| Pharmacist FAQs |
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A: 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 MAPD 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), Special Needs Plans (SNP), and Medicare Medical Savings Accounts (MSA).
A: 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. Patients must live in the Medicare Advantage service area. Currently, more than 8 million Medicare patients are enrolled in Medicare Advantage plans.
A: When patients enroll in a Medicare Advantage plan, they continue to pay their monthly Medicare Part B premium to Medicare ($96.40 in 2009). 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.
A: Yes! The three most common types of Medicare Advantage plans are: HMO (Health Maintenance Organization), PPO (Preferred Provider Organizations), and PFFS (Private Fee-for-Service). HMOs are by far the most common type of plan, accounting for the majority of Medicare Advantage enrollments. HMOs and PPOs both utilize provider networks and are collectively referred to as Local Coordinated Care Plans. However, with PPOs, patients can choose to obtain care outside the network for a higher cost-share amount. Private Fee-for-Service plans are more flexible than HMOs and PPOs because they are not required to establish provider networks. Patients can see “any willing provider,” as long as they accept the plan’s terms and conditions. However, this is expected to change in 2010, as PFFS plans also will have to establish provider networks.
Q: What is the difference between Medicare Advantage prescription drug (MAPD) coverage and prescription drug plan (PDP) coverage?
A: 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, MAPD plans have all the same requirements (beneficiary protections, appeals, and grievances, bidding) as PDPs. However, MAPD 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.
A: Millions of Medicare patients 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.
A: Like Medicare PDPs, MAPDs (Medicare Advantage plans that offer prescription drug coverage) are required to provide Medication Therapy Management (MTM) to certain high-risk individuals. Stand-alone Medicare Advantage plans (those that do not offer drug coverage), are exempt from this requirement.
A: Many patients will undoubtedly turn to their community pharmacist, their trusted health care professional, to help them determine if Medicare Advantage plans are a good fit for their health care needs.
However, Medicare Advantage plans are complex and are best explained by a licensed professional. Interested patients are best referred to a licensed agent, who can explain these plans and their associated benefits to your patients and help them decide if Medicare Advantage plans are a good fit for their health care needs. Some types of Medicare Advantage plans are not a good option for dual-eligible patients, who receive both Medicare and Medicaid, or those who have existing medical coverage through an employer.
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