Medicare Advantage Plans

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(June 2007)

If you are near the Medicare-eligible age of 65 or already on Medicare, you may be able to join a Medicare Advantage plan depending on where you live. This publication provides general information about Medicare Advantage options in Texas.

What is Medicare Advantage?

Medicare Advantage (formerly called Medicare+Choice) offers several health care alternatives to original Medicare. Original Medicare allows you to visit any doctor, hospital, or health provider that accepts Medicare. Medicare pays for many of the health care services and supplies you receive but doesn’t pay for all costs. You may be required to pay for coinsurance, copayments, and deductibles.

Medicare Advantage plans may offer more benefits and have lower out-of-pocket costs. Medicare Advantage plans are available from private companies that contract with the Center for Medicare and Medicaid Services (CMS), the federal agency that administers the Medicare program. The plans have at least the same benefits as Medicare Part A (hospital coverage) and Part B (medical coverage) and often include additional benefits, such as the Medicare prescription drug coverage (Medicare Part D).

To be eligible to join a Medicare Advantage plan, you must live in the plan’s service area, be enrolled in Medicare Part A and Part B, and not have end-stage renal (kidney) disease. You can typically enroll in a Medicare Advantage plan even if you have existing health problems, except for end-stage renal disease. (You can continue in the Medicare Advantage plan if you develop end-stage renal disease while you are in the plan.) Medicare Advantage special needs plans may be an option for some people with chronic health conditions.

If you enroll in a Medicare Advantage plan, you are still part of the Medicare program. Medicare will pay your Medicare Advantage plan a set amount each month. You pay your monthly Medicare Part B premium in addition to any additional premium the Medicare Advantage plan charges.

Each year, Medicare Advantage plans can decide to join or leave Medicare. If your plan leaves Medicare, you will receive prior notice and have several options to obtain Medicare benefits. You may join another Medicare Advantage plan in your area or return to original Medicare. If you return to original Medicare, you have a right to buy a Medicare supplement insurance policy. Medicare supplement insurance, sometimes called Medigap, pays some of the expenses that original Medicare doesn't cover. If you apply within 63 days of the date your Medicare Advantage coverage ends, an insurance company must sell you a Medigap policy regardless of your medical history or pre-existing conditions. This protection is called a “guaranteed issue right.” The departing plan will provide you information about this and other rights and options available.

Medicare Advantage Options in Texas

In Texas, the Medicare Advantage options available include managed health care plans, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs); private fee-for-service plans; Medicare special needs plans; and Medicare medical savings account plans. Not all of the options are available in every county, however.

CMS annually publishes its Medicare & You guide that contains information about changes in Medicare and information about Medicare Advantage plans available in the state. Beneficiaries receive copies in the mail, and the guide is available on the Medicare website

www.medicare.gov
1-800-Medicare (633-4227)
1-877-486-2048 (TYY)

HMOs

In most cases, a Medicare HMO's members must use doctors, hospitals, and health care providers under contract with the HMO. These providers make up the HMO's "network.” Some HMOs have an option called “point of service” that allows members to use providers who aren’t in the HMO’s network, although they'll have to pay more for any care received from outside the network. Each HMO member has a primary care physician who provides or oversees the member’s health care.

Preferred Provider Organizations

PPOs, like HMOs, have networks of doctors, hospitals, and health care providers under contract with the PPO. Members of PPOs can pay extra to visit specialists or out-of-network providers without a referral from their primary care physician. Some services may require prior approval, however.

Private Fee-For-Service Plans

Private-fee-for-service plans are offered by private insurance companies under contract with Medicare. They differ from managed care plans because they allow you to go to any doctor, hospital, or other provider that agrees to accept the private fee-for-service plan’s terms of payment. You don’t have a primary care physician to oversee your care, so you don’t need a referral to go to a specialist. Although you must live in the plan’s service area to be eligible, you can receive treatment anywhere in the United States, as long as the provider is willing to treat you. As with Medicare HMOs and PPOs, you must have both Medicare Part A and Part B and not have end-stage renal disease to join a plan.

Special Needs Plans

Medicare special needs plans provide focused health care for people with specific diseases or specialized health needs. To be eligible for a plan, you must have the health conditions covered by the specific plan. In some cases, you may have to change your health care provider, or your provider must be willing to work with the plan. Some plans are for people in certain long-term care facilities or people eligible for Medicare and Medicaid.

Medical Savings Account Plans

Medicare-approved medical savings account plans are offered by private insurance companies. In addition to the plan premium, you must also pay a high deductible before you can access the money that is deposited into an account for your health care costs.

Medicare Advantage Service Areas

Medicare HMOs and PPOs are generally available in urban areas in Texas. HMOs are required to have a network of providers within a specific travel distance for their members. PPOs don’t have those same restrictions. Therefore, if transportation is a problem, find out where the PPO’s preferred providers are located.

Private fee-for-service plans should be available in many areas of the state, including rural areas where it’s less likely that you’ll find a Medicare HMO. Since the private fee-for-service plans do not have networks of providers, it is important for you to find out which local providers are willing to accept the payment terms and conditions of these plans.

The Medicare special needs plans are sometimes medical demonstration, or trial plans, and might not continue after one year.  For Medicare Advantage options available in your area, call Medicare or visit the website and select the search tool, “Compare Health Plans and Medigap Policies in Your Area.

Medicare Advantage Plan Costs

Medicare Advantage plan members must pay their Medicare Part B premium and, typically, an additional plan premium. The plan premium will vary by plan. Some plans may offer several premium options with varying levels of benefits.

Each time you receive medical care through a provider or at an emergency room, you will pay a copayment. Copayments for doctor’s visits usually range from $5 to $20, while copayments for emergency room visits are higher. If your plan covers Part D prescription drugs, you’ll also pay a copayment for each prescription.

You may have to pay a deductible before the plan pays any of your health care costs, and you’ll generally pay coinsurance for the services you receive. Your coinsurance payment will be a percentage of the cost of the services.

It’s important to note that a private fee-for-service plan may allow providers to charge you up to 15 percent more than what the plan pays for the services you receive. This cost is in addition to the amount you pay in copayments and coinsurance. If you’re considering a private fee-for-service plan, be sure to find out whether the plan allows providers to charge you more than the amount paid by the plan for your health care services.

Although the premiums for a Medicare Advantage plan may be less than that of a Medicare Supplement policy, you also need to consider what you will pay in deductibles and copayments with the Medicare Advantage plan.

A Medigap policy only works with original Medicare. If you drop your Medigap policy to join a Medicare Advantage plan, you may not be able to get it back.

The "Compare Health Plans and Medigap Policies in Your Area" search tool on the Medicare website allows you to enter your ZIP code, age, and general health condition to get an estimate of out-of-pocket costs for different plans. It can also sort by cost and types of plans.

Medicare Advantage and the Medicare Prescription Drug Benefit

Medicare Advantage plan sponsors may offer at least one Medicare Advantage plan with prescription drugs (MA-PD). Because you generally enroll in a drug plan for a year, if you enroll in an MA-PD, you must remain in the plan until the next annual enrollment period.

If you have other insurance, such as a group retirement plan, Medicaid, or a medical savings account, find out how and if the Medicare Advantage plan works with what you have.

A Medigap policy only works with original Medicare. If you drop your Medigap policy to join a Medicare Advantage plan, you may not be able to get it back.

Medicare Advantage and Medicare Prescription Drug Plan Enrollment Periods

Both Medicare Advantage plans and Part D plans can change each year. A company may decide not to offer the same number of plans or may decide to end services in certain communities. Plans can also change the services or prescriptions they cover or increase their costs. For these same reasons, people on Medicare are allowed to change plans yearly.

There is an annual open enrollment period each year from November 15 to December 31. If you are in a Medicare Advantage plan, you may be eligible to switch one more time between January 1 and March 31. Other than at these two times, most people are required to remain in their chosen plan for the remainder of the year.  Certain situations allow you to switch plans at other times. Read the Medicare & You brochure for information about joining and switching plans. You can also call 1-800-Medicare and explain your situation. They can verify if you have a right to leave your current plan.

Medicare Advantage Plan Pros and Cons

Medicare Advantage plans have advantages and disadvantages. Consider these carefully before deciding whether a Medicare Advantage plan is right for you, and which type of plan better suits your needs.

Advantages of Medicare Advantage Plans

• Generally, your out-of-pocket costs may be less than if you enroll in original Medicare and buy a Medigap policy. Some Medicare Advantage plans don’t charge a premium in addition to the Medicare Part B premium but will have deductibles and copayments.
• Medicare Advantage plans may provide more benefits than original Medicare, such as hearing and vision screening or dental care. It’s important to compare the benefits among the different types of plans available in your area.
• You can generally enroll in a Medicare Advantage plan regardless of your health history, unless you have end-stage renal disease. A Medicare Advantage plan cannot drop you if you are diagnosed with end-stage renal disease after you’ve joined the plan. The Medicare Advantage option may offer more services, and at lower cost, for people who are not yet age 65 since this age group is limited to getting only Medicare supplement Plan A in Texas.

Disadvantages of Medicare Advantage Plans

• HMOs require that you use their doctors and other providers. In a PPO, you can visit providers outside the network, but you will pay more of the cost to see those providers. The private fee-for-service plan allows you to see any doctor or provider, but your providers may not want to work with this plan because it is different from original Medicare. With all Medicare Advantage plans, there are exceptions for emergency care and urgent care if you are outside your HMO’s or PPO’s service area.
• You must follow the rules of the plan you joined to receive the services. Plans are required to ensure you understand their rules and know how to receive services.
• A Medicare Advantage plan may not be the best option if you see providers frequently. Use the “Compare” tool on the Medicare website to estimate your out-of-pocket costs for various Medicare Advantage plans based on your health status. Medicare and your HMO or PPO negotiate contracts on a yearly basis. Your plan could decide to leave Medicare or change its benefits, premiums, and copayments at the end of each year.
• Unlike Medicare Supplement plans, you do not get a “free look” period to review the Medicare Advantage or Part D plans when you enroll. Before giving your Medicare number to anyone, know that you can be enrolled in a plan without your consent and signature. Unless you can prove fraud, you might have to stay with a plan that does not work for you.

Medicare Advantage Plans and Medicare Prescription Drug Plans: How to Protect Yourself

Companies offering Medicare approved plans usually contract with brokers and insurance agents to sell their plans to consumers. Companies are responsible for the actions of any person that is selling their plans and are required to work with state-licensed agents.
People enrolled in Medicare are often targets for fraud and scams related to Medicare-approved plans. Be cautious of callers claiming to be with Medicare or wanting to visit you at home. Medicare rules do not allow agents to come to your home without an appointment or to misrepresent the product they are selling. Many people who fall victim to fraud are told they will have lower premiums or additional benefits. Work with people you know and trust. If you do become a victim, call 211 for local assistance and report the fraud to 1-800 Medicare (1-800-633-4227).

How to Decide if a Medicare Advantage Plan is Right for You

• First, find out if any Medicare Advantage plans are available in your area. You must live in a plan’s service area to join.
• If you have other insurance, such as a group retirement plan, Medicaid, or a medical savings account, ask your other insurance plan if the Medicare Advantage plan coordinates well with what you have.
• If you’re thinking about joining a Medicare HMO, consider how you would feel about giving up your current doctors, including specialists, if they are not in the HMO’s network. You may be able to keep your current doctors in a private fee-for-service plan if they are willing to accept the plan’s payment terms.
• If you travel a great deal, make sure you understand how to get health care when you are out of your plan’s service area or if you need emergency care. With a private fee-for-service plan, you can receive care anywhere in the United States as long as the provider is willing to accept your plan’s payment terms.
• Consider other lifestyle and health factors that could affect your choice. For instance, if you have high prescription drug costs, finding a plan with a prescription drug benefit that includes your medications could be important.
• Compare the costs and benefits of Medicare Advantage plans with your other coverage options. You have several. You can choose original Medicare alone or original Medicare with a Medicare supplement insurance policy. If you or your spouse is still working, you should be able to keep your coverage through the employer. Some employers extend this coverage to retirees as well. Employer-sponsored group coverage is usually your best and least costly option. You also may be able to get coverage through a union or association you belong to. The biggest advantage of maintaining group coverage is that your pre-existing health conditions will be covered. With some of your other options, you may have to wait before the plan will pay for treating your pre-existing conditions.
• If you need help comparing a Medicare Advantage plan with original Medicare or other options, call your local Area Agency on Aging (AAA) office. AAAs provides free one-on-one counseling to seniors about insurance and related issues

1-800-252-9240

How to Select a Medicare Advantage Plan

• If you have more than one plan to choose from, compare their costs and benefits. Your local AAA office can help you. If you have access to the Internet, you can view comparison charts with prices, benefits, and copayment amounts for the plans in your ZIP code at Medicare’s website. If you don’t have access to the Internet at home, call 1-800-Medicare (633-4227).
• If a prescription benefit is important to you, look at plans that offer prescription coverage. Find out whether there’s an additional premium and whether the medications you take are covered.
• If you’re considering an HMO, call the network doctors you are interested in and ask if they are accepting new patients. For a PPO, find out if your doctors are in the PPO’s network. If you are considering a private fee-for-service plan, ask your doctors if they are willing to accept private fee-for-service patients.
• If you’re considering an HMO, ask whether the HMO has conducted physician or member satisfaction surveys and ask to see the results.
• Ask the plan how many physicians left the plan during the previous year.
• Ask how many members dropped out during the previous year.
• Find out how the plan handles complaints or denials of medical services.
• Find out about the company’s customer service and financial strength. The Texas Department of Insurance (TDI) has information on complaints against HMOs and insurance companies and financial rating information from an independent rating organization. Call TDI’s Consumer Help Line

  1-800-252-3439
  463-6515 in Austin

• Discuss the pros and cons of each plan with friends, relatives, or your doctor. They may have experiences that will help you make a decision.

Getting the Most from your Medicare Advantage Plan

• Read your member booklet or evidence of coverage. Make sure you know what services are covered and what out-of-pocket costs you will have to pay. TDI doesn’t regulate all Medicare Advantage plans because some are offered by companies that are not insurance companies. This means that we may not be able to assist you if you have a complaint. You must follow the complaint process of the Medicare Advantage plan you select.
• Keep the plan’s telephone numbers handy. Call your plan if you have questions. Make sure you understand how the HMO or PPO handles regular appointments and visits to specialists.
• Know how your plan covers emergency care. An HMO must pay for emergency care wherever you receive it. You’re the judge of whether you’re having a medical emergency. Notify the HMO as soon as possible if you receive emergency care in a facility outside the HMO’s network. All HMOs cover care outside the service area for life-threatening conditions and other urgently needed treatment. “Urgently needed care” will be defined in your contract. Ask how the plan handles ambulance charges if the condition was not an emergency.
• Know how a private fee-for-service plan handles billing. Make sure you know whether the plan allows providers to bill you directly for services.
• Request an advance coverage decision from your plan. Medicare Advantage plans must pay for any health care service that Medicare would pay for. This means that if a service is medically necessary under Medicare’s coverage rules, a Medicare Advantage plan must pay for it. You can ask the plan for an advance coverage decision to make sure a service is medically necessary and will be covered. If the plan decides a service is not medically necessary, you have the right to appeal the decision.
• Know how to file a complaint. If you are not satisfied with the care you received, first try to resolve the problem with your doctor or with the plan. If you have a question about a particular treatment you did or did not receive, ask your doctor for an explanation. If the plan denied payment for a treatment you received that you believe should be covered, look for statements in your plan’s evidence of coverage booklet that you believe support your position. If you are still not satisfied, contact your plan’s customer service representative and file a complaint. If you feel the plan did not resolve your problem, contact the local Area Agency on Aging for assistance.

  1-800-252-9240

• Know how to file an appeal. Federal regulations require that Medicare Advantage plans provide an appeal procedure for members. If you are denied medical services, or if a service is stopped, you have the same appeal rights as you do with original Medicare. Read your member booklet for details about the appeal process.
• Know how to leave a plan. You may withdraw from a Medicare Advantage plan by notifying the plan in writing. If you withdraw from a Medicare Advantage plan, you are automatically re-enrolled in original Medicare. You will be notified in writing that you are officially back on original Medicare without any lapse in your Medicare benefits. You may also choose another Medicare Advantage plan instead of returning to original Medicare, if another plan is available in your area.
  If you leave a Medicare Advantage plan and go back to original Medicare, you might want to consider a Medicare supplement policy to help pay for services that Medicare won’t cover. Some insurance companies sell Medicare supplement policies on a “guaranteed issue” basis. This means they will sell you a policy even if you have health problems. TDI’s Medicare Supplement Insurance Handbook and Rate Guide includes information on companies, rates, and policies. The handbook lists the companies that sell on a guaranteed issue basis. You can view the publication on the TDI website or call the Publication's Order Line for a free copy.
• Know what to do if your plan ends its Medicare contract. Your plan must give you notice if it intends to leave Medicare. If your plan leaves Medicare and you return to original Medicare, you have the right to buy Medicare supplement insurance regardless of your health. You must buy a policy within 63 days of the date your plan’s coverage ends, however. Your Medicare Advantage plan and Medicare will inform you of your options. Be sure to keep your final notification letter from the Medicare Advantage plan as proof that you are entitled to buy a Medicare supplement policy despite any health problems you might have.

For More Information or Assistance

If you have questions about Medicare or what Medicare Advantage options are available in your area, call the Medicare Hot Line or visit the Medicare website. For quality of care information about Medicare Advantage plans and satisfaction survey comparisons, visit the interactive Medicare Health Plan Compare page on the Medicare website

1-800-MEDICARE (633-4227)
1-877-486-2048 (for the hearing and speech impaired)
www.medicare.gov

If you need more information about a Medicare Advantage plan in your community, call your local Area Agency on Aging (AAA) office

1-800-252-9240

If you are a Texan age 60 or older and have questions about your rights, your benefits, or the law, call the Legal Hot Line for Texans

1-800-622-2520
477-3950 in Travis County

For answers to general insurance questions or for information on filing an insurance-related complaint, visit our website or call the Consumer Help Line between 8 a.m. and 5 p.m., Central time, Monday-Friday

www.tdi.state.tx.us
1-800-252-3439
463-6515 in Austin

For printed copies of consumer publications, call the 24-hour Publications Order Line

1-800-599-SHOP (7467)
305-7211 in Austin

Help us prevent insurance fraud. To report suspected fraud, call our toll-free Fraud Hot Line

1-888-327-8818

To report suspected arson or suspicious activity involving fires, call the State Fire Marshal’s 24-hour Arson Hot Line

1-877-4FIRE45 (434-7345)

The information in this publication is current as of the revision date. Changes in laws and agency administrative rules made after the revision date may affect the content. View current information on our website. TDI distributes this publication for educational purposes only. This publication is not an endorsement by TDI of any service, product, or company.

For more information contact: ConsumerProtection@tdi.state.tx.us