Medicare Advantage Plans Training Workbook APPRISE Volunteer Training
Medicare Advantage Plans Training Workbook APPRISE Volunteer Training Program Module 4 of Classroom Training
Today’s Agenda • • Review: Medicare Coverage Choices Medicare Advantage Plan Basics Medicare Advantage and Medicare Health Plans Medicare Advantage & Prescription Drugs Plan Enrollment Periods & Marketing Guidelines Find and Compare Medicare Advantage Plans Practice: Comparing Medicare Advantage Plans Questions & Comments May-21 APPRISE, Pennsylvania Department of Aging 2
Review: Medicare Coverage Choices Original Medicare with Prescription Drug Plan (PDP) May-21 Original Medicare Advantage With TRICARE, VA, employee, retiree coverage or COBRA with Medigap (Medicare Supplement) with prescription drug coverage (MA-PD) with prescription drug coverage with Prescription Drug Plan (PDP) APPRISE, Pennsylvania Department of Aging 3
What Is a Medicare Advantage Plan? • Also referred to: – – Part C MA Plans Medicare Health Plans (previous Medicare + Choice) Managed Care Plans • Run by private companies – They receive a monthly fee from Medicare, called a “capitated payment” – They must provide all services offered by Original Medicare, except hospice services • Not generally available to people with End-Stage Renal Disease (ESRD) May-21 APPRISE, Pennsylvania Department of Aging 4
Extra Coverage Sometimes Offered by Medicare Advantage Plans • • Vision Hearing Dental Other Health & Wellness Programs May-21 APPRISE, Pennsylvania Department of Aging 5
Medicare Advantage Plan Costs • A beneficiary must continue to pay their Part B and Medicare Advantage monthly premiums – Some MA Plans have $0 premiums • Plans can charge out-of-pocket costs that are different than Original Medicare – For example: deductibles, copays, and other cost sharing – Can also set rules for how to access care (provider networks, etc. ) May-21 APPRISE, Pennsylvania Department of Aging 6
Review: Compare Plan Types Original Medicare May-21 Medicare Advantage APPRISE, Pennsylvania Department of Aging 7
Types of Medicare Plans Medicare Advantage Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Private Fee for Service (PFFS) Medicare Health Plans Programs of All Inclusive Care of the Elderly (PACE) Medicare Cost Plans Special Needs Plan (SNP) Medicare Savings Account (MSA) May-21 Demonstration/Pilot Programs APPRISE, Pennsylvania Department of Aging 8
Medicare Advantage Plan: Health Maintenance Organization • • HMO The most restrictive type of plan Primary Care Doctor oversees care Must stay in-network for care Referrals needed to see a specialist Services may require prior-authorization Usually includes drug coverage May include extra benefits – Vision, dental • Medicare pays a monthly rate for each member in the plan May-21 APPRISE, Pennsylvania Department of Aging 9
Medicare Advantage Plan: Preferred Provider Organization • PPO • More flexible than an HMO • May go outside the network for care, but will cost more • Referrals not needed to see a specialist • Services may require prior-authorization • Usually includes drug coverage • May include extra benefits – Vision, dental • Medicare pays a monthly rate for each member in the plan May-21 APPRISE, Pennsylvania Department of Aging 10
Medicare Advantage Plan: Private Fee-for-Service • PFFS • Not to be confused with Original Medicare fee-for-service • Providers agree to accept the plan on a case-by-case basis –They are not required to accept the plan –They can charge up to 15% more than the plan rate to recoup costs • Care is not coordinated • Services may require prior-authorization • Sometimes includes drug coverage • May include extra benefits – Vision, dental • Medicare pays a monthly rate for each member in the plan May-21 APPRISE, Pennsylvania Department of Aging 11
Medicare Advantage Plan: Special Needs Plan • SNP • Only available to beneficiaries who are dual-eligible, institutionalized, or have chronic or disabling conditions • Care coordinators manage care • Must stay in network for care • Referrals needed to see a specialist • Services may require prior-authorization • Always includes drug coverage • May include extra benefits – Vision, dental • Medicare pays a monthly rate for each member in the plan May-21 APPRISE, Pennsylvania Department of Aging 12
Medicare Advantage Plan: Medicare Medical Savings Account • MSA • Includes a high deductible health plan and a bank account • Must set up account with a bank that the plan selects; the plan deposits money into the account • Can use funds for health costs that aren’t covered by Medicare • Funds are tax free & roll over each year • Does not include drug coverage, need a separate PDP • Medicare pays a monthly rate for each member in the plan May-21 APPRISE, Pennsylvania Department of Aging 13
Medicare Health Plan: Programs of All Inclusive Care of the Elderly • PACE • For beneficiaries age 55 and older who are impaired, frail, and nursing home eligible • Financial eligibility determined by County Assistance Office • Team manages care in community • Care must be approved by PACE team • Must live in service area • Always includes drug coverage May-21 APPRISE, Pennsylvania Department of Aging 14
Medicare Health Plan: Medicare Cost Plan • Health Maintenance Organization • Primary Care Doctor directs & oversees care • May go outside network and have services paid for by Original Medicare • Referrals not needed to see a specialist • May include drug coverage • May include extra benefits – Vision, dental • Paid a on a fee-for-service basis by Medicare for each member May-21 APPRISE, Pennsylvania Department of Aging 15
Medicare Health Plan: Demonstration/Pilot Programs • Research Studies • Covers basic Medicare services, and possibly more • To assess the effect of potential changes in Medicare coverage, payment, and quality of care • Open for a limited amount of time • For specific population and/or geographic area May-21 APPRISE, Pennsylvania Department of Aging 16
Practice: HMO Advantages & Disadvantages Advantages Disadvantages May-21 APPRISE, Pennsylvania Department of Aging 17
Practice: PPO Advantages & Disadvantages Advantages Disadvantages May-21 APPRISE, Pennsylvania Department of Aging 18
Practice: PFFS Advantages & Disadvantages Advantages Disadvantages May-21 APPRISE, Pennsylvania Department of Aging 19
Practice: SNP Advantages & Disadvantages Advantages Disadvantages May-21 APPRISE, Pennsylvania Department of Aging 20
Practice: MSA Advantages & Disadvantages Advantages Disadvantages May-21 APPRISE, Pennsylvania Department of Aging 21
Practice: PACE Advantages & Disadvantages Advantages Disadvantages May-21 APPRISE, Pennsylvania Department of Aging 22
Practice: Cost Plan Advantages & Disadvantages Advantages Disadvantages May-21 APPRISE, Pennsylvania Department of Aging 23
Practice: Pilot Advantages & Disadvantages Advantages Disadvantages May-21 APPRISE, Pennsylvania Department of Aging 24
MA Prescription Drug Coverage • Included with some plans • Plans that include drug coverage are called MA-PD plans • Usually can’t have prescription drug coverage through a Medicare Advantage Plan and a Stand-Alone Prescription Drug Plan (PDP) at the same time May-21 APPRISE, Pennsylvania Department of Aging 25
Initial Enrollment Period (IEP) Month 1 Month 2 Month 3 65 th Birthday or Disability Eligibility Month 5 Month 6 Month 7 Note: Medicare General and Special Enrollment rules also apply to Medicare Advantage Plans May-21 APPRISE, Pennsylvania Department of Aging 26
Things to Know About MA Plans • One pre-existing condition exclusion: ESRD • Available plans and plan benefits change each year • Generally, cannot have a stand-alone PDP and a Medicare Advantage Plan with drug coverage at the same time • If a beneficiary first enrolls into a plan without Rx coverage he or she may have to pay a penalty to get Rx coverage later May-21 APPRISE, Pennsylvania Department of Aging 27
Annual Open Enrollment Period (AOEP) Can join, switch, or drop a Medicare Advantage Plan October 15 November December 7 Coverage Starts January 1 During This Time, Beneficiaries Cannot … • Switch from a Medicare Advantage Plan without Rx coverage to a Stand-Alone Prescription Drug Plan (PDP) without a penalty May-21 APPRISE, Pennsylvania Department of Aging 28
Medicare Advantage Disenrollment Can leave Medicare Advantage Plan & return to Original Medicare (and stand-alone Rx Plan) January 1 February 14 Coverage Starts First Day of Following Month During This Time, Beneficiaries Cannot … • Switch from Original Medicare to a Medicare Advantage Plan • Switch from one Medicare Advantage Plan to another • Switch from one Stand-Alone Prescription Drug Plan to another • Join, switch, or drop a Medicare Medical Savings Account Plan May-21 APPRISE, Pennsylvania Department of Aging 29
Beneficiary Can Switch Plans Any Time… • …if they are switching to a 5 -star rated Plan that serves their geographic area • …if they qualify for any level of subsidy – LIS/Extra Help and/or MSP • …if they are eligible for a plan Special Enrollment Period May-21 APPRISE, Pennsylvania Department of Aging 30
Plan Special Enrollment Periods • Can Switch if Beneficiary … – Moves out of plan’s service area – Becomes eligible for any level of subsidy – Moves in, resides in, or moves out of a nursing home – Loses coverage through no fault of their own May-21 APPRISE, Pennsylvania Department of Aging 31
Case Study: When Can Martin Join? Martin’s 65 th birthday is on December 13 th. He is just about to enroll in Medicare and wants to join a Medicare Advantage Plan with prescription drug coverage. When is the earliest he can do so? When will his coverage start? Three years later, on his birthday, Martin decides he wants to switch to another Medicare Advantage Plan with Rx coverage. He is not eligible for any special enrollment periods. When is the earliest he can do so? What if he wanted to enroll in a 5 -star plan in his area? May-21 APPRISE, Pennsylvania Department of Aging 32
Disclosure of Plan Benefits • Medicare Advantage Plans must disclose plan information at time of enrollment • Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) must be received by members by September 30 each year Note: Plans negotiate fees and contract with providers on a yearly basis. To ensure services will be covered, each fall beneficiaries should check with their preferred providers to confirm which plans they will be accepting for the coming year. They should also review the plan’s list of network providers to identify any changes in hospitals, etc. May-21 APPRISE, Pennsylvania Department of Aging 33
Sales & Marketing Rules Sales Agents Can … • Offer gifts of less than $15 in value • Provide snacks at sales events (but not meals) • Distribute marketing materials at facilities of providers who accept that plan, if invited • Schedule visits with facility residents, if invited May-21 Sales Agents Cannot … • Cross sell other products • Sell door-to-door • Solicit via telephone • Approach beneficiaries in common areas or areas intended for health care • Make uninvited visits or calls after sales event • Send unsolicited emails • Attend educational events APPRISE, Pennsylvania Department of Aging 34
Case Study: What’s Wrong with this Picture? Did the sales agent break any rules? May-21 Hilda recently attended a community meeting. There she ran into a neighbor who sells plans. He was stocking a resource table with his brochures. Hilda picked one up, noting that she was interested in switching plans. Later, he approached her in the parking lot, asking her if he could give her a call to talk about options. She demurred, noting she was busy this week. The next morning, he arrived on her doorstep to drop off an information kit and encouraged her to call him if she was interested. APPRISE, Pennsylvania Department of Aging 35
Find & Compare MA Plans May-21 APPRISE, Pennsylvania Department of Aging 36
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For Discussion: Comparing Plans Matt has had Medicare for three years. He has decided to cancel his Medigap policy and purchase an MAPD Plan. His local SHIP Counselor helps him with a Plan Finder search and they focus on comparing three plans. What are the differences between the three options the counselor should highlight? When can he switch? What else does he need to know about changing coverage? May-21 APPRISE, Pennsylvania Department of Aging 47
Practice: Medicare Advantage Plan Research Instructions Questions • Go to the Plan Finder on www. Medicare. gov. • Type in local zip code. • Search for Medicare Health Plans with and without drug coverage. • Search for Special Needs Plans. • Search for plans with 5 -star ratings. • Which plan types are the least expensive? • Which companies tend to sell the plans with lower annual health & drug costs? • Which companies have the highest plan ratings? • Is there any difference in what’s available for those with Medicaid? • Which plan cover “extra” benefits (e. g. , vision, etc. )? May-21 APPRISE, Pennsylvania Department of Aging 48
Review: True or False? Question True False 1) A Medicare Advantage sales agent is allowed to put out snacks at a table they set up at a local SHIP community presentation. 2) The 5 -Start SEP occurs anytime outside of the AOEP. 3) The annual plan costs generated by the Plan Finder does not include plan premiums in the estimated total. 4) From Jan 1 - Feb 14, beneficiaries who have been on Medicare more than a year can switch from an MA plan without Rx to one with Rx without paying a late penalty. 5) Medicare’s AOEP runs from October 15 through December 7 each year. 6) All Medicare Advantage Plans must send an ANOC to beneficiaries each Spring. 7) Medicare Advantage PACE Plans (known as Life Programs in PA) are available to some beneficiaries with low-income age 55 and up. May-21 APPRISE, Pennsylvania Department of Aging 49
Questions? Helpful Reference Tools Job Aids • • • May-21 Plan Comparison Tip Sheet (PA) Plan Comparison Worksheet (PA) Medicare Coverage Options (PA) Medicare Plan Enrollment Periods (PA) New to Medicare Checklist (CMS) APPRISE, Pennsylvania Department of Aging 50
Answers from Workbook Exercises May-21 APPRISE, Pennsylvania Department of Aging 51
Review: Compare Plan Types Original Medicare – Public insurance coverage – Also called Medicare fee-for-service – May require a Medigap or other insurance coverage to fill in coverage gaps – Beneficiary pays Part B premium + Part A premium, if any – Must pay Medicare Part A & Part B deductibles – Can see any doctor that accepts Medicare – Must purchase separate, stand-alone Medicare Prescription Drug Plan – Beneficiary receives a Medicare Summary Notice – Premiums are set each year, based on inflation May-21 Medicare Advantage – – – – – Private insurance product Also called Managed Care Covers all services required by Medicare Plan receives a monthly amount from Medicare for each member Beneficiary pays Part B premium + plan premium, if any Plan costs can be different than Original Medicare May need to use in network providers Can buy with (MA-PD) or without (MA) Rx coverage No Medicare Summary Notice APPRISE, Pennsylvania Department of Aging 52
Practice: HMO Advantages & Disadvantages Extra benefits Network of available doctors Advantages Covers all basic Medicare benefits & services May have the option to add prescription drug coverage May-21 Preferred doctor may not be in network Doctors may leave the plan while the member is locked in Require priorauthorization Require referrals to see a specialist Choose primary care doctor APPRISE, Pennsylvania Department of Aging Disadvantages 53
Practice: PPO Advantages & Disadvantages Extra benefits May be able to see both in and out-of-network doctors May save money if using in network providers Advantages Covers all basic Medicare benefits & services May have the option to add prescription drug coverage In most cases, referrals are not needed May offer out-of-pocket limits not available with Original Medicare Does not require to have Primary Care Physician May-21 Preferred doctor may not be in network Will pay a higher cost share for out-of-network care Doctors may leave the plan while the member is locked in Disadvantages May require referrals to see a specialist APPRISE, Pennsylvania Department of Aging 54
Practice: PFFS Advantages & Disadvantages Extra benefits May be able to see both inand out-of-network doctors May save money if using in network providers Covers all basic Medicare Advantages benefits & services May have the option to add prescription drug coverage Not required to have a referral from a primary care physician to see a specialist. May offer out-of-pocket limits not available with Original Medicare May-21 May need to purchase stand alone prescription drug plan Preferred doctor may not be in network Doctors may leave the plan while the member is locked in Providers without a contract can choose to accept the plan on a visit-by-visit basis Out-of-pocket cost can vary APPRISE, Pennsylvania Department of Aging Disadvantages 55
Practice: SNP Advantages & Disadvantages Allows you to receive services from providers that do not accept the Medicaid card Extra benefits Covers all basic Medicare benefits & services Advantages In most cases. Certain services, like yearly screening mammograms, don’t require a referral May offer out-of-pocket limits not available with Original Medicare Network of available doctors RX coverage included May-21 Preferred doctor may not be in network They may require referrals to see a specialist (certain situations) Will pay a higher cost share for out-of-network care May require to have Primary Care Physician Membership is limited to those who qualify APPRISE, Pennsylvania Department of Aging Disadvantages 56
Practice: MSA Advantages & Disadvantages Potentially less expensive, half the deductible is matched by CMS Unused funds in savings account roll over to the next year After deductible is reached, plan pays for 100% of care, Advantages for the rest of the year Able to see any provider that accepts Medicare Covers all basic Medicare benefits & services Not required to have a referral to see a specialist Offers out-of-pocket limits not available with Original Medicare May-21 Potentially more expensive, if not healthy Services covered by the plan, but not by Original Medicare, generally cost more When member runs out of funds, they must pay outof-pocket for medical services until deductible is reached APPRISE, Pennsylvania Department of Aging Disadvantages 57
Practice: PACE Advantages & Disadvantages Covers a nursing home level of care & allows member to continue to live at home Covers services that may not be covered by Original Advantages Medicare or Medicaid Those who qualify for Medicare and Medicaid pay a small monthly payment or nothing for nursing home level of care No deductibles or copayments for drugs or services approved by the PACE team May-21 Must be eligible based on functioning status, income & asset levels. Care not approved by PACE team is not covered & must be paid for out of pocket APPRISE, Pennsylvania Department of Aging Disadvantages 58
Practice: Cost Plan Advantages & Disadvantages Extra benefits May be able to see both inand out-of-network doctors May save money if using in network providers Covers all basic Medicare benefits & services Advantages Also may have the option to add prescription drug coverage Not required to have a referral from a primary care physician to see a specialist Can access any provider that participates in Original Medicare using their Original Medicare benefits Can choose to return to Original Medicare throughout the year May-21 Plans only available in certain geographic areas APPRISE, Pennsylvania Department of Aging Disadvantages 59
Practice: Pilot Advantages & Disadvantages Costs may be lower Participants may have Advantages more flexibility in what is covered Participants help contribute to learning more about how to improve Medicare Costs may not be as predictable as in Original Medicare or Medicare Advantage Beneficiary may not be able to access their preferred doctors Offered for a limited time only Disadvantages May only be offered for specific population and/or geographic area May-21 APPRISE, Pennsylvania Department of Aging 60
Review: True or False? Question True 1) A Medicare Advantage sales agent is allowed to put out snacks at a table they set up at a local SHIP community presentation. 2) The 5 -Start SEP occurs anytime outside of the AOEP. False ✔ ✔ 3) The annual plan costs generated by the Plan Finder does not include plan premiums in the estimated total. ✔ 4) From Jan 1 - Feb 14, beneficiaries who have been on Medicare more than a year can switch from an MA plan without Rx to one with Rx without paying a late penalty. ✔ 5) Medicare’s AOEP runs from October 15 through December 7 each year. ✔ 6) All Medicare Advantage Plans must send an ANOC to beneficiaries each Spring. 7) Medicare Advantage PACE Plans (known as Life Programs in PA) are available to some beneficiaries age 55 and up with low-income. May-21 APPRISE, Pennsylvania Department of Aging ✔ ✔ 61
This publication has been created or produced by the State of Pennsylvania with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency. May-21 APPRISE, Pennsylvania Department of Aging 62
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