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Medicare Advantage Plan (Medicare Part C)

Managed care programs Alternative to traditional fee-for-service Medicare part A & Medicare part B Medicare part C covers hospital care, outpatient care & prescription drugs* [1] * most plans cover prescription drugs, vision & dental Oct 15-Dec 7 beneficiaries covered by Medicare part A & part B have the option of joining any Medicare Advantage program in their area Beneficiaries cannot be denied enrollment for any health condition except end-stage renal disease [1] Jan 1-March Medicare Advantage beneficiaries may switch Medicare Advantage plans or switch back to Medicare part A & Medicare part B Out-of-pocket costs: - Medicare Advantage plan do not provide more generous benefits on high-cost items - skilled nursing care - brand-name medications. - most plans cover additional benefits such as vision & dental benefits & charge low (or no) premiums or deductibles. - co-payments for outpatient visits are maintained, often at the time of service health care services from the plan's provider network Medicare Advantage Plans served 30% of the Medicare population in 2014 [1] Participating providers register as Medicare Advantage Plan providers. For each beneficiary, the Medicare Advantage program must provide services offered by Medicare part A, Medicare part A & Medicare part D Older adults who choose Medicare Advantage plans are generally healthier & have lower costs than those who opt for fee-for-service Medicare Beneficiaries cannot be denied enrollment because of health problems except end-stage renal disease Beneficiaries must continue to pay their part B monthly premiums to Medicare Beneficiaries may be charged additional premiums to cover additional services Average premium to beneficiary from participating provider in 2016 $32.50/year [1] Special needs plans are available are available for beneficiaries who live in nursing homes. have a chronic or diabling condition, or are dually eligible to Medicare & Medicaid [1,3] - benefits continue in the event of a transition to a different health care setting - all special needs plans must report all HEDIS measures Reimbursement: - capitated payment from Medicare - neither physicians or other providers receive additional fee-for-service payments from Medicare - average payments from Medicare Advantage are ~12% higher than fee-for-service Medicare - reimbursement directly from Medicare Advantage Plan - plans operate on medicare risk adjustment (MRA) based upon ICD diagnosis provided to Medicare - effective Oct 2015, ICD10 codes in effect [1] Medicare Advantage plans may be provided by: - health maintenance organization (HMO) - preferred provider organization (PPO) - provider-sponsored organization - private fee-for-service plans - may charge beneficiaries a premium - may charge beneficiaries copayments of up to 15% [1] - special needs plans - Medicare savings accounts - may use any Medicare provider - catastrophic insurance included - maximum out of pocket $6000/year Notes: - larger, older & non-profit plans receive higher ratings [3] - UnitedHealth Group & other insurance companies accused of "systematically bilking" Medicare Advantage of billions of dollars annually [5] - United Health accused of using data-mining to find ways to increase apparent seriousness of patients' illnesses, thus Medicare's payments to the insurer [5] - when one gets sick, out-of-pocket costs can soar [6] - once in an Medicare Advantage plan, getting out can be even less affordable [6]

General

Medicare

References

  1. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - eriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  2. Berenson RA and Horvath J Confronting the barriers to chronic care management in Medicare. Health Affairs Web Exclusive 2003. W3:37-53 http://www.carecontinuum.org/members/downloads/ConfrontingtheBarrierstoChronicCareManagement.pdf
  3. Xu P et al. Relationships between Medicare Advantage contract characteristics and quality-of-care ratings: An observational analysis of Medicare Advantage star ratings. Ann Intern Med 2015 Mar 3; 162:353 PMID: 25732277 http://annals.org/article.aspx?articleid=2173504
  4. Elia J, Fairchild DG, Di Francesco L Medi-scam at Medicare Advantage? Insurers Accused of Gaming the System. Physician's First Watch, May 17, 2017 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org https://www.medpagetoday.com/publichealthpolicy/medicare/83661
  5. Centers for Medicare & Medicaid Services: Special Needs Plans. http://www.cms.gov/specialneedsplans/04_SNPQuality.asp
  6. Clark C Medicare Advantage Enrollees Discover Dirty Little Secret. Getting out is a lot harder than getting in.