals in certain health care settings


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            Appeals in Medicare Advantage

 Plan must say in writing how to appeal if
     – Will not pay for a service
     – Does not allow a service
     – Stops or reduces a course of treatment
 Can ask for fast (expedited) decision
     – Plan must decide within 72 hours
 See plan's membership materials
     – Include instructions on how to file an appeal or
       grievance


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                 Required Notices

 After every
     – Adverse determination
     – Adverse appeal
 Include
     – Detailed explanation of why services denied
     – Information on next appeal level
     – Specific instructions and how to proceed




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