What Are My Medicare Coverage Choices?

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Medicare Coverage Discussion

If you have Medicare coverage, you may have more options for health coverage than you knew. Most people still have original Medicare, know they probably need a Supplement, and have an understanding of the coverage they have. However, if they are not covered by a retiree plan or group plan, they may not understand all of the choices for coverage they have available.

These plans are offered under Medicare Advantage (MA) plans. So what exactly is a MA? Original (or traditional) Medicare is administered by the Center for Medicare and Medicaid Services (CMS). In the late 1990s, CMS began contracting with insurance companies to offer plans at least as good as the original Medicare, administer and service these plans. CMS would pay these insurance companies a monthly fee per person enrolled to perform these services. The enrollee would continue to pay Medicare Part B premiums and may or may have an additional premium payable to the MA Company.

MAs may be offered in three formats: HMOs, PPOs, or PFFS. First – Medicare Health Maintenance Organization (HMO) plans. HMOs are the most restrictive and require you to see only network providers. In addition, HMOs require an enrollee to choose a primary care physician (PCP) from their network of providers. If the enrollee needs to see a specialist, he/she would need the PCP to make the referral. Importantly and again: these plans are the most restrictive. Their clients must only use a specific network of providers, except in case of emergency. Also, the enrollee must live in a service area.

Second – Medicare Preferred Provider Organization (PPO) plans allow enrollees to receive in or out of network services, but direct their enrollees toward in-network medical providers by providing better benefits. There are several PPOs in the Tri-County area; different PPOs serving different networks. (i.e. Methodist/Proctor or St Francis)

Third – “Private Fee for Service Plans” (PFFS) allow more access to providers than the two aforementioned types of MA plans. A PFFS enrollee must present his/her insurance card each time they see a medical provider and to use this provider, the provider must agree to accept the plan’s terms and conditions for payment (unless in an emergency situation). If the provider will not accept the PFFS’s terms and conditions, the enrollee would need to find another provider who will accept the PFFS plan.

Very importantly, if you have any MA plan you must use their ID card and not show your Medicare card to a provider. In addition, MAs are not standardized, but must provide benefits at least equal to the original Medicare benefits. When gathering information for these plans, be sure to speak to qualified professionals that will also be there to help with your questions in the future. They should NOT “be actively selling” or use any sort of pressure, but provide the service of answering your questions. Research your personal situation on www.medicare.gov (Medicare’s official website) and read carefully any information on plans you are considering. Be sure to see the benefits, limitations, and exclusions in the “Summary of Coverage”. This is a

very specialized area. If you talk with an insurance agent, be sure he/she specializes in this area. Be sure they have a track record of helping seniors. In addition, know that the plan your neighbor has may not be best plan for you.

While all of this may be confusing, it is important to know that you have options. Perhaps one of these options may work very well for you. Medicare’s Open Enrollment Period continues until 3/31/13. In addition, you can change plans yearly. This column just touched on some of the basics of MAs, be sure to gather more information before making any decisions. As always, if we can provide further information, feel free to call our office.

Written by

Steven A. Buttice is the president of Medical Reimbursement & Management Services, Inc., a firm specializing in issues affecting seniors, including seminars and consultation on Medicare Plans, Long Term Care and other types of insurance, claims issues, and sales/service of insurance products since 1984.

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