You may elect a Medicare Advantage option if you are entitled to Part A and enrolled in Part B of Medicare, you do not have end-stage renal disease, and you live in a geographic area served by the option. Possible Medicare Advantage options became available January 1, 1999. The Medicare Advantage options include:
- Health Maintenance Organizations (HMOs). MOs provide or make available health care services that may include preventive medical care and pharmacy services for which an enrolled person pays a pre-determined monthly rate. HMOs are available to those persons living in specified geographical areas. Generally, members must receive health care services from the HMO staff at a designated HMO facility, although some emergencies are covered at facilities outside the normal service area.
- Preferred Provider Organizations (PPOs). Generally in a PPO you can see any doctor or provider that accepts Medicare. You don’t need a referral to see a specialist or any provider out-of-network. If you go to doctors, hospitals or other providers who aren’t part of the plan (out-of-network or non-preferred), you will usually pay more.
- Private Fee-For-Service (PFFS) Plans. Medicare Private Fee-for-Service Plans are fee-for-service plans offered by private companies. The general rules for how Medicare Private Fee-for-Service Plans work are below:
- You can go to any Medicare-approved doctor or hospital that accepts the terms of your plan’s payment.
- You 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 how much it will pay and what you pay for the services you get.
- If you’re in a Medicare Private Fee-for-Services Plan, you can get your Medicare prescription drug coverage from the plan if it’s offered, or you can join a separate Medicare Prescription Drug Plan to add prescription drug coverage if drug coverage isn’t offered by the plan.
- Medicare Savings Accounts (MSAs). Medicare MSA Plans have two parts: a high-deductible plan and a bank account. Medicare gives the plan an amount each year for your health care, and the plan deposits a portion of this money into your account.
- Special Needs Plan (SNPs). SNPs serve people who either 1) live in certain institutions (like a nursing home) or who require nursing care at home, or 2) are eligible for both Medicare and Medicaid, or 3) have one or more specific chronic or disabling conditions (like diabetes, congestive heart failure, mental illness, or HIV/AIDS.
Most Medicare beneficiaries are eligible for enrollment in a Medicare Advantage plan, and most parts of the country are served by one or more plans that have contracts with the Centers for Medicare and Medicaid Services (CMS) to serve Medicare beneficiaries. The only enrollment requirements are:
- You must at least be enrolled in Medicare Part B and continue to pay the Part B monthly premium. The premium is $115.40 for 2011.
- You cannot have elected care from a Medicare-certified hospice, and you cannot be medically determined to have end-stage renal disease (ESRD).
- You must live within the area in which the plan has a Medicare contract to provide services.
- The plan must enroll Medicare beneficiaries, including younger disabled Medicare beneficiaries without health screening.
How and when can a beneficiary disenroll?
Once you are enrolled in an HMO, you may wish to disenroll at some point. Whether you stay enrolled or leave an HMO is your decision. Your HMO cannot try to keep you from disenrolling, nor can the HMO try to get you to leave.
To disenroll, a beneficiary should state in writing that he or she wants to withdraw from the plan and return to fee-for-service Medicare coverage. The written statement should go to either the plan’s administrative office, the local Social Security Administration or, if appropriate, the Railroad Retirement Board office. The coverage under the fee-for-service system will begin the first day of the following month.
If you want to change from one managed care plan to another, you may do so by simply enrolling in the other plan as long as it has a Medicare contract. You will be automatically disenrolled from the first plan.
If you disenroll from an HMO, return to original Medicare and do not purchase a Medicare supplemental insurance policy, you will have to pay any deductibles or coinsurance under the payment rules of the traditional Medicare program.