Medicare Advantage by ert634


									                                 Medicare Advantage

For Most Seniors, Medicare Alone is not Enough

Medicare is designed to provide a basic foundation of hospital and medical insurance
benefits; it is not intended to pay 100 percent of all medical bills. If you rely on Medicare
coverage alone, you will still have large medical bills because of Medicare's deductibles and
co-payments. Also, there are certain health care services that Medicare does not cover at
all. Most seniors need some kind of insurance plan to fill in the "gaps" in Medicare's basic
coverage. Some have this need met through their employer's retirement benefits. Others
purchase Medicare supplemental insurance or "Medigap" plans, private insurance policies
that are specifically designed to fill in the holes in Medicare's basic benefits. Another option
is a Medicare Advantage plan. Compared to Medigap, Medicare Advantage fills in the same
gaps in Medicare's basic benefits, often offers additional benefits, and usually costs less.

Having Health Insurance Problems? For free counseling, call SHIIP at 1-800-259-5301 or
(225) 342-5301 in Baton Rouge.

Medicare Has Two Delivery Systems

In a fee-for-service health care delivery system, your health insurance and health care
providers are separate. When you receive a health care service, your health care provider
(doctor, hospital, laboratory, etc.) submits a bill to the insurer, charging a separate fee for
every service. This is the way Medicare and Medigap plans have historically worked.

You may also choose to receive your Medicare services through Medicare Advantage which
includes Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO)
and Private Fee-for-Service (PFFS) plans. In this system, the functions of both health
insurance and health services are combined in one organization. Some plans offer medical
and preventive services through networks of contracted hospitals, doctors, other providers.
Medicare Advantage managed care plans manage diverse health care services into an
integrated health care delivery system that coordinates care, maintains records, and handles
the paperwork. Health Maintenance Organizations (HMOs), are a common type of managed
care organization. Managed care plans are sometimes referred to collectively as HMOs.

How Managed Care Works

It is often said that there is a trade-off between managed care and fee-for-service. In
managed care, members give up some freedom as they have to stay in the plan's network
and have to use a plan-contracted primary care physician (PCP), who acts as a gatekeeper
to specialty services. Your PCP delivers all basic medical-level services and generally must
write a referral before you can see a specialist or be admitted into a hospital.

Most managed care plans have "lock-in" requirements. "Lock-in" means that you must
receive all covered services through the plan's provider network. Neither Medicare is
obligated to pay for unauthorized care received from providers outside the plan. When a
plan member is traveling outside of the plan's service area, managed care plans generally
only cover medical services that are either emergencies or urgent in nature.
Yet Medicare Advantage also offers some significant advantages over traditional Medicare
fee-for-service -- it is generally true that managed care plans tend to cost less and provide
more benefits. Many managed care plans do not charge a premium) though you still must
pay your Medicare Part B premium). Even managed care plans with premiums generally
have lower premiums, co-payments, and deductibles than most fee-for-service insurance.

Managed care plans may cover, or partially cover, a wide range of services that are
frequently not covered under fee-for-service, including prescription drugs, preventive
services, podiatry and chiropractic services, and dental check-ups, just to name a few. In
addition, because managed care plan members receive care from a comprehensive health
care network, they rarely fill out forms or have to forward their medical records.

Types of Managed Care Plans

In Louisiana, most Medicare managed care plans are risk plans. That is, these risk plans
assume the risk for paying for their members' health care costs. Risk plans have strict "lock-
in" requirements. In most cases, if you receive services outside the plan that are not
authorized, neither the plan nor Medicare will pay.

Some managed care plans offer greater flexibility, by allowing members to go outside of
their provider network. These risk plans with point-of-service options and cost plans vary a
great deal from plan to plan and are not yet widely available. Members of these plans are
responsible for some payments when they go out of network, and generally pay higher

Comparing Managed Care Plans

To find out if managed care is right for you, and which managed care plans are contracted
by Medicare in your area, contact the Senior Health Insurance Information Program (SHIIP)
at the Louisiana Department of Insurance at 1-800-259-5301 or (225) 342-5301 in Baton
Rouge. Insurance counselors are ready to discuss whether or not managed care is right for
you. Counseling is free.

Having trouble understanding Medicare Advantage marketing materials? SHIIP can help.

In some areas, Medicare beneficiaries have a choice of two or more managed care plans. In
this case, you may want to comparison shop the different plans. Each plan will have its own
package of covered services, co-payments, and premiums. Make sure you are comfortable
with the plan's providers and make sure they are convenient to you. Examine the plan's
rules for people who travel or live part of the year in another area. Remember that if you
enroll in a plan and later move out of the plan's service area, you will probably have to
disenroll from the plan. If you wish to see a side-by-side comparison of the benefits of
Medicare Advantage plans offered in your area, go to and go to
"Medicare Health Plan Compare."

Enrolling in a Medicare Advantage Plan
Most Medicare beneficiaries can enroll in a Medicare Advantage plan. To qualify, you must
live within a plan's service area and have Medicare Parts A and B. You will continue paying
Part B premiums while a member of the Medicare Advantage plan. The plan will not enroll
you if you are receiving hospice care or have permanent kidney failure at the time you apply
for enrollment.

All Medicare Advantage plans must have at least one 30-day open enrollment period a year.
The plan will let you know, in writing, when your coverage will begin. You may not want to
discontinue your previous health insurance until you are certain that you are comfortable
with your managed care coverage.

While in a Medicare Advantage plan, you generally do not need Medigap or other
supplemental coverage. However, before canceling supplemental insurance, be sure that
Medicare Advantage is right for you. You may not be able to get the same Medigap
coverage back once you cancel it. While "double coverage" in a Medicare Advantage plan
and a "Medigap" plan is legal, it is expensive and generally not wise (except perhaps for a
short transitional period).

Medicare Advantage and Grievances

Your plan's handbook should include a description of how to file a grievance with the plan.
Usually plans have more than one level of grievance review, so you can appeal a plan's
initial grievance decision if you are displeased with that decision.

In additional, the Louisiana Department of Insurance's Quality Management Division,
investigates insurance complaints, and Louisiana Health care Review, the state's Quality
Improvement Organization, investigates complaints about medical care. The Centers for
Medicare and Medicaid Services (CMS), the Federal agency that administers Medicare, also
examines complaints about Medicare Advantage plans. Together, these agencies work to
make sure that you have access to good medical care whether inside or outside of a
Medicare Advantage plan.

Leaving a Medicare Advantage Plan

You can stay in a Medicare Advantage care plan as long as it has Medicare contract. Before
leaving your Medicare Advantage plan, be sure that you have selected alternative health
insurance coverage.

You may go to another Medicare Advantage plan or return to fee-for-service Medicare from
November 15th through December 31st of every year. You may also make one change from
January 1st through March 31st of every year. To switch from one Medicare Advantage plan
to another, simply enroll in the other plan. You will be automatically disenrolled from the
first plan on the day your new coverage begins. To leave a managed care plan and return to
fee-for-service Medicare, send a signed disenrollment request to the plan or to your local
Social Security office (or the Railroad Retirement Board, if you are a railroad retiree).

Remember that it may take some time for your paperwork to catch up with you when you
switch insurance coverage, so you may experience some claims delays when you first make
the change. Be aware that you may not be able to purchase some Medigap plans (especially
those with prescription drug benefits) and that some policies will only be available with
waiting periods for pre-existing conditions. Contact the Senior Health Insurance Information
Program at the Louisiana Department of Insurance for more information on switching
insurance coverage.

People are ready to help you: SHIIP 1-800-259-5301
Quality Improvement Organization 1-800-433-4958
CMS Regional Office - Dallas (214)767-6401
SHIIP Counselors:1-800-259-5301 or (225)342-5301 in Baton Rouge

   •   Provide health insurance counseling objectively and at no cost.
   •   Do not sell insurance.
   •   Provide options.
   •   Empower the client.

Medicare Advantage Plan Checklist

  Medicare Advantage Plan Checklist                 Plan A                  Plan B

  Premium (not including Part B premium)               $                      $

  Outpatient Benefits

  Primary Care Physician Visits                    $ co-pay               $ co-pay

  Specialist Office Visits, w/ Referral               $ co-pay               $ co-pay

  Diagnostic X-Rays                                $ co-pay               $ co-pay

  Routine Physical Exams                           $ co-pay               $ co-pay

  Gynecological Exams                              $ co-pay               $ co-pay

  Mammograms, Annual                                 $ co-pay               $ co-pay

  Surgeries                                        $ co-pay               $ co-pay

  Inpatient Benefits
  Hospital Services, Authorized                    max. days             max. days

  Psychiatric Inpatient Services                 max. days              max. days

  Skilled Nursing Home Care                      max. days              max. days

  Special Services

  Emergency Room Services, Approved                 $ co-pay              $ co-pay

  Urgent Care Out of Area, Approved                 $ co-pay              $ co-pay

  Mental Health, Authorized Outpatient               $ co-pay               $ co-pay

  Home Health Services, Approved                    $ co-pay              $ co-pay

  Outpatient Therapy                              $ co-pay               $ co-pay

  Podiatry, w/ Referral                             $ co-pay               $ co-pay

  Chiropractic Services, w/ Referral                $ co-pay               $ co-pay

  Vision Services, Lens & Contacts                   $ co-pay               $ co-pay

  Hearing Services and Aids                       $ co-pay               $ co-pay

  Dental Care, Preventive Care Only                ___ visits/yr.         ___ visits/yr.

  Prescription Drugs                              $ co-pay               $ co-pay

                                                  $ max/yr.             $ max/yr.

  Plan representatives should be able to
  explain their plan's coverage for each of
  these benefits. You may wish to include
  additional categories in this checklist.

This checklist includes only benefits and covered services. Even more important, make
certain that you are comfortable with the plan's doctors and rules.

Advantages of Medicare Advantage
Medicare Advantage plans provide comprehensive services. They must cover, or partially
cover, more services than Medicare with typical Medigap insurance. These benefits may
include prescription drug coverage, dental check-ups, and preventive services.

Some Medicare Advantage plans coordinate your care. In a managed care plan, your
primary care physician coordinates your care. The plan will keep your medical records

Medicare Advantage plans save you money. Most managed care plans have low premiums
and co-payments. They also cover more services than Medigap plans.

Medicare Advantage plans do not health-screen based on pre-existing conditions. Unless you
have permanent kidney failure or qualify for hospice care, you may join any Medicare
managed care plan in your area. Enrollment cannot be denied or delayed based on a pre-
existing condition. Generally, as long as you stay in your plan, you will have little or no

Disadvantages of Medicare Advantage

In some Medicare Advantage plans, you are "locked in" to using only the plan's providers.
Unless you receive authorization, the plan will only cover services performed by plan

Managed care plans have Primary Care Physicians (PCPs) who may limit access to
specialists. In most managed care plans, you cannot see a specialist without a referral from
your PCP.

Managed Care plans provide only limited care for travelers. If you are outside of your plan's
service area, the plan only covers urgent or emergency medical services. Members must
submit claims for out of area services. The plan reviews these claims to make sure the
services were urgent or emergent.

Medicare Advantage plans may alter their plans. Plans may alter their packages of benefits,
payments, and providers each year (but they must always provide standard Medicare

Managed care plans are generally not made for "snow birds." Plans generally must disenroll
you if you move outside their service area for ninety days or more.

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