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Advantage?

What Are Medicare Advantage Plans?

In 2004, Medicare Advantagereplaced the Medicare pri- vate health plan options known as Medicare + Choice. These plans are designed to offer beneficiaries access to more health plan choices and better benefits. There are three types of Medicare Advantage plans available to Medicare beneficiaries living in Ohio. They are:

• Health Maintenance Organizations (HMOs), • Private Fee-For-Service Organization (PFFS), and • Preferred Provider Organization (PPOs)

Medicare offers you different ways to get your Medicare benefits. One option is the Original Medicare Plan, which is administered by the Federal Government. Many people who are enrolled in the Original Medicare Planpurchase a Medicare supplemental insurance policy, described in Chapters 3 and 4.

Some private companies contract with the Medicare program to offer Medicare health plans, giving Medicare beneficiaries other options. These choices are called Medicare Advantageplans.

Who Can Enroll in a Medicare Advantage Plan?

Any person with Medicare who: • lives in the plan’s service area;

• is covered under Medicare Part A and Medicare Part B; and • does not have permanent kidney failure (ESRD)

How Much Does It Cost to Enroll in a Medicare Advantage Plan?

People who choose to enroll in a Medicare Advantage plan must pay the Medicare Part B premium($88.50 per month in 2006), and may pay an additional premium. You may also be required to pay the provider any

co-paymentamounts outlined in the contract. If you choose a Medicare Advantage plan, your co-payments and deductibleswill be different than those under Original Medicare.

Chapter 6:

How Much Does It Cost to Enroll in a Medicare Advantage HMO? Medicare AdvantageHMOs may charge a monthly premium. Premium amounts vary from plan to plan. You may also have a co-paymentfor each doctor’s visit or health care service.

What Are

The Different

Types

of Medicare

Advantage Plans?

What Are The Different Types of Medicare Advantage Plans?

Three types of Medicare Advantageplans are available to Medicare beneficiaries living in Ohio. They are

• Health Maintenance Organizations (HMOs),

• A Private Fee-For-Service Organization (PFFS), and • Preferred Provider Organization (PPO)

What is a Medicare Advantage HMO?

A Medicare AdvantageHMO plan is offered by a private insurance company that has a contract with Medicare. HMOs agree to contract with Medicare for one year at a time. Medicare pays the HMO a set amount every month for each member in the plan. Medicare HMOs submit the terms of their coverage, premiumsand co-paymentsto the federal gov- ernment each year. Medicare decides whether an HMO may serve the county in which you live. Most HMOs with Medicare contracts for Ohio are called Medicare Advantage HMOs (formerly called Risk HMOs). Other types of HMOs, known as "Cost" HMOs, may also contract with Medicare, but are not Medicare Advantage plans. Benefits and cost can change each year.

How do Medicare Advantage HMOs Work?

If you enroll in a Medicare AdvantageHMO, you must use the HMO’s doctors and facilities for all of your health care, unless it is an

emergency situation. If you go outside of the network (except in emergencies), you will be required to pay the entire bill.

Medicare Advantage HMOs must offer minimum coverage equal to the original medicare plan. Most Medicare HMO plans offer "comprehensive care" including physical exams and other services not covered by

What Are

The Different

Types

of Medicare

Advantage Plans?

If you divide your time between Ohio and another location, Medicare Advantage HMO plans may not be for you. HMOs must cover you for emergency or urgent care while you travel for up to 6 months. However, coverage for other types of care is not required.

Questions to Ask Before You Join a Medicare Advantage HMO

• Which plans will my primary doctor accept? • Do my other doctors participate in the plan? • How much is the monthly premium?

• What are the co-paymentamounts for office calls, inpatient days, outpatient procedures, therapy?

• Is there a prescription drug benefit?

• Is there an annual (or quarterly) limit on how much the plan will pay for prescriptions? If so, how does it work?

• Are the specific drugs I take covered under the plan?

• Which hospitals, skilled nursing facilities, etc. are in the plan’s network?

What is a Preferred Provider Organization (PPO)?

A PPO is a Medicare AdvantagePlan in which you use doctors,

hospitals and providers that belong to a network. You can use doctors, hospitals and providers outside of the network for an additional cost. You must live in the PPO’s service area to enroll in the plan.

A PPO plan contracts annually with Medicare to serve beneficiaries. Medicare pays the plan a set amount every month for each beneficiary enrolled in the plan. The plan decides where to make its service available. The benefits, cost and service area can change annually. Beginning in 2006, regional PPOs will be sold in all 88 counties.

What Are

The Different

Types

of Medicare

Advantage Plans?

What is a Private Fee-For-Service Plan (PFFS)?

A PFFS plan is a Medicare Advantageplan offered by a private

insurance company in a contract with Medicare. People who enroll in a PFFS must live in the plan’s service area, but can receive care from any Medicare doctor that agrees to the plan’s terms. The plan chooses the counties where service is available and the service is subject to change each year.

How do PFFS Plans Work?

Medicare pays a PFFS Plan a set amount every month for each

beneficiary enrolled in the plan. The plan pays providers on a fee-for- service basis. A PFFS plan offers the same benefits (medically

necessarycare) covered under Original Medicare. The plan may provide extra benefits, but you may have to pay more to receive those benefits.

Remember, you can not purchase a MedSup policy if you enroll in a Medicare Advantage plan (HMO, PPO, or PFFS) because Medicare Advantage takes the place of Original Medicare and a MedSup policy. But, whatever option you choose, you are enrolled in Medicare.

What if I Move Out of My Medicare Advantage Plan’s Service Area?

If you move, you can disenroll from the HMO, PFFS or PPO Medicare Advantage plan and buy a MedSuppolicy (you will then be in the Original Medicare Plan). Or, you can join a Medicare Advantageplan in your new county, if one is offered.

When and How Often Can I Switch My Plan?

You can change Medicare Advantageplans or move between Medicare Advantage and Original Medicareon a limited basis.

• Beginning in 2006, people with Medicare can change plans once between January 1 and June 30. After making one change they must keep that plan until the end of the year.

• In 2007 and thereafter, people with Medicare can change plans once between January 1 and March 31. After making one change, they must keep that plan until the end of the year.

Is There An Open Enrollment Period for Medicare Advantage Plans?

All people with Medicare have an Annual Coordinated Election Period from November 15 through December 31. During this time, Medicare patients can select a different medicare health plan and/or Medicare Part D plan. Any changes made will take effect the following January 1st.

M/A HMO's

On County list

appears as Company Medicare plan name Customer phone

ASA Anthem Senior Advantage 800-467-1199

HAH Carelink Health Plan Health Assurance Advantra 800-896-9612

HHP Home Town Health Plan SecureCare 877-236-2290

M Mt. Carmel Healthplan MediGold 800-964-4525

PM Paramount Paramount Elite 888-891-0707

PT PrimeTime PrimeTime Health Plan 800-577-5084

Q Qualchoice Health Plan Qualchoice Medicare Prime 800-206-7279

SC SummaCare SummaCare Secure 330-996-8885

HPU The Health Plan of the Upper OH Valley The Health Plan 800-624-6961

UHC United HealthCare of Ohio Medicare Complete 800-504-4848

Cost HMO's

On County list

appears as Company Medicare plan name Customer phone

K Kaiser Permanente Health Plan Medicare Plus 800-551-5353

HPU The Health Plan of the Upper OH Valley The Health Plan 800-624-6961 ext. 7656

M/A PPO's

On County list

appears as Company Medicare plan name Customer phone

H Carelink Health Plan Advantra PPO 800-896-9612

E United HealthCare Evercare 800-393-0993

U United Healthcare Medicare Complete Choice 800-350-5230

M/A PFFS

On County list

appears as Company Medicare plan name Customer phone

S Sterling Life Sterling Option I 888-858-8551