By Melinda M. Houser
Extension Agent
Family and Consumer Sciences

Jan. 1 to March 31 marks the annual Medicare Advantage open enrollment period. While some beneficiaries choose to stay with Original Medicare, others have found that Medicare Advantage (MA) plans can offer more diverse coverage. Just like with any insurance or financial decision, it’s important for you to understand the terms of the product and know the laws surrounding Medicare Advantage.

MA plans typically require additional copayments and coinsurance, but they also have an out-of-pocket maximum and eliminate the need for a Medicare supplement policy. They may also require beneficiaries to use an in-network provider, that’s why it’s important to determine if a patient’s current doctors and hospitals accept MA plans before you sign up. No matter what Medicare health insurance option beneficiaries choose, they will continue to pay the Medicare Part B premium. The four types of MA plans each work differently and are as follows:

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1. Medicare Health Maintenance Organizations —People with Medicare who join an HMO are required to receive all their non-emergency Medicare services from the HMO’s network of providers. Typically, HMOs have small copayments for covered medical services and require referrals for specialized medical services.

2. Preferred Provider Organizations — Medicare PPOs also have a network of medical providers; however, PPOs usually do not require the primary care physician’s referral for specialized medical services. PPOs have copayments for medical services received from providers in the network, and higher out-of-pocket expenses for medical services received outside the network.
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Private Fee-for-Service Plans — Medicare PFFS Plans are offered by private companies to provide health care coverage to people with Medicare on a pay-per-service agreement. The PFFS plan may offer additional health benefits, including prescription drug benefits, vision, hearing and wellness programs, and other coverage. With a PFFS plan you can go to any Medicare-approved doctor or hospital in the United States that accepts the terms of the PFFS plan. Since there is no network of providers, you should check with your doctor or hospital to be sure they accept the PFFS plan.

3. Special Needs Plans — Medicare Special Needs Plans typically limit their membership to people in specific institutions, such as a nursing home, people who are eligible for both Medicare and Medicaid, or people with certain chronic or disabling conditions.

In 2008, the federal government imposed regulations about how Medicare Advantage plan can be marketed. According to these new federal rules, individuals who contact Medicare recipients about any type of private Medicare coverage must comply with the following:

• Must be licensed by the state. Check out agent and company license status online: www.ncdoi.com/Consumer/Consumer_home.asp.
• May not make unsolicited contacts with prospective beneficiaries, such as door-to-door sales, cold calls or approaching a beneficiary in a parking lot.
• Must have an appointment in advance before coming to your home.
• Must arrange, in advance, the type of products that will be discussed during a scheduled sales appointment. At the appointment, the salesperson may not try to sell other types of insurance coverage other than the type(s) agreed upon in advance.
• May not try to sell non-health care related products — like a life insurance policy or an annuity — during a sales or marketing presentation of a Medicare prescription drug or Medicare Advantage plan.
• May not attempt to sell plans in certain health care settings, such as a doctor’s office or pharmacy.
• May not attempt to sell plans at an educational event.
• May not offer free meals at promotional or sales events.
• May not offer gifts or other promotional items whose value is in excess of $15.

N.C. SMP (Senior Medicare Patrol) wants folks to know that even with these new regulations, there may be times when a rogue agent might use pushy or even illegal measures when selling their Medicare Advantage products. To protect yourself from becoming a victim of scams, follow these N.C. SMP fraud prevention tips:

• Beware of door-to-door sales people. Agents cannot solicit business at your home without an appointment. Do not let uninvited agents into your home.
• Check with the Department to make sure the salesperson is a licensed agent. Ask the salesperson for their name and contact information, or even better get their business card and keep it with the information they provide.
• Do not share personal information, such as Social Security numbers, bank account numbers or credit card numbers to anyone you have not verified as a licensed agent. People are not allowed to request such personal information in their marketing activities and cannot ask for payment over the Internet. They must send you a bill.
• Make sure your health care providers will accept the plan you are considering before you buy it, or you may be stuck paying for all your charges yourself! Call your doctor and ask before you buy.
• If you have other health insurance, such as your employer plan through retiree coverage, check with that plan before you enroll in a Medicare Advantage plan.
• Do not be pressured into making quick decisions. The agent can wait for you to think this over, discuss it with someone else, call your doctor and/or call SHIIP for assistance.

If you’re considering a Medicare Advantage plan, contact Cooperative Extension at 704-736-8461 or visit www.ncshiip.com; if you have questions about Medicare fraud, waste or abuse, call N.C. SMP at 1-800-443-9354.

The SHIIP Program (Senior Health Insurance Information Program) is coordinated by Melinda Houser, NC Cooperative Extension in Lincoln County. Local counselors are trained through the NC Department of Insurance to assist individuals, educate and provide information concerning their Medical insurance and Prescription Drug Plan choices. Folks in Lincoln County have saved thousands of dollars in medical and prescription drug costs as a result of this program.