SOUTHEAST TENNESSEE LEGAL SERVICES

 

 

Medicare and Managed Care

Managed care plans can represent good health care value. They provide all Medicare’s benefits and frequently more, and there is little or no paperwork.

You may have to pay a fixed monthly premium and a co-payment each time a service is used. The premiums and co-payments vary from plan to plan and can be changed each year. You also must continue to pay the Part B premium to Medicare. You do not pay Medicare’s deductibles and coinsurance.

Usually there are no other charges no matter how many times you visit the doctor, are hospitalized, or use other covered services. Your costs are therefore more predictable than under fee-for-service Medicare.

In addition to offering you all your Medicare benefits, many plans promote preventive health care by providing extra benefits such as eye examinations, hearing aids, routine physicals, scheduled inoculations and prescription drugs for little or no extra fee.

Each plan has its own network of hospitals, skilled nursing facilities, home health agencies, doctors and other professionals. Depending on how the plan is organized, services are usually provided either at one or more centrally located health facilities or in the private practice offices of the doctors and other health care professionals that are part of the plan. You generally must receive all covered care through the plan or from health care professionals to whom the plan refers you or else the plan will not pay.

Most managed care plans allow you to select a primary care doctor from those that are part of the plan. If you do not make a selection, one will be assigned to you. Your primary care doctor is responsible for managing your medical care, admitting you to a hospital and referring you to specialists. You are allowed to change your primary care doctor as long as you select another primary care doctor affiliated with the plan.

Types of Plans

Before enrolling in a managed care plan, find out whether the plan has a "risk" or a "cost" contract with Medicare. There’s an important difference.

Risk Plans: These plans have "lock-in" requirements. This means that you generally re locked into receiving all covered care through the plan or through referrals by the plan. In most cases, if you receive services that are not authorized by the plan, neither the plan nor Medicare will pay.

The only exceptions recognized by all Medicare-contracting plans are for emergency services, which you may receive anywhere in the United States, and for services you urgently need when you are temporarily out of the plan’s service area.

A third exception offered by a few risk plans is called the "point-of-service" (POS) option. Under the POS option, the plan permits you to receive certain services outside the plan’s provider network and the plan will pay a percentage of the charges. In return for this flexibility, expect to pay at least 20 percent of the bill.

Cost Plans: These plans do not have lock-in requirements. If you enroll in a cost plan, you can either go to health care providers affiliated with the plan or go outside the plan. If you go outside the plan, the plan probably will not pay but Medicare will.

Medicare will pay its share of charges it approves. You will be responsible for Medicare’s coinsurance, deductibles and other charges, just as if you were receiving care under the fee-for-service system.

Because of this flexibility, a cost plan may be a good choice for you if you travel frequently, live in another state part of the year, or want to use a doctor who is not affiliated with a plan.

Enrolling in a Plan

Most Medicare beneficiaries can enroll in a managed care plan. To enroll:

1. You must have Medicare Part B and continue paying Part B premiums.

2. You must live in the plan’s service area.

3. You cannot be receiving care in a Medicare-certified hospice.

4. You cannot have permanent kidney failure at the time of enrollment.

The names of the plans in your area are available by calling your state insurance counseling office. Insurance counselors will give you information about the plans in your state to help you decide whether managed care is right for you.

All plans that have contracts with Medicare must have an advertised open enrollment period of at least 30 days once a year. Plans must enroll Medicare beneficiaries in the order of application. You cannot be rejected because of poor health.

If your area is served by more than one plan, compare the doctors’ qualifications, facilities, premiums, co-payments, and benefits to determine which plan best suits your needs at a price you can afford. Determine whether the plan’s providers are in a location convenient to you and whether transportation is available at all hours to get you to them.

Carefully weigh the advantages and disadvantages of plan membership if you travel a lot or live part of the year in another state. Plans must provide coverage for a fixed period of time when you travel.

Also keep in mind that if you enroll in a plan and later move out of the plan’s service area, you will have to disenroll and either return to a fee-for-service Medicare or enroll in a plan that serves your new location. Because each plan is different, your benefits and premiums probably will not be exactly the same if you enroll in another plan.

Leaving A Plan

You can stay in a managed care plan as long as it has a Medicare contract or you can leave at any time to join another plan or to return to fee-for-service Medicare.

To End your enrollment, send a signed request to the plan or to your local Social Security Administration office or, if appropriate, the Railroad Retirement Board. You return to fee-for-service Medicare the first day of the next month after the plan receives your request to disenroll.

To change from one managed care plan to another, simply enroll in the other plan as long as it has a Medicare contract. You are automatically disenrolled from the first plan.

Medigap insurance is another issue that you should consider if you are thinking about enrolling in a plan or if you are already in a plan and are thinking about disenrolling.

If you have a Medigap policy and decide to enroll in a plan, you may either keep the policy or, if after deciding you like the plan, you may cancel it. You generally do not need a Medigap policy if you are in a managed care plan.

A Medigap policy could be of value to you if you leave the plan and return to fee-for-service Medicare. If you previously had a Medigap policy but dropped it while in the plan or never had one before you joined the plan, you might not be able to buy the policy of your choice, especially if you have a health problem.