Home

For Most Seniors, Medicare Alone is not Enough

Medicare is designed to provide a basic foundation of hospital and medical insurance benefits, it is not intended to pay 100 percent of all medical bills. If you rely on Medicare coverage alone, you will still have large medical bills because of Medicare's deductibles and co-payments. Also, there are certain health care services that Medicare does not cover at all. Most seniors need some kind of insurance plan to fill in the "gaps" in Medicare's basic coverage. Some have this need met through their employer's retirement benefits. Others purchase Medicare supplemental insurance or "Medigap" plans, private insurance policies that are specifically designed to fill in the holes in Medicare's basic benefits. Another option is a Medicare-contracted managed care plan. Compared to Medigap, managed care fills in the same gaps in Medicare's basic benefits, often offers additional benefits, and usually costs less.

Having Health Insurance Problems? For free counseling, call SHIIP at 1-800-259-5301 or (225) 342-5301 in Baton Rouge.

Medicare Has Two Delivery Systems

In a fee-for-service health care delivery system, your health insurance and health care providers are separate. When you receive a health care service, your health care provider (doctor, hospital, laboratory, etc.) submits a bill to the insurer, charging a separate fee for every service. This is the way Medicare and Medigap plans have historically worked.

You may also choose to receive your Medicare services through managed care health care delivery system. In managed care, the functions of both health insurance and health services are combined in one organization. These plans offer medical and preventive services through networks of contracted hospitals, doctors, other providers. Managed care plans manage diverse health care services into an integrated health care delivery system that coordinates care, maintain records, and handles the paperwork. Health Maintenance Organizations (HMOs), are a common type of managed care organization. Managed care plans are sometimes referred to collectively as HMOs

How Managed Care Works

It is often said that there is a trade off between managed care and fee-for-service. In managed care, members give up some freedom as they have to stay in the plan's network and have to use a plan-contracted primary care physician (PCP), who acts as a gatekeeper to specialty services. Your PCP delivers all basic medical level services and generally must write a referral before you can go see a specialist or be admitted into a hospital.

Most managed care plans have "lock-in" requirements. "Lock-in" means that you must receive all covered services through the plan's provider network. Neither Medicare is obligated to pay for unauthorized care received from providers outside the plan. When a plan member is traveling outside of the plan's service area, managed care plans generally only cover medical services that are either emergencies or urgent in nature.

Yet managed care also offers some significant advantages over fee-for-service -- it is generally true that managed care plans tend to cost less and provides more benefits. Many managed care plans do not charge a premium )though you still must pay your Medicare Part B premium). Even managed care plans with premiums generally have lower premiums, co-payments, and deductibles than most fee-for-service insurance.

Managed care plans may cover, or partially cover, a wide range of services that are frequently not covered under fee-for-service, including prescription drugs, preventive services, podiatry and chiropractic services, and dental check-ups, just to name a few. In addition, because managed care plan members receive care from a comprehensive health care network, they rarely fill out forms or have to forward their medical records.

Types of Managed Care Plans

In Louisiana, most Medicare managed care plans are risk plans. That is, these risk plans assume the risk for paying for their members' health care costs. Risk plans have strict "lock in" requirements. In most cases, if you receive services outside the plan that are not authorized, neither the plan nor Medicare will pay.

Some managed care plans offer greater flexibility, by allowing members to go outside of their provider network. These risk plans with point of service options and cost plans vary a great deal from plan to plan and are not yet widely available. Members of these plans are responsible for some payments when they go out of network, and generally pay higher premiums.

Comparing Managed Care Plans

To find out if managed care is right for you, and which managed care plans are contracted by Medicare in your area, contact the Senior Health Insurance Information Program (SHIIP) at the Louisiana Department of Insurance at 1-800-259-5301 or (225) 342-5301 in Baton Rouge. Insurance counselors are ready to discuss whether or not managed care is right for you. Counseling is free.

Having trouble understanding HMO marketing materials? SHIIP can help.

In some areas, Medicare beneficiaries have a choice of two or more managed care plans. In this case, you may want to comparison shop the different plans. Each plan will have its own package of covered services, co-payments, and premiums. Make sure you are comfortable with the plan's providers and make sure they are convenient to you. Examine the plan's rules for people who travel or live part of the year in another area. Remember that if you enroll in a plan and later move out of the plan's service area, you will probably have to disenroll from the plan. If you wish to see a side-by-side comparison of the benefits of Medicare HMO's offered in your area, go to www.medicare.gov and go to "Medicare Health Plan Compare" - now containing year 2000 data.

Enrolling in a Managed Care Plan

Most Medicare beneficiaries can enroll in a Medicare managed care plan. To qualify, you must live within a plan's service area and have Medicare Parts A and B. You will continue paying Part B premiums while a member of the managed care plan. The managed care plan will not enroll you if you are receiving hospice care or have permanent kidney failure at the time you apply for enrollment.

All Medicare managed care plans must have at least one 30-day open enrollment period a year. The plan will let you know, in writing, when your coverage will begin. You may not want to discontinue your previous health insurance until you are certain that you are comfortable with your managed care coverage.

While in a managed care plan, you generally do not need Medigap or other supplemental coverage. However, before canceling supplemental insurance, be sure that managed care is right for you. You may not be able to get the same Medigap coverage back once you cancel it. While "double coverage" in a managed care plan and a "Medigap" plan is legal, it is expensive and generally not wise (except perhaps for a short transitional period).

Managed Care and Grievances

Your plan's handbook should include a description of how to file a grievance with the plan. Usually plans have more than one level of grievance review, so you can appeal a plan's initial grievance decision if you are displeased with that decision.

In additional, the Louisiana Department of Insurance's Consumer Affairs Division, under Commissioner Robert Wooley, investigates insurance complaints, and your state's Quality Improvement Organization investigates complaints about medical care. The Health Care Financing Administration, the Federal agency that runs Medicare, also examines complaints about Medicare managed care plans. Together, these agencies work to make sure that you have access to good medical care whether inside or outside of a managed care plan.

Leaving a Managed Care Plan

You can stay in a Medicare managed care plan as long as it has Medicare contract, or you can leave the plan at any time. Before leaving your managed care plan, be sure that you have selected alternative health insurance coverage.

You may go to another Medicare managed care plan or return to fee-for-service Medicare. To switch from one Medicare managed care plan to another, simply enroll in the other plan. You will be automatically disenrolled from the first plan on the day your new coverage begins. To leave a managed care plan and return to fee-for-service Medicare, send a signed request to the plan or to your local Social Security office (or the Railroad Retirement Board, if you are a railroad retiree).

Remember that it may take some time for your paperwork to catch up with you when you switch insurance coverage, so you may experience some claims delays when you first make the change. Be aware that you may not be able to purchase some Medigap plans (especially those with prescription drug benefits) and that some policies will only be available with waiting periods for pre-existing conditions. Contact the Senior Health Insurance Information Program at the Louisiana Department of Insurance for more information on switching insurance coverage.

People are ready to help you: SHIIP 1-800-259-5301
Quality Improvement Organization 1-800-433-4958
HCFA Regional Office - Dallas (214)767-6401
SHIIP Counselors:1-800-259-5301 or (225)342-5301 in Baton Rouge

• Provide health insurance counseling objectively and at no cost.
• Do not sell insurance.
• Provide options.
• Empower the client.

Managed Care Plan Checklist

Managed Care Plan Checklist	Plan A	Plan B
Premium (not including Part B premium)	$	$
Outpatient Benefits
Primary Care Physician Visits	$ co-pay	$ co-pay
Specialist Office visits, w/ referral	$ co-pay	$ co-pay
Diagnostic X-Rays	$ co-pay	$ co-pay
Routine Physical Exams	$ co-pay	$ co-pay
Gynecological Exams	$ co-pay	$ co-pay
Mammograms, annual	$ co-pay	$ co-pay
Surgeries	$ co-pay	$ co-pay
Inpatient Benefits
Hospital Services, authorized	max. days	max. days
Psychiatric Inpatient Services	max. days	max. days
Skilled Nursing Home Care	max. days	max. days
Special Services
Emergency Room Services, approved	$ co-pay	$ co-pay
Urgent Care Out of Area, approved	$ co-pay	$ co-pay
Mental Health, authorized outpatient	$ co-pay	$ co-pay
Home Health Services, approved	$ co-pay	$ co-pay
Outpatient Therapy	$ co-pay	$ co-pay
Podiatry, w/referral	$ co-pay	$ co-pay
Chiropractic Services, w/referral	$ co-pay	$ co-pay
Vision Services, lens& contacts	$ co-pay	$ co-pay
Hearing Services and Aids	$ co-pay	$ co-pay
Dental Care, Preventive care only	___ visits/yr.	___ visits/yr.
Prescription Drugs	$ co-pay	$ co-pay
	$ max/yr.	$ max/yr.
Plan representatives should be able to explain their plan's coverage for each of these benefits. You may wish to include additional categories in this checklist.

This checklist includes only benefits and covered services. Even more important, make certain that you are comfortable with the plan's doctors and rules.

Advantages of Managed Care

Medicare managed care plans provide comprehensive services. Managed care plans cover, or partially cover, more services than Medicare with typical Medigap insurance. These benefits include prescription drug coverage, dental check-ups, and preventive services.

Medicare managed care plans coordinate your care. In a managed care plan, your primary care physician coordinates your care. The plan will keep your medical records current.

Medicare managed care plans save you money. Most managed care plans have low premiums and co-payments. They also cover more services than Medigap plans.

Medicare managed care plans do not health screen based on pre-existing conditions. Unless you have permanent kidney failure or qualify for hospice care, you may join any Medicare managed care plan in your area. Enrollment cannot be denied or delayed based on a pre-existing condition. Generally, as long as you stay in your plan, you will have little or no paper-work.

Disadvantages of Managed Care

In most managed care plans, you are "locked in" to using only the plan's providers. Unless you receive authorization, the plan will only cover services performed by plan providers.

Managed care plans have Primary Care Physicians (PCPs) who any limit access to specialists. In most managed care plans, you cannot see a specialist without a referral from your PCP.

Managed Care plans provide only limited care for travelers. If you are outside of you plan's service area, the plan only covers urgent or emergency medical services. Members must submit claims for out of area services. The plan reviews these claims to make sure the services were urgent or emergent.

Medicare managed care plans may alter their plans. Plans may alter their packages of benefits, payments, and providers each year (but they must always provide standard Medicare services).

Managed care plans are generally not made for "snow birds." Plans generally must disenroll you if you move outside their service area for ninety days or more.

Request for Publications from SHIIP