Medicare Advantage Plans & Other Medicare Plans

1. Medicare Advantage Plans & Other Medicare Plans with edits by Illinois SHIP - Module 11

2. Medicare Choices Original Medicare Medicare Advantage (MA) Plans Medicare drug plans Medicare Prescription Drug Plans Medicare Advantage Plans with prescription drug coverage 9/23/2014 Medicare Advantage

3. Ways to receive Medicare Medicare Advantage (HMO, PPO, etc) Original Medicare Part – B Part A & B Part – A Part – DorSecondary MedSup or Secondary Some will include Part D Medicare Advantage

4. What Are Medicare Advantage (MA) Plans? • Health plan options approved by Medicare • Run by private insurance companies • Part of the Medicare program • Sometimes called “Part C” or Medicare Health Plans • Provides Medicare-covered benefits • May cover extra benefits, e.g.; vision or dental Medicare Advantage

5. How MA Plans Work • You are still in the Medicare program • You receive Medicare-covered services through the plan • All Part A and Part B covered services • Some plans may provide additional benefits • Most plans include prescription drug coverage • You may need to use network doctors or hospitals • MA plans may be different than Original Medicare • Benefits and cost-sharing • If the plan leaves Medicare • You can join another MA plan • You can return to Original Medicare • You still have Medicare rights and protections Medicare Advantage

6. Types of Medicare Advantage Plans • Medicare Health Maintenance Organization (HMO) • Medicare Preferred Provider Organization (PPO) • Medicare Private Fee-for-Service (PFFS) • Medicare Special Needs Plan (SNP) Medicare Advantage

7. Medicare HMO Plans Generally must get care and services from plan’s network Use doctors and hospitals that belong to the plan May need to choose primary care doctor Usually need a referral to see a specialist Doctors can join or leave Copayment amounts set by plan May have to pay in full for care outside plan’s network Covered if emergency or urgently needed care May include prescription drug coverage If signing up for Part D, must take coverage with same plan Some plans may offer a Point-of-Service (POS) option May allow you to get some services out-of-network You may have to pay a higher cost share for these services Medicare Advantage

8. Medicare PPO Plans Have the option to use network providers or out-of-network providers that accepts Medicare Don’t need referral to see specialist Copayment and coinsurance amounts set by plan Will usually pay more for out-of-network care There are two types of PPO’s offered Local PPOs Can service one county or multiple counties Regional PPOs Coverage can be a region such as, an entire state or a multi-state coverage area Have annual limit on out-of-pocket costs Varies by plan May have higher deductible and/or premium than other PPOs May offer Medicare prescription drug coverage Medicare Advantage

9. Medicare PFFS Plans Can see any Medicare-approved doctor or hospital that accepts the plan Can get services outside service area Plan sets copayment amounts For PFFS network rules see individual plan info If offered, can get Medicare prescription drug coverage If not offered, can join a stand-alone Medicare Prescription Drug Plan (PDP) Medicare Advantage

10. Changes in Access Requirements for PFFS Plans – By 2011 Medicare PFFS If two or more network-based MA Plans (such as HMOs and PPOs) exist in a service area they must offer a network Employer PFFS Must have contracts with networks of providers Medicare Advantage

11. 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 Medicare Advantage

12. Special Needs Plans (continued) Three types of SNPs Must limit membership to people With certain chronic or disabling conditions Heart disease, diabetes, etc. Eligible for Medicare and Medicaid In certain institutions (confined to a nursing home) Available in some areas Visit www.medicare.gov Call 1-800-Medicare Medicare Advantage

13. 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 enrollment • Some exceptions • To join an MA plan, a person must also • Agree to provide the necessary information to the plan • Agree to follow the plan’s rules • Belong to only one Medicare Advantage plan at a time Medicare Advantage

14. *Plan must be allowing new members to join. Medicare Advantage

15. *Plan must be allowing new members to join. Medicare Advantage

16. Medicare Advantage

17. MA Plan Cost • Must still pay Part B premium • Some people may be eligible for state assistance • Medicare Savings Program (MSP) • May pay an additional monthly premium to plan • You pay deductibles, coinsurance and copayments • Different from Original Medicare • Varies from plan to plan • Costs may be higher if you go out of network Medicare Advantage

18. Monthly Premiums- 2011 • Starting January 1, 2011 Part D monthly premiums may be higher based on income • Includes PDP and MA-PD plans • If income is above • $85,000 filing individual tax return • $170,000 filing a joint tax return Additional monthly adjustments will be charged in addition to part D premiums • SSA will be contacting those who have to pay higher premiums in November Medicare Advantage

19. Non-renewing MA plans Guaranteed Options • Plan must send notification of non-renewal 90 days prior to last day of coverage • Affected Members have a Special Enrollment Period-SEP • Can pick up a new MA plan • October 1, 2010 to January 31, 2011 • Effective dates of either • January 1 or February 1, 2011(depending on application date) • If another MA plan is not selected • Beneficiary will be defaulted to Original Medicare on effective date of termination • 63 days to join a PDP • 63 days for a guaranteed issue Medicare Supplement policies A, B,C,F, K, L Medicare Advantage

20. Medicare Advantage Trial Right Special Election Period People who join an MA plan for the first time When first eligible for Medicare at age 65 or Leave Original Medicare and drop Medigap policy Can disenroll from MA plan during first 12 months Join Original Medicare Have guaranteed issue for Medigap policy Medicare Advantage

21. Comparing Plans • Use on-line tool at www.Medicare.gov • Choose the “Health and Drug Plans” tab • Compare, Review, and Enroll • Make sure MA plan services your area • If seeking MA plan with drug coverage make sure the plan has needed drugs in formulary • Call the plan or Visit their website Medicare Advantage

22. 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 Medicare Advantage

23. Appeals in MA 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 Medicare Advantage

24. Required Notices After every Adverse determination Adverse appeal Include Detailed explanation of why services denied Information on next appeal level Specific instructions Medicare Advantage