Understanding Medicare Advantage and Medigap Carol Mandlebaum

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Understanding Medicare Advantage and
MedigapCarol Mandlebaum Cindy Loftin
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Medicare Advantage Plans

• What are Medicare Advantage (MA) Plans
• Who can join and when
• How MA Plans work
• Types of MA Plans

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Medicare Health Plan Options

• Original Medicare
• With Medigap
• With Medicare Prescription Drug Plan, OR
• Medicare Advantage Plans
• Health plan options approved by Medicare
• Run by private companies
• Part of the Medicare program
• Sometimes called Part C

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Who Can Join?

• Eligibility requirements
• Live in plans service area
• Entitled to Medicare Part A
• Enrolled in Medicare Part B
• Not have End-Stage Renal Disease (ESRD)at time
  of enrollment
• Some exceptions

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When Can People Join?

• A person can join MA Plan or other plan
• When first eligible for Medicare
• Initial Enrollment Period
• During specific enrollment periods
• Annual Election Period
• MA Open Enrollment Period
• Special Enrollment Period

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When Can People Switch?

• Annual Election Period (AEP)
• MA Open Enrollment Period (MA-OEP)
• Special Enrollment Period (SEP)
• Move out of the plans service area OR move and
  have new MA or Part D options available
• Plan leaves Medicare program
• Other special situations

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Annual Election Period

• November 15 December 31
• Can choose new plan
• MA Plan
• Medicare Prescription Drug Plan
• Original Medicare
• New plan effective January 1

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MA Open Enrollment Period

• January 1 March 31
• Same period each year
• Change effective first day of following month
• Cannot be used to start or stop Medicare drug
  coverage
• May only make one change during this time period

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Trial Rights for People New to MA

• 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 during first 12 months
• Join or return to Original Medicare
• Have guaranteed issue for Medigap policy

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How Do MA Plans Work?

• Generally get all Medicare-covered services
  through the plan
• Can include prescription drug coverage
• May have to see certain doctors or go to certain
  hospitals to get care
• Emergency care covered anywhere in the U.S.
• Benefits and cost-sharing may be different from
  Original Medicare

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Out-of-Pocket Costs

• Generally must still pay Part B premium
• Some plans may pay all or part
• May pay additional monthly premium
• Will have to pay other out-of-pocket costs

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People In MA Plan

• Still in Medicare program
• Still have Medicare rights and protections
• Still get all regular Medicare-covered services
• May get extra benefits
• Such as vision, hearing, dental care

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Types of MA Plans

• Medicare Health Maintenance Organization (HMO)
• Medicare Preferred Provider Organization (PPO)
• Medicare Private Fee-for-Service (PFFS)
• Medicare Special Needs Plan (SNP)
• Medicare Medical Savings Account (MSA)

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Medicare HMO Plans

• Copayment amounts set by plan
• Usually must use network doctors and hospitals
• May pay in full for care outside plans network
• Covered if emergency or urgently needed care
• POS option allows visits to out-of-network
  providers
• May need to choose primary care doctor
• Usually need a referral to see a specialist
• Doctors can join or leave
• May include prescription drug coverage

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Medicare PPO Plans

• Can see any doctor or provider that accepts
  Medicare
• Dont need referral to see specialist
• Dont need referral to see out-of-network
  provider
• Copayment and coinsurance amounts set by plan
• Will usually pay more for out-of-network care
• May get Medicare prescription drug coverage

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Medicare PFFS Plans

• Can see any Medicare-approved doctor or hospital
  that accepts the plan
• Can get services outside service area
• Dont need referral to see a specialist
• Plan sets copayment amounts
• If offered, can get Medicare prescription drug
  coverage
• If not offered, can join a Medicare Prescription
  Drug Plan

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Special Needs Plans (SNPs)

• Designed to provide
• Focused care management
• Special expertise of plans providers
• Benefits tailored to enrollee conditions
• Must include prescription drug coverage

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Special Needs Plans (continued)

• Three types of SNPs
• Must limit membership to people
• With certain chronic or disabling conditions
• Eligible for Medicare and Medicaid or
• In certain institutions
• Available in some areas
• Visit www.medicare.gov
• Select Search Tools at top of the page
• Call 1-800-Medicare

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MSA Plans

• Similar to Health Savings Account Plans
• Have two parts
• Medicare Advantage Plan with high deductible
• Pays covered costs after deductible is met
• Medical Savings Account
• Medicare deposits money the person may use
• To pay health care costs
• Not available in all areas

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Medicare PACE Plans

• Programs of All-inclusive Care for the Elderly
• Combine services for frail elderly people
• Medical
• Social
• Long-term care services
• Include prescription drug coverage
• Might be better choice than nursing home
• Only in states that offer it under Medicaid
• Qualifications vary from state to state
• Contact state Medical Assistance office for
  information

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Medigap Basics
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What Is Medigap?

• Health insurance policy
• Sold by private insurance companies
• Cover gaps in Original Medicare
• Follow Federal and state laws that protect you
• Must say Medicare Supplement Insurance

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What Is Medigap? (continued)

• Health insurance policy
• 12 standardized policies in most states
• Plans A L
• Non-standardized policies
• Massachusetts
• Minnesota
• Wisconsin
• Costs may vary
• By plan
• By company
• Where you live

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How Medigap Works

• Only works with Original Medicare
• Don't need Medigap policy in
• Medicare Advantage Plan
• Other Medicare plans
• Can go to any doctor, hospital, or provider that
  accepts Medicare
• Unless you have Medicare SELECT policy networks

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Medigap Is Not

• Medicare Advantage Plans
• Medicare Part B
• Medicare Prescription Drug Plans
• Medicaid
• Employer or union plan
• TRICARE
• Veterans benefits

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Who Can Buy Medigap?

• Must have Medicare Parts A and B
• May not be able to buy Medigap under 65
• People with a disability
• People with End-Stage Renal Disease
• Guaranteed right to buy a Medigap policy
• In your Medigap open enrollment period
• Covered under a Medigap protection (guaranteed
  issue)

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Gaps in Original Medicare Coverage
What you pay in 2009Part A

• Hospital Stays
• Skilled Nursing
• Blood

• 1,068 deductible for days 1 60
• 267 per day for days 61 90
• 534 per day for days 91 150
• 0 for first 20 days
• Up to 133.50 per day for days 21 100
• 100 after day 100
• 100 for first 3 pints
• 20 for additional pints

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Gaps in Original Medicare Coverage
What you pay in 2009Part A

• Home Health Care
• Hospice Care

• 0 for home health care services
• 20 for durable medical equipment
• Up to 5 copayment for outpatient prescription
  drugs
• 5 for inpatient respite care
• Room and board, in some cases

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Gaps in Original Medicare Coverage
What you pay in 2009Part B

• Part B Deductible
• Part B Services

• 135 per year
• 20 coinsurance for most covered services
• 50 coinsurance for outpatient mental health
• Copayments for hospital outpatient services

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Medigap Coverage
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Medigap Coverage Plans A - J
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Medigap Coverage Plans K L
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Items Not Covered

• Long-term care
• Vision and dental care
• Including eyeglasses
• Hearing aids
• Private-duty nursing
• Outpatient prescription drugs

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MIPPA Changes(Effective June 1, 2010)

• Adds hospice coverage
• Basic benefit to all plans
• Deletes preventive services at-home recovery
• Creates new Plans D G
• Eliminates E, H, I, and J Plans
• Creates a new Plans M N

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2010 MIPPA Medigap Changes( denotes new plans
and benefits)
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2010 Carryover Medigap Plans
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F and J High-Deductible Option

• 2,000 deductible for 2009
• Amount can go up each year
• Often have lower premium
• Out-of-pocket costs may be higher
• May not be able to change plans
• Additional deductibles
• Prescription drugs
• Foreign travel

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Plans K and L

• Pay only partial costs after Medicare pays
• Have annual out-of-pocket maximum
• Plan K covers
• 50 for most services
• 4,620 out-of-pocket limit in 2009
• Plan L covers
• 75 for most services
• 2,310 out-of-pocket limit in 2009

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Medicare SELECT

• A type of Medigap policy (Plans A L) with
  networks
• To get full benefits (except in emergency)
• Must use specific hospitals
• In some cases must see specific doctors
• Generally cost less than non-network plans
• Can switch to another Medigap plan
• Same or lower value
• May not be offered in your state

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Guaranteed Issue Rights

• Rights to purchase in most cases Plans A, B, C,
  F, K, or L, if
• Medicare Advantage or PACE coverage ends
• Employer group health plan coverage that pays
  secondary to Medicare ends
• Health coverage ends because you move out of the
  plan's service area
• You joined a Medicare Advantage or PACE Plan
• First eligible for Medicare at age 65 and leave
  within 12 months

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Guaranteed Issue Rights (continued)

• You dropped a Medigap policy and enrolled in
  Medicare Advantage Plan for first time
• Stayed in the plan less than a year and
• Want to switch back
• Medigap coverage ends through no fault of your
  own
• Plan or insurance company committed fraud

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Information Sources for Medigap

• 2009 Choosing a Medigap Policy A Guide to Health
  Insurance for People With Medicare
• Available on www.medicare.gov
• Oklahoma Shoppers Guide
• SHIP 1-800-763-2828
• 1-800-MEDICARE
• 1-800-633-4227
• 1-877-486-2048 for TTY users

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