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Day 2 Medicare Advantage (Part C)


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Title: Day 2 Medicare Advantage (Part C)

Day 2 Medicare Advantage (Part C)
  • 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

  • Pays for reasonable and medically necessary
  • 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

  • 3 Enrollment Types
  • Automatic Already receiving Social Security
  • Voluntary Dont have enough SS work credits,
    must purchase AB
  • Standard Enrollment Eligible for SS and didnt
    take benefit before 65
  • 3 Enrollment Periods
  • Initial 7 months surrounding 65th birthday
  • Special 8 months following loss of coverage from
    ACTIVE employment (individuals or
  • General Jan 1stMar 31st of each year . July 1st
    effective date

  • Can delay Part B enrollment if receiving health
    coverage through ACTIVE employment of individual
    or spouse
  • 8 month SEP to join Part B once ACTIVE employment
    coverage has ended
  • 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 dont enroll when
    initially eligible
  • Part B 10 of premium for each full 12 month
    period the individual delayed enrollment

  • Physicians Services
  • Medically-necessary physicians services covered
  • Welcome to Medicare Exam Annual Wellness Visit
  • Does not cover yearly routine physical exams
  • Benefit period
  • Period of time that Medicare pays for a persons
    care in a hospital or SNF
  • Ban on Balanced Billing
  • Massachusetts has a law prohibiting excess
    charges by physicians

Medicare Advantage (Part C)
  • Also known as Medicare Part C, MA Plan, or a
    Medicare Health Plan
  • One option available for beneficiaries to get
    additional coverage to cover the gaps in Original
  • 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
  • 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)
  • Provide all the rights and protections guaranteed
    under Medicare
  • Must offer extensive network of health care
  • 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 Advantage HMOs and PPOs have different
    coverage, standards, etc. than regular HMOs and

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
  • Give members information about appeal rights

  • Eligibility requirements
  • Have Medicare Part A Part B (must pay Part B
  • Cannot have ESRD (except if have coverage with a
    non-Medicare plan from the same company prior to
    being diagnosed)
  • Must live in the plans service area
  • Cannot be out of plans 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
  • Month earlier if birthday is the 1st of the 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
  • Downgrade to exclude Medicare Prescription Plan

Special Enrollment Period
  • Some qualifying events for SEP eligibility
  • Move out of plans service area
  • Nonrenewal or termination of plan
  • Have or lose MassHealth
  • Have Extra Help or Prescription Advantage
  • Within trial period (first 12 months) of MA
    plan if enrolled into MA plan when first eligible
    for Medicare at age 65
  • In last 12 months, left a Medigap policy to join
    a MA plan for the first time
  • FYI There is NO SEP if a doctor leaves the plan

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
  • If switch to Original Medicare during this
    period, will have until February 14th to also
    join a Medicare Prescription Drug Plan
  • Coverage 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 dont 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)
  • Not all plans are offered in all regions of the

HMO Plans
  • HMO (Health Maintenance Organization)
  • Typically lower premium than other types of MA
  • Most restrictive type of managed care plan
  • Plan rules must be followed for services to be
  • Members must use network providers
  • Referrals from Primary Care Physician are
  • 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
  • May include extra benefits like vision, hearing
    or dental

Advantages/Disadvantages to HMO Membership
Advantages Disadvantages
Quality of care enhanced due to coordination of services Easier to budget medical costs because premiums and co-pays are fixed amounts Other out-of-pocket expenses to enrollee minimal predictable Less paperwork and no forms Extra benefits such as hearing, dental, routine exams, vision Health promotion and disease prevention 24 hour care Restriction on use of doctors, hospitals, health care providers Must have prior approval to see a specialist, have surgery, or obtain other medical services Enrollee may have to change from current physician HMO facilities may not be easily accessible Limitation on out-of-service area coverage Ongoing treatment of chronic conditions may not be covered while outside the service area
  • 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 plans
    basic premium OR
  • A 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 usually 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,

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

SNP Plans
  • SNP (Special Needs Plan)
  • Comprehensive program of medical care with
    membership limited to certain groups of people
  • Those in certain institutions (like nursing
  • Those eligible for both Medicare MassHealth
  • Those with certain chronic or disabling
  • Generally provides greater benefits to members
  • Specialty care coordination
  • Hospital case management
  • Communication with caregivers
  • Routine patient visits

Quick Reference Pros 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
  • Pros
  • Convenience of having only one plan (drug plan
    can be included)
  • More choices available (HMOs, PPOs)
  • Lower premiums than Medigap plans
  • Potential for better coordination of care (HMOs
    provide this)
  • Additional benefits such as hearing, dental,
    vision and annual exams

Counseling Beneficiaries Is Additional Coverage
  • Does every Medicare beneficiary need additional
    Medicare coverage?
  • Questions to ask beneficiary
  • Does she/he understand the gaps in Medicare
  • Does she/he have other coverage to help pay for
    out-of-pocket costs associated with Medicare?
    (Retiree Coverage, Medigap plan, MassHealth)
  • Can she/he afford to purchase additional
    coverage? (screen for Public Benefit programs)

Medicare Advantage Review
  • Review
  • What is a Medicare Advantage Plan?
  • What are the advantages of Medicare Advantage?
  • What are the disadvantages of Medicare Advantage?
  • Who can enroll in a Medicare Advantage Plan?
  • When can a person enroll?
  • What is the difference between an HMO and PPO?

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
  • How would you help him?

Case Study 4 Chad R. Boxx
  • Mr. Boxx comes to see you at the SHINE office.
    He recently moved to another part of the state to
    live closer to his daughter. The Medicare
    Advantage plan he had is not available in this
    new location. He wants to know what his options
  • How would you help him?

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 doesnt see why he
    should sign up for the prescription plan if he
    doesnt take medication. Mr. Gone has already
    checked that his doctor participates, so hes
    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
  • How would you help her?

Medical Insurance Explained for the HMO Systems
  • Q. What does HMO stand for?
  • 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
  • No only those you need.
  • Q. Can I get coverage for my pre-existing
  • Certainly, as long as they dont require any
  • Q. What happens if I want to try alternative
    forms of medicine?
  • A. Youll need to find alternative forms of

Medical Insurance Explained for the HMO Systems,
  • 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 dont worry the remaining doctor who
    is still in the plan, and accepting new patients,
    has an office just a half-days 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 Im away from home and I get sick?
  • A. You really shouldnt do that.

Medicare Advantage Quiz
  • 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?
  • When can a Medicare beneficiary join a Medicare
    Advantage Plan?
  • 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

Medicare Advantage Quiz, cont.
  • 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 MA plan 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 MA plan and all
    plans have to accept him
  • List the eligibility criteria to enroll in a
    Medicare Advantage Plan.