Medicare Advantage Plans Guide - Illinois Division of Insurance

Medicare Advantage Plans Shopping Guide
(formerly known as Medicare+Choice plans)

March 2004

How to Use this Guide

Medicare Advantage plans (formerly known as Medicare+Choice plans) are alternative systems of health care that combine delivery of care and payment to promote cost-effective health care. While this may lower costs for members, it may also place restrictions on their health care.

Understanding the options available in order to make an informed decision about Medicare Advantage plans can sometimes be confusing. The Illinois Division of Insurance, Senior Health Insurance Program (SHIP) has prepared this guide to help you understand these plans.

Take your time and read this guide carefully. If you have questions after reading it, SHIP counselors will provide you with free, objective assistance with your health insurance questions. However, SHIP will NOT make recommendations about health insurance.

How Medicare Works

Traditional (or original) Medicare was never meant to pay all of the health care costs of its beneficiaries. People on Medicare are responsible for health care expenses NOT covered by Medicare in addition to deductibles and co-insurance associated with Medicare-covered services. These expenses are referred to as the "gaps" in Medicare.

There are several options available to people on Medicare to fill the gaps in coverage, including:

Retired employer group health plans;
Medicare supplement insurance;
Medicare Advantage plans (Medicare HMOs, PPOs or PFFS);
Private Fee-For-Service plans; and
QMB and SLMB programs for low- income beneficiaries administered through the Illinois Department of Human Services.

Medicare Advantage Plans

In 1997, Congress passed the Balanced Budget Act, which created several Medicare health plans as alternatives to traditional Medicare. Their intent was to give people on Medicare a choice in the way they received health coverage. Three types of the alternative Medicare Advantage plans are currently available to some or all Illinois residents who have Medicare, depending on where they live. They are:

Health Maintenance Organizations (HMOs)
Preferred Provider Organizations (PPOs)
Private Fee-For-Service Plans (PFFS)

These plans provide a broad range of services, usually for a lower cost, due in part to the fact that Medicare pays these plans a set amount per month for each Medicare enrollee. They often provide additional services beyond what Medicare covers, such as preventive health care, prescription drugs, dental and vision care. All plans require you to pay part of the cost of your care in the form of co-payments each time you use a service. Each of these plans has it's own set of rules, which must be followed to minimize your out of pocket costs. If you enroll in a Medicare Advantage plan, you do not lose your Medicare coverage, nor do you need to purchase a Medicare supplement (Medigap) policy. Medicare Advantage plans are your Medicare and your Medicare secondary plan all in one. Please note that all of the plans listed in the front of this guide have contracted with the federal government to provide coverage to people on Medicare.

Health Maintenance Organizations (HMOs)

This type of Medicare Advantage plan utilizes a network of providers, doctors and hospitals, which have been contracted with by the HMO to provide services to their members. You must stay within this network of contracted providers in order for the plan to pay for your care. If you are covered by a traditional HMO and go outside this network, the HMO will not pay nor will Medicare. You will be responsible for the entire cost of your care from the out-of-network provider, unless you are in an emergency situation.

An exception to this rule is if you belong to a Cost plan HMO. A cost plan allows you to utilize the services of non-network providers, but at a higher cost to you. If you stay in network, the Cost plan pays more.

Preferred Provider Organizations (PPOs)

This Medicare Advantage plan was new to the market in 2003. It is fashioned after the PPOs available to many Americans under the age of 65. PPOs are only available in certain counties in Illinois. PPOs offer people on Medicare a broader choice of health care providers than HMOs by allowing you to use providers outside the plan's network. Again, you will pay more if you choose to see out-of-network providers. The PPO option is also a way for you to obtain some limited prescription drug coverage.

Private Fee-For-Service (PFFS)

These plans differ from HMOs and PPOs in that they do not utilize a network of contracted providers. A PFFS member can obtain services from any provider in the U.S. who is eligible to be paid under Medicare rules and is willing to accept the plan's terms and conditions of payment. Any provider is deemed to have a contract with a PFFS plan if the provider knows, before furnishing services, that you are a PFFS plan member and either knows the terms of plan payment or has reasonable access to the terms and conditions of payment. We urge you to contact your providers before purchasing a PFFS plan to see if they will accept this type of insurance.

Enrolling in a Medicare Advantage Plan

You may enroll in a Medicare Advantage plan if you meet the following requirements:

You must have both Parts A and B of Medicare. If you only have Medicare Part B, you must purchase Part A to join the Medicare managed care plan.
You must continue to pay the Part B premium.
You must live in a plan's geographic service area.
As a Medicare beneficiary, you cannot be denied membership in a Medicare Advantage plan because of poor health, a disability, or a pre-existing condition, with the exception of End Stage Renal Disease (ESRD). See below.

If you meet these guidelines, you can enroll in a Medicare Advantage plan at any age. The plan cannot charge you a higher premium than other plan members in your area.

New law regarding people with End Stage Renal Disease: If you were enrolled in a Medicare Advantage plan that left the Medicare program or stopped providing coverage in your area on or after December 31, 1998, you now have the option to enroll in another Medicare Advantage plan (either an HMO, PPO or a Private-Fee-For-Service plan) if one is available in your area. This protection does not apply to Medicare cost contracts (See explanation of cost contracts on page 3). Call SHIP at 1-800-548-9034 for further information regarding this protection.

Emergency and Urgently Needed Care

Emergency Care

Medicare Advantage plans will pay for emergency services, even if you go to a provider outside the plan's network. It is recommended that you try to reach your primary care physician if at all possible. Members should contact the plan within 24 hours or as soon as possible after the emergency occurs outside the service area.

Urgently Needed Care

The Medicare Advantage plan will also pay for your care if you have an unexpected illness or injury while you are temporarily outside of the plan's service area. Your illness or injury must be serious enough to require medical attention that cannot wait until you return to the service area. Again, call the plan as soon as possible after you receive the out-of-area, urgently needed medical care.

If you are within the Medicare Advantage plan service area, you must go to a plan provider for urgently needed care. Note: Under a PPO you may have a higher copayment amount for urgently needed care that is out-of-network.

More specific information about how to handle both emergency and urgently needed care will be explained in the Evidence of Coverage and Disclosure Information you receive from a Medicare Advantage plan should you choose to enroll in one. Detailed information will be included in the Evidence of Coverage regarding filing a complaint, how to file grievances, utilizing the Quality Improvement Organization, formal appeals procedures and voluntary disenrollment from the plan.

Disenrolling from a Medicare Advantage Plan

Voluntary Disenrollment

If you choose to voluntarily leave the Medicare Advantage plan, you must:

Notify the plan in writing; and
Write or visit your local Social Security Office (railroad retirees must contact the Railroad Retirement Board.)

SHIP recommends that you send your written request to the plan, the Social Security Office or the Railroad Retirement Board via certified mail, return receipt requested. This gives you written proof of the date you mailed your letter and the date it was received by the plan.

You will be covered by traditional Medicare beginning on the first day of the month that follows the month in which the plan, the Social Security Office or the Railroad Retirement Board receives your written request to leave the plan.

If you need medical care during the disenrollment period, you must contact your plan physician.

Before you disenroll, you should call SHIP at 1-800-548-9034 to discuss your rights and options for obtaining supplemental insurance or joining another Medicare Advantage plan.

Involuntary Disenrollment

The only reasons you can be involuntarily disenrolled from a Medicare Advantage plan are:

You cancel your Medicare Part B coverage;
You fail to pay the required Medicare Advantage plan premiums or copayments;
You permanently move out of the plan's service area or leave the area for an extended absence of more than 12 months;
You commit fraud or permit abuse of your plan membership card;
The plan or the Centers for Medicare & Medicaid Services (CMS) cancels the plan's Medicare contract; or
Your behavior is disruptive, unruly, abusive or uncooperative and it impairs the plan's ability to furnish services to you or others.

In these cases, the plan must attempt to contact you and send you written notice regarding the disenrollment action. This notice will explain any rights you may have as a result of the disenrollment.

Consumer Tips

Anyone can sell a Medicare Advantage plan. No licensing is required for sales representatives.
Complete written information must be provided to the member, which explains benefits, appeals and grievance procedures.
You do not need to complete or sign anything unless you decide to enroll.
You cannot be enrolled without your permission.
Door-to-door solicitation is not allowed. A sales person must have your permission in advance to meet in your home. However, telephone solicitation is allowed.
You should not have to answer health related questions or take a physical exam before enrolling.

Questions You Should Consider

Does the plan have a contract with Medicare?
Does the plan have a network of providers?
Can I go to providers out-of-network?
Are the doctors that I use in the plan's network?
How do I change my primary care physician?
How does the plan handle referrals to specialists?
Can I choose a specialist as my primary care physician?
Are providers' offices in locations that are convenient for me?
Have I read and do I understand the plan's handbook of coverage?
What coverage do I currently have and how does it compare to the coverage I will receive from the plan?
How does the plan that I am considering compare to other Medicare Advantage plans? See the SHIP publication, "Medicare Advantage Plans by County" for a side-by-side comparison of available Medicare Advantage plans or visit www.medicare.gov on the Internet and choose Medicare Health Plan Compare.
Are physical therapy, speech pathology and occupational therapy covered in my home and as outpatient services?
What if I need hospice care?
Is there a limit on the prescription drug benefit?
Are prescription drugs available through my local pharmacy or must I obtain them from a mail order house or a large pharmaceutical chain?
Are my current prescriptions available as I take them now, or will I have to switch to generic or alternative choices?

Advantages

and

Limitations

Medicare Advantage plans cannot refuse to enroll you because of your poor health or pre-existing conditions.
The plan must provide all Medicare covered services.
Preventive care, such as routine physicals, dental care, eye exams and wellness programs may also be covered. Some plans also cover prescription drugs.
There may be fewer out-of-pocket expenses, such as co-payments for doctor services and prescription drugs.
The plan may coordinate your care and services.
You have very little paperwork.
You have the option to receive care from another physician within the plan by changing your primary care physician designation.
You are allowed to visit an obstetrician/gynecologist who is a plan network provider without a referral from your primary care physician.
Unlike traditional Medicare, it is not necessary to have a three-day prior hospital stay before being admitted to a Medicare-approved skilled nursing facility.

The plan's contract may be canceled by either the plan or the Centers for Medicare & Medicaid Services.
The plan may increase its premium and/or reduce benefits annually.
You must get all of your medical care and services from the plan, except emergency care or urgently needed care, unless otherwise provided by the plan.
You may be disenrolled from the plan if you are living out of the service area for over 12 months, unless your plan offers the extended travel benefit.
You must receive a referral from your primary care physician to receive care from another provider or that care will not be covered or may require a higher copayment.
Appeals can be slow.
Disenrollment from a Medicare Advantage plan may cause problems. Pre-existing conditions may prevent you from obtaining traditional Medicare supplement insurance. A waiting period may be required for pre-existing conditions.
You may have to begin a new doctor-patient relationship because your current doctor may not be in the plan or may drop out of the plan. Also, a plan doctor may not be taking new patients.

What is SHIP?

The Senior Health Insurance Program (SHIP) is a free insurance counseling service for Medicare beneficiaries and their caregivers. SHIP is sponsored by the Illinois Division of Insurance. This service, offered statewide, is available to Medicare beneficiaries of all ages.
SHIP is not affiliated with any insurance company.
SHIP counselors do not sell or solicit any type of insurance.
SHIP counselors are trained by the Illinois Division of Insurance to:
- Answer questions about Medicare, Medicare supplement, long term care insurance, Medicare HMOs, Preferred Provider Organizations, Private Fee-For-Service and other Medicare plans;
- Organize and assist in filing Medicare and Medicare supplement claims;
- Analyze Medicare supplement and long term care insurance policies;
- Educate consumers about Medicare, Medicare supplement, long term care insurance, Medicare HMOs and other health insurance.

For Further Information...
Write or call us at:	Or visit our website at:
Senior Health Insurance Program Illinois Division of Insurance 320 West Washington Springfield, IL 62767-0001 1-800-548-9034 217-524-4872 (TDD)	www.idfpr.com/DOI/default2.asp

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Medicare Advantage Plans Shopping Guide (formerly known as Medicare+Choice plans)