AHIP TRAINING MODULE #2 (Q & A)

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LOPEZ has heard that he can sign up for a product called MA, but is not sure about what type of plan designs are available through this program (MA plan, types) - ANSWER They are Medicare health plan... s such as HMO, PPO, PFFS, SNP AND MSA WHALEN is trying to understand the difference between Original Medicare and MA. (MA vs Original Medicare) - ANSWER MA is a way of covering ALL of the Original Medicare benefits through private health insurance companies. During a sales presentation in Ms. Sully's home, she tells you that she has hearing about a type of Medicare plan known as PFFS. She wants to know if this would be available to her. (MA-PFFS) - ANSWER A PFFS plan is one of various types of MA plans offered by private entities and she may enroll in one if it is available in her area. RADFORD asks whether there are any special eligibility requirement s for MA (MA requirements/eligibility) - ANSWER Mrs. Radford MUST be entitled to Part A and enrolled in Part B to enroll in MA. BASS lives on a limited fixed income and is concerned about the cost of healthcare. What should you tell her about the sort of help available to low income individuals under the Medicare program? (Help for individuals with limited income/resources) - ANSWER As a Medicare beneficiary with limited income/resources she may contact her State Medicaid agency to apply for assistance paying for the Part B premium and cost sharing and Part D Rx coverage. KUMAR is considering MA HMO and has questions about his ability to access providers. (MA HMO providers) - ANSWER In MOST MA HMO's, Mr. Kumar MUST obtain his services only from providers who have a contractual relationship with the plan (Except in an Emergency) RAMOS is considering a MA PPO and has questions about which providers she can go to for her health care. (MA PPO providers) - ANSWER Mrs. Ramos can obtain care from any provider who participates in Original Medicare, but generally will be charged a lower co-payment if she goes to one of the plan's PREFERRED providers. SINCLAIR has diabetes and heart trouble and is generally satisfied with the care he has received under Original Medicare, but he would like to know more about MA SNP. (MA SNP eligibility) - ANSWER SNP's have special programs for enrollees with chronic conditions, like Mr. Sinclair, and they provide Rx coverage that could be very helpful as well. GRECO is in excellent health, lives in his own home, and has a sizeable income from his investments. He has a friend enrolled in a MA SNP. His friend has mentioned that the SNP charges very low cost sharing amts. and Mr. Greco would like to join the plan. (MA SNP eligibility) - ANSWER SNP LIMIT enrollment to certain sub-populations of beneficiaries. Given his current situation, he is unlikely to qualify and would NOT be able to enroll in the SNP GOMEZ notes that a PFFS plan available in his area has an attractive premium. He wants to know if he must use doctors in a network like his current HMO plan requires him to do. (MA PFFS providers) - ANSWER He may receive health care services from ANY doctor allowed to bill Medicare, as long as he shows the doctor the plan's identification card and the doctor agrees to accept the PFFS plan's payment terms and conditions, which could include balance billing. LEE is discussing with you the possibility of enrolling in a PFFS plan. As part of the discussion, what should you be sure to tell her? (MA PFFS) - ANSWER If she uses NON-NETWORK providers, he doctors and hospital could decide whether to treat her on a VISIT BY VISIT basis. McTAGGERT notes that a PFFS plan available in his area has an attractive premium. He wants to know what makes them different from an HMO or a PPO. (MA PFFS vs. HMO or PPO) - ANSWER Enrollees in a PFFS plan can obtain care from ANY provider in the US, who accepts Original Medicare, as long as the provider has a reasonable opportunity to access the plan's terms and conditions and agrees to accept them. Dr. Elizabeth Brennan does not contract with the PFFS plan, but accepts the plan's terms and conditions for payment, how will she get paid? (MA PFFS provider payment) - ANSWER Generally, the PFFS plan will pay Dr. Brennan directly the same amt. Original Medicare would pay her. LYONS is in good health, uses a single Rx, and lives independently in her own home. She is attracted by the idea of maintaining control over a MSA, but is not sure if the plan associated with the acct. will fit her needs. (MA MSA) - ANSWER ALL MSA's cover Part A and Part B benefits, but NOT Part D Rx benefits, which could be obtained by also enrolling in a separate Rx plan. DAVIES is turning 65 next month. he would like to enroll in a Medicare health plan, but does not want to be limited in terms of where he obtains his care. What should you tell him about how a Medicare cost plan might fit his needs. (MA costs) - ANSWER Cost plan enrollees can choose to receive Medicare covered services under the plan's benefits by going to plan network providers and paying plan cost sharing, or may receive services from Non-network providers and pay cost-sharing due under Original Medicare. ROMERO is 64, retiring soon, and considering enrollment in his employer-sponsored retiree group health plan that includes Rx coverage with nominal copays. He heard about a neighbor's MA-PD plan that you represent and because he takes numerous Rx's, he is considering signing up for it. (MA-PD_ - ANSWER It is ALWAYS the best option to talk with his benefits administrator to see whether he needs both an employer sponsored plan and a private MA-PD and what might happen if he were to sign up for both. WALTER'S is enrolled in her state's Medicaid program in addition to Medicare. What should she be aware of when considering enrollment in a Medicare Health plan? (Medicaid) - ANSWER Medicaid will coordinate benefits ONLY with Medicaid participating providers. ANDREWS asked how a PFFS plan might affect her access to services since she receives some assistance for her health care costs from the State. What should you tell her? (PFFS and Medicaid) - ANSWER Medicaid may provide additional benefits, but Medicaid will coordinate benefits ONLY with Medicaid participating providers. LOMBARDI is interested in a MA PPO plan that you represent. It is one of three plan operated by the same organization in Mr. Lombardi's area. The MA-PPO plan does NOT include drug coverage, but the other two plans do. Mr. Lombardi likes the PPO plan that does not include drug coverage and intends to obtain his drug coverage through a stand-alone Medicare Rx plan. (MA PPO) - ANSWER He could enroll in one of the MA plans that include Rx coverage or a Medigap plan and a stand-alone Rx plan, but he CAN'T enroll in the MA-only PPO plan and a stand-alone Rx plan. CHOU likes a PFFS plan available in her area that does not offer drug coverage. She wants to enroll in the plan and enroll in a stand-alone Rx plan. What should you tell her? (MA-PFFS) - ANSWER She COULD enroll in a PFFS plan and a stand-alone Medicare Rx plan. Medicare Advantage plans - ANSWER **Private companies offer health plan that cover all Medicare Part A and B benefits. --Many also cover Part D Rx benefits MA-PD plans --ALL MA plans offer a max out of pocket limit. --Many MA plans offer extra benefits that Medicare DOESN'T cover --Certain plans can restrict enrollment eligibility to: ****SNP; employees and/or retirees waiver plans*** Other types of Medicare plans such as: MEDICARE COST PLANS; PACE PLANS; MEDICARE-MEDICAID; DEMONSTRATION PLAN; AND PILOT PROGRAMS Types of MA plans are: - ANSWER --HMOs; some have a POS benefit --PPO, local and regional --PFFS --MSA MA Eligibility - ANSWER --Must be entitled to Part A AND enrolled in Part B --Must live in MA plan's service area --Must continue to pay Part B premium --May need to pay a MA plan premium MA limited income help from state or CMS to pay: - ANSWER --Part A and B premiums, deductibles and cost sharing --Some Part D Rx costs and/or some benefits NOT covered by Medicare (personal care or rides to doctor appts. MA HMO Coordinate Care Plans - ANSWER -enrollees MUST use doctors and hospitals within plan networks to receive most covered services -ER and urgently needed services outside plan network are covered -temporarily absent from plan's service area, dialysis are covered -OTHER CASES if care is out of network w/o prior authorization from the plan, they have to pay it themselves. -MUST have a max limit on member out of pocket costs not greater than $6,700 per year and many plans have lower limits. MA POS Coordinate Care Plans - ANSWER -allows to go to non-plan doctors and hospitals w/o prior authorization for certain services -cost sharing is higher than services obtained from network providers -may need to select a PCP and need referral for specialty care -if needs specialist who is NOT in network, plan will arrange for care outside of network. MA PPO Coordinate Care Plans - ANSWER -May get care from ANY provider in US who accepts Medicare, but will pay less if goes to "preferred" provider network. -Usually pay higher cost sharing if use non-preferred provider -Must have max limit on member out of pocket cost for network providers of NOT greater than $6,700 per year and aggregate limit on network and non-network cost of $10,000 -Enrollees DON'T need a referral to see out of network provider, may be encouraged to contact the plan to be sure service is medically necessary and will be covered MA SNP Coordinate Care Plans - ANSWER -Must limit new enrollees to certain sub-population of beneficiaries -Only plan type that can limit enrollment to these populations -Types include: Dual eligible SNP; Medicare-Medicaid; chronic care SNP; Institutional SNP -ALL SNPs provide Part D Rx coverage MA PFFS Coordinate Care Plans - ANSWER -May receive covered services from ANY provider in US who is eligible to provide Medicare services AND agrees to accept plan's terms and conditions of payment -Some plans contract with network providers. If plan has a network, enrollees pay more for out of pocket providers -EXCEPT for emergencies; enrollees must notify providers BEFORE receiving services that they are PFFS members, so providers can decide whether to accept the plans terms and conditions -NON-network providers may, on patient by patient; visit by visit basis. -NON-network providers that accept Original Medicare may choose NOT to accept PFFS plan enrollees -Individuals enrolled in PFFS receive their Medicare benefits through the plan -PFFS is NOT the same as Original Medicare -PFFS is NOT a Medicare supplement, Medigap, or Medicare Select. MA PFFS Options available - ANSWER -Enrolling in PFFS plan offering only Medicare A/B benefits and NOT obtaining Part D coverage -Enrolling in PFFS that combines A/B and Part D Rx benefits MA-PD plan -Enrolling in a stand-alone Part D plan -Generally pay non-network providers the same amt. Original Medicare would pay them. -Providers are NOT permitted to charge the enrollee more than the cost sharing specified in PFFS terms and conditions of payment -PFFS MUST have max limit on member out of pocket costs for network and NON-network providers of NOT greater than $6,700 per year. MA MSA Coordinate Care Plans - ANSWER -IS a higher deductible health plan combined with a savings acct of health care expenses. Medicare makes a contribution to the savings acct. -Enrollees pay for health care expenses from the savings acct and then out of pocket until annual deductible has been met, then plan pays 100% covered services. -Cover Part A/B benefits, but NOT Part D (may enroll in stand-alone) -Enrollees pay the Part B premium and any premium for supplement benefits -May receive covered services from any Medicare approved provider in US -May NOT have a network or MSA's may have a network of providers who will provide services at lower costs -ALL providers must accept the same amt. that the Original Medicare would pay them as payment in full -Plans MUST offer coverage of preventive services before the enrollee has net the deductible. + MA EMPLOYER/UNION PLANS - ANSWER -May contact directly with CMS or offer an M plan to its retirees. -Usually cover Medicare eligible spouses -Plan options vary depending on the employer or union. -Beneficiaries SHOULD check with their employer/union group benefits admin. before changing plans to avoid losing coverage they want to keep. -SOME beneficiaries may be able to use their employer/union coverage along with a Medicare plan. MA PACE Coordinate Care Plans Programs of All Inclusive Care for the Elderly - ANSWER -Medicare plan for frail, elderly beneficiaries -Available in limited areas of the country -Include comprehensive medical and social service delivery systems using an interdisciplinary team approach in an Adult Day health center, supplemented by in-home and referral services. MA AND DUAL ELIGIBLE beneficiaries - ANSWER -Who qualify for both Medicare-Medicaid -For services covered under M&M, most dual eligible will NOT have to pay costs sharing more than the Medicaid cost sharing amts. for the services. -Whether network providers accept both M&M patients -Whether single M&M plan that combines M&M benefits is available to the beneficiary Dual eligible beneficiaries Categories - ANSWER QMB only-Part A/B premiums; cost sharing for A/B benefits QMB Plus-Part A/B premiums; cost sharing A/B benefits; full Medicaid benefits. SLMB ONLY-Part B premiums SLMB PLUS-Part B premium; full Medicaid benefits QI-Part B premium Other FBDE-Part B premium; full Medicaid benefits QDWI (qualified disabled and working individual)-Part A premium -May enroll in any type of MA plan EXCEPT an MA MSA MA AND RX - ANSWER -An organization offering coordinated care MA plans MUST offer at least one MA plan with Rx coverage (MA-PD) in every service area -Outpatient Rx benefits offered by MA plans MUST meet Part D program requirements -CMS requires MA and Part D to maintain a medical lost ratio of at least 85% -If administrative costs NOT related to patient care and profits exceed 15%, MA and Part D plans will be obligated to return the excess to CMS with further penalties in the future if this problem continues -If beneficiaries enrolls in an MA plan that includes Part D Rx coverage, beneficiary can ONLY receive Part D Rx coverage through that plan -If beneficiary enrolls in MA plan that is an HMO or PPO that DOESN'T include Part D coverage, the beneficiary CAN'T joint a stand-alone Rx plan. 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