Ten Important Medicare Managed Care Concepts

1. Beneficiaries are still in Medicare and can decide if they want to enroll in a Medicare Advantage plan or stay in Original Medicare. They must have both Medicare Parts A and B to enroll in a Medicare Advantage plan.

Medicare = Medicare = Medicare

2. Generally beneficiaries can enroll in an MA plan regardless of their health status.

There are exceptions for Medicare Advantage Special Needs Plans (SNPs).
Those with End Stage Renal Disease may not join most Medicare Advantage plans.

3. Beneficiaries may only enroll or disenroll in Medicare Adavantage during an enrollment period.

Annual Coordinated Enrollment Period - November 15 to December 31 each year
Open Enrollment Period - January 1 to March 31 - Can make one switch regarding Medicare Advantage, but not into or out of Part D Prescription Drug Coverage.
Special Election Periods

4. The managed care plan must provide all Medicare-covered services for which the enrollee meets the applicable Medicare coverage criteria.

The plan must arrange for enrollees to get all Medicare-covered services.
The amount charged to the enrollee for each service may differ from plan to plan.
However, some plans may arrange for some Medicare services to be provided out-of-network, called point-of-service.

5. Beneficiaries might get "extra" benefits through a Medicare Advantage plan that are not available through Original Medicare.

6. Generally, enrollees must stay in the plan's network of health care providers.

There are exceptions for emergency care or urgently needed care.
Some types of Medicare Advantage plans offer different rates for out-of-network care.
The Private Fee for Service type of MA plan has no formal network of providers.

7. Enrollees will probably end up paying more for each service received at an out-of-network provider.

8. Beneficiaries must follow the plan's rules about getting prior approval to see specialists or obtain services.

9. Enrollees have a right to meaningful and timely redress for decisions they believe to be erroneous. These appeals may be decided on an expedited basis if necessary.

10. There are five different kinds of Medicare Advantage plans (also known as Medicare Health Plans or Medicare Part C):

Local Coordinated Care Plans

Health Maintenance Organizations
Preferred Provider Organizations

Regional Preferred Provider Organizations
Private Fee for Service
Medical Savings Account plans
Special Needs Plans