3 Medicare managed care plans offer some choice
Location may limit choice
You should be aware that your Medicare managed care patients may be beneficiaries of any one of three types of contracts risk, cost, or health care prepayment plans (HCPPs) all of which receive a monthly payment from the Medicare program. Nationally, three-fourths of beneficiaries have a choice of at least one managed care plan, while more than half have a choice of two or more plans. Medicare managed care enrollment varies greatly depending on geographic location. The majority of beneficiaries enrolled in such plans live in Arizona, California, Florida, Hawaii, New York, and Oregon.
• Risk plans are paid a per capita premium set at approximately 95% of the projected average expenses for fee-for-service beneficiaries in a given county. Risk plans assume full financial risk for all care provided to Medicare beneficiaries. Risk plans must provide all Medicare-covered services, and most plans offer additional services, such as prescription drugs and eyeglasses. With the exception of emergency and out-of-area urgent care, members of risk plans must receive all care through the plan. However, the plans can provide an out-of-network option that, subject to certain conditions, allows beneficiaries to go to providers who are not part of the plan. Currently, 86% of Medicare beneficiaries in managed care are in risk plans 248 out of 350 plans.
• Cost plans are paid a predetermined monthly amount per beneficiary based on a total estimated budget. Adjustments to that payment are made at the end of the year for any variations from the budget. Cost plans must provide all Medicare-covered services, but do not provide the additional services that some risk plans offer. Beneficiaries may obtain Medicare-covered services outside the plan without limit. When a beneficiary goes outside the plan, Medicare pays its traditional share of those costs and the beneficiary pays Medicare’s coinsurance and deductibles.
• HCPPs are paid in a similar way as cost plans, but don’t cover all the Medicare benefit package. HCPPs do not cover Medicare Part A (inpatient hospital care, skilled nursing, hospice, and some home health care), but some do arrange for services and may file Part A claims for members.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content