Medicare Advantage HMOs

Medicare Advantage HMOs Medicare Advantage HMOs are managed care plans that have contracts with Medicare. These HMOs are also called MA HMOs. If you are in one, you will get your Medicare services through the HMO. HMO stands for Health Maintenance Organization. Medicare Advantage HMOs must offer their members all the services that Medicare covers. Some Medicare Advantage HMOs offer extra benefits, like dental care and eye glasses. Medicare pays the HMO a monthly fee for each person in the MA HMO plan. Some HMOs also charge a monthly premium. The premium covers the added benefits the HMO offers. Medicare Advantage Plans that have Medicare Part D Drug Coverage are called MAPD plans. Most Medicare Advantage HMOs in Los Angeles County are MAPD plans. Who Can Join a Medicare Advantage HMO? You must have Medicare Part A and Part B to join a MA HMO. You cannot be denied coverage because of a pre-existing condition, unless you have End Stage Renal Disease (ESRD). When Can I Join or Leave a Medicare Advantage HMO? You can only join or leave a MA HMO during an enrollment period. Initial Enrollment Period (IEP) This is a seven month period that starts three months before the first month you are first eligible to enroll in Medicare Part B and ends three months later. Need help? Call the Center for Health Care Rights at 1-800-824-0780. The Center for Health Care Rights (CHCR) is a California non-profit organization that provides free information and help with Medicare. This flyer is funded by the Health Insurance Counseling and Advocacy Program grant provided by the Los Angeles County Area Agency on Aging. Copyright April 2012 by Center for Health Care Rights

You can start your membership in a Medicare Advantage HMO the month you start your Medicare Part B coverage. Annual Election Period (AEP) As of 2011, this period starts October 15th and ends December 7th each year. During this enrollment period, you can change to another Medicare Advantage plan, switch to a Part D drug only plan or go back to original Medicare with no Part D plan. Your new Medicare plan will start on January 1st of the next year. Medicare Advantage Disenrollment Period This period starts January 1st and ends February 14th each year. This enrollment period allows you to make one change during this period. You can make any of the following changes: Current Part D coverage: Medicare Advantage Plan with drug coverage (MA-PD) Medicare Advantage Plan with drug coverage (MA-PD) Can change to: Original Medicare with a Part D PDP plan Original Medicare with no Part D coverage Your new Medicare drug plan will start the first day of the month after you request the change. For example, if you request the change in January, your new plan will start on February 1st. Have questions about Medicare Advantage HMOs? Call us at 1-800-824-0780 for more information. Medicare Advantage HMOs Center for Health Care Rights Page 2

Special Enrollment Periods If you have full Medi-Cal or the Low-Income Subsidy Program, you can change your MA-PD HMO or Part D PDP plan monthly. If you only have Medicare, you can join or leave a MA HMO in certain situations. For example: You lose your drug coverage. You move out of your HMO s service area. You enter or leave a nursing home. In these situations, you will have 2 months to join or leave a MA HMO. How Can I Find out about Medicare Advantage HMOs in My Area? For a list of Medicare Advantage HMOs in Los Angeles County, call us at 1-800-824-0780. For a list of Medicare Advantage HMOs in other counties in California, visit the Medicare Web site at www.medicare.gov. How Do I Join or Leave a Medicare Advantage HMO? To join a MA HMO, call the HMO during an enrollment period. If you are changing to a different MA HMO or Part D drug plan (PDP), you will automatically be dropped from the old plan and changed to the new plan. To leave a MA HMO and return to Original Medicare, call Medicare at 1-800-MEDICARE or 1-800-633-4227. Write down the date you called the HMO or Medicare. Ask for confirmation of the change, the date the new plan starts, and the name of the person you spoke to. Medicare Advantage HMOs Center for Health Care Rights Page 3

Am I Still in Medicare If I Join a Medicare Advantage HMO? Yes, you are still in Medicare. You must get all of your medical care from the doctors, hospitals, and other providers who are part of the MA HMO. This is called the HMO network. In an emergency, you can go to a hospital that is not part of the MA HMO network. It is an emergency if you think your health or your life is in serious danger and you need care right away. When you travel, you can get urgent care from a hospital or doctor who is not part of the MA HMO network. Urgent care is care you need to treat an unexpected illness or injury. What Are the Advantages of Medicare Advantage HMOs? You may have benefits that are not covered by Original Medicare, such as eye glasses and dental care. Medicare Advantage HMOs cannot refuse to enroll you because of your health history. Only persons with End Stage Renal Disease (ESRD) cannot join a Medicare Advantage HMO. The costs you have to pay are usually less. You will be charged co-payments when you use HMO network providers and when you receive emergency and urgent care from non-hmo providers. What Are the Disadvantages of Medicare Advantage HMOs? You must use the doctors and other providers who are part of the HMO network, unless you need emergency or urgent care. You must get a referral from your primary care doctor to see a specialist and to get other services, such as surgery, lab tests and medical equipment. Medicare Advantage HMOs Center for Health Care Rights Page 4

Do Medicare Advantage HMOs Cover Prescription Drugs? Most Medicare Advantage HMOs in Los Angeles County offer Medicare Part D, the Medicare prescription drug benefit. They are called MA-PD plans. If a Medicare Advantage HMO offers Medicare drug coverage, you will get your drugs through the HMO participating pharmacies or a mail order program. Each MA-PD plan has a list of drugs that it covers. This is called a formulary. Each MA-PD plan also sets its own drug co-payments. If a Medicare Advantage HMO does not offer Medicare Part D drug coverage, you will be charged full price for any prescription drugs you fill. What If My MA HMO Refuses to Give Me the Medical Care I Need? Your MA HMO has 14 days to approve or deny a request for care. If the plan does not make a decision within 14 days, you have the right to appeal. If the HMO denies your request, it must give you a written notice that tells you why the service was denied and how to appeal the denial. If the HMO denies your request, you have the right to appeal the denial. If you need help, call us at 1-800-824-0780. What If I Need a Faster Appeal? You have the right to get an answer from your MA HMO within 72 hours if waiting 14 days would place your health at risk. This is called an expedited appeal. Medicare Advantage HMOs Center for Health Care Rights Page 5

You or your doctor can ask the MA HMO for an expedited appeal. If your doctor asks, the HMO must give you an answer within 72 hours. What If My MA HMO Says It Is Stopping Care I Am Getting Now? Call the Health Services Advisory Group (HSAG), the California Medicare Quality Improvement Organization to ask for a fast-track appeal if: You are asked to leave the hospital before you think you are ready. You are getting care from a skilled nursing facility or a home health care agency and your MA HMO informs you that it will no longer pay for this care. Call HSAG at 1-800-841-1602 by noon the day before the care or service is going to end. If you are TDD hearing impaired, call 1-800-881-5980. How Do I Get My HMO to Pay for Emergency or Urgent Care Provided by Non-HMO Providers? Your MA HMO must pay for emergency or urgent care you get from doctors and hospitals that are not part of the HMO network, as long as the care was medically necessary. You or the health care provider must send the itemized bills to the HMO. If you are submitting the claims, also send a letter that explains why you needed emergency or urgent care. The HMO has 60 days to decide whether or not it will pay. If the HMO says it will not pay, you have 60 days to file an appeal. Medicare Advantage HMOs Center for Health Care Rights Page 6

How Do I File a Complaint about My Medicare Advantage HMO? To file a complaint about a problem with your MA HMO, contact the HMO Member Services. This type of complaint is called a grievance. Remember, if you are having problems getting medical care from your HMO, you should file an appeal. To file a complaint about quality of care, access to specialists or other problems in your MA plan, call the California Medicare Quality Improvement Organization: Health Services Advisory Group (HSAG) 1-866-800-8749 TDD Hearing Impaired 1-800-881-5980 Or Write to: Health Services Group, Inc. Attention: Beneficiary Protections 700 N. Brand Blvd., Suite 370 Glendale, CA 91203 Need more information on Medicare Advantage HMOs? Call the Center for Health Care Rights at 1-800-824-0780. The Center for Health Care Rights (CHCR) is a California non-profit organization that provides free information and help with Medicare. CHCR is funded by government and private foundation grants. Funding for this flyer is provided by Los Angeles County Area Agency on Aging HICAP grant. Medicare Advantage HMOs Center for Health Care Rights Page 7