Southwestern Connecticut Agency on Aging

OVERVIEW OF MEDICARE ADVANTAGE

Medicare Advantage (Previously Medicare Plus Choice) generally includes Medicare Managed Care Plans provided through a Health Maintenance Organization (HMO), Preferred Provider Organization Plans (PPO), Medicare Special Needs Plans & Private Fee-for Service Plans. To access a CHOICES booklet on Medicare Advantage, click on the following link: http://www.ct.gov/agingservices/lib/agingservices/pdf/hmoguidefairfield07final110607.pdf

HMO Plans must cover all of the benefits that original Medicare A & B cover. In fact, some HMO Plans may cover extra benefits like an annual physical exam or vision exam. An HMO also may have a lower premium than traditional Medigap plans. However, HMO Plans differ from Original Medicare in that , except in emergencies or certain cases where care is urgently needed, the beneficiary can only go to doctors, specialists and hospitals on the plan's list. They use a limited network of health care providers and facilities and a system of "prior approval" from a primary care physician, sometimes referred to as a "gatekeeper", to achieve these goals.

When you are enrolled in a Medicare Managed Care Plan:

You remain enrolled in Medicare but are now receiving Medicare benefits through the HMO.
The beneficiary must remain enrolled in both Medicare A and Medicare B and receives all of the rights and benefits entitled under Original Medicare.
A beneficiary enrolls in either the Original Medicare or a Medicare Managed Care Plan BUT NOT BOTH

Possible Advantages of Medicare Managed Care Plans

The emphasis on preventive care
Comprehensive service and coordinated care
Additional benefits and no health screening based on pre-existing conditions.

Possible Disadvantages of Medicare Managed Care Plans:

Limitations on procedures for receiving specialized care
Must use plan providers only with out-of-area care limitations
Providers can terminate their contracts with plans during the course of the benefit
year
Plans may change their benefit packages, premiums, payments and service area annually
Disenrollment issues, lock-in provisions and regulatory authority

Considerations Before Enrolling in a Medicare Managed Care Plan

Read the membership materials carefully
Determine the nature and extent of the plan coverage
Compare benefits, costs and features of a plan for a price the beneficiary can afford
Check with the plan physicians and other providers (such as hospitals and pharmacies) and determine their availability to you.
Learn how to use the plan complaint system, and how grievances and appeals are handled.

For additional information regarding Medicare Managed Care Plans:

CHOICES program at your local Area Agency on Aging. It is the designated State Health Insurance Program (SHIP), and is funded by the Federal Center for Medicare and Medicaid Services. Information is free of charge. Services include direct phone contact, mailing of printed materials, as well as referral to other community counselors.
Phone: (800)-994-9422 or (203)333-9288
e-mail: MWong@SWCAA.org or GDiaz@SWCAA.org or JPeterson@swcaa.org
Center for Medicare Advocacy phone:1-800-262-4414 http://www.medicareadvocacy.org
Visit www.ctelderlyservices.state.ct.us to acquire a booklet entitled "Medicare Managed Care (HMO) Choices". Look under "publications" on the DSS Elder Services web site. This booklet will give you up-to-date information on the issues.
Visit www.medicare.gov. Select "publications" and there is the ability to read, print or order booklets.