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Medicare Advantage expands health care options for Medicare beneficiaries. These options were created with the Balanced Budget Act of 1997 to reduce the growth in Medicare spending, make the Medicare trust fund last longer, and give beneficiaries more choices.
With Medicare Advantage (also called Medicare Part C), you can choose from new ways in which to receive your Medicare benefits.
It is important to remember that each of these options will have advantages and limitations, and no option will be right for everyone. Also, not all options will be available in all areas.
Please Note: If you do not actively choose and enroll in a new plan, you will stay in Original Medicare or the original Medicare managed care plan you currently have.
When learning about these new options, please keep in mind that you do not have to change if you are happy with how you currently receive Medicare benefits. You should not change to a new program until you have carefully analyzed it and determined how you would benefit from it.
View a complete list of Medicare Advantage Plans available in Indiana by county (2013)
Original Medicare will always be available. If you want to continue receiving your benefits this way, then you do not have to do anything.
This is a managed care plan with a network of providers who contract with an insurance company. You choose a primary care physician who coordinates your care. You agree to follow the rules of the HMO and use the HMO's providers.
This is similar to the Medicare Advantage HMO, except you can use providers outside of the network. However, you will pay higher deductibles and copayments when you go outside of the network.
This is another managed care plan. It is formed by a group of doctors, hospitals, and other providers who contract with an insurance company. You do not have to choose a primary care physician. You can go outside of the network, but you will pay higher deductibles and copayments when you do.
This is a managed care plan with a network of providers. The providers administer the plan and take the financial risk. You choose a primary care physician and agree to use plan providers. Most services will be provided by the network.
This is an insurance plan, not a managed care plan. The plan, not Medicare, sets the fee schedule for providers, but providers can bill up to 15% more. You see any providers you choose, as long as the provider agrees to accept the payment schedule. Medical necessity is determined by the plan. The plan does not have to have a quality assurance program.
This is one of the managed care plan types (HMO, HMO w/pos, PPO, PSO) which is formed by a religious or fraternal organization. These plans may restrict enrollment to members of their organization.
This is a health insurance policy with a high deductible ($3,000) combined with a savings account ($2,000). Medicare pays the insurance policy premium and deposits moey into your MSA each month. You can use the money in your MSA to pay your medical costs (tax free). You have free choice of providers. The providers have no limit on what they charge.
The Centers for Medicare and Medicaid Services monitors appeals and marketing plans. All plans, except for Private Fee-for-Service, must have a quality assurance program.
If you meet the following requirements, the Medicare Advantage plan must enroll you.
You may be under 65 and you cannot be denied coverage due to pre-existing conditions.
Another type of Medicare Managed Health Maintenance Organization is a Cost Contract HMO. These plans have different requirements for enrollment.
Currently in Indiana, Medicare Advantage plans are widely available throughout the state.
Medicare Advantage plans that include prescription coverage may require you to use particular medications to lower their costs and yours.
In order to enable beneficiaries to try a Medicare Advantage plan, but still have the option of returning to Original Medicare, a number of protections are in place. These protections will enable beneficiaries, in certain situations, to try a plan, but then return to Original Medicare and a Medicare Supplement policy if they want to do so.
Under these protections, beneficiaries will have guarantee issue of a Medicare Supplement policy as long as they meet one of the following criteria. For eligible beneficiaries, companies which sell supplement policies will not be able to deny coverage, charge more, or exclude benefits. However, to receive these protections, beneficiaries must apply for a supplement policy within 63 days of disenrolling from the health plan, or within 63 days of the termination of the health plan.
A beneficiary would be eligible for the Medicare Supplement protections if they meet one of the following criteria.
You are enrolled in a Medicare Advantage plan (such as a Medicare HMO) and one of the following happens:
In this case, you would get a guaranteed issue of a Medicare Supplement Plan A, B, C, or F from any company (as long as you apply within 63 days of losing your other coverage).
You have a Medicare Supplement plan and you cancel it in order to enroll in a Medicare Advantage plan for the first time. Then you disenroll from the plan within 12 months and return to Original Medicare.
You are able to return to the same Medicare Supplement plan with the same company if it is still available. If it is not still available, you will get a Medicare Supplement plan A, B, C, or F from any company (as long as you apply within 63 days from disenrolling).
When you first take Medicare Part B, you enroll in a Medicare Advantage plan. Then you disenroll from the plan within 12 months and return to Original Medicare.
You are guaranteed to get any Medicare Supplement plan with any company (as long as you apply within 63 days from disenrolling).
You have an employer group health plan which supplements Medicare and your employer terminates the health plan, or stops providing supplemental coverage. (This does not apply if you voluntarily drop the employer group health plan.)
You are guaranteed to get a Medicare Supplement policy A, B, C, or F from any company.
Remember, to be eligible for any of these protections, you must apply within 63 days of losing, or disenrolling from your other health coverage.
Currently, you can choose from three types of Medicare Managed Care:
These plans are available in selected counties of Indiana and it is important to know the differences between them.
Medicare will reimburse the plan for covered services you receive. You choose a primary care provider within the HMO network. When you stay within the network, you pay nothing except the plan premium and any small copayment amounts preset by the HMO.
You may also choose to use services outside of the network. When you choose to use a service or provider outside the Cost Contract HMO network, Medicare would still pay their usual share of the approved amount. You would be responsible for the Medicare deductibles and copayments. The Cost Contract HMO would not pay these. Cost Contract HMOs may enroll you if you don't have Medicare Part A but have and pay for Medicare Part B. Cost Contract HMOs do not have to enroll you if you have end-stage kidney disease or are already enrolled in the Medicare hospice program.
This type of managed care plan maintains a list of preferred providers but lets you see doctors and hospitals outside the plan for an additional cost. If you choose to use a provider outside of the network, the plan will pay the same reimbursements as Original Medicare will unless you need emergency or urgent care.
You will be responsible for the Medicare deductibles and co-insurance. Usually with a preferred provider organization you are not required to have a primary care physician and do not need a referral to see a doctor outside the plan. You must have both Medicare Part A and B.
If you enroll in a private fee-for-service, you can receive care from any Medicare doctor that agrees to the plan's terms, but you must live in the plan's service area to be eligible. Medicare pays the plan a set amount every month for each beneficiary enrolled in the plan. The plan pays providers on a fee-for-service basis. The plan charges enrollees a premium and cost-sharing amounts.
The PFFS plan offers the same benefits covered under Original Medicare and may provide extra benefits, but you have to pay more for any extra benefits. In most cases, beneficiaries enrolled in the private fee-for-service plan will pay less to see a doctor than under original fee-for-service.