Module 2 - Part C: Medicare Advantage Plan Benefits Flashcards
Characteristics of Part C: Medicare Advantage Plan Benefits:
– All Medicare Advantage (MA) plans must cover all Part A and Part B benefits.
– Most Medicare Advantage plans also cover part of the Original Medicare cost-sharing for Part A and Part B benefits
– Medicare Advantage plans may also cover extra benefits not covered by Original Medicare (known as “supplemental benefits”), such as:
- Vision services, including glasses
- Hearing Aids
- Routine Dental Services
– Supplemental benefits may be optional or mandatory
- Mandatory supplemental benefits are embedded in the Medicare Advantage plan and must be purchased as part of the plan. they can include reductions in cost-sharing for benefits under Original Medicare and are paid for in the form of premiums and cost-sharing, or by an application of the beneficiary rebate.
- Optional supplemental benefits may be added to an MA plan at the option of the beneficiary who pays for them in the form of premiums or cost-sharing.
Are there Medicare Advantage plans that offer special benefits for individuals with certain chronic health conditions?
Yes. Medicare Advantage plans may offer special benefits for individuals with certain chronic health conditions, such as diabetes, heart failure, COPD, or other conditions, that are not available to members of the same plan without the specified condition. There are two categories of such benefits:
- Primarily Health Related Benefits: Primarily health-related benefits for chronically ill enrollees may include items such as: decreased cost sharing for certain services, or supplemental benefits such as at-home palliative care or transportation to medical appointments.
- Special Supplemental Benefits: Benefits that are not primarily health related (the latter generally address social determinants of health and are known as Special Supplemental Benefits for the Chronically Ill, or SSBCI). SSBCI may include items such as: groceries, meals beyond a limited basis, pest control, and non-medical transportation.
Consequently, it is useful for agents to know if their clients have conditions that may qualify them for these types of benefits if they are available in the clients’ area.
What is Medicare Advantage Plan - Utilization Management?
Medicare Advantage plans may implement mechanisms to manage the utilization of covered services that do not apply under Original Medicare.
Such mechanisms include requiring a referral or prior authorization to obtain a service.
Plans may also implement step therapy requirements for Part B or Part D drugs. Step therapy is when a plan requires a beneficiary to try less expensive options before “stepping up” to drugs that cost more.
Under what circumstances are drugs administered under Medicare Part B coverage?
Medicare Part B covers the administration of drugs under certain circumstances12:
The drugs must be non-oral or biological, administered through an IV or applied under the skin for a period of at least 15 minutes.
The drugs must be considered “reasonable and necessary” and not self-administered.
Medicare Part B covers injectable and infusible drugs that are not usually self-administered and that are furnished and administered as part of a physician service.
In the home setting, to be covered by Part B, the drug to be infused must require administration using a Part B-covered infusion pump, and administration of the drug in the home must be reasonable and necessary.
Examples include certain intravenous drugs for heart failure and pulmonary arterial hypertension, and subcutaneous immune globulin.
Please note that this is not an exhaustive list and there may be other circumstances under which drugs are covered under Medicare Part B. It’s always best to check with Medicare or a healthcare provider for specific coverage information.
