Medicare Advantage Plan (Medicare Part C)

Introduction

Managed care programs

Alternative to traditional fee-for-service Medicare part A & Medicare part B

Medicare part C covers hospital care, outpatient care & prescription drugs*

* most plans cover prescription drugs, vision & dental

Oct 15-Dec 7 beneficiaries covered by Medicare part A & part B have the option of joining any Medicare Advantage program in their area

Beneficiaries cannot be denied enrollment for any health condition except end-stage renal disease

Jan 1-March Medicare Advantage beneficiaries may switch Medicare Advantage plans or switch back to Medicare part A & Medicare part B

Out-of-pocket costs:

• Medicare Advantage plan do not provide more generous benefits on high-cost items
  • skilled nursing care
  • brand-name medications.
• most plans cover additional benefits such as vision & dental benefits & charge low (or no) premiums or deductibles.
• co-payments for outpatient visits are maintained, often at the time of service

health care services from the plan's provider network

Medicare Advantage Plans served 30% of the Medicare population in 2014

Participating providers register as Medicare Advantage Plan providers.

For each beneficiary, the Medicare Advantage program must provide services offered by Medicare part A, Medicare part A & Medicare part D

Older adults who choose Medicare Advantage plans are generally healthier & have lower costs than those who opt for fee-for-service Medicare

Beneficiaries cannot be denied enrollment because of health problems except end-stage renal disease

Beneficiaries must continue to pay their part B monthly premiums to Medicare

Beneficiaries may be charged additional premiums to cover additional services

Average premium to beneficiary from participating provider in 2016 $32.50/year

Special needs plans are available are available for beneficiaries who live in nursing homes. have a chronic or diabling condition, or are dually eligible to Medicare & Medicaid

• benefits continue in the event of a transition to a different health care setting
• all special needs plans must report all HEDIS measures

Reimbursement:

• capitated payment from Medicare
• neither physicians or other providers receive additional fee-for-service payments from Medicare
• average payments from Medicare Advantage are ~12% higher than fee-for-service Medicare
• reimbursement directly from Medicare Advantage Plan
• plans operate on medicare risk adjustment (MRA) based upon ICD diagnosis provided to Medicare
• effective Oct 2015, ICD10 codes in effect

Medicare Advantage plans may be provided by:

• health maintenance organization (HMO)
• preferred provider organization (PPO)
• provider-sponsored organization
• private fee-for-service plans
  • may charge beneficiaries a premium
  • may charge beneficiaries copayments of up to 15%
• special needs plans
• Medicare savings accounts
  • may use any Medicare provider
  • catastrophic insurance included
    • maximum out of pocket $6000/year

Notes

• larger, older & non-profit plans receive higher ratings
• UnitedHealth Group & other insurance companies accused of "systematically bilking" Medicare Advantage of billions of dollars annually
  • United Health accused of using data-mining to find ways to increase apparent seriousness of patients' illnesses, thus Medicare's payments to the insurer
• when one gets sick, out-of-pocket costs can soar
• once in an Medicare Advantage plan, getting out can be even less affordable

More general terms

• Medicare