HMO

HMO with Point-of-Service (HMO w/pos)

This is similar to the Medicare Advantage HMO, except you can use providers outside of the network.  However, you will pay higher deductibles and copayments when you go outside of the network.

Preferred Provider Organization (PPO)

This is another managed care plan.  It is formed by a group of doctors, hospitals, and other providers who contract with an insurance company.  You do not have to choose a primary care physician.  You can go outside of the network, but you will pay higher deductibles and copayments when you do.

Provider Sponsored Organization (PSO)

This is a managed care plan with a network of providers.  The providers administer the plan and take the financial risk.  You choose a primary care physician and agree to use plan providers.  Most services will be provided by the network.

Private Fee for Service Plans (PFFS)

This is an insurance plan, not a managed care plan.  The plan, not Medicare, sets the fee schedule for providers, but providers can bill up to 15% more.  You see any providers you choose, as long as the provider agrees to accept the payment schedule.  Medical necessity is determined by the plan.  The plan does not have to have a quality assurance program.

Religious Fraternal Benefit Society Plans

This is one of the managed care plan types (HMO, HMO w/pos, PPO, PSO) which is formed by a religious or fraternal organization.  These plans may restrict enrollment to members of their organization.

Medical Savings Accounts (MSA)

This is a health insurance policy with a high deductible ($3,000) combined with a savings account ($2,000). Medicare pays the insurance policy premium and deposits moey into your MSA each month. You can use the money in your MSA to pay your medical costs (tax free). You have free choice of providers. The providers have no limit on what they charge.

Medicare Advantage Plans: Beneficiary Protections

• Guaranteed Issue:  The plan must enroll you if you meet the requirements.
• Care must be available 24 hours per day, seven days a week.
• You must have access to specialists.
• Doctors must be allowed to inform you of all treatment options.
• The plan must have a grievance and appeal procedure.
• If a layperson would think that a symptom could be an emergency, then the plan must pay for the emergency treatment.

Medicare Advantage Managed Care Plans: Beneficiary Protections

• The plan cannot charge more than a $50 copayment for visits to the emergency room.
• You or your doctor can appeal a denial of service and the appeal must be handled in a "timely" way.  The plan must make an initial determination within 14 days.  Reconsideration of a decision must be made within 30 days.  Decisions regarding urgent care must be made within 72 hours.
•  The plan must have a process for identifying and evaluating persons with complex or serious medical conditions.  A treatment plan must be developed within 90 days of your enrollment. 
• If your treatment plan includes specialists, you must have direct access to those specialists.  You do not need a referral from your primary care physician.

Medicare Advantage Plans: Common Elements

• All plans have a contract with the Centers for Medicare and Medicaid Services (Medicare).
• The plan must enroll anyone in the service area that has Part A and Part B, except for end-stage renal disease patients.
• Each plan must offer an annual enrollment period.
• You must pay your Medicare Part B premium.
• You pay any plan premium, deductibles, or copayments.
• All plans may provide additional benefits or services not covered by Medicare.
• There is usually less paperwork for you.
• The Centers for Medicare and Medicaid Services (Medicare) pays the plan a set amount for each month that a beneficiary is enrolled.

The Centers for Medicare and Medicaid Services monitors appeals and marketing plans.  All plans, except for Private Fee-for-Service, must have a quality assurance program.

Who is eligible to enroll in a Medicare Advantage plan?

If you meet the following requirements, the Medicare Advantage plan must enroll you. 

You may be under 65 and you cannot be denied coverage due to pre-existing conditions.

• You have Medicare Part A and Part B.
• You pay the Medicare Part B premium.
• You live in a county serviced by the plan.
• You pay the plan's monthly premium.
• You are not receiving Medicare due to end-stage kidney disease.

Another type of Medicare Managed Health Maintenance Organization is a Cost Contract HMO.  These plans have different requirements for enrollment.

• You have Medicare Part A and Part B, or only Part B.
• You pay the Medicare Part B premium.
• You live in a county serviced by the plan.
• You pay the plan's monthly premium.
• You are not receiving Medicare due to end-stage kidney disease, and you are not in the Medicare Hospice program.

What are the benefits and limitations of Medicare Advantage plans?

Currently in Indiana, Medicare Advantage plans are widely available throughout the state.

Advantages

• Medicare Advantage plans cannot turn you down due to age, poor health, or pre-existing conditions during the Annual Open Enrollment Period from November 15 to December 31 of each year or when you first become eligible for Medicare. (Exceptions: You can be turned down if you have end-stage renal disease.)
• If you are under 65 with Medicare due to a disability, you may enroll in a Medicare Advantage plan and not be denied.
• Medicare Advantage plans must provide all Medicare covered services and are approved by Medicare.
• Medicare Advantage plans may provide some services that Medicare doesn't usually cover, such as routine physicals and foot care, dental care, eye exams, prescriptions, hearing aids, and other preventive services.
• Medicare HMOs may provide some services that Medicare doesn't usually cover, such as routine physicals and foot care, dental care, eye exams, prescriptions, hearing aids, and other preventive services.
• You usually have less out-of-pocket expenses, such as premiums, copayments for doctor services and prescription drugs. You do not need a Medicare supplement policy.
• You have no bills or claim forms to complete. Filing and organizing of claims is done by the Medicare Advantage plan.
• You have 24-hour access to services, including emergency or urgent care with providers outside of the network.  This includes foreign travel not covered by Medicare.
• Medicare requires and monitors quality assurance for doctors and facilities.
• The Medicare Advantage plans must enable you to appeal denial of claims or services. If the service is still denied, then you have other appeal rights with Medicare.

Limitations

• You must live within the service area of the Medicare Advantage plan. If you move outside of the service area, then you must join a different plan or get a Medicare supplement policy to go with your Original Medicare.
• You must follow the rules and use the providers in the plan, except for emergency or urgently needed care. (Exception: PPOs allow you to use providers outside of the network, and Medicare will still pay 80% of the approved amount. PFFSs do not have a network of providers, but your provider may not accept the plan.)
• Your current doctor or hospital may not be part of the Medicare Advantage network so you would have to choose a new doctor or hospital.
• You must get a referral from your Primary Care Physician to receive care from health care providers outside of the network, or the plan will not pay (unless you are in a PPO or PFFS).
• A provider could leave the plan, or the plan's contract with Medicare could be canceled. Then, you would have to find another Medicare Advantage plan or get a Medicare Supplement Policy to go with your Original Medicare.
• If your Primary Care Physician (PCP) leaves the plan, then you would have to choose another PCP.
• If you live outside of the plan area for 12 or more months in a row, the Medicare Advantage plan may ask you to disenroll and re-enroll when you return to the area. However, if a Medicare Advantage plan is available where you are living outside of Indiana, you could enroll in it for coverage while you were outside of your regular plan area, and then re-enroll in your Indiana plan when you return home.
• When you travel outside of the plan’s service area, you are only covered for emergency or urgent care. For routine health care services, you would need to return to your Primary Care Physician.

Medicare Advantage plans that include prescription coverage may require you to use particular medications to lower their costs and yours.

Back to top

Are there any protections if I enroll in a plan and do not like it?

In order to enable beneficiaries to try a Medicare Advantage plan, but still have the option of returning to Original Medicare, a number of protections are in place.  These protections will enable beneficiaries, in certain situations, to try a plan, but then return to Original Medicare and a Medicare Supplement policy if they want to do so. 

Under these protections, beneficiaries will have guarantee issue of a Medicare Supplement policy as long as they meet one of the following criteria.  For eligible beneficiaries, companies which sell supplement policies will not be able to deny coverage, charge more, or exclude benefits.  However, to receive these protections, beneficiaries must apply for a supplement policy within 63 days of disenrolling from the health plan, or within 63 days of the termination of the health plan. 

A beneficiary would be eligible for the Medicare Supplement protections if they meet one of the following criteria.

Case #1

You are enrolled in a Medicare Advantage plan (such as a Medicare HMO) and one of the following happens:

• The contract between Medicare and the plan ends.
• The plan service area no longer covers the county where you live.
• You move out of the plan service area.
• There are violations by the plan.

Protection: 
In this case, you would get a guaranteed issue of a Medicare Supplement Plan A, B, C, or F from any company (as long as you apply within 63 days of losing your other coverage).

Case #2

You have a Medicare Supplement plan and you cancel it in order to enroll in a Medicare Advantage plan for the first time.  Then you disenroll from the plan within 12 months and return to Original Medicare. 

Protection:
You are able to return to the same Medicare Supplement plan with the same company if it is still available.  If it is not still available, you will get a Medicare Supplement plan A, B, C, or F from any company (as long as you apply within 63 days from disenrolling).

Case #3

When you first take Medicare Part B, you enroll in a Medicare Advantage plan.  Then you disenroll from the plan within 12 months and return to Original Medicare. 

Protection:
You are guaranteed to get any Medicare Supplement plan with any company (as long as you apply within 63 days from disenrolling).

Case #4

You have an employer group health plan which supplements Medicare and your employer terminates the health plan, or stops providing supplemental coverage.  (This does not apply if you voluntarily drop the employer group health plan.) 

Protection: 
You are guaranteed to get a Medicare Supplement policy A, B, C, or F from any company. 

Remember, to be eligible for any of these protections, you must apply within 63 days of losing, or disenrolling from your other health coverage.

Back to top

Are any Medicare Managed Care Plans available where I live?

Currently, you can choose from three types of Medicare Managed Care:

• Cost Contract HMO
• Medicare Advantage PPO
• Medicare Advantage PFFS

These plans are available in selected counties of Indiana and it is important to know the differences between them.

Cost Contract HMO

Medicare will reimburse the plan for covered services you receive. You choose a primary care provider within the HMO network. When you stay within the network, you pay nothing except the plan premium and any small copayment amounts preset by the HMO.

You may also choose to use services outside of the network. When you choose to use a service or provider outside the Cost Contract HMO network, Medicare would still pay their usual share of the approved amount. You would be responsible for the Medicare deductibles and copayments. The Cost Contract HMO would not pay these. Cost Contract HMOs may enroll you if you don't have Medicare Part A but have and pay for Medicare Part B. Cost Contract HMOs do not have to enroll you if you have end-stage kidney disease or are already enrolled in the Medicare hospice program.

Medicare Advantage PPO

This type of managed care plan maintains a list of preferred providers but lets you see doctors and hospitals outside the plan for an additional cost. If you choose to use a provider outside of the network, the plan will pay the same reimbursements as Original Medicare will unless you need emergency or urgent care.

You will be responsible for the Medicare deductibles and co-insurance. Usually with a preferred provider organization you are not required to have a primary care physician and do not need a referral to see a doctor outside the plan. You must have both Medicare Part A and B.

Medicare Advantage PFFS

If you enroll in a private fee-for-service, you can receive care from any Medicare doctor that agrees to the plan's terms, but you must live in the plan's service area to be eligible. Medicare pays the plan a set amount every month for each beneficiary enrolled in the plan. The plan pays providers on a fee-for-service basis. The plan charges enrollees a premium and cost-sharing amounts.

The PFFS plan offers the same benefits covered under Original Medicare and may provide extra benefits, but you have to pay more for any extra benefits. In most cases, beneficiaries enrolled in the private fee-for-service plan will pay less to see a doctor than under original fee-for-service.

Back to top