The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 renamed +Choice "Medicare Advantage". Other managed Medicare plans include (non-capitated) COST plans, dual-eligible (Medicare/Medicaid) plans and PACE plans (which try to keep seniors that need custodial care in their homes). However 97% of the beneficiaries in Part C are in one of the roughly one dozen types of Medicare Advantage plans (HMO, EGWP, SNP, regional PPO, etc.), primarily in classic vanilla HMOs.
Evidence is mixed on how quality and access compare between Medicare Advantage and "traditional" Medicare. ("traditional" in quotes because it is not the same as Original Medicare; everyone in Medicare must begin by joining Original Medicare; the term "traditional" typically refers to FFS and almost always means the beneficiary has a private group or individually purchased supplement to Original Medicare). Most research suggests that enrollees in Medicare HMOs tend to receive more preventative services than beneficiaries in traditional Medicare; however, beneficiaries, especially those in poorer health, tend to rate the quality and access to care in traditional Medicare more favorably than in Medicare Advantage. It is difficult to generalize the results of studies across all plans participating in the program because performance on quality and access metrics varies widely across the types of Medicare Advantage plans and among the dozens of providers of Medicare Advantage plans.
Health Maintenance Organization (HMO) plans: These plans offer a network of doctors and hospitals that members are generally required to use to be covered. Because of this, HMOs tend to have strict guidelines, meaning that any visits and prescriptions are subject to the plan approval. If you use providers outside of the plan network, you may need to pay the full cost out of pocket (with the exception of emergency or urgent care). You generally need to get a referral from your primary care doctor to see a specialist.
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.
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In 2006, the SGR mechanism was scheduled to decrease physician payments by 4.4%. (This number results from a 7% decrease in physician payments times a 2.8% inflation adjustment increase.) Congress overrode this decrease in the Deficit Reduction Act (P.L. 109-362), and held physician payments in 2006 at their 2005 levels. Similarly, another congressional act held 2007 payments at their 2006 levels, and HR 6331 held 2008 physician payments to their 2007 levels, and provided for a 1.1% increase in physician payments in 2009. Without further continuing congressional intervention, the SGR is expected to decrease physician payments from 25% to 35% over the next several years.
Through 2016, these trigger points have never been reached and IPAB has not even been formed. However, in the 2016 Medicare Trustees Report, the actuaries estimate that the trigger points will be reached in 2016 or 2017 and that IPAB will affect Medicare spending for the first time in 2019 (meaning it will need to be formed and recommend its cuts in 2017).
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.