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Senior Citizen's Guide

Making the Right Choice
Medicare advantage plans.

Congress created Medicare Advantage Plans to let more private insurance companies offer coverage to people with Medicare, giving them more choices in how to get their Medicare benefits. If people join one of these plans, they generally get all their Medicare-covered health care through that plan and the plan may offer extra benefits that Medicare doesn't cover, such as vision or dental services. Medicare pays a set amount of money for a person's care every month to these private health plans, whether or not the member uses services. People must have both Medicare Part A and Part B and must live in the plan's geographic service area to join a Medicare Advantage Plan. They may pay an additional monthly premium to the plan and they will have to pay other costs (such as copayments) for the services they get. The plan may also have special rules that its members need to follow.

In some plans, like Medicare Health Maintenance Organizations (HMOs), people may only be able to see certain doctors or go to certain hospitals. However, members have the right to get emergency care anywhere in the United States when they need it without any prior approval from the plan. Since each plan can vary, it's important that people review plan materials carefully for details about co-payment and coverage information.

There are currently five main types of Medicare Advantage Plans:

  1. Medicare Health Maintenance Organizations (HMO)
    HMO plans cover all Part A and B services and may provide extra services. You can generally only go to doctors, specialists, or hospitals that are part of the plan's network, except in an emergency. People who join a Medicare HMO Plan may be asked to choose a primary care doctor. The primary care doctor is the doctor they see first for most health problems. They usually need a referral to see a specialist (such as a cardiologist) or to get certain services. People who are considering joining a Medicare HMO and want to keep seeing their current doctor and specialists should call and ask if them if they are in that Medicare HMO's network and they can continue to see them if they join the plan. People who are willing to change their primary care doctor can ask the plan for the names of doctors who practice in their area. Doctors can join or leave a Medicare HMO.

  2. Medicare Preferred Provider Organization (PPO)
    This plan is similar to an HMO plan, but members in a Medicare PPO generally can see any doctor or provider that accepts Medicare. They don't need a referral to see a specialist. The plan has a network of preferred doctors and specialists. If members go to doctors, hospitals, or other providers that aren't part of the plan ("out-of-network" or "non-preferred"), they don't need a referral, but they will usually pay more. Every Medicare PPO Plan must pay for all covered services received out-of-network, but every plan is different in what their members must pay.

  3. Medicare Special Needs Plans (SNP)
    Membership in a SNP is limited to certain groups of people, such as those with certain chronic or disabling conditions or in some institutions like a nursing home. Medicare Special Needs Plans are Medicare Advantage Plans designed to provide focused care management, special expertise of the plan's providers, and benefits tailored to enrollee conditions. These plans provide case management, care monitoring, health education, and monitoring tools, if needed, to provide specialized care.

  4. Medicare Private Fee-for-Service (PFFS)
    This plan's members can go to any provider that accepts the plan's terms and conditions of payment, and they may get extra benefits. A Private Fee-for-Service plan is a Medicare Advantage Plan offered by a private insurance company under contract to the Medicare program. Some companies may offer more than one plan in an area, with different benefits and costs. The private company decides how much it will pay and how much members pay for services. There are general rules for how Medicare Private Fee-for-Service Plans work. Members can choose which provider they will see, do not need a referral to see a specialist, and can get services outside their service area. However, while they can go to any Medicare-approved doctor or hospital, that provider must accept the terms and conditions of their plan's payment. Members may get extra benefits not covered under the Original Medicare Plan, such as extra days in the hospital. The private company, rather than the Medicare program, decides what members pay for the services they get. Doctors can also join or leave these plans at any time.

  5. Medicare Medical Savings Account (MSA)
    MSA plans combine a high deductible Medicare Advantage Plan and a bank account. These Medicare plans are similar to Health Savings Account plans available outside of Medicare, and they have two parts. The first part is a Medicare Advantage Plan with a high deductible. This health plan won't begin to pay covered costs until the person has met the annual deductible, which varies by plan. The second part is a Medical Savings Account into which Medicare deposits money that the person with Medicare may use to pay health care costs until the deductible is met. After the deductible is met, Medicare will pay 100% of Medicare covered services. If the funds are not used, they will continue in the account.

There are three other types of Medicare plans.

There are special trial rights available for people who have joined a Medicare Advantage plan for the first time. They can drop their MA plan and enroll in the Original Medicare Plan anytime within the first 12 months of their Medicare Advantage plan coverage. People are eligible for this trial right if they either joined an MA plan when first eligible for Medicare at age 65, or were in the Original Medicare Plan, enrolled in a MA plan for the first time, and dropped a Medigap policy. The trial right allows them to disenroll from the MA plan during the first 12 months and return to Original Medicare and their Medigap policy. People new to Medicare also have a guaranteed issue opportunity to purchase a Medigap (Medicare supplement) policy.

When comparing Original Medicare and joining a Medicare Advantage Plan a person must make sure they know all the costs and co-pays. Original Medicare has deductibles and usually only pays 80% of the cost. A person needs to supplement Medicare with a Medigap Policy, Medicare Advantage Plan, Group Retirement Plan, TriCare, or Medicaid. It is also important to be sure a person can pay the monthly premiums, co-pays and deductibles. If a person stays in Original Medicare they have coverage nationwide and many doctors and hospitals accept Medicare. Medicare Advantage members need to stay in their networks except in emergencies or pay more money. If a person is on Medicaid, some states do not pay the co-payments for Medicare Advantage Plans.

Medicare Advantage Plans in your area are listed in the back of the Medicare and You 2008 book. There will be salespeople marketing these plans. The open enrollment period is November 17 to December 31 and January 1 to March 31. Medicare Advantage Plans can be sold all year long to people in the Medicare Savings Programs and people new to Medicare. It is important to review the co-payments and premium costs for the plan before you enroll. If a person joins a Medicare Advantage Plan they will still be in Medicare but need to get all their services through the MA plan. If you want to join a plan but need to change doctor's, you need to make sure a doctor in your neighborhood who is participating in the plan is accepting new patients before you enroll. Remember, Medicare pays a set amount of money for a person's care every month to these private health plans, whether or not the member uses services. Original Medicare will no longer accept bills from providers for Medicare services.

It is important to understand that Medicare Advantage Plans may not solicit Medicare beneficiaries door-to-door prior to receiving an invitation. They cannot send unsolicited email to a beneficiary or enroll people by phone, unless the person calls them. Salespersons must comply with the "Do not call registry". They cannot offer beneficiaries cash payments as an inducement to enroll or use high-pressure sales tactics to enroll a beneficiary. All offenses should be reported to 1-800-Medicare.

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