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QUESTION:
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Medicare Advantage Program | Background:
Medicare provides federal health insurance for 42 million who are aged or diabled or have end stage renal disease. Part A of Medicare (Hospital Insurance) covers provides medical insurance inpatient services proivded by hospitals as well as skilled nursing and hospice care. Part B of Medicare (Supplementary Medical Insurance)covers services provided by phusicians and other practioners, hospitals' outpatient departments, and suppliers of medical equipment. Home health care is covered by Part A and Part B. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)added a voluntary prescription drug benefit beg9nning in 2006 under Part D.
The majority of Medicare beneficiaries receive services through the traditional Fee For Services (FFS) part of the program, which compensates providers using a set fee for each service.
Medicare Advantage Programs:
In nearly all areas of the country however Medicare beneficiaries have the option of enrolling in Medicare Advantage -- the program through which private plans participate in Medicare -- rather than receiving their care through the FFS program.
As of January 2007 about 19 percent of beneficiaries were enrolled in private health plans, which accept the responsibility and financial risk for providing Medicare benefits.
Although the payment system for private plans has been modified several times during the more than 20 years that they have participated in Medicare, a key feature has remained intact: Plans that offer Medicare benefits for less than the amount of their payment from the government are required to give enrollees additional benefits, or, in an option that became available recently, rebates on their Part A or Part D premiums.
Those additional benefits and rebates of premiums are a major incentive for benefciaries to enroll in Medicare Advantage plan and are particularly attractive to people without Medicaid or Employer sponsored supplemental health insurance.
HMOs, PPOs:
About 75 percent of Medicare beneficiaries enrolled in private plans are in Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). Both HMOs and PPOs have comprehensive networks of providers, but the PPOs allow beneficiaries to obtain care outside the network if they pay a higher amount.
Some HMOs offer coverage for services received outside their network (and thus resemble PPOs) while others require that their enrollees receive all of their nonemergency care within the network.
PPOs under Medicare Advantage are either local or regional; regional PPOs, an option that became available in 2006, are required to serve broad regions of the country rather than defining their service area on a county by county basis. (One reason that this is stipulated is that based upon health records and other reasons, an insurer might want to avoid geographical areas where the incidence of demands for services were particularly high while the participants ability to pay were low.)
A key feature of many HMO and PPO plans is care management services, which are intended to promote better coordination and more effective use of health care.
The other main tyoe of Medicare Advantage plans is Private Fee For Service (PFFS). PFFS plans allow their enrollees to obtain care from any provider that will furnish it and are not required to provide networks of providers. Providers must decide each time they see a patient whether to accept a PFFS plan's terms of participation and thus agree to their payment rates, usually those of the Medicare's FFS program. |  | asked by grandpa24551, 4/13/2007 |
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Categories:
Health and Health Care, Supplemental Medical Insurance, Health Insurance, Medicare, Prescription Drug Coverage, Medicaid
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