Managed Care 101

Managed Care 101

Your Health Plan and You

Your choices in managed care include:

  • The original Medicare Plan
  • The original Medicare Plan with a Supplemental Insurance Policy
  • Medicare Advantage Plans

No matter how you access your Medicare Health Care, you are still in the Medicare program.

The Original Medicare Plan is also known as "fee-for-service"

You are usually charged a fee for each health care service or supply you get. If you are happy getting your health care this way, you do not have to change. You will stay in the Original Medicare Plan unless you join a Medicare Advamtage Plan. Under the Original Medicare Plan, you can use your red, white and blue Medicare card when you get health care. You may go to any doctor, specialist, or hospital that accepts Medicare. Generally, a fee is charged each time you get a service. Under the Original Medicare Plan, you pay the monthly Part B premium. It is usually taken out of your monthly Social Security, Railroad Retirement, or Civil Service Retirement payment. Each year you also pay a deductible before Medicare pays its part. Thereafter, Medicare pays its share and you pay your share.

After you get a health care service, you get an Explanation of Medicare Benefits or a Medicare Summary Notice in the mail. These are sent by a company that handles bills for Medicare. The notice lists what was charged, what Medicare paid, and how much you must pay.

Under Original Medicare - How Do My Out-of-Pocket Costs Vary?

Your costs depend on:

  • Whether your doctor or supplier agrees to accept what Medicare pays.
  • How often you need health care.
  • What type of health care you need.
  • If you get health care while traveling outside of the United States.
  • Whether you choose to pay for services or supplies not covered by Medicare.

Original Medicare Plan with a Supplemental Insurance Policy

There are many companies who offer private health coverage that pays for some or all of the health care costs not covered by Medicare. This coverage is sometimes called "supplemental coverage."

These types include:

  • Employee Coverage* (from an employer or union)
  • Retiree Coverage* (from a former employer or union); and
  • Medigap Insurance (from a private company or group)

* If you drop your employer or union based group health insurance coverage, you probably won't be able to get it back.

What is Medigap?

  • A Medigap policy fills gaps in Original Medicare Plan coverage.
  • Medigap insurance must follow Federal and State laws. These laws protect you.
  • All Medigap policies are clearly marked "Medicare Supplemental Insurance."
  • In most states, a Medigap policy must be one of ten standardized policies to help you compare them easily. Each policy has a different set of benefits. Three of the standardized policies may have a high deductible option.
  • In an emergency, you may use any doctor or hospital.
  • If you are in a Medicare Advantage plan or if you are covered by Medicaid, you do not need a Medigap policy.
  • For 6 months after the first day of the month in which you are age 65 or older and first join Medicare Part B, you have the right to buy the Medigap policy of your choice. During this open enrollment period, the insurance company cannot deny you insurance coverage or change the price of a policy because of past or current health problems.

Ror more information about medigap policies, call 1(800) medicare (1-800-633-4227)

You can join a Medicare Managed Care Plan if:

  • You have both Part A (Hospital Insurance) and Part B (Medical Insurance)
  • You do not have End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant)
  • You live in the service area of the plan.

If you join a Medicare Managed Care Plan:

  • You are still in the Medicare program.
  • You must continue to pay the monthly Part B premium.
  • You will keep your Medicare rights and protections.
  • You still get all your regular Medicare covered services.

How does Managed Care work?

  • In managed care plans, you can only go to certain doctors and hospitals (in network) who have agreed to treat members of the plan. Generally, you can only see a specialist when you get a referral, which means your primary care doctor/IPA authorizes it.
  • You can often get extra benefits, for example, vision or dental.
  • Some managed care plans offer a Point-of-Service option. This allows you to go to other doctors and hospitals who are not on the plan's list. Most of the time this option costs you more, but gives you more choices.