Medicare Advantage Plans: An Overview

Transcription

2 CONTENTS Medicare 101 Understanding Medicare Advantage Medicare Advantage Networks Medicare Advantage Plan Supplemental Benefits 2

3 Medicare 101 3

4 Medicare 101 Eligibility: People 65 or older People under 65 with certain disabilities People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant) Components of Medicare: Medicare Part A (Hospital Insurance) Helps cover inpatient care in hospitals, skilled nursing facility, hospice, and home health care. Medicare Part B (Medical Insurance) Helps cover doctors and other health care providers services, hospital outpatient care, durable medical equipment, home health care and many preventive services. Medicare Part C (also known as Medicare Advantage) Run by Medicare-approved private insurance companies. Group Medicare Advantage Plans cover benefits and services covered under Part A and Part B and include extra medical and case management benefits. Medicare Part D (pharmacy) Can be incorporated with a Medicare Advantage Plan (MAPD) or through an Employer Group Waiver Plan through an insurance company and/or existing stand-alone Pharmacy Benefit Manager. 4

5 Medicare 101 continued Original Medicare Medicare Advantage Medical Part A Hospital Insurance Part B Medical Insurance Combines Part A and Part B Pharmacy EGWP Medicare Group Part D Plan OR RDS Employer Group Pharmacy Benefit RDS Employer Group Pharmacy Benefit OR Medicare Part D Plan EGWP or MAPD Supplemental Coverage Medicare Supplement Insurance to cover benefits not covered by Medicare Parts A & B If you join/offer a Medicare Advantage Plan, you don t need/can t take a Medigap Policy 5

6 Understanding Medicare Advantage 6

7 Understanding Medicare Advantage Replaces Original Medicare (Parts A and B), any Medicare supplemental or secondary coverage Adding Medicare Part D, creates a Medicare Advantage Prescription Drug plan (MAPD) Must provide all benefits included in Original Medicare Group MA or MAPD plans provide significantly better benefit coverage than individual street plans Includes benefits not offered by Original Medicare Medical management programs Case management Wellness Hearing, Vision Discounts Health Fitness Discounts (SilverSneakers ) Simpler, easier for members: One ID card One toll-free service number One Explanation of Benefits (EOB) statement 7

8 Understanding Medicare Advantage continued Rules regulated by CMS (Centers for Medicare and Medicaid Services) Retiree Communication Materials Carrier literature highly regulated by CMS Can be dense and confusing Fund driven announcement notice and retiree meetings will mitigate confusion Enrollment Two options; Opt-out (auto enrollment) or Opt-in (choice enrollment period by retiree) Auto enrollment (opt-out) reduces stress and confusion and therefore typically serves as solution for plan and retiree Medication Distribution Channels Retirees can fill prescriptions anywhere (any willing provider) 30 or 90 at retail Cannot limit or apply restrictions to any distribution channel mail order, specialty or retail Medicare Part D formulary Some clinical rules may change CMS requires at least 2 drugs in every therapeutic category be covered Disruption is expected but can be managed through effective communication Not all drugs are covered by Medicare Secondary (Plus or wrap) Part B versus Part D coverage for some drug products 8

9 Medicare Advantage Networks 9

10 Medicare Advantage Networks Medicare Advantage Carriers contract with CMS on a County level. PASSIVE PPO NETWORK PPO passive network allows the retiree to go to any doctor or other licensed medical professional that accepts Medicare, anywhere in the United States. Out-of-network providers who participate in Medicare, but do not accept Medicare assignment may balance bill the plan up to the Medicare limiting charge. The excess charge will be paid by the carrier, not the member. Providers who do not have a contract with an MA or MAPD carrier have the choice to accept the plan, except in the case of a medical emergency. The vast majority of providers (98%) will accept at the Medicare reimbursement level even if they are not contracted with the carrier for your MA or MAPD. It is more likely for a provider to refuse the individual (street) plan and not a group MA or MAPD, but they are often confused at the point of service. 10

11 Medicare Advantage Supplemental Benefits Aetna Humana UnitedHealthcare 11

12 Supplemental Benefits Aetna Care Management Case Management Compassionate Care Silver Sneakers Hypertension Program Fitness Discount Program Personal Health Record Aetna Navigator Informed Health Line Extra Benefits & Services Aetna Vision Discount Program Aetna Hearing Discount Program Aetna Natural Products and Services Discount Program Aetna Weight Management Discount Program Aetna Healthy Lifestyle Coaching Summary Aetna Medicare Advantage Registered nurse led team, providing support to members during or immediately following an acute health event. Improved quality of life for members with life-threatening conditions and their families. Available through SilverSneakers, members have access to fitness centers at no charge. Contributes to longer-term reduction in strokes, coronary artery disease events and fewer deaths. Savings on gym memberships and workout equipment for your home. Access family medical history, review office visits, prescriptions and ongoing treatments. Secure member website review claims, plan design and request new ID cards. 24 hour nurse line. Summary Savings on routine eye exams, prescription eyeglasses, non-prescription eyeglasses, contact lenses, sunglasses, designer frames, LASIK eye surgery. Savings on hearing aids (behind ear and in-canal), discounts on digital hearing aids, repairs and exams plus free follow-up services for one full year. Savings on massage therapy, acupuncture, chiropractic care, dietetic counseling and vitamins, herbal and nutritional supplements, and natural products. Discounts on Jenny weight-loss programs and services, ediets weight-loss meals and Nutrisystem weight-loss meal plans. Licensed professionals available via phone to discuss everything from weight loss management to smoking cessation. 12

13 Supplemental Benefits Humana Care Management Health Resources Case Management Humana Cares Field Case Management Transplant Management Bariatric Management Chronic Condition Management Programs Humana Achieve Employee Portal Silver Sneakers Smart Summary Extra Benefits & Services Well Dine Discounts on OTC and Nutritional Supplements Vision Care Discounts Guidance Centers Summary Humana Medicare Advantage Improving physical and social well-being through highly integrated acute and chronic condition management, including home visits, discharge planning and care coordination. Registered nurse led team, providing support to members during or immediately following an acute health event. Supplement to Case Management, this is a patient-centered model support program with a multi-disciplinary team of professional healthcare providers, working to improve access to providers and community resources. Team of nurses working with members in their homes, nursing homes, hospital or doctor's office. National Transplant Network works with member and the provider throughout planning stages, the procedure, hospital stay and for one year post transplant. Services include guidance on bariatric surgery centers of excellence, access to a dedicated clinical advisor for pre and post-surgery support. Registered nurse led team providing educational guidance related to treatment plans and condition management. A health management style program designed to proactively engage members with high-risk and co-occurring (medical and behavioral) conditions. Secure participant website includes library of resources, tools, information on programs and a personal health records page. Available through SilverSneakers and Silver&Fit, members have access to fitness centers at no charge. Monthly summary designed to provide a clear and concise explanation of benefits. Summary Service provides a 10 day supply of frozen meals delivered to a member s home following an overnight stay in a hospital or skilled nursing facility. Discounts on nutritional supplements and a wide variety of over-the-counter medicines. Through Luxottica Vision Care, members receive reduced rates and savings on eye exams, frames and lenses. (Includes LensCrafters, Pearle Vision, Sears, Target and JCPenney). A walk-in program available to members through the Humana Active Outlook.com site there are currently 17 local guidance centers across the country. 13

14 Supplemental Benefits UnitedHealthcare Medical Management Program Nurseline Coaching Program Access Support / Advocacy Treatment Decision Support Silver Sneakers Preventive Care Reminders Hearing Devices Routine Hearing Exams Hearing Aids Solutions for Caregivers Case Management Programs Focused Care Management High Risk Care Management Disease Management Programs Treatment Decision Support Congestive Heart Failure Coronary Artery Disease / Diabetes End-stage Renal Disease Transplant Network and Case Management Advanced Illness UnitedHealthcare Medicare Advantage Summary Empowering retirees to make better healthcare decisions using 4 basic value pillars: Right Care, Right Provider, Right Medical and Right Lifestyle. Helping members to identify appropriate, high quality providers along with assistance with scheduling, screenings and preventative care. Provides information to help members about their medical conditions, treatment options and the clinical and cost ramifications of treatment choices. Offers an innovative blend of physical activity, healthy lifestyle education and socially-oriented programming that allow retirees to take greater control of their health. Using claims and administrative data, the program makes outreach to members on preventive care and other education focused literature. Providing access to more affordable hearing devices through HealthInnovations, a discount hearing device provider. One routine hearing exam per year. $0 copay for hearing exam every 12 months and an allowance of $500 every 36 months. Providing professional assessment, consultation and care management services to people who have long term or advanced illness, are older, or have disabilities, while providing support and consultation to their caregivers. Summary Registered nurse led team, providing telephonic services to members who would benefit from a short-term duration, focused intervention (generally for a period of three to six months) to support stabilization of a clinical condition or rectification of a care coordination issue. Providing face to face (generally in home) high touch, intensive services to members with complex illnesses and multiple comorbidities. Summary Led by a professionally licensed team, the programs provide members with educational support, self-management techniques and support of physicians treatment plans for medication adherence, disease management and selfmonitoring. NOTE: Chronic Obstructive Pulmonary Disease, Cancer Support Program and Smoking Cessation QuitPower are all optional programs that can be included for an additional fee. 14