Review

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

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

Medicare 3 Enrollment Types

• Automatic: Already receiving Social Security benefits• Voluntary: Don’t have enough SS work credits, must

purchase A+B• Standard Enrollment: Eligible for SS, enroll at 65

3 Enrollment Periods• Initial: 7 months surrounding 65th birthday month • Special: 8 months following loss of coverage from ACTIVE

employment• General: Jan 1st–Mar 31st of each year . July 1st effective date

Medicare Can delay Part B enrollment if ACTIVELY working

• 8 month SEP after ending ACTIVE work to join B

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

Medicare Out-of-pocket costs for Part A & B

• See Benefits & Gaps chart for amounts• Changes yearly

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

Medicare Advantage(Part C)

Overview Also known as “Medicare Part C” or a “MA 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)

Medicare Advantage Plans Must cover at least services covered under Original Medicare

(Part A & Part B) Must offer extensive network of health care providers Must have access to services available throughout service area Plan must offer a plan with Part D drug coverage – members who

want drug coverage may only take 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 HMOs and PPOs have different coverage, standards, etc. than regular HMOs and PPOs

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

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

Four Enrollment Periods

Initial Enrollment Period (IEP)

Open Enrollment Period (OEP)

Special Enrollment Period (SEP)

Medicare Advantage Disenrollment Period (MADP)

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

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

Special Enrollment Period Some qualifying events for SEP eligibility:

• Move out of plan’s service area• Nonrenewal or termination of plan• Plan violates provision of its contract• Gain or lose MassHealth• Dis-enroll during first 12 months of trying a Medicare

Advantage Plan for the first time (“trial period")• Involuntarily dis-enrolled from PACE Program

FYI: There is NO SEP if a doctor leaves the plan network

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 Cannot have a stand alone Medicare Prescription Drug Plan

along with a Medicare Advantage Plan

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 disenrolling• If switch to Original Medicare during this period, will have until

February 14th to also join a Medicare Prescription Drug PlanCoverage begins the first day of the month after the plan gets

enrollment form.

•Cannot join another MA plan during this period

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

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)

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

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

ORA mandatory or supplemental benefit for which the plan

will charge a higher premium

PPO Plans PPO (Preferred Provider Organization)

•Can have a higher monthly premium•Can go outside of network but will 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

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

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

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

Medicare Advantage Review Review

1. What is a Medicare Advantage Plan?

2. What are the advantages of Medicare Advantage?

3. What are the disadvantages of Medicare Advantage?

4. Who can enroll in a Medicare Advantage Plan?

5. When can a person enroll?6. What is the difference between an HMO and PPO?

Medicare Advantage Quiz1. Amanda is a 67 year old beneficiary enrolled in a Medicare Advantage

Plan. As a member of this plan Amanda has all the rights and protections guaranteed under Medicare. Is this True or False?

2. When can a Medicare beneficiary join a Medicare Advantage Plan?

3. Ms. King joined a Medicare Advantage Plan 6 months ago when she first became eligible for Medicare. She wants to change to a new PCP (primary care physician) but learned he is not affiliated with her MA plan. Ms. King wants to change to original Medicare, but was told that she would have to wait until the Open Enrollment Period to make a change. How would you assist her?

Medicare Advantage Quiz, cont.

4. Gordon has ESRD (End Stage Renal Disease) and belongs to an HMO through his employer. He will be 65 next month and will retire from his employment. He has been on Medicare for the past 7 months and wants to purchase a MA plan once he retires. He has Part A now and will enroll in Part B when he retires. Check all that apply.

____ He can purchase a MAplan if the employer HMO offers a MA plan. ____ He cannot purchase a MA plan under any circumstances

because he has ESRD. ____He can purchase any MAplan and all plans have to accept him

5. List the eligibility criteria to enroll in a Medicare Advantage Plan.

Case Study 1:Havvah Heart

Havvah meets with you at the SHINE office. She has just retired from her job. She has Medicare A & B and wants to know what her options are for additional insurance over and above Medicare. She asks you to explain the differences between Medicare and a Medicare Advantage Plan, and wants to know which is better.

• What would you tell her?

Case Study 2:Tyme Leeness

Tyme Leenes comes to the SHINE office to get information on Medicare and Medicare HMO plans. He will be retiring in 3 months and wants to know when he can join a plan. He tells you that he spends 5 months of the year in Florida and the other 7 months in Massachusetts.

• How would you assist him?

Case Study 3:Ty Juan On

Ty Juan On calls you at the SHINE office. He has just become eligible for Medicare and received his card. He wants to know if he would need a referral from a primary care physician to access medical services when using Part A or B. Also, he heard that he needs to buy additional insurance - something called a Medicare Advantage Medigap Plan.

How would you help him?

Case Study 4:Ima King

Ms. King joined a Medicare Advantage Plan 6 months ago when she first became eligible for Medicare. She wants to change to a new primary care physician but learned she is not affiliated with her Medicare Advantage Plan. Ms. King wants to change to original Medicare, but was told that she would have to wait until the Open Enrollment Period to make a change.

• Is this correct?

Case Study 5:Will B. Gone

Mr. Gone meets with you at the SHINE office to clarify questions about Medicare and other insurance. He will be turning 65 in a few months. He has a friend who belongs to a Medicare Advantage Plan and is very pleased with the services he receives. Mr. Gone takes no medication and wants to enroll in the cheaper, non-prescription plan. He doesn’t see why he should sign up for the prescription plan if he doesn’t take medication. Mr. Gone has already checked that his doctor participates, so he’s pretty well set on the plan. In discussing his upcoming retirement, Mr. Gone tells you of his plans to spend more time with family in Florida.

• What information would you give to Mr. Gone?

Case Study 6:Fran Chise

Ms. Fran Chise meets with you at the SHINE office. She is 66 and has been retired for the past year. She did not sign up for Medicare Part B as her husband continued to work and she has been covered under his employer insurance plan. Her husband is retiring next month but the company will continue to provide full insurance coverage to both of them for six months after he stops working. Ms. Chise called Social Security to see when she must pick up Part B. Social Security told her she must pick up Part B immediately in order to avoid a penalty. Since she is covered in full for six months, she wanted to delay the Part B.

• What information would you give her?

Case Study 7:Jan Itor

Jan Itor calls you at the SHINE office. Her parents are moving to Massachusetts from Montana. They are enrolled in a Medicare Advantage Plan in Montana. She wants to start the process of getting them insurance coverage in Massachusetts, but she knows nothing about Medicare or where to begin.

• How would you help her?

Medical Insurance Explained for the HMO Systems

Q. What does HMO stand for?A.This is actually a variation of the phrase, “HEY MOE” Its roots go back to a concept by Moe of the Three Stooges, who discovered that a patient could be made to forget about the pain in his foot if he was poked hard enough in the eyes.

Q. Do all diagnostic procedures require pre-certification?A.No — only those you need.

Q. Can I get coverage for my pre-existing conditions?A.Certainly, as long as they don’t require any treatment.

Q. What happens if I want to try alternative forms of medicine?A. You’ll need to find alternative forms of payment.

Medical Insurance Explained for the HMO Systems, cont.

Q. I just joined a HMO. How difficult will it be to choose the doctor I want?A. Just slightly more difficult than choosing your parents. Your insurer will provide

you with a book listing all the doctors in the plan. These doctors fall into 2 categories - those who are no longer accepting new patients and those who will see you, but are no longer participating in the plan. But don’t worry; the remaining doctor who is still in the plan, and accepting new patients, has an office just a half-day’s drive away.

Q. My pharmacy plan only covers generic drugs, but I need the name brand. I tried the generic drugs, but it gave me a stomach ache. What should I do?

A. Poke yourself in the eye. Q. What if I’m away from home and I get sick? A. You really shouldn’t do that.