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Medicare 101: Know the basics

As your source to learn everything on Medicare Advantage, Better Medicare Alliance wants to make sure beneficiaries know the facts. Medicare Academy week one is complete, and advocates got to learn about the basics from enrollment to types of MA plans. The most powerful tool an advocate can have to help BMA fight for affordable, high quality care is knowledge of the issues. Once you understand Medicare Advantage coverage, enrollment, benefits and limitations together we can build a stronger voice to advocate.  Consider this your cheat sheet to Medicare Advantage 101.

Key terms

Medicare Advantage: A Medicare coverage option that provides Part A and B benefits, as well as enhanced or supplemental benefits such as hearing, dental, vision, and wellness benefits.

Open enrollment: Annual time period when beneficiaries can join a Medicare Advantage plan, switch Medicare Advantage plans, or leave a Medicare Advantage plan and enroll in Traditional Fee-for-Service Medicare.

Enhanced benefits: Vision, hearing, dental, and wellness benefits that are offered by 97% of Medicare Advantage plans.

Dual eligible: A beneficiary who is eligible for both Medicare and Medicaid.

Extra Help: A program that helps beneficiaries with limited incomes and resources pay for Medicare prescription drug costs.

Open enrollment takes place from October 15 to December 7 each year. You can choose a Medicare Advantage plan during your initial enrollment period or each year during open enrollment. You could change Medicare plans each year depending on your economic and health needs but only during open enrollment period.

The total enrollment of Medicare Advantage beneficiaries exceeds 20 million. Individuals eligible for Medicare Advantage include people age 65 or older, people who are disable and people with pre-existing condition (except ESRD which has special rules under Medicare Advantage).

Medicare Advantage is another way to get Medicare coverage. When you choose Medicare Advantage your health coverage is provided through a Medicare Approved Organization rather than the federal government. Unlike Traditional Medicare, for which you pay a separate monthly premium for Part A (Hospital), Part B (Doctors, Outpatient), and Part D (Prescription Drugs), Medicare Advantage covers all Parts A, B, and if selected, Part D all in one monthly premium, often at a lower cost to you.

As an extra help, most Medicare Advantage plans also cover additional benefits, such as dental, hearing, vision and transportation at no additional cost. The biggest difference from traditional Medicare and Medicare Advantage is that Medicare Advantage has an annual out out-of-pocket spending limit.

Research has showed Medicare Advantage enrollees experience fewer hospitalizations than Traditional Fee-for-Service Medicare beneficiaries and often have access to chronic disease management. The type of Medicare Advantage plan you enroll in (i.e. PPO, HMO, SNP, PFFS) could impact the services or providers you receive.


Ready to test your knowledge on the basics of Medicare Advantage?

Click here to take the Medicare 101 Quiz Now!


Understanding Special Need Plans

Special Needs Plans (SNPs) were established by Congress through the Medicare Modernization Act of 2003. Since then, Congress has continued to reauthorize these specialized plans. The program has grown by over 60% and now represents 12.5% of Medicare Advantage. Special Needs Plans (SNPs) are a type of Medicare Advantage plan tailored to serve high-cost, high-need beneficiaries.

The primary three types of Special Needs Plans are (1) Dual-Eligible SNPs (D-SNPs), which serves beneficiaries eligible for coverage under both Medicare and Medicaid, known as dual-eligible beneficiaries. (2) The Chronic Condition SNPs (C-SNPs) which serves beneficiaries with a disabling chronic condition, such as End Stage Renal Disease (ESRD), severe diabetes, dementia, or cancer and (3) Institutional SNPs (I-SNPs) that serves institutionalized beneficiaries residing in a long-term care facility, such as a Skilled Nursing Facility, or living at home but requiring an institutional level of care.

Medicare Advantage Special Needs Plans include all Medicare Part A, Part B, and Part D benefits. Also, may include other services to beneficiaries depending on specific health status or quality of life. SNPs members usually have specialists tailored to focus on supporting their specific condition.

As of 2017, over 2.4 million beneficiaries are enrolled in nearly 600 SNPs nationwide.
Different types of SNPs may be available for different parts of the country. Every state or/and county decides what is available for their beneficiaries. Benefits and costs vary depending on area and insurance company. Some counties might offer a selection of Special Needs Plans through insurance companies if they have created that business opportunity. Parts of the country do not have access to these types of plans.

One of the biggest benefits of SNPs include ‘Model of Care’ (MOC) were the Centers for Medicare & Medicaid Services (CMS) requires approval by the National Committee for Quality Assurance (NCQA) for each Special Need Plan. MOC is a quality improvement tool that makes SNPs unique because they ensure the needs of each beneficiary enrolled are identified and addressed.

The main difference between a Medicare Advantage plan and a SNP are the tailored benefits and care delivery models that are provided to the specific populations SNPs serve. Better Medicare Alliance wants to ensure that beneficiaries understand and get more access to information on SNPs. As of this year, Congress has permanently authorized the special needs plan and we will continue to advocate for more access to beneficiaries around the country that can benefit from the enrollment in SNPs.

Learn more by watching the video below.