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Part C: Medicare advantage.


D-1. What is Medicare Advantage?

Medicare Advantage (formerly known as Medicare+Choice) permits contracts between the Centers for Medicare & Medicaid Services and a variety of different managed care and fee-for-service entities. Most Medicare beneficiaries may choose to receive benefits through the original Medicare fee-for-service program or through one of the following Medicare Advantage plans:

* Coordinated care plans, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Provider-Sponsored Organizations (PSOs).

* Private fee-for-service plans which reimburse providers on a fee-for-service basis, and are authorized to charge enrolled beneficiaries up to 115% of the plan's payment schedule (which may be different from the Medicare fee schedule).

Since 2005, Medicare Advantage provides for regional preferred provider plans. These plans benefit from unique financial and administrative provisions and incentives under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

D-2. What is a health maintenance organization (HMO)?

An HMO is a managed care plan that provides to its members, who are also Medicare beneficiaries, either directly or through arrangement with others, at least all the Medicare covered services that are available to Medicare beneficiaries who are not enrolled in the HMO who reside in the geographic area serviced by the HMO. Some HMOs also provide services not covered by Medicare, either free to the Medicare enrollee (that is, funded out of the payment Medicare makes to the HMO) or for an additional charge. HMOs typically charge a set monthly premium and nominal copayments for services instead of Medicare's coinsurance and deductibles.

Each plan has its own network of hospitals, skilled nursing facilities, home health agencies, doctors, and other professionals. Depending on how the plan is organized, services are usually provided either at one or more centrally located health facilities or in the private practice offices of the doctors and other health care professionals that are part of the plan. A beneficiary generally must receive all covered care through the plan or from health care professionals referred to by the plan.

Most managed health plans allow the beneficiary to select a primary care doctor from those that are part of the plan. If the beneficiary does not make a selection, one will be assigned. The primary care doctor is responsible for managing the beneficiaries' medical care, including admitting the beneficiary to a hospital or referring the beneficiary to specialists. The beneficiary is allowed to change the primary care doctor as long as another primary care doctor affiliated with the plan is selected.

Before enrolling in a managed care plan, the beneficiary should find out whether the plan has a "risk" or a "cost" contract with Medicare. There is an important difference.

Risk Plans. These plans have "lock-in" requirements. This means that the beneficiary generally is locked into receiving all covered care through the plan or through referrals by the plan. In most cases, if the beneficiary receives services that are not authorized by the plan, neither the plan nor Medicare will pay. The only exceptions recognized by all Medicare-contracting plans are for emergency services, which the beneficiary may receive anywhere in the United States, and for services the beneficiary urgently needs when temporarily out of the plan's service area.

Cost Plans. These plans do not have lock-in requirements. If a beneficiary enrolls in a cost plan, he can either go to health care providers affiliated with the plan or go outside the plan. If a beneficiary goes outside the plan, the plan probably will not pay but Medicare will. Medicare will pay its share of charges it approves. The beneficiary will be responsible for Medicare's coinsurance, deductibles, and other charges, just as if receiving care under the regular Medicare program.

D-3. What is a Medicare Advantage private fee-for-service plan?

A private fee-for-service plan is defined as a plan that reimburses doctors, hospitals and other providers on a fee-for-service basis, does not place them at risk, does not vary payment rates based on utilization, and does not restrict which doctor or hospital the member can use. The insurance plan, rather than the Medicare program, decides how much to reimburse for services received by the beneficiary. The beneficiary pays the Part B premium ($96.40 in 2010 for most beneficiaries--see C-7), any monthly premium the private fee-for-service plan charges, and an amount per visit or service.

D-4. What is a Provider-Sponsored Organization (PSO)?

PSOs are public or private entities established by or organized by a health care provider, such as a hospital, or a group of affiliated health care providers, such as a geriatric unit of a hospital, that provide a substantial proportion of health care items and services directly through that provider or group. Affiliated providers share, directly or indirectly, substantial financial risk and have at least a majority financial interest in the PSO.

D-5. What is a religious fraternal benefit society plan?

These plans may restrict enrollment to members of the church, convention, or group with which the society is affiliated. They must meet Medicare financial solvency requirements and Medicare may adjust payment amounts to these plans to take into account the actuarial characteristics and experience of plan enrollees.


D-6. What is the enrollment/disenrollment process for Medicare Advantage?

Beneficiaries entitled to Hospital Insurance (Part A) and enrolled in Medical Insurance (Part B) are eligible to enroll in a plan that serves the geographic area in which they reside, except beneficiaries with end-stage renal disease (although beneficiaries who develop end-stage renal disease may remain in the plan if already enrolled) and beneficiaries receiving inpatient hospice care. Part B only enrollees are ineligible.

The Centers for Medicare & Medicaid Services has established procedures for enrollment and disenrollment in Medicare Advantage options. Newly eligible enrollees who do not choose a Medicare Advantage plan are deemed to have chosen the original Medicare fee-for-service option, except that the Centers for Medicare & Medicaid Services may (but has not done so) establish procedures under which "age-ins" enrolled in a plan with a Medicare Advantage contract are deemed to have elected that plan for their Medicare coverage. Individuals remain enrolled in the option of their choice until they choose another plan.

D-7. What are the enrollment periods?

Beneficiaries can choose a Medicare Advantage plan at initial eligibility or during one of the enrollment periods described below. From 1998 through 2004, they could enroll (if the plan was open to new enrollees) or disenroll on a monthly basis. For the first six months of 2005 (or the first six months of eligibility in year 2005, in the case of person first eligible for Medicare Advantage in 2005), beneficiaries could enroll and disenroll from plans, but they could only change plans once during that period. The same process applies in years after 2005, except that the freedom to change must be exercised in the first three months of the year (or the first three months of eligibility) or during the annual coordinated enrollment period:

* The annual coordinated enrollment period runs from November 15 through December 31 of each year. Enrollments at this time are effective the following January 1. In conjunction with the annual coordinated enrollment period, the Department of Health and Human Services must sponsor a "Health Information Fair" to publicize Medicare Advantage options.

* Beginning in 2002, special election periods are available in which a beneficiary can disenroll if the plan was terminated, the beneficiary moved out of the plan's service area, the beneficiary demonstrates that the plan violated its contract or misrepresented the plan in marketing, or any other conditions specified by the Centers for Medicare & Medicaid Services.

* Also, beginning in 2002, newly eligible beneficiaries who elect a Medicare Advantage option may disenroll into the original Medicare fee-for-service option any time during the first 12 months of their enrollment.

Plans must accept all beneficiaries on a first-come-first-serve basis, subject to capacity limits.

Plans may only disenroll beneficiaries for cause (i.e., failure to pay premiums or disruptive behavior) or plan termination in the beneficiary's geographic area. Beneficiaries terminated for cause are enrolled in the original Medicare fee-for-service program. Others may have a special election period.

Medicare Advantage plans must submit marketing materials, including application forms, to the Centers for Medicare & Medicaid Services at least 45 days prior to distribution. The material must be approved by the Department of Health and Human Services. Medicare Advantage plans must conform to fair marketing standards, including a prohibition on the plan from offering cash or rebates. If a plan's marketing materials were approved for one service area, they will be deemed to be approved in all of the plan's service areas, except in regard to area-specific information.

Note: Organizations cannot contract to enroll Medicare beneficiaries under the Medicare Advantage program until they have met standards of the Department of Health and Human Services.

D-8. How is information provided to beneficiaries?

At least 15 days before the required November coordinated election period (see D-7), the Centers for Medicare & Medicaid Services must mail to each beneficiary general information on Medicare and comparative information on Medicare Advantage plans available in their area. General information includes information on covered benefits, cost sharing, and balance billing liability under the original fee-for-service program; election procedures; grievance and appeals rights; and information on Medigap insurance and Medicare SELECT. Comparative information includes extensive information on benefits and beneficiary liability; premiums; service areas; quality and performance; and supplemental benefits. The Centers for Medicare & Medicaid Services must make available a toll-free number for inquiries on Medicare Advantage options and an Internet site providing information on Medicare Advantage options.


D-9. What basic benefits are provided by Medicare Advantage plans?

All Medicare Advantage plans are required to provide the current Medicare benefit package (excluding hospice services) and any additional health services required under the adjusted community rate (ACR) process.

Medicare Advantage plans may offer mandatory supplemental benefits, subject to approval by the Centers for Medicare & Medicaid Services. Mandatory supplemental benefits must be approved unless it is determined that offering such benefits would substantially discourage enrollment. Medicare Advantage plans may also offer optional supplemental benefits. Private fee-for-service plans may offer supplemental benefits that include payment for some or all of the permitted balance billings amounts and additional services that the plan determines are medically necessary.

Medicare Advantage plans must provide payments to non-contracting providers or other persons so that the total payments (the plan's payment plus any cost sharing) are equal to at least the total payment that would have been paid under Medicare fee-for-service, including any balance billing amounts.

D-10. What standards must Medicare Advantage plans meet for protection of beneficiaries?

In general, Medicare Advantage plans must meet standards similar to those related to disclosure, access, quality, grievances and appeals, confidentiality, and information on advance directives.

D-11. What are the rules regarding antidiscrimination?

Medicare Advantage plans cannot screen enrollees based on their health, nor can they discriminate with respect to participation, payment, or indemnification against any provider acting within the scope of the provider's license or certification. But a Medicare Advantage plan is not limited in its ability to selectively contract.

D-12. What are the rules regarding disclosure to enrollees?

A Medicare Advantage plan must provide in a clear, accurate, and standardized form certain information to each enrollee, such as the plan's service area, benefits, number, mix and distribution of providers, out-of-area coverage, emergency coverage, supplemental benefits, prior authorization rules, appeals and grievance procedures, and quality assurance program. Upon request, enrollees must be provided comparative information, information on the plan's utilization control mechanisms, information on the number of grievances and appeals, and compensation arrangements.

D-13. What are the access to services requirements for Medicare Advantage plans?

Medicare Advantage plans are permitted to select the providers who may furnish benefits to enrollees, as long as benefits are available and accessible to all enrollees with reasonable promptness and assured continuity, 24 hours a day, 7 days a week. The plan must also cover services provided other than through the organization for (1) non-emergency services needed immediately because of an unforeseen illness or injury, if it was not reasonable to obtain the services through the plan, (2) renal dialysis services for enrollees who are temporarily out of the plan's service area, and (3) maintenance or post-stabilization care after an emergency condition has been stabilized, subject to guidelines by the Centers for Medicare & Medicaid Services.

Medicare Advantage plans are required to pay for emergency services without regard to prior authorization or whether the provider has a contractual relationship with the plan. An emergency medical condition is defined using a "prudent layperson" standard (including conditions that may be manifested by "severe pain").

Private fee-for-service plans must demonstrate that the plan includes a sufficient number and range of providers willing to furnish services. This requirement is presumed to have been met if the plan has established payment rates that are not less than payment rates under Medicare, and/or has contracts or agreements with a sufficient number and range of providers.

D-14. Is there a quality assurance program for Medicare Advantage plans?

Medicare Advantage plans must have an internal quality assurance program. There are numerous requirements for internal quality assurance programs, but private fee-for-service plans must meet only a subset of those requirements, plus two requirements specific to those plans. Plans can meet internal quality assurance requirements by receiving accreditation from a private organization approved by Centers for Medicare & Medicaid Services. Medicare Advantage plans (except private fee-for-service plans that do not employ utilization review) must also undergo external quality reviews by QIOs or independent review organizations. Except in the case of the review of quality complaints, the Centers for Medicare & Medicaid Services is required to ensure that the external review activities are not duplicative of the review activities conducted as part of the accreditation process. The Centers for Medicare & Medicaid Services can waive external review requirements for organizations with good track records.

D-15. How are grievances handled by Medicare Advantage plans?

Medicare Advantage plans must maintain meaningful procedures for hearing and resolving grievances. Medicare Advantage plans must have a procedure for making determinations regarding whether an enrollee is entitled to receive services and the amount the individual is required to pay for such services. Determinations must be made on a timely basis. The explanation of a plan's determination must be in writing and must explain the reasons for the denial in understandable language and describe the reconsideration and appeals processes. The time period for reconsiderations will be specified by the Centers for Medicare & Medicaid Services (CMS) but must not be greater than 60 days after the request by the enrollee. Reconsiderations of coverage determinations to deny coverage based on lack of medical necessity must be made by a physician with expertise in the field of medicine which relates to the condition necessitating treatment.

Plans are required to have an expedited review process in cases where the normal time frame for making a determination or reconsideration could seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function. Either the beneficiary or the physician can request an expedited review. Requests for expedited reviews made by physicians (even those not affiliated with the organization) must be granted by the plan. Expedited determinations and reconsiderations must be made within time periods specified by the CMS, but not later than 72 hours after the request for expedited review, or such longer period as the CMS may permit in specified cases.

The CMS is required to contract with an independent, outside entity to review and resolve plan reconsiderations not favorable to the beneficiary. If the independent review is unfavorable to the beneficiary, the beneficiary has the right to the same appeals process (e.g., Administrative Law Judge, judicial review) as under existing HMO procedures.

D-16. Are there special rules covering provider participation?

Yes, a Medicare Advantage plan must establish procedures relating to participation of physicians in the plan, such as notice of rules of participation, written notice of adverse participation decisions, and an appeals process. Medicare Advantage plans must consult with participating physicians regarding medical policy, quality, and medical management procedures.

Plans are prohibited from restricting health care professionals from advising their patients about the patient's health status or treatment options.

A provider, health professional, or other entity is treated as having a contract with a private fee-for-service plan if the provider, health professional, or other entity furnishes services that are covered under a private fee-for-service plan, and before providing those services, was informed of the individual's enrollment, and either was informed of the terms and conditions of payment for the services under the private fee-for-service plan or was given a reasonable opportunity to obtain information concerning the terms and conditions.

D-17. Are there billing limits under Medicare Advantage?

Non-contracting physicians and other entities must accept as payment in full the amount that would have been paid under Medicare fee-for-service. Non-contracting providers must also accept as payment in full, the amount that would have been paid under Medicare.

Contracting physicians, providers, and other entities of private fee-for-service plans must accept as payment in full an amount not to exceed (including any deductibles, coinsurance, copayments or balance billing permitted under the plan) an amount equal to 115% of the plan's payment rate. Plans must establish procedures to carry out this requirement. If a plan does not establish and enforce its procedures, the plan is subject to intermediate sanctions.

Private fee-for-service plans must provide enrollees with an explanation of benefits that includes a clear statement regarding enrollee liability, including any balance billing. The plan must also provide that the hospital give enrollees prior notice before they receive inpatient services and certain other services, when the amount of balance billing could be substantial. The notice must include a good faith estimate of the likely amount of balance billing based upon the presenting conditions of the enrollee.


D-18. How do Medicare Advantage plans submit proposed premiums?

All Medicare Advantage plans must submit to the Centers for Medicare & Medicaid Services (CMS) information on enrollment capacity. Managed care plans must submit adjusted community rate (ACR) proposals for basic and supplemental benefits, the plan's premium for the basic and supplemental benefits, a description of cost sharing, the actuarial value of cost sharing for basic and supplemental benefits, and a description of any additional benefits and the value of these benefits. Private fee-for-service plans must submit ACRs for basic and additional benefits, the premium for the basic and additional benefits, a description of cost sharing and the actuarial value of the cost sharing, a description of additional benefits and the actuarial value of these benefits, and the supplemental premium.

In general, CMS must review ACRs, premiums, and the actuarial values and approve or disapprove these rates, amounts, and values. But CMS will not review premiums of private fee-for-service plans.

Important: Organizations cannot contract to enroll Medicare beneficiaries under the Medicare Advantage program until they have met standards published by CMS.

D-19. What other premium rules should a beneficiary know about?

* A Medicare Advantage plan can terminate an enrollee for failure to pay premiums, but only under specified conditions.

* A Medicare Advantage organization cannot offer cash or other monetary rebates as an inducement for enrollment or otherwise.

* Premiums cannot vary among plan enrollees.

* No state can impose a premium tax or similar tax on premiums of Medicare Advantage plans or the offering of these plans.


D-20. How does a plan become part of the Medicare Advantage program?

A Medicare Advantage plan must generally be organized and licensed under state law as a risk bearing entity to offer health insurance or health benefits coverage.

Special rules formerly applied to Provider-Sponsored Organizations (PSOs). A PSO could seek a waiver from the requirement that it be licensed under state law by filing an application with the Centers for Medicare & Medicaid Services (CMS) no later than November 1, 2002. Waivers were effective for three years, were not applicable in any other state, and were not renewable.

New regional Preferred Provider Organizations are also eligible for temporary waiver of state licensure requirements. This is intended to facilitate the introduction of these multi-state plans. The CMS has indicated that it will grant these waivers only in cases where the organization is licensed in one state and has submitted applications in the other states. The length of the waiver will typically be for less than one year, but will depend on how long states take to process applications.

A plan cannot receive payment from Medicare unless it has a contract with the CMS. The contract period is for one year and may be automatically renewed in the absence of notice by either party of intention to terminate.

The CMS can terminate a contract if (1) the organization has failed to substantially carry out the contract, (2) the organization was carrying out the contract in a manner substantially inconsistent with the efficient and effective administration of the Medicare Advantage program, or (3) the organization no longer substantially meets Medicare Advantage conditions. The CMS may not contract with a plan that has been terminated within the last five years, except in special circumstances determined by the Administrator of the CMS.

Medicare Advantage plans must meet minimum enrollment requirements: 5,000 for plans in urban areas (1,500 for PSOs), 1,500 for plans in rural areas (500 for PSOs). These requirements can be waived in the first three contract years.

Medicare Advantage plans must provide prompt payment to non-contracting providers and to enrollees in the case of private fee-for-service plans. If the CMS determines (after notice of an opportunity for a hearing) that the plan has failed to pay providers or enrollees promptly, it can provide for direct payment. In these cases, the Centers for Medicare & Medicaid Services will reduce Medicare Advantage payments accordingly.

The CMS may impose intermediate sanctions if the plan (1) fails to provide medically necessary services required under law or the contract and the failure adversely affects or has the substantial likelihood of adversely affecting the enrollee, (2) imposes premiums in excess of the premium permitted, (3) acts to expel or refuses to re-enroll an individual in violation of the Medicare Advantage requirements, (4) engages in practices that effectively deny or discourage enrollment, (5) misrepresents or falsifies information to the CMS or to others, (6) violates rules regarding physician participation, (7) employs or contracts with individuals who are excluded from participation in Medicare, or (8) performs any other actions that are grounds for termination and, in the case of private fee-for-service plans, does not enforce balance billing limits. The remedies may include civil money penalties, suspension of enrollment, or suspension of payment.

Medicare Advantage plans must assume full financial risk for the provision of Medicare services except that plans can (1) obtain insurance or make other arrangements for costs in excess of amounts periodically determined by the Centers for Medicare & Medicaid Services (2) obtain insurance or make arrangements for services needing to be provided other than through the plan, (3) obtain insurance or make other arrangements for not more than 90% of the amount by which its fiscal year costs exceeded 115% of its income for the year, or (4) make arrangements with providers or health institutions to assume all or part of the risk on a prospective basis for the provision of basic services.


D-21. What rules apply regarding Medigap insurance and Medicare Advantage plans?

A Medigap insurance policy cannot be sold or issued to an individual with the knowledge that the policy duplicates health benefits to which the individual is entitled under the Medicare Advantage plan or another Medigap policy, unless accompanied by a written disclosure statement.

A Medicare Advantage plan is not considered a Medigap insurance policy. Medigap insurance policies supplement original fee-for-service Medicare coverage while a Medicare Advantage plan is an alternative to original fee-for-service Medicare coverage. See Section F for more information on Medigap insurance.

D-22. What are the special rules regarding Medigap protections under the Medicare Advantage program?

If an individual described below seeks to enroll in a Medigap policy within 63 days of the events described below, the issuer may not (1) deny or condition the issuance of a Medigap policy that is offered or available, (2) discriminate in the pricing of a policy because of health status, claims experience, receipt of health care, or medical condition, and (3) impose a preexisting condition exclusion. See Section F for more information about Medigap insurance.

There is guaranteed issuance of Medigap insurance policies "A", "B", "C", or "F" for:

(1) Individuals enrolled under an employee welfare benefit plan that provides benefits supplementing Medicare if the plan terminates or ceases to provide all benefits.

(2) Persons enrolled with a Medicare Advantage organization who discontinue under circumstances permitting disenrollment other than during an annual election period. These include (1) the termination of the entity's certification, (2) the individual moves outside the entity's service area, or (3) the individual elects termination due to cause.

(3) Persons enrolled with a risk or cost contract HMO, a similar organization operating under a demonstration project authority, a health care prepayment plan, or a Medicare SELECT policy, if enrollment ceases under the same circumstances that permit discontinuance of a Medicare Advantage election. In the case of a SELECT policy, there must also be no applicable provision in state law for continuation of the coverage.

(4) Individuals enrolled under a Medigap policy if enrollment ceases because of the bankruptcy or insolvency of the issuer, or because of other involuntary termination of coverage (and there is no provision under applicable state law for the continuation of coverage), or the issuer violated or misrepresented a provision of the policy.

There is guaranteed issuance of Medigap insurance plans "A", "B", "C", "F" or the Medigap insurance policy that the individual most recently previously enrolled in, if the individual (1) was enrolled under a Medigap policy, (2) subsequently terminates enrollment and enrolls with a Medicare Advantage organization, a risk or cost contract HMO, a similar organization operating under a demonstration project authority or a Medicare SELECT policy, and (3) terminates the Medicare Advantage enrollment within 12 months, but only if the individual was never previously enrolled with a Medicare Advantage organization.

There is guaranteed issuance of any Medigap plan to an individual who upon first becoming eligible for Medicare at age 65, enrolled in a Medicare Advantage plan, and disenrolled from the plan within 12 months of the effective date of enrollment.


D-23. What are the rules about the marketing of Medicare Advantage plans?

In 2008, the Centers for Medicare & Medicaid Services (CMS) issued final regulations governing the marketing of Medicare Advantage plans (Part C). Plans and agents must have been in compliance with the new regulations when they began their marketing activities on October 1, 2008 for the 2009 open enrollment period.

On May 16, 2008, CMS issued proposed regulations governing Medicare Part C, including new restrictions on the marketing of Part C plans to Medicare beneficiaries. On July 15, 2008, Congress enacted the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Section 103 of MIPPA, effective for plan years beginning on January 1, 2009, established new statutory prohibitions and limitations on sales and marketing activities, many of which were similar (or identical) to the CMS proposed regulations. The final regulations implemented those rules immediately.

Among other prohibitions, Section 103 of MIPPA and the final regulations significantly restrict the marketing of Medicare Part C plans:

* The rules broadly prohibit "cold calls" and other unsolicited contact. This prohibition includes door-to-door sales and unsolicited telephone calls. The rules do not prohibit plan mailings, but the final regulations prohibit calling to confirm that the beneficiary received the mailing. Agents may call in response to specific requests by beneficiaries to be contacted.

* The rules prohibit sales activities at educational events. Events designed to provide the public with objective information about Medicare must be free of any marketing materials or enrollment information for a specific plan or organization. Plans and agents may hold sales events that are clearly labeled as such, but they may not be disguised as educational events.

* The rules prohibit plans and agents from providing meals at Medicare sales meetings. CMS has not yet defined the terms, but light refreshments and "snacks" are permissible.

* The rules prohibit sales activities in settings where individuals receive healthcare services. This rule permits marketing in common areas such as waiting rooms, but prohibits marketing in treatment rooms. Plans may arrange meetings with residents in long-term care facilities as with any other private residence.

* The rules prohibit marketing any non-health insurance product (such as life insurance or annuities) during a Medicare marketing or sales meeting.

The rules also require agents to document that, prior to making an appointment, beneficiaries agree to the scope of products to be discussed at the meeting. Appointments made in person require written documentation; appointments made over the phone require recorded documentation. At a meeting in an agent's office or on the phone, additional products may not be discussed unless the beneficiary requests the information. In a meeting at a beneficiary's home, an agent may not discuss any product not within the originally-identified scope of the meeting. They must schedule a separate appointment at least 48 hours later.
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Publication:All About Medicare
Date:Jan 1, 2010
Previous Article:Part B: medical insurance.
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