The Medicare Advantage Program

1
The Medicare Advantage Program

• Centers for Medicare Medicaid Services
• Marty Abeln
• June 23, 2008

2
Medicare Advantage Program

• CMS administers the Medicare Advantage (MA)
  program.

• Private insurers offer MA plans to beneficiaries
  under a contract with CMS.
• There are several types of MA plans
• Health Maintenance Organizations
• Local Regional Preferred Provider Organizations
• Special Needs Plans
• Private Fee-For-Service Plans
• MSA Plans

3
What do Medicare Advantage Plans Offer?

• Provide the full package of Medicare Part A and B
  benefits (cost sharing may vary). Referred to as
  Part C
• May offer additional health benefits to
  beneficiaries.

4
Relationship to the Part D Prescription Drug
Benefit

• The MMA requires that most MA plans offer at
  least one MA plan with prescription drugs in its
  service area.
• MA plans offering a prescription drug plan (known
  as MA-PDs), follow all of the Part D requirements.

5
Information for Beneficiaries

• Beneficiaries may chose a plan each year.

• CMS provides information on the plans and their
  benefits through 1-800-MEDICARE, the Medicare
  You Handbook and on the Medicare Options Compare
  web tools.
• SHIPs and other community resources are also
  available to beneficiaries to help them make
  informed choices.
• The MAOs are also required to educate
  beneficiaries about the benefits through mailings
  and customer service lines. MAOs must follow CMS
  marketing guidelines.

6
Key Plan Types and Features

• Health Maintenance Organizations (HMO)
• This network model requires enrollees to use a
  primary care doctor who coordinates care and
  refers enrollees to specialists generally within
  the HMOs network.
• Some HMOs offer a Point-of-Service (POS) option
  that allows beneficiaries to go to non-plan
  doctors and hospitals without receiving prior
  approval for certain services.

7
Key Plan Types and Features

• Preferred Provider Organizations (PPO)
• Enrollees generally may get care from any
  provider, but will pay less they go to one of the
  preferred providers in the MA plans network.
• Enrollees will usually pay higher cost-sharing if
  they get care from a non-preferred provider.
• Some PPOs are local (specified counties in a
  state).
• Regional PPOs cover entire states or groups of
  states (as specified in regulation).

8
Key Plan Types and Features

• Special Needs Plans (SNP)
• These plans are permitted to limit enrollment to
  certain sub-populations of beneficiaries and are
  designed primarily for individuals in three
  categories
• those who are institutionalized
• those also entitled to Medicaid (so-called dual
  eligibles)
• other high-risk or chronically ill or disabled
  individuals.

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Key Plan Types and Features

• Special Needs Plans are tailored to treat a more
  frail population of beneficiaries and must
  develop models of care explaining how they will
  do this.
• All SNPs provide Part D prescription drug
  coverage.

10
Key Plan Types and Features

• Medical Savings Account (MSA)
• High deductible health plans combined with a
  savings account for health care expenses in which
  enrollees pay out-of-pocket until the deductible
  is met.
• This type of plan does not generally have a
  network.
• Medicare makes a contribution to the
  beneficiarys savings account.
• MSAs do not cover Part D prescription drug
  benefits.
• Beneficiaries can also join a stand alone Part D
  prescription drug plan that complements the MSA.
• Beneficiaries pay the Part B premium but no plan
  premium except for any premium for supplemental
  benefits.

11
Key Plan Types and Features

• Private-Fee-for-Service (PFFS)
• PFFS plans are unlike traditional managed care.
  While other MA plans have provider networks and
  manage care, most PFFS plans do not have a
  network and do not manage care..
• Some of the other differences between PFFS plans
  and other MA coordinated care plans include
• PFFS that do not have a network are required to
  pay providers at least what they would have
  received under original Medicare for the services
  they furnish.
• PFFS plans are exempt by statute from reporting
  information associated with quality measures

12
Deeming Process
13
Key Plan Types and Features

• Enrollees may go to any provider in the U.S who
  accepts the plans terms and conditions which
  outline how the provider is paid.
• Providers are not required to accept PFFS plan
  members, and some that accept Original Medicare
  may not accept PFFS plan members.
• Part D may be offered.

14
CMS Actions to address Payment Marketing
problems.

• 1. Non-contract Payment guide.
• 2. Model terms conditions of payment.
• 3. Provider payment dispute resolution process.
• 4. New Medicare regulations addressing marketing
  of PFFS and MA plans.

15
Payment of FQHCs RHCs by MA Plans

• As a direct contract with an MA Plan.
• Possibility of a CMS wrap-around payment
  depending on contracted payment rate from MA
  plan. Possible CMS wrap-around payment.
• As a non-contract provider by an MA plan.
• MA plans may pay the original Medicare payment
  amount or billed charges which ever is the lowest
  amount.
• As a deemed provider by a PFFS plan.
• Must pay according to terms conditions of
  payment.

16
Access to MA Plans

• Almost all Medicare beneficiaries have plans from
  two or more MA contract types available in their
  area and most have at least three available
  choices.
• PFFS choice is particularly common, with 82
  percent of beneficiaries having such plans
  available to them in 2008 (up from 52 percent in
  2007) and with little variation between urban and
  rural areas.

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MA Plan Information
18
Plans by County (2007)
19
Plans by County (2008)
Legend
20
MA Enrollment Facts and Figures

• MA Enrollment Compared to Original Medicare
• 18 in 2007
• (27 predicted by 2016)
• Enrollees by Plan Type2007
• HMO
• PPO 72
• PFFS 17
• Regional PPO 2
• MS 1
• NOTABLE PFFS plan enrollment has gone from
  208,990 in 2005 to the current, 2007 figure, of
  1,148,393.
• SNPs are a type of HMO or PPO. Enrollment has
  gone from 627,000 in 2006 to 999,000 in 2007.

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Relationship to Employer Plans

• Employer and union group plan sponsors may choose
  to enroll their members in individual MA plans
  open to general enrollment.
• Some MAOs offer or administer employer only
  customized group plans, including MA-PD benefits.
  These are known as 800 series plans.
• Employers and unions also may choose to directly
  contract with CMS to offer these kinds of
  customized group benefits to their members

22
CMS Oversight of the MA Program

• CMS reviews specific plans and plan offerings
  over the course of a contract year by
• Reviewing applications for the contract year
  The review includes determining that plans have
  adequate network.
• Reviewing bids Except for PFFS plans, CMS
  reviews pricing each contract year. CMS reviews
  PFFS bids to ensure that their benefit structure
  is not discriminatory.
• Reviewing marketing materials.
• CMS conducts day-to-day monitoring CMS conducts
  day-to-day monitoring based on complaints and
  other information gathered about plan performance.

23
CMS Sources of Information on the Medicare
Advantage Program

• Managed Care Manual http//www.cms.hhs.gov/manual
  s
• Managed Care Marketing Guidelines
  http//www.cms.hhs.gov/ManagedCareMarketing
• 2009 MA, MA-PD, Cost Plan, and Part D Call
  Letter
• http//www.cms.hhs.gov/HealthPlansGenInfo/

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CMS Sources of Information on the Medicare
Advantage Program

• The following CMS web link provides a
  non-contract payment guide describing how FQHCs
  RHCs are to be reimbursed by PFFS Plans when
  paying at original Medicare rate (see pages
  11-12)
• http//www.cms.hhs.gov/PrivateFeeforServicePlans
  /
•   
• The following web link is to the CMS proposed
  regulation.
• http//www.cms.hhs.gov/HealthPlansGenInfo/
• Contact information
• Marty.Abeln_at_cms.hhs.gov
• Phone [phone]