The most common versions of Medicare Advantage available in Louisiana:
- Health Maintenance Organization (HMO). This is a managed care plan with a network of providers who contract with an insurance company. You choose a primary care physician who coordinates your care. You agree to follow the rules of the HMO and use the HMO’s providers.
- Preferred Provider Organization (PPO). This is another managed care plan. It is formed by a group of doctors, hospitals, and other providers who contract with an insurance company. You do not have to choose a primary care physician. You can go outside of the network, but you will pay higher deductibles and copayments when you do.
- Private Fee for Service Plans (PFFS). This is an insurance plan, not a managed care plan. The plan, not Medicare, sets the fee schedule for providers, but providers can bill up to 15% more. You see any providers you choose, as long as the provider agrees to accept the payment schedule. Medical necessity is determined by the plan. The plan does not have to have a quality assurance program.
Medicare Advantage Plans include the following beneficiary protections:
- Care must be available 24 hours per day, seven days a week.
- Doctors must be allowed to inform you of all treatment options.
- Guaranteed Issue: The plan must enroll you if you meet the requirements.
- If a layperson would think that a symptom could be an emergency, then the plan must pay for the emergency treatment.
- If your treatment plan includes specialists, you must have direct access to those specialists. You do not need a referral from your primary care physician.
- The plan cannot charge more than a $100 copayment for visits to the emergency room.
- The plan must have a grievance and appeal procedure.
- The plan must have a process for identifying and evaluating persons with complex or serious medical conditions. A treatment plan must be developed within 90 days of your enrollment.
- You must have access to specialists.
- You or your doctor can appeal a denial of service and the appeal must be handled in a “timely” way. The plan must make an initial determination within 14 days. Reconsideration of a decision must be made within 30 days. Decisions regarding urgent care must be made within 72 hours.
Other common elements of Medicare Advantage plans:
- All plans have a contract with the Centers for Medicare and Medicaid Services (Medicare).
- All plans may provide additional benefits or services not covered by Medicare.
- All plans, except for Private Fee-for-Service, must have a quality assurance program.
- Each plan must offer an annual enrollment period.
- The Centers for Medicare and Medicaid Services (Medicare) pays the plan a set amount for each month that a beneficiary is enrolled.
- The plan must enroll anyone in the service area who has Part A and Part B, except for end-stage renal disease patients.
- There is usually less paperwork for you.
- You must pay your Medicare Part B premium.
- You pay any plan premium, deductibles, or copayments.
Pro’s and Con’s of Medicare Advantage plans:
- If you are under 65 with Medicare due to a disability, you may enroll in a Medicare Advantage plan and not be denied.
- Medicare Advantage plans cannot turn you down due to age, poor health, or pre-existing conditions during the Annual Open Enrollment Period from October 15 to December 7 of each year or when you first become eligible for Medicare. (Exceptions: You can be turned down if you have end-stage renal disease.)
- Medicare Advantage plans may provide Part D coverage. If you want drugs included you will need to enroll with a plan that offers drug coverage and verify it covers YOUR medication.
- Medicare Advantage plans may provide some services that Medicare doesn’t usually cover, such as routine physicals and foot care, dental care, eye exams, prescriptions, hearing aids, and other preventive services.
- Medicare Advantage plans must provide all Medicare covered services and are approved by Medicare.
- Medicare HMOs may provide some services that Medicare doesn’t usually cover, such as routine physicals and foot care, dental care, eye exams, prescriptions, hearing aids, and other preventive services.
- Medicare requires and monitors quality assurance for doctors and facilities.
- The Medicare Advantage plans must enable you to appeal denial of claims or services. If the service is still denied, then you have other appeal rights with Medicare.
- You have 24-hour access to services, including emergency or urgent care with providers outside of the network. This includes foreign travel not covered by Medicare.
- You have no bills or claim forms to complete. Filing and organizing of claims is done by the Medicare Advantage plan.
- You usually have less out-of-pocket expenses, such as premiums, copayments for doctor services and prescription drugs. You do not need a Medicare supplement policy. If you have a Medicare Supplement (Medigap) plan, YOU are responsible for notifying the company in writing when you wish to drop/disenroll from such plan.
- A provider could leave the plan, or the plan’s contract with Medicare could be canceled. Then, you would have to find another Medicare Advantage plan or get a Medicare Supplement Policy to go with your Original Medicare.
- If you live outside of the plan area for 12 or more months in a row, the Medicare Advantage plan may ask you to disenroll and re-enroll when you return to the area. However, if a Medicare Advantage plan is available where you are living outside of Louisiana, you could enroll in it for coverage while you were outside of your regular plan area, and then re-enroll in your Louisiana plan when you return home.
- If your Primary Care Physician (PCP) leaves the plan, then you would have to choose another PCP.
- Medicare Advantage plans that include prescription coverage may require you to use particular medications to lower their costs and yours.
- When you travel outside of the plan’s service area, you are only covered for emergency or urgent care. For routine health care services, you would need to return to your Primary Care Physician.
- You must follow the rules and use the providers in the plan, except for emergency or urgently needed care. (Exception: PPOs allow you to use providers outside of the network, and Medicare will still pay 80% of the approved amount. PFFSs do not have a network of providers, but your provider may not accept the plan.)
- You must get a referral from your Primary Care Physician to receive care from health care providers outside of the network, or the plan will not pay (unless you are in a PPO or PFFS).
- You must live within the service area of the Medicare Advantage plan. If you move outside of the service area, then you must join a different plan or get a Medicare supplement policy to go with your Original Medicare.
- Your current doctor or hospital may not be part of the Medicare Advantage network, so you would have to choose a new doctor or hospital.