2 MEDICARE ADVANTAGE OVERVIEW
2.1 About Medicare Advantage
Medicare beneficiaries have a choice of getting their Medicare health care services through original Medicare or through a Medicare Advantage Plan. The Centers for Medicare & Medicaid Services (CMS) mails a copy of the document Medicare & You to Medicare beneficiaries describing Medicare benefits and plan choices every fall.
Medicare beneficiaries can enroll in Medicare Advantage plans during election periods.
Five
important election periods are:
- 1. Annual Election Period (AEP): The AEP occurs from October 15-December 7 every year. Medicare beneficiaries can enroll into or disenroll from a Medicare Advantage plan during this time. The effective date of the change is January 1 of the following year.
- 2. Medicare Advantage Disenrollment Period (MAPD): During the MADP, Medicare beneficiaries have the opportunity to disenroll from a Medicare Advantage plan and return to original Medicare. If they choose to return to original Medicare, they have the option of enrolling into a stand-alone prescription drug plan. The time frame for this election period is January 1-February 14 of each year.
- 3. Initial Coverage Election Period (ICEP): When a person first becomes eligible for Medicare Part A and enrolls in Medicare Part B, he or she has a seven-month period to enroll in a Medicare Advantage plan. This usually happens around the person’s 65th birthday.
- 4. Initial Enrollment Period for Part D (IEP): This is the period when an individual is first eligible to enroll in a Part D plan. An individual is eligible to enroll in a Part D plan when he or she is entitled to Part A or is enrolled in Part B and permanently resides in the service area of the plan. Generally, individuals will have an IEP that is the same period as the Initial Enrollment Period for Medicare Part B, a sevenmonth period that begins three months before the month the individual meets the eligibility requirements for Part B and ends three months after the month of eligibility.
- 5. Special Election Period (SEP): CMS has identified several circumstances under which a person may change Medicare options outside of the annual or initial enrollment periods. For example, Medicare beneficiaries who are also eligible for Medicaid can enroll in or disenroll from Medicare Advantage plans throughout the year.
- Note:
- Special Needs Plan (SNP): These enrollees may change Medicare Advantage plans at any time during the year with changes effective the first of the following month, subject to CMS approval.
- Dual-Eligible: Medicare covers a diverse group of people. Most are over 65, but 15 percent (nearly 7 million) are people under 65 who have a disability. Almost half (47 percent) have modest or low incomes, and over one-third (36 percent) of the Medicare population has three or more chronic conditions. Medicare also covers many people who have a cognitive or mental impairment (29 percent of the Medicare population).
- A significant portion (17 percent) of the Medicare population is also enrolled in Medicaid. These beneficiaries are known as dual-eligibles.
- 1. An ID card
- 2. A provider directory
- 3. A formulary (which lists the prescription drugs covered)
- 4. An Evidence of Coverage (EOC) document
- 5. Summary of Benefits
After CMS confirms the enrollee's eligibility, the health plan sends the member a letter to confirm his or her enrollment. A new member will also receive:
Additionally, CMS can perform a retro-enrollment or retro-disenrollment in limited circumstances. CMS provides directives on member enrollment and disenrollment dates; they are not determined by the plan. If retro-activity occurs, this may have an impact on claims payments.
IntegraNet is contracted with Medicare Advantage companies that provider Medicare Advantage Special Needs Plans (SNPs) and integrated Medicare Advantage Prescription Drug (MA-PD) plans. All network providers are contracted with IntegraNet through a Participating Provider Agreement. As a participating provider in the IntegraNet Medicare network, your contract will have a participation addendum for each plan that includes the rate sheet in which you participate.