Archive for the ‘HMO’ Category

Medicare Part D – Overview, eligibility, coverage, and enrollment

Friday, February 3rd, 2012

Overview and eligibility

Medicare Part D is the prescription drug part of the Medicare program. It came into being as the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (the Medicare Act of 2003). Part D, also known as a Prescription Drug Plan (PDP), is a voluntary drug plan that is available to all Medicare recipients who have either Part A or Part B. It is available through private insurers that are approved by and contracted with Medicare.

Essentially, there are 2 ways to get prescription drug coverage under Medicare:

  1. Stand-alone drug coverage plans can be added to the basic, Original Medicare. They can also be added to certain Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account (MSA) Plans.
  2. HMO and PPO Medicare Advantage plans include prescription drug coverage in their plans. Remember, you must have both Part A and Part B in order to qualify for a Medicare Advantage plan.

Coverage

Most insurance companies offering Part D are allowed to design their own drug plans, so coverage will vary from plan to plan. Specific coverages are extensive and complicated, but in general the “basic Part D” meets the following conditions:

  • The annual deductible can’t be more than $310 for 2011.
  • The plan must cover at least two drugs in each drug class.
  • The plan must cover substantially all drugs in these six categories: antidepressants, antipsychotics, anticonvulsants, antiretrovirals (AIDS treatments), anticancer drugs, and immunosuppressants.
  • Members must be able to seek an exception if a drug is medically necessary but not covered under the plan.
  • Plans must have a network of pharmacies that provide convenient access.
  • Lists of covered drugs and pharmacy networks must be readily available to members.
  • Plans must work with nursing homes.
  • Plans must help transition a member’s current drug coverage.
  • Plans must offer catastrophic coverage that is at least as good as the coverage outlined in the 2003 Medicare Act.

(from Medicare.org)

 

Enrollment

 

Medicare Part D has both standard enrollment periods and special enrollments. There are also late enrollment fees that Medicare participants may encounter.

Those signing up for the first time can do it in one of 4 different ways:

  1. Sign up during the Initial Enrollment Period (IEP). As mentioned in previous articles, the initial enrollment period for most individuals begins at 65. If you’re eligible when you turn 65, you can sign up during the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.
  2. You can join, switch, or drop a prescription drug plan during the Annual Coordinated Election Period (AEP). This period runs from October 5th to December 7th. Any changes made during this time will take effect on January 1st of the following year.
  3. If you get Medicare due to a disability.
  4. If you get Extra Help, a special program offered by Medicare and Social Security for participants with low income and limited resources

 

Generally, participants are required to stay with a plan for a calendar year, but sometimes individuals with extenuating circumstances may be able to join, switch, or drop their plans during Special Enrollment Periods (SEP). If you move out of your plan’s coverage area, lose other prescription drug coverage, or if you live in a nursing home or personal care home, you may qualify for SEP.

Late enrollment penalty:

If your initial enrollment period lapses for 63 days or more in a row, when you do not have Part D or another approved medicare prescription drug coverage plan, you will be charged a late enrollment penalty. This penalty is approximately 1% of the average national premium, for each month that you delay enrolling in a Part D. This amount is rounded to the nearest $.10 and added to your monthly premium.

 

Sources used in this article

http://www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-d.aspx#msip

http://www.medicare.org/medicare-basics/part-d.html

http://www.aarp.org/health/medicare-insurance/info-11-2009/part6_enrolling_in_Medicare_partd.html

http://www.kff.org/medicare/upload/7044-12.pdf

Medicare Part C – Medical Advantage plans – Description of types, and your costs

Friday, January 27th, 2012

Private insurance companies offer the following types of coverage through Medicare Advantage plans:

  • Health Maintenance Organization (HMO) Plans
  • Preferred Provider Organization (PPO) Plans
  • Private Fee-for-Service (PFFS) Plans
  • Special Needs Plans (SNP)

Other, less common types of Medicare Advantage Plans include:

  • HMO Point-of-Service (POS) Plans — An HMO plan that may allow you to get some services out-of-network for a higher cost.
  • Medical Savings Account (MSA) Plans — An MSA plan combines a high deductible health plan with a bank account.

Local HMOs and PPOs contract with provider networks to deliver Medicare benefits. Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) will cost participants the least amount of money for health care, but they are the most restrictive. For the most part, individuals are covered only when using the provider’s doctors, specialists, and hospitals.

In 2011, HMOs accounted for the majority (65%) of total Medicare Advantage enrollment. Local PPOs accounted for 18% of all Medicare Advantage enrollees.

Regional PPOs were established to provide rural beneficiaries greater access to Medicare Advantage plans, and cover entire statewide or multi-state regions. Regional PPOs accounted for 9% of all Medicare Advantage enrollees in 2011.

Private Fee-for-Service plans (PFFS) are the most flexible plans, but also the most costly. Participants are allowed to see their own Medicare-approved doctor or hospital who accepts the plan’s payment terms. They were originally authorized in 1997, but at the time they were not required to establish physician/specialist networks. However, since 2011, most have generally been required to do so. PFFS enrollment was approximately 0.6 million enrollees in 2011, which is 5% of all Medicare Advantage enrollees.

Special Needs Plans (SNPs), are usually HMOs with specific restrictions. Beneficiaries of these plans must be:

  1. Dually eligible for Medicare and Medicaid;
  2. Live in long-term care institutions (or would otherwise require an institutional level of care);
  3. Have certain chronic conditions.

 

From 2006 to 2011, the number of SNP enrollees has increased from 0.5 million to 1.3 million enrollees.

Medical Advantage Costs

According to the latest information from Medicare.org, participants’ out-of-pocket expenses depend on several different variables. These may include:

  • Whether the plan charges a monthly premium in addition to your Part B premium
  • Whether the plan pays any of the monthly Part B premium (some plans offer this option, usually for an additional cost)
  • Whether the plan has a yearly deductible or any additional deductibles
  • How much you pay for each visit or service (copayments)
  • The type of health care services you need and how often you get them
  • Whether you follow the plan’s rules, like using network providers
  • Whether you need the additional benefits and if the plan charges for it
  • The plan’s yearly limit on your out-of-pocket costs for all medical services

 

Sources used for this article:

http://www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-c.aspx

http://www.medicare.org/medicare-basics/part-c.html#what%20is%20part%20c

http://www.kff.org/medicare/upload/2052-15.pdf

 

 

Part C – Medicare Advantage Plans – Reasons to choose one, enrolling, and leaving Medicare Advantage plans

Friday, January 20th, 2012

Reasons to choose an Advantage Plan

Qualified Medicare participants choose to participate in an Advantage Plan for many reasons. As we have already mentioned, Medicare Advantage offers additional coverage that original Medicare doesn’t have, such as vision, hearing, dental, and/or health and wellness programs. Most also include prescription drug coverage. Additionally, Medical Advantage plans also provide coverage for emergency and urgent care. Keep in mind that these additional coverages often come with additional monthly premiums that the participants are responsible for. In addition to your Part B premium, Medical Advantage participants usually pay a copayment or coinsurance for covered services, and as well as a monthly premium.

Many Medicare beneficiaries have a wider array of health plan options from which they can choose, when they enroll in a Medicare Advantage HMO or PPO. These plans typically offer Medicare recipients benefits at a lower cost because enrollees can only get covered health care through the plan’s network of providers. This restriction allows the insurance company to “manage” the costs. The result is that participants are allowed to obtain the best coverage they can get at a cost they can afford.

Enrolling in a Medicare Advantage Plan

Participants who enroll in a Medicare Advantage program will continue to receive all Original Medicare covered services. Additionally, you may be able to lower your out-of-pocket costs and also receive extra benefits and services that are not offered by Original Medicare. Whether or not you save money, as well as the number and type of extra benefits and services you receive is dependent upon which Medicare Advantage plan you sign up for.

Note: Private insurance companies that offer Medicare Advantage plans have the freedom to change the plans’ benefits on an annual basis. They can also decide whether or not they choose to continue participating in Medicare; they can join or leave the Medicare program at any time.

Qualified Medicare recipients must be entitled to Medicare Part A and be enrolled in Part B in order to enroll in a Medicare Advantage plan. Most recipients do not realize that not all plans are available in all areas. You can only enroll in a plan that is available in your area. Qualified individuals can enroll in a Medicare Advantage plan when they first become eligible, if they are new to Medicare.

Your initial eligibility time frame is a seven-month period called the Initial Enrollment Period (IEP). It begins three months before your birthday month (if your birthday falls on the first of the month, your birthday month is the previous month), includes your birthday month, and the three months after your birthday month.

Thereafter, if you are enrolled in a Medicare Advantage plan, you can only make changes to the plan or adopt a different plan during scheduled times called enrollment periods.

 One enrollment period is called the Annual Coordinated Election Period (AEP) and occurs from October 15 to December 7 of each year. During this time period, anyone with Medicare can make changes to their coverage such as selecting a new Medicare health plan and/or a Medicare prescription drug plan. Any changes made during this time will take effect July 1. For more information, go to Medicare.gov or call Medicare at 1-800-MEDICARE (1-800-633-4227).

Leaving a Medical Advantage Plan

As of January 1, 2011, there is no longer an Open Enrollment Period (OEP). Instead, there is now the Medicare Advantage Disenrollment Period (MADP). The MADP runs from January 1 through February 14. Participants can disenroll from their Medicare Advantage plan and return to Original Medicare during the MADP. By disenrolling from the Medicare Advantage plan, individuals may also enroll in a Part D Prescription Drug plan, whether or not their Medicare Advantage plan included prescription drug coverage. They are also then eligible to apply for a Medicare Supplement (Medigap) policy.

Participants may also qualify to leave their Medicare Advantage plan if they become eligible for a Special Election Period (SEP).

 Some examples of special election period qualifications are:

  • That you are in a MA plan that is leaving Medicare.
  • Your Medigap insurance company goes bankrupt and you lose your coverage.
  • You are in a MA plan and you move out of the plan’s service area.
  • You live in a Long Term Care Facility (e.g., a nursing home or rehabilitation hospital).
  • You are losing Employer or Union Group Health Coverage.

 

 

Sources used for this article:

http://www.medicare.gov/navigation/medicare-basics/medicare-benefits/part-c.aspx

http://www.medicare.org/medicare-basics/part-c.html

http://www.medicare.org/medicare-basics/part-c.html

 

 

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