Anthem Medicare Preferred. A Medicare Advantage PPO July 25, 2005. Impact of Medicare Modernization Act of 2003 (MMA) . In 2003, the Medicare Modernization and Prescription Drug Act was enacted which significantly impacted the Medicare eligible market
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Anthem Medicare Preferred A Medicare Advantage PPO July 25, 2005
Impact of Medicare Modernization Act of 2003 (MMA) • In 2003, the Medicare Modernization and Prescription Drug Act was enacted which significantly impacted the Medicare eligible market • MMA provides for new Regional PPOs in 2006 spanning single state or multi-state regions • Local PPO plan freeze from 2006-2007 • HMO and PPO Plans must offer at least one actuarial equivalent Part D option in 2006 • The Center for Medicare and Medicaid Services (CMS) payment rates to the local Medicare Advantage (MA) Plans increased significantly in 2004 and 2005
Impact of Medicare Modernization Act of 2003 • Local and Regional PPO plans will participate in a new risk adjusted bidding process for 2006 and forward • The new rate formula implemented in 2006 is expected to keep payment rates in line with medical inflation • As a result of the increase reimbursements that health plans are receiving from CMS, health plans are re-entering the Medicare Advantage market
MA Current and Future Options Current Private Plan Options Future Private Plan Options • HMOs • PPOs • Private Fee-for-Service (PFFS) • Medical Savings Accounts (MSAs) • Medical Cost Contracts • Local HMOs continue • No new local PPOs in 2006-2007 • Regional PPOs (beginning 2006) • PFFS continue • MSAs made permanent • Medicare Cost Contract may be renewed indefinitely until 2008 (starting 2008 only renewable in areas with less than 2 MedicareAdvantage plans)
Medicare Advantage Plans • Medicare Advantage provides all services provided under Original Medicare and typically additional benefits. • Government pays private health plans what they estimate they would have paid for Medicare Parts A and B • The health plan provides at a minimum actuarially equivalent benefits. The beneficiary must be enrolled in Medicare Part A and Part B • Any additional plan premium for Medicare Advantage products are collected by the insurer
MA Regional Plans 2006 • MA regional plan defined as: • Coordinated care plan that • Has a provider network • Provides reimbursement for covered benefits (in-network and out-of-network) • Serves one or more MA regions • May be PPO, HMO with POS, and, possibly, specialized MA plan • Virginia and North Carolina have been designated as one Region
MA Local Plans 2006 • County-based service areas • HMOs, PPOs, POS plans • Moratorium on new MA local PPOs in 2006-2007 • Specialized MA plans for beneficiaries with special needs • Private FFS plans • MSAs
Private Fee for Service (PFFS) Plans • PFFS plans do not contract with providers • PFFS members are responsible for ensuring that the provider will accept payment under the PFFS plan prior to receiving service • Members may obtain health services from any provider in the United States who is willing to provide care for the member and who is eligible to be paid by Medicare • Providers who furnish services to PFFS members are paid by the PFFS plan according to its terms and conditions of payment • PFFS plans are not required to provide a Part D benefit, but may if the plans choose to do so
Medicare Cost Plans • Allowed to continue indefinitely, but beginning in 2008, required to exit portions of service areas where two MA regional or MA local plans meet minimum enrollment requirements • Cost plan may elect to offer Part D benefit to enrollees as optional supplemental benefit
Part D Impact to MA Plans Summary • MA risk plans must offer at least one actuarial equivalent Part D plan • MA cost plans may elect to offer Part D is they choose to do so • PFFS may elect to offer Part D benefits but are not required • MSA plans cannot offer Part D benefits
Anthem Medicare Preferred • On August 1st Anthem will launch an Anthem Medicare Preferred Product (AMP) – first effective date September 1st • AMP is a Medicare Advantage PPO product • Offered under Medicare Part C
Anthem Medicare Preferred Plans And Premiums • Three plans in 2005 under AMP: • PPO Basic - $0 Plan Premium • PPO Standard - $25 Plan Premium • PPO Preferred - $99 Plan Premium • Members continue to pay the Medicare Part B premium of $78.20
Anthem Medicare Preferred Eligibility • Eligible individuals include those who: • Are enrolled in Medicare Part A and Part B • Reside in the approved service area – currently approved to sell in the Richmond and Peninsula areas • Do Not have End Stage Renal Disease (ESRD) at enrollment [exceptions under certain circumstances are made]
Anthem Medicare Preferred Service Area • Products will be sold in 13 counties located in the Richmond and Peninsula/Williamsburg areas: • In Richmond: Richmond, Chesterfield, Hanover, Goochland, Henrico • In Peninsula: Williamsburg, Hampton, James City, Mathews, Newport News, Powhatan, York and Gloucester
Anthem Medicare Preferred Network • Facilities: • In Richmond – St Mary’s Hospital, Memorial Regional Medical Center, Richmond Community Hospital, St. Francis Medical Center • In Peninsula – Riverside Regional Medical Center, Riverside Walter Reed Hospital, Riverside Tappahannock Hospital • Physicians/Other Providers – about 800 unique providers in 1400 locations, 300 ancillary providers
Anthem Medicare Preferred Marketing Plan • Products will be marketed through our direct marketing programs targeting individuals who may not be able to afford a Medicare Supplement plan. • Peggy Waldron will also market the product through home visits and large group settings
Anthem Medicare Preferred Benefits • AMP plans include an actuarial equivalent of benefits that are provided by Original Medicare (Part A and Part B) • AMP plans have additional benefits not provided by Original Medicare such as limited prescription drug coverage, reduced inpatient admission fee, routine office visits, vision exam, etc • Members pay less when obtaining services from network providers but have the option of receiving services from any provider they choose
Anthem Medicare Preferred Benefits • Please refer to the Anthem Medicare Preferred Summary of Benefits
Payment to Out-of-Network Providers • Under urgent or emergency care situations, members may be treated by any doctor. Physician payment is based on Medicare’s allowable. • For Durable Medical Equipment (DME) providers or customized suppliers (such as prosthetic providers) that do not participate (or accept Medicare Assignment), payment is based on charge. DME and customized suppliers are not subject to the limiting charge rule. • Facilities (in-patient & outpatient hospitals, SNFs, Home Health, Dialysis, Ambulance, Independent labs, etc.) are required to participate with Medicare if they treat a Medicare beneficiary. If out-of-network services are received, payment is 100% of Medicare’s allowed
AMP and Employer Group Health Coverage • Termination of the employer group health plan (whether voluntary or involuntary) could result in termination of dependents; health benefits, and other group benefits, i.e., life insurance, pensions, etc. Furthermore, the beneficiary may not be able to re-enroll in the group’s health plan, once that coverage has been canceled. To verify this information, the enrollee should call the group’s benefit manager.
AMP and the Working Aged • The working aged may continue receiving benefits through the employer’s health plan, as well as assign Medicare benefits to AMP simultaneously.
AMP and Retirees • Retirees usually will not be able to continue coverage through their former employers when enrolled in AMP. Typically, the employer is replacing the group plan with an enhanced Medicare Advantage plan. In rare situations, the group plan may offer a prescription or dental plan that is not tied to Medicare benefits, and it is possible that the beneficiary could keep using those benefits, as well as enroll in AMP. To determine how benefits are coordinated with a Medicare Advantage Plan, the retiree should contact the group’s benefit manager.
AMP and Veteran Affairs • Medicare beneficiaries that qualify for veteran’s benefits may continue receiving VA benefits, and assign Medicare benefits to AMP simultaneously. VA benefits must be provided or authorized through VA facilities. AMP will not pay for VA benefits. All AMP benefits must be provided or authorized through AMP.
AMP and Medicaid Eligible Beneficiaries • Medicare beneficiaries that qualify for Medicaid benefits may enroll in AMP. AMP benefits are primary, and all AMP benefits must be provided or authorized by AMP. Medicaid will cover those Medicaid benefits not covered by AMP, i.e., long-term care, etc. Medicaid benefits must be received through Medicaid providers. Beneficiaries should contact their social work with questions.
Med Supp Guaranteed Issue Rights • Med Supp guaranteed issue products A, B, C and F in 2005 and A, B, C, F, K and L in 2006 may be obtained: • When first time MA member disenrolls within the first 12 months of MA plan. Member may also return to previous Med Supp plan with prior carrier • When member moves out of the plan’s service area permanently • When MA plan is terminated • Med Supp guaranteed issue products A, B, C, F, H, I and J in 2005 and A, B, C, F, K, and L in 2006 may be obtained: • When member enrolled in MA plan upon first becoming eligible under Medicare Part A and leaves MA Plan w/in 12 months of effective date of enrollment
Medigap Guaranteed Issue Rights • These provisions apply only to individuals who are 65 and over. Anthem guaranteed issue Plan F is available for those individuals who meet qualifying conditions and are under 65. • Medigap plan must be in effect within 63 days of disenrollment date. • Proof of disenrollment from the applicant’s prior carrier must be submitted.
Anthem Medicare Preferred A Medicare Advantage PPO