Medicare Advantage was formerly called Medicare + Choice and comprised Part C of Medicare.Medicare Advantage plans join Medicare Parts A (hospital insurance) and B (medical insurance) into one comprehensive benefit. Some Medicare Advantage plans, called MA-PD plans, offer Part D (prescription drug) benefits as well. There are many different types of Medicare Advantage plans, including Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-For-Service (PFFS),Medicare special needs plans, and Medicare Medical Savings Accounts (MSA).
Most patients who qualify for Medicare Part A and B also are eligible for Medicare Advantage plans. The exceptions include patients who have end-stage renal disease. Beneficiaries must live in the Medicare Advantage service area. Currently, more than 8 million Medicare beneficiaries are enrolled in Medicare Advantage plans.
When patients enroll in a Medicare Advantage plan, they continue to pay their monthly Medicare Part B premium to Medicare. In addition, depending on the plan they select, they may have to pay a monthly premium to their Medicare Advantage plan for the extra benefits provided by the plan.
Medicare Advantage plans that offer prescription drug coverage are known as MAPD plans and offer Medicare Part A, Part B, and Part D benefits, whereas PDPs are stand-alone plans and offer only prescription drug coverage (Part D benefits). In general, MA-PD plans have all the same requirements (bidding and beneficiary protections) as PDPs. However, MA-PD plans can use Medicare payment funds for Part A and Part B to buy down the cost of Part D benefits. That s why Medicare Advantage organizations can frequently offer Medicare basic drug coverage at little to no monthly drug premium.
Millions of Medicare beneficiaries have joined the Medicare Advantage program because the plans provide patients with more coordinated care, often with additional benefits, such as eye glasses and dental care, and lower out-of-pocket costs than traditional Medicare. Some Medicare Advantage plans, including Private Fee- For-Service plans, allow patients greater choice over selecting their health care providers.
Historically, all Medicare Advantage plans were managed care products, under which beneficiaries were limited, at least to some extent, to a specific network of providers. The biggest difference between Private Fee-For-Service plans and other Medicare Advantage plans is that in Private Fee-For- Service plans, a beneficiary is free to seek services from any provider who is willing to accept the plan s terms and conditions of payment. Plans are required to provide their terms and conditions on their Web site. If a provider does not agree to accept the terms of the fee-for-service plan, the provider may not provide health care services to the patient, except in the case of an emergency. In Private Fee-For-Service plans, patients do not need to designate a primary care physician, nor do they need a referral to see a specialist. By law, Private Fee-For-Service plans must provide enrollees with the same benefits they would receive under traditional Medicare. Lastly, it is important to note that Medicare Advantage Private Fee-For-Service plans are not the same as Medicare supplement plans.
When selecting a Private Fee-For-Service plan, patients should be sure to confirm the plan is accepted by his/her health care providers. Excluding emergency situations, providers have a choice of whether to accept Private Fee-For-Service plans. Patients should also be aware of what the plan covers. Although Private Fee-For-Service plans guarantee payment for medically necessary services covered under Medicare, patients may be responsible for a service that does not meet this criteria and is not covered by the Private Fee-For- Service plan. Similarly, while Private Fee- For-Service plans often are less costly than traditional Medicare plans, they also can charge deductible, copay, and coinsurance amounts that are different than those under Medicare and may charge a premium for the extra benefits they provide, such as prescription drugs. It is important to look at the plan s coverage, premiums, copays, and all other out-of-pocket costs before making a final decision.
Like Medicare PDPs, MA-PDs (Medicare Advantage plans that offer prescription drug coverage) are required to provide Medication Therapy Management (MTM). Some types of Medicare Advantage plans, such as Private Fee-For-Service plans, are exempt from this requirement. That s why it is important to look closely at the various plan options. Some Private Fee-For-Service plans do provide MTM programs because of the additional benefits they provide to high-risk patients in reducing overall health care costs. The MA-PD product that will utilize the Community CCRx product will continue to use MirixaPro to deliver MTM services at the community pharmacy level.