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Medicare Advantage: An Overview
By Jaime Mulligan
Doctors of chiropractic increasingly encounter Medicare beneficiaries enrolled in various types of Medicare Advantage plans, which allow beneficiaries to access their Medicare benefits through private insurance plans.
Medicare Advantage plans fall under Medicare Part C, formerly Medicare+Choice. The administration of these plans often leads to beneficiary or provider confusion and/or difficulties accessing certain types of Medicare benefits. For this reason, ACA has been very concerned about the effects of Part C plans on beneficiary access to chiropractic care.
Types of Plans and Enrollment Statistics
There are several different types of Part C plans. A 2006 Centers for Medicare and Medicaid Services (CMS) publication outlines Medicare Part C plan options for beneficiaries as follows:
Medicare Health Maintenance Organization (HMO) Plans—You generally must get your care from primary care doctors, specialists or hospitals on the plan’s list (network), except in an emergency.
Medicare Preferred Provider Organization (PPO) Plans—In most of these plans, you pay less if you use primary care doctors, specialists and hospitals on the plan’s list (network). You can go to any doctor, specialist or hospital that is not on the plan’s list, but it will usually cost extra.
Medicare Special Needs Plans—These plans provide healthcare coverage designed for specific groups of people.
Medicare Private Fee-for-Service (PFFS) Plans—If you join one of these plans, you can go to any primary care doctor, specialist or hospital that accepts the terms of the plan’s payment. The private company, rather than the Medicare Program, decides how much it will pay.1
A 2009 update of the same publication informs beneficiaries that Medical Savings Account (MSA) plans are a current option, as well as Provider Sponsored Organizations (PSOs) and Religious Fraternal Benefit (RFB) plans.2 However, the most popular plans remain HMO, PPO and PFFS options. In 2008, HMOs and PPOs (local and regional) accounted for 74 percent of all Medicare Advantage enrollees. PFFS plans accounted for 22 percent of the total Medicare Advantage enrollees.3
Overall, in 2008, approximately 23 percent of the Medicare beneficiary population was enrolled in some type of Part C plan.3 This is up from 20 percent in 2006.4
According to a 2007 Economic and Budget Issue Brief from the Congressional Budget Office, the taxpayers’ cost per beneficiary is 12 percent higher if a beneficiary accesses Medicare benefits through a Medicare Advantage plan (Part C) than through fee-for-service (Part B).5 Part C plans are more expensive because the insurance companies that administer them receive significant bonuses, which were part of the Medicare Modernization Act of 2003.
Medicare beneficiaries are often offered Medicare Advantage plans as a way to access their prescription drug benefit, and many beneficiaries may not realize that they could continue with their usual fee-for-service coverage and opt into the prescription drug benefit using a stand-alone plan (Part D). Instead, they are rolled into a Medicare Advantage plan that significantly restructures much of their care delivery, including high co-pays and classifications for specialists. Often, this is the result of confusing marketing schemes, an issue the federal government is working to control. (ACA has developed a Healthy Living fact sheet to assist doctors whose patients are navigating these options. See the sidebar “Protect Your Patients’ Access to Chiropractic Care.”)
Due to the serious costs of Part C and the complications that have arisen in its implementation, many policymakers are pressing for reform. President Obama has stated that Medicare Advantage is an example of a program that “just doesn’t work.” Prior to his withdrawal as HHS secretary nominee, Senator Tom Daschle (D-S.D.) spent a lot of time discussing the problems surrounding Medicare Advantage. It is very likely that any healthcare reform plan supported by the Obama Administration and the Democratic Congress will contain serious reforms to Medicare Advantage. ACA, of course, will advocate on behalf of the profession throughout these reform processes.
1. “Medicare & You” for the year 2006, Centers for Medicare and Medicaid Services, www.Medicare.gov/publications/pubs/pdf/10050.pdf, page 30.
2. “Medicare & You” for the year 2009, Centers for Medicare and Medicaid Services, www.medicare.gov/publications/pubs/pdf/10050.pdf, page 50.
3. “Medicare Advantage Fact Sheet.” Kaiser Family Foundation. Sep 2008. www.kff.org/medicare/upload/2052-11.pdf.
4. CMS Press Release June 14 2006, “Over 38 Million People With Medicare Now Receiving Prescription Drug Coverage,” http://hhs.gov/news/press/2006pres/20060614.html
5. “Medicare Advantage: Private Health Plans in Medicare.” Congressional Budget Office 2007 Jun 28.
ACA News Extra...
Medicare: What’s with All the Parts?
Here’s a glance at how Medicare services are divided. Doctors of chiropractic generally deal with patients in Parts B and C.
Medicare Part A: Hospital
Medicare Part B: Outpatient fee-for-service
Medicare Part C: Managed care (also known as Medicare Advantage; formerly known as Medicare + Choice)
Medicare Part D: Stand-alone drug benefit plans
ACA News Extra...
Did You Know…
In 2005, ACA sued the federal government over the administration of the chiropractic benefit in the Part C plans. In many cases, plans did not have doctors of chiropractic available in their network and told beneficiaries that they could access “manual manipulation of the spine to correct a subluxation” by visiting an MD, DO or PT. As a result of this suit, CMS sent an official notice stating that physical therapists could not perform manipulation, as it is a physician-level service. For more information, go to www.acatoday.org/medicare and click on “HHS Lawsuit Background.”
ACA News Extra...
Protect Your Patients’ Access to Chiropractic Care
We strongly recommend that, whenever possible, DCs utilize ACA resources to educate patients about the Medicare program, particularly during enrollment time (November to December each year). The following Web site includes a Healthy Living fact sheet that doctors can print and make available in their offices: www.acatoday.org/MedicarePDB
We also recommend that doctors visit www.ChiroVoice.org, a chiropractic patient advocacy initiative, and encourage patients to join. The more names and e-mail addresses in ChiroVoice, the more likely it is that ACA will be successful in effectively representing the profession on Capitol Hill. For more information, visit www.chirovoice.org.