Health Maintenance Organization (HMO) plans: One of the most popular types of managed-care plans, this type of Medicare Advantage plan comes with a provider network that you must use to be covered by the plan (with the exception of medical emergencies). If you use non-network providers, you may have to pay the full cost for your care. You’re also required to have a primary care physician; if you need to see a specialist, you’ll need to a get a referral from your primary care doctor first.
Remember, you still have Medicare if you enroll in an MA Plan. This means that you likely pay a monthly premium for Part B (and a Part A premium, if you have one). If you are enrolled in an MA Plan, you should receive the same benefits offered by Original Medicare. Keep in mind that your MA Plan may apply different rules, costs, and restrictions, which can affect how and when you receive care. They may also offer certain benefits that Medicare does not cover, such as dental and vision care.
In 1998, Congress replaced the VPS with the Sustainable Growth Rate (SGR). This was done because of highly variable payment rates under the MVPS. The SGR attempts to control spending by setting yearly and cumulative spending targets. If actual spending for a given year exceeds the spending target for that year, reimbursement rates are adjusted downward by decreasing the Conversion Factor (CF) for RBRVS RVUs.
The Centers for Medicare and Medicaid Services (CMS), a component of the U.S. Department of Health and Human Services (HHS), administers Medicare, Medicaid, the Children's Health Insurance Program (CHIP), the Clinical Laboratory Improvement Amendments (CLIA), and parts of the Affordable Care Act (ACA) ("Obamacare"). Along with the Departments of Labor and Treasury, the CMS also implements the insurance reform provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and most aspects of the Affordable Care Act of 2010 as amended. The Social Security Administration (SSA) is responsible for determining Medicare eligibility, eligibility for and payment of Extra Help/Low Income Subsidy payments related to Part D Medicare, and collecting some premium payments for the Medicare program.
Sicker people and people with higher medical expenditures are more likely to switch from Medicare Advantage plans to Original Medicare. This statistic is primarily driven by people on Medicaid in custodial care at nursing home; such people no longer have need of any Medicare supplement, either a public Part C plan or a private Medigap or group retirement plan. The Part C risk adjusted payments to Medicare Advantage plans are designed to limit this churn between types of Medicare (managed vs. FFS), but it is unclear how effective that policy is.
Renew or change your current plan. During the open enrollment period, you can renew your existing plan. You won’t have to do anything if you want to keep what you have. But if your current plan is changing — for instance, your PCP is leaving the network, or your drugs aren’t in the list of covered medications — then you may want to switch to a plan that best suits your current needs. If you need to change policies, the open enrollment period is the best time.
Part B also helps with durable medical equipment (DME), including canes, walkers, lift chairs, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered.
Part B Late Enrollment Penalty If you don't sign up for Part B when you're first eligible, you may have to pay a late enrollment penalty for as long as you have Medicare. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn't sign up for it. Usually, you don't pay a late enrollment penalty if you meet certain conditions that allow you to sign up for Part B during a special enrollment period.
When you apply for Medicare, you can sign up for Part A (Hospital Insurance) and Part B (Medical Insurance). Because you must pay a premium for Part B coverage, you can turn it down. However, if you decide to enroll in Part B later on, you may have to pay a late enrollment penalty for as long as you have Part B coverage. Your monthly premium will go up 10 percent for each 12-month period you were eligible for Part B, but didn’t sign up for it, unless you qualify for a special enrollment period.