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Advantage Plans

Medicare Advantage (Part C) Plans in Pennsylvania

A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, you still have Medicare. You will get your Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from the Medicare Advantage Plan and not Original Medicare. In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan. Medicare Advantage Plans aren’t supplemental coverage.

Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan.

Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you have to go to only doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care). These rules can change each year.

There are several different types of Medicare Advantage Plans. The most common are:

  • Health Maintenance Organization (HMO) Plans—In most HMOs, you can only go to doctors, other health care providers, or hospitals on the plan’s list except in an emergency. You may also need to get a referral from your primary care doctor.
  • Preferred Provider Organization (PPO) Plans—In a PPO, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network.
  • Private Fee-for-Service (PFFS) Plans—PFFS plans are similar to Original Medicare in that you can generally go to any doctor, other health care provider, or hospital as long as they agree to treat you. The plan determines how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.
  • Special Needs Plans (SNP)—SNPs provide focused and specialized health care for specific groups of people, such as those who have both Medicare and Medicaid, who live in a nursing home, or have certain chronic medical conditions.

APPRISE recommends—as it does for other Medicare options—that you review a Medicare Advantage plan every fall, during the open-enrollment period. Sometime, people become too dependent on a particular plan. And they can be devastated when it goes through changes.

According to a report from the Philadelphia-based Center for Advocacy for the Rights and Interests of the Elderly (CARIE):

In early fall 2009, Independence Blue Cross announced it would be discontinuing its Keystone 65 Complete plan, a Special Needs Plan, and its Keystone Value Plan, a zero premium Medicare Advantage plan, as well as its Personal Choice PPO plan in Chester, Delaware and Montgomery Counties. Later in the fall, Aetna and Evercare announced the discontinuation of additional Medicare Advantage plans. In sum, Medicare beneficiaries in Southeastern Pennsylvania were facing the loss of several Medicare Advantage plans impacting approximately 64,550 Medicare beneficiaries, including about 32,050 dually eligible beneficiaries. (The majority of beneficiaries were enrolled in Blue Cross plans.) These plan discontinuations, when coupled with Medicare’s Annual Open Enrollment Period, placed a huge strain on the local APPRISE (Pennsylvania’s State Health Insurance Assistance Program or SHIP) programs and other professionals in the community. The anxiety and fear among beneficiaries was high as they faced many complex choices and deadlines.

Among the conclusions that CARIE found:

  1. The letters CMS mailed to beneficiaries were inaccurate, too complicated and confusing.
  2. CMS restricts the frequency of communication health insurers can distribute to current members.
  3. Not all consumers knew their current plan name.
  4. Medicare’s website and toll free number need to be featured in all communications.
  5. Part D auto enrollment occurred in early December without notifying APPRISE or the public.
  6. Information was not communicated to professionals in the aging and disability network.
  7. Those not dually eligible face limited options.
  8. CMS should monitor the customer service being provided by insurance providers during these transitions.
  9. The local APPRISE programs were not equipped to respond to the onslaught of callers needing help.
  10. There was an increased need for additional community outreach sessions.
  11. Other community agencies, providers and professionals were in need of information.
  12. There needs to be more direction in addressing the needs of persons with disabilities.