Medicare Advantage (MA) Plans

1. Medicare Advantage (MA) Plans

2. What is a Medicare Advantage Plan? • Health plan options • Approved by Medicare • Run by private companies • Part of the Medicare program • Sometimes called “Part C” • Available across the country • Must provide all Medicare-covered benefits • May cover extra benefits

3. Eligibility/Enrollment Requirements Who can join When a beneficiary can join or switch • Initial Enrollment Period • Annual Enrollment Period • Special Enrollment Period

4. Who Can Join? • Eligibility requirements • Live in plan service area • Entitled to Medicare Part A (Hospital Insurance) • Enrolled in Medicare Part B (Medical Insurance) • Has not been medically determined to have End-Stage Renal Disease (ESRD) at enrollment • Some exceptions • To join a Medicare beneficiary must • Provide necessary information to the plan • Agree to follow the plan rules • Only be enrolled in one MA or Part D plan at a time

6. *Plan must be open to new members

7. How MA Plans Work • Receive services through the plan providers • All Medicare Part A and Part B covered services • Some plans may provide additional benefits • Most plans include prescription drug coverage • Plan may require prior authorization before receiving certain services • Have standard cost-sharing for services • Provider network must be maintained to MA access and availability standards

8. Cost-sharing • Must still pay Part B premium • State Medicaid pays for those eligible • Plan may have an additional monthly premium • Plan may pay deductible and coinsurance • Enrollee responsible for all cost-sharing listed – neither plan nor provider can waive • POS plans – cost-sharing may be higher for out-of-network services

9. Medicare Advantage – New requirements • Plans can’t charge more than Original Medicare • Chemotherapy • Dialysis • Skilled nursing facility care • Plans must limit and track out-of-pocket costs

10. Types of MA Plans Coordinated Care Plans • Health Maintenance Organization (HMO) • Preferred Provider Organization (PPO) • HMO Point-of-Service Plan (HMO-POS) • Special Needs Plan (SNP)

11. Medicare Preventive Services

12. There is no cost sharing to a beneficiary for Medicare designated preventive services.