Medicare Advantage (Part C)

1. Medicare Advantage(Part C)

2. Review

3. Medicare • For people 65+ and under 65 with a disability • 4 parts of Medicare • Part A: Hospital Insurance • Part B: Medical Insurance • Part C:Medicare Advantage Plans • Part D: Prescription Drug Coverage • Part A & B called Original Medicare

4. Medicare • Pays for reasonable and medically necessary services • There are coverage gaps in Medicare including: • Part A in-patient hospital deductible • Part A daily co-payment for in-patient hospital days 61-90 • Part A daily co-payment for in-patient hospital days 91-150 • Part A daily co-payment for SNF days 21-100 • Part B annual deductible • Part B co-insurance (usually 20%) • First three pints of blood • Coverage outside the United States

5. Medicare • 3 Enrollment Types • Automatic: Already receiving Social Security benefits • Voluntary: Don’thave enough SS work credits, must purchase A+B • Standard Enrollment: Eligible for SS and didn’t take benefit before 65 • 3 Enrollment Periods • Initial: 7 months surrounding 65th birthday month • Special: 8 months following loss of coverage from ACTIVE employment (individuals or spouses) • General: Jan 1st–Mar 31st of each year . July 1st effective date

6. Medicare • Can delay Part B enrollment if receiving health coverage through ACTIVE employment of individual or spouse • 8 month SEP to join Part B once ACTIVE employment coverage has ended • Late Enrollment Penalties • Part A: Capped at 10% of premium and goes away after penalized for twice the length of time the person delayed enrollment • For voluntary enrollees who don’t enroll when initially eligible • Part B: 10% of premium for each full 12 month period the individual delayed enrollment

7. Medicare • Physician’s Services • Medically-necessary physician’s services covered • Welcome to Medicare Exam & Annual Wellness Visit • Does not cover yearly routine physical exams • Benefit period • Period of time that Medicare pays for a person’s care in a hospital or SNF • Ban on Balanced Billing • Massachusetts has a law prohibiting excess charges by physicians

8. Medicare Advantage(Part C)

9. Overview • Also known as “Medicare Part C”, “MA Plan”, “MA-PD”, or a “Medicare Health Plan” • One option available for beneficiaries to get additional coverage to cover the gaps in Original Medicare • Offered by a private company that contracts with Medicare to provide a beneficiary with their Part A & Part B benefits • Is a “replacement” plan where beneficiary gets Part A & B coverage from MA Plan, not Original Medicare • Must still pay Part B premium • Most MA plans include prescription drug coverage (Part D)

10. Medicare Advantage Plans • Must cover at least services covered under Original Medicare (Part A & Part B) • Provide all the rights and protections guaranteed under Medicare • Must offer extensive network of health care providers • Plan must offer a plan with Part D drug coverage – members who want drug coverage may onlytake drug plan offered by Medicare Advantage Plan • If enroll in stand alone PDP, will be dis-enrolled from Part C and returned to Original Medicare • Medicare Advantage HMO’s and PPO’s have different coverage, standards, etc. than regular HMO’s and PPO’s

11. Medicare Advantage Companies • Companies are required to: • Have package of benefits approved by Medicare • Give beneficiaries written information about coverage, cost, and effective date • Provide a quality of service which meets Medicare standards • Give members information about appeal rights

12. Eligibility • Eligibility requirements: • Have Medicare Part A & Part B (must pay Part B premium) • Cannot have ESRD (except if have coverage with a non-Medicare plan from the same company prior to being diagnosed) • Must live in the plan’s service area • Cannot be out of plan’s service area for more than 6 consecutive months

13. Four Enrollment Periods • Initial Enrollment Period (IEP) • Open Enrollment Period (OEP) • Special Enrollment Period (SEP) • Medicare Advantage Disenrollment Period (MADP)

14. Initial Enrollment Period • Same as Part B seven month enrollment period • 3 months before 65th birthday (or year of entitlement to Medicare for those under 65 with a disability), month of birthday, 3 months after birthday month • Month earlier if birthday is the 1st of the month

15. Open Enrollment Period • October 15th -December 7th (effective Jan 1st) • During this period a beneficiary may change from: • Original Medicare to Medicare Advantage Plan • Medicare Advantage Plan to Original Medicare • Medicare Advantage Plan to another Medicare Advantage Plan • Upgrade to include Medicare Prescription Plan coverage • Downgrade to exclude Medicare Prescription Plan coverage

16. Special Enrollment Period • Some qualifying events for SEP eligibility: • Move out of plan’s service area • Leave employer coverage • Nonrenewal or termination of plan • Have or lose MassHealth • Have Extra Help or Prescription Advantage • Within “trial period“ (first 12 months) of MA plan if enrolled into MA plan when first eligible for Medicare at age 65 • In last 12 months, left a Medigap policy to join a MA plan for the first time • FYI: There is NO SEP if a doctor leaves the plan network

17. Special Enrollment Period • Special Enrollment Period • How long beneficiary has to make new selection depends on event • Once selection is made, the SEP is over • If coverage is lost and no other selection is made, beneficiary returns to Original Medicare with no drug coverage • If beneficiary is eligible and selects a stand alone Medicare drug plan, beneficiary will automatically be dis-enrolled from Medicare Advantage Plan • Cannothave a stand alone Medicare Prescription Drug Plan along with a Medicare Advantage Plan

18. Medicare Advantage Disenrollment Period (MADP) • Disenrollment Period: • January 1st – February 14th • Can leave plan and return to Original Medicare • Coverage begins the first of the month after dis-enrolling • If switch to Original Medicare during this period, will have until February 14th to also join a Medicare Prescription Drug Plan • Coverage begins the first day of the month after the plan gets enrollment form. • Cannotjoin another MA plan during this period

19. Changing MA plans • Automatic disenrollment when changing Medicare Advantage Plans • Beneficiaries don’t need to call the plan they are leaving to dis-enroll • Enrolling in the new MA plan will automatically alert the old plan

20. Plan Types • Types of Medicare Advantage Plans • HMO (Health Maintenance Organization) • HMO-POS (HMO with Point-of-Service option) • PPO (Preferred Provider Organization) • SNP (Special Needs Plan) • PFFS (Private Fee for Service) • Not all plans are offered in all regions of the state

21. HMO Plans • HMO (Health Maintenance Organization) • Typically lower premium than other types of MA plans • Most restrictive type of managed care plan • Plan “rules” must be followed for services to be paid • Members must use network providers • Referrals from Primary Care Physician are required • If plan does not pay, original Medicare will NOT pay as back-up • Care outside the service area for emergencies and urgent care situations ONLY (notification rules apply) • May include extra benefits like vision, hearing or dental

22. Advantages/Disadvantages to HMO Membership

23. HMO-POS Plans • HMO-POS (HMO with Point-of-Service option) • POS benefit allows the enrollee to use doctors, hospitals, and other providers who are not in the HMO or other plan network • May have to pay deductible and any other fee Medicare does not cover for services received through POS option • Medicare Advantage Plans may offer a POS option as either: • An additional benefit included in the plan’s basic premium OR • A mandatory or supplemental benefit for which the plan will charge a higher premium

24. PPO Plans • PPO (Preferred Provider Organization) • Can have a higher monthly premium • Can go outside of network but will usually pay higher out-of-pocket costs • Plan has network of providers (usually different than HMO network, even if same company) • Generally does not require referrals from Primary Care Physician • May include extra benefits like vision, hearing, dental

25. PFFS Plans • (PFFS) Private Fee-For-Service • Beneficiary can go to any provider that agrees to the terms of the plan • No referrals needed for specialist • May pay different amount for services under Part A & B but will get all the same services covered • May pay extra for extra benefits

26. SNP Plans • SNP (Special Needs Plan) • Comprehensive program of medical care with membership limited to certain groups of people including: • Those in certain institutions (like nursing homes) • Those eligible for both Medicare & MassHealth (Duals) • Those with certain chronic or disabling conditions • Generally provides greater benefits to members including: • Specialty care coordination • Hospital case management • Communication with caregivers • Routine patient visits

27. Quick Reference:Pro’s of Medicare Advantage Plans • Medicare Advantage Plans tend to attract people who are not high utilizers of medical services. They also attract people who want a lower premium plan • Pro’s: • Convenience of having only one plan (drug plan can be included) • More choices available (HMO’s, PPO’s…) • Lower premiums than Medigap plans • Potential for better coordination of care (HMO’s provide this) • Additional benefits such as hearing, dental, vision and annual exams

28. Counseling Beneficiaries: Is Additional Coverage Needed? • Does every Medicare beneficiary need additional Medicare coverage? • Questions to ask beneficiary: • Does she/he understand the “gaps” in Medicare coverage? • Does she/he have other coverage to help pay for out-of-pocket costs associated with Medicare? (Retiree Coverage, Medigap plan, MassHealth) • Can she/he afford to purchase additional coverage? (screen for Public Benefit programs) 28

29. Medicare Advantage Review • Review • What is a Medicare Advantage Plan? • What are the advantages of Medicare Advantage? • What are the disadvantages of Medicare Advantage? • Who can enroll in a Medicare Advantage Plan? • When can a person enroll? • What is the difference between an HMO and PPO?