Day 2
Medicare Advantage
(Part C)
Review
Medicare

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
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Medicare


Pays for reasonable and medically necessary services
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
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Medicare

3 Enrollment Types
• Automatic: Already receiving Social Security benefits
• Voluntary: Don’t have enough SS work credits, must
purchase A+B
• Standard Enrollment: Eligible for SS and didn’t take benefit
before 65

3 Enrollment Periods
• Initial: 7 months surrounding 65th birthday month
• Special: 8 months following loss of coverage from ACTIVE
employment (individuals or spouses)
• General: Jan 1st–Mar 31st of each year . July 1st effective date5
Medicare


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 don’t enroll when initially
eligible
• Part B: 10% of premium for each full 12 month period the
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individual delayed enrollment
Medicare

Physician’s Services
• Medically-necessary physician’s 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 person’s
care in a hospital or SNF

Ban on Balanced Billing
• Massachusetts has a law prohibiting excess charges
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by physicians
Medicare Advantage
(Part C)
Overview

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 Medicare

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 Medicare
• Must still pay Part B premium
Most MA plans include prescription drug coverage (Part D)

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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 providers

 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
 Medicare Advantage HMO’s and PPO’s have different
coverage, standards, etc. than regular HMO’s and PPO’s ‘10
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
standards
• Give members information about appeal rights
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Eligibility

Eligibility requirements:
• Have Medicare Part A & Part B (must pay Part B
premium)
• Cannot have ESRD (except if have coverage with a
non-Medicare plan from the same company prior to
being diagnosed)
• Must live in the plan’s service area
• Cannot be out of plan’s service area for more than 6
consecutive months
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Four Enrollment Periods
 Initial Enrollment Period (IEP)
 Open Enrollment Period (OEP)
 Special Enrollment Period (SEP)
 Medicare Advantage Disenrollment
Period (MADP)
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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
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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
coverage
• Downgrade to exclude Medicare Prescription Plan
coverage
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Special Enrollment Period

Some qualifying events for SEP eligibility:
• Move out of plan’s 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 network
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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
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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 dis•
enrolling
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
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Changing MA plans

Automatic disenrollment when changing Medicare
Advantage Plans
• Beneficiaries don’t need to call the plan they are
leaving to dis-enroll
• Enrolling in the new MA plan will automatically
alert the old plan
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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 state
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HMO Plans

HMO (Health Maintenance Organization)
• Typically lower premium than other types of MA plans
• Most restrictive type of managed care plan
• Plan “rules” must be followed for services to be paid
• Members must use network providers
• Referrals from Primary Care Physician are required
• 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 apply)
• May include extra benefits like vision, hearing or dental
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Advantages/Disadvantages to
HMO Membership
Advantages
 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
Disadvantages
•
•
•
•
•
•
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
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HMO-POS Plans

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 plan’s basic premium
OR
A mandatory or supplemental benefit for which the plan
will charge a higher premium
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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,
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dental
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
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SNP Plans

SNP (Special Needs Plan)
• Comprehensive program of medical care with membership
•
limited to certain groups of people including:
Those in certain institutions (like nursing homes)
Those eligible for both Medicare & MassHealth (Duals)
Those with certain chronic or disabling conditions
Generally provides greater benefits to members including:
 Specialty care coordination
 Hospital case management
 Communication with caregivers
 Routine patient visits
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Quick Reference:
Pro’s 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 plan
 Pro’s:
• Convenience of having only one plan (drug plan can be
included)
• More choices available (HMO’s, PPO’s…)
• Lower premiums than Medigap plans
• Potential for better coordination of care (HMO’s provide this)
• Additional benefits such as hearing, dental, vision and annual
exams
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Counseling Beneficiaries:
Is Additional Coverage Needed?

Does every Medicare beneficiary need additional
Medicare coverage?
• Questions to ask beneficiary:
 Does she/he understand the “gaps” in Medicare
coverage?
 Does she/he have other coverage to help pay for outof-pocket costs associated with Medicare? (Retiree
Coverage, Medigap plan, MassHealth)
 Can she/he afford to purchase additional coverage?
(screen for Public Benefit programs)
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Medicare Advantage Review

Review
1. What is a Medicare Advantage Plan?
2. What are the advantages of Medicare
Advantage?
3. What are the disadvantages of Medicare
Advantage?
4. Who can enroll in a Medicare Advantage Plan?
5. When can a person enroll?
6. What is the difference between an HMO and
PPO?
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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?
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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?
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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 Plan.

How would you help him?
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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 are.
•
How would you help him?
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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 doesn’t see why he should
sign up for the prescription plan if he doesn’t take medication.
Mr. Gone has already checked that his doctor participates, so
he’s 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?
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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?
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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 begin.
• How would you help her?
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Medical Insurance Explained
for the HMO Systems
Q. What does HMO stand for?
A. 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 pre-certification?
A. No — only those you need.
Q. Can I get coverage for my pre-existing conditions?
A. Certainly, as long as they don’t require any treatment.
Q. What happens if I want to try alternative forms of medicine?
A. You’ll need to find alternative forms of payment.
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Medical Insurance Explained
for the HMO Systems, cont.
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 don’t worry; the remaining doctor who is still in the plan, and
accepting new patients, has an office just a half-day’s 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 I’m away from home and I get sick?
A. You really shouldn’t do that.
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Medicare Advantage Quiz
1. 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?
2. When can a Medicare beneficiary join a Medicare Advantage Plan?
3. 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 her?
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Medicare Advantage Quiz,
cont.
4. 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
5.
List the eligibility criteria to enroll in a Medicare Advantage Plan.
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