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1、Medicare Advantage Plans and Other Medicare Plans,Module 11,4-25-07,2,Medicare Plan Choices,Original Medicare PlanMedicare Advantage PlansOther Medicare plansMedicare drug plansMedicare Prescription Drug PlansMedicare Advantage Plans and other Medicare plans with prescription drug coverage,4-25-07,3
2、,Medicare Advantage Plans,What are Medicare Advantage PlansWho can join and whenHow Medicare Advantage Plans work Types of Medicare Advantage PlansRights and protectionsIncluding appeals and marketing guidelines,4-25-07,4,What Are Medicare Advantage(MA)Plans?,Health plan options approved by Medicare
3、 Run by private companies Part of the Medicare programSometimes called“Part C”,4-25-07,5,Who Can Join?,Eligibility requirementsLive in plans service areaEntitled to Medicare Part AEnrolled in Medicare Part BNot have End-Stage Renal Disease(ESRD)at time of enrollmentSome exceptions,4-25-07,6,When Can
4、 People Join?,A person can join a Medicare Advantage Plan or other Medicare planWhen first eligible for MedicareDuring specific enrollment periodsAnnual Election PeriodMedicare Advantage Open Enrollment PeriodSpecial Enrollment PeriodsLimited Open Enrollment Period,4-25-07,7,When Can People Switch?,
5、Annual Election Period(AEP)MA Open Enrollment Period(MA-OEP)Special Enrollment Period(SEP)Move out of the plans service area and cant stay in the planPlan leaves Medicare programOther special situations,4-25-07,8,MA Trial Right SEP,People who join an MA plan for the first timeWhen first eligible for
6、 Medicare at age 65 or Leave Original Medicare Plan and drop a Medigap policyCan disenroll from MA plan during first 12 monthsJoin Original Medicare PlanHave guaranteed issue for Medigap policy,4-25-07,9,Annual Election Period,November 15 December 31Can choose new planMedicare Advantage PlanMedicare
7、 prescription drug planOriginal Medicare PlanNew plan starts January 1,4-25-07,10,MA Open Enrollment Period,January 1 March 31,2007Same period each yearChange effective first day of following monthCannot be used to start or stop Medicare drug coverage,4-25-07,11,10,4-25-07,12,Limited Open Enrollment
8、 Period,Only people in Original Medicare Plan Can join an MA-only plan Plan without Medicare prescription drug coverageDuring 2007 and 2008Does NOT allow enrollment inMedicare Medical Savings Account(MSA)PlansMA plans that offer Medicare prescription drug coverage(MA-PDs)Medicare Prescription Drug P
9、lans(PDPs),4-25-07,13,How Do MA Plans Work?,Generally get all Medicare-covered services through the planCan include prescription drug coverageMay have to see certain doctors or go to certain hospitals to get careEmergency care covered anywhere in the U.S.Benefits and cost-sharing may be different fr
10、om Original Medicare Plan,4-25-07,14,Out-of-Pocket Costs,Generally must still pay Part B premiumSome plans may pay all or partMay pay additional monthly premiumWill have to pay other out-of-pocket costs,4-25-07,15,People In Medicare Advantage,Still in Medicare programStill have Medicare rights and p
11、rotectionsStill get all regular Medicare-covered servicesMay get extra benefitsSuch as vision,hearing,dental careMay be able to get prescription drug coverage,4-25-07,16,Medicare Advantage Plans,Medicare Health Maintenance Organization(HMO)Medicare Preferred Provider Organization(PPO)Medicare Privat
12、e Fee-for-Service(PFFS)Medicare Special Needs Plan(SNP)Medicare Medical Savings Account(MSA),4-25-07,17,Other Medicare Plans,Medicare Cost PlansDemonstrations/Pilot ProgramsPrograms of All-inclusive Care for the Elderly(PACE),4-25-07,18,Medicare HMO Plans,Copayment amounts set by planGenerally must
13、get care and services from plans networkUse doctors and hospitals that belong to the plan May have to pay in full for care outside plans networkCovered if emergency or urgently needed carePoint-of-Service option allows visits to“out-of-network”providers,4-25-07,19,Medicare HMO Plans(contd),May need
14、to choose primary care doctorUsually need a referral to see a specialistDoctors can join or leave May include prescription drug coverage,4-25-07,20,Medicare PPO Plans,Can see any doctor or provider that accepts MedicareDont need referral to see specialistDont need referral to see out-of-network prov
15、ider Copayment amounts set by planWill usually pay more for out-of-network careMay get Medicare prescription drug coverage,4-25-07,21,Medicare PPO Plans(contd),Regional PPOs New in 2006Available in most areas of the country Have annual limit on out-of-pocket costsVaries by planMay have higher deduct
16、ible and/or premium than other PPOs,4-25-07,22,Medicare PFFS Plans,Can see any Medicare-approved doctor or hospital that accepts the planCan get services outside service areaDont need referral to see a specialistPlan sets copayment amountsIf offered,can get Medicare prescription drug coverageIf not
17、offered,can join a Medicare Prescription Drug Plan,4-25-07,23,Special Needs Plans(SNPs),Designed to provideFocused care managementSpecial expertise of plans providersBenefits tailored to enrollee conditionsMust include prescription drug coverage,4-25-07,24,Special Needs Plans(contd),Three types of S
18、NPsMay limit all or most of membership to peopleWith certain chronic or disabling conditionsEligible for Medicare and MedicaidIn certain institutionsAvailable in some areasVisit www.medicare.govSelect“Search Tools”at top of the pageCall 1-800-Medicare,4-25-07,25,MSA Plans,Offered beginning in 2007Si
19、milar to Health Savings Account plansHave two partsMedicare Advantage Plan with high deductiblePays covered costs after annual deductible is metMedical Savings Account Medicare deposits money the person may useTo pay health care costsMSA demonstration in some areas,4-25-07,26,Cost Plans,Available in
20、 limited areasSimilar to Medicare HMO Plans Except out-of-network services covered under Original Medicare PlanCan join any time plan accepts new membersCan leave at any timePrescription drug coverage may be offeredCan choose to join a stand-alone Medicare Prescription Drug PlanRules may differ for
21、some plans,4-25-07,27,Demonstrations/Pilot Programs,Special projectsTest improvements in Medicare coverage,payment,and quality of careEligibility usually limitedSpecific group of peopleSpecific area of countryExamplesMedicare Advantage Plan for ESRD patientsNew Medicare preventive services,4-25-07,2
22、8,Medicare PACE Plans,Programs of All-inclusive Care for the ElderlyCombine medical,social,and long-term care services for frail elderly peopleInclude prescription drug coverageMight be better choice than nursing homeOnly in states that offer it under MedicaidQualifications vary from state to stateC
23、ontact state Medical Assistance office for information,4-25-07,29,Comparing Plans,Are prescription drugs covered?Do I need to choose a primary care doctor?Can I get my health care from any doctor or hospital?Do I have to see a primary care doctor to get a referral to see a specialist?What else do I
24、need to know about this type of plan?,4-25-07,30,Rights in All Medicare Plans,People with Medicare have certain guaranteed rightsTo get the health care services they needTo receive easy-to-understand informationTo have their personal medical information kept private,4-25-07,31,Rights in MA Plans,Add
25、itional rights and protectionsAccess to health care providersKnow how doctors are paidFair,efficient,and timely appeals processFast appeals in certain health care settings,4-25-07,32,Appeals in Medicare Advantage,Plan must say in writing how to appeal ifWill not pay for a serviceDoes not allow a ser
26、viceStops or reduces a course of treatmentCan ask for fast(expedited)decisionPlan must decide within 72 hoursSee plans membership materialsInclude instructions on how to file an appeal or grievance,4-25-07,33,Required Notices,After every Adverse determinationAdverse appeal IncludeDetailed explanatio
27、n of why services deniedInformation on next appeal levelSpecific instructions,4-25-07,34,Appeal Levels,Plan ReconsiderationIndependent Review Entity(IRE)Administrative Law Judge(ALJ)Medicare Appeals Council(MAC)Judicial Review,4-25-07,35,Fast-Track Appeals,When services are ending too soonSkilled nu
28、rsing facilityHome health agencyComprehensive outpatient rehabilitation facility Will get Notice of Medicare Non-coverageAt least 2 days before services endIf appealed,will get Detailed Explanation of Non-coverageDecision from Quality Improvement Organization(QIO)within 2 days,4-25-07,36,Inpatient H
29、ospital Appeals,When services are ending too soonProvider/plan must give Notice of Discharge and Medicare Appeal RightsAt least the day before services end ifThe enrollee disagrees with the discharge decision,orThe provider/plan is lowering the level of the enrollees care within the same facilityDec
30、ision from QIO usually within 2 days,4-25-07,37,Disclosure of Protected Health Information(PHI),Plan may disclose relevant PHITo those identified by the member as involved in his/her care or payment,such as Family member or other relativeClose personal friendCMS staff or Congressional office staffWh
31、en member agrees/does not objectIf member not present or incapacitated,if disclosure is in members best interests,4-25-07,38,When Plan May Disclose PHI,Examples Daughter resolving monthly premium costs of hospitalized motherHuman resources representativeIf person is on the line or gives permission b
32、y phoneCongressional officeThat has faxed persons request for assistanceCMSIf information satisfies plan that the person requested CMS assistance,4-25-07,39,Plan Marketing Guidelines,May send informationMay conduct outbound telemarketingHealth related products,as HIPAA permitsMedicare Advantage Plan
33、s with prescription drug coverage mayUse,4-25-07,40,Plan Marketing Guidelines,Medicare Advantage Plans mustUse marketing materials that have beenReviewed by CMSAccording to guidelines Comply with the“Do not call registry”Provide information in a professional mannerUse state-licensed,certified,or reg
34、istered individuals to market plansIf state requires it,4-25-07,41,Plan Marketing Guidelines,Medicare Advantage Plans may notSolicit Medicare beneficiaries door-to-doorUnless invitedSend unsolicited emailEnroll people by phoneUnless the person calls themOffer cash payment as an inducement to enrollM
35、isrepresent or use high pressure sales tactics,4-25-07,42,Medicare Advantage Plans,What are Medicare Advantage PlansWho can join and whenHow Medicare Advantage Plans work Types of Medicare Advantage PlansRights and protectionsIncluding appeals and marketing guidelines,4-25-07,43,Resources,Medicare p
36、ublicationsMedicare&You handbookUnderstanding the Choices You Have in How You Get Your Medicare Health Care Coverage(Pub.11225)State Health Insurance Assistance Programswww.medicare.govMedicare Options Compare toolMedicare publicationswww.cms.hhs.gov1-800-MEDICARE(1-800-633-4227)TTY/TDD 1-877-486-2048,
