CMS (The Centers for Medicare & Medicaid Services) is taking a closer look this year at Medicare Advantage plans and the co-pays enrollees must pay for medical services.  Their objective is to spot Advantage plans with high co-pays that help the plans “cherry pick” healthier enrollees.

High co-pays for durable medical equipment such as oxygen are considered discriminatory.  Co-pays for a stay in a skilled nursing facility will be another target for CMS.  When these co-pays are raised by an Advantage plan, sicker members will likely shop for a plan with lower cost sharing. Having the option to change to another Advantage plan with lower cost sharing is a good thing for seniors, but CMS is concerned that some plans are pushing sicker, more costly enrollees out, with a goal of attracting and keeping healthier seniors.  Healthier enrollees lead to  higher profit margins for insurance companies.

Healthy seniors who are shopping for a Medicare Advantage plan will often look at high co-pays for something like oxygen and say that doesn’t affect them. If the co-pay for a skilled nursing facility (SNF) starts from day 1 at $100 per day, that may not concern a healthy 65 year-old.  A senior with health problems will likely avoid this Advantage plan.

Medicare Advantage plans have flexibility in designing their benefit packages, but (1) they must provide all Medicare-covered services except hospice care, (2) their overall cost sharing requirements must be actuarially equivalent or lower than those under Medicare fee-for-service, and (3) they cannot discriminate on the basis of health status.

According to the Government Accountability Office (GAO), of the 2,930 MA plan benefit packages submitted for contract year 2010, about 40 percent were identified as likely to be discriminatory.

Then there are MOOPs:

To help provide financial protection to beneficiaries who might otherwise have high cost-sharing expenses, Medicare Advantage plans may voluntarily establish out-of-pocket maximums (OOPs or MOOPs) which are dollar limits on the amount a beneficiary must pay in cost sharing during the year.  For contract year 2010, CMS allowed Advantage plans with a MOOP at or below $3,400 greater flexibility in establishing cost-sharing amounts.

Folks turning 65 and shopping for a Medicare Advantage plan should compare several plans and their co-pays.  In 2011, all Advantage plans are supposed to have a MOOP, but some will be $3,400 and some may be $6,000 or higher.

The 280,000 Arizonans already enrolled in a Medicare Advantage plan should study the Annual Notice of Change they will receive in October from their Advantage plan.  Their plan may change for the better by finally having a MOOP.  Or their plan may introduce a MOOP but raise co-pays for specialist visits, hospital stays, and other services.

People enrolled in Medicare Advantage plans will be able to switch plans between November 15^th and December 31^st this year, with the change taking effect on January 1, 2011.  After January 1, they will be locked into their MA plan for the entire year – unless they want to get out of Medicare Advantage and go back to Original Medicare (and enroll in a pay for a stand-alone Part D plan). This change will be allowed during the first 45 days of 2011.

MORE INFORMATION ON COMPARING MEDICARE ADVANTAGE CAN PLANS BE FOUND ON MY WEBSITE.

This entry was posted on Thursday, June 10th, 2010 at 7:25 am and is filed under Health. Tags for this post: Arizona Medicare, arizona medicare advantage, change medicare advantage plans, Healthcare reform, Medicare, Medicare Advantage, medicare advantage arizona, medicare advantage problems, medicare advantage tucson, medicare arizona, medicare blog, medicare change, part d, tucson medicare, turning 65, turning 65 medicare. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.