Questions & Answers from Sarasota Memorial Health Care System about
Original Medicare Plans, Private Medicare Advantage/Managed Care Plans
and Medigap/Medicare Supplemental Plans

Recent changes in Medicare have resulted in a number of new health insurance plans for eligible participants. With so many options to choose from, it’s important to research your options carefully to help ensure you receive comprehensive health coverage at the hospital or health care provider of your choice. Here are some questions you should ask before choosing a plan:

1. Is my preferred hospital and physician in the health plan's network?

Many times, patients are told by sales representatives that "all hospitals and physicians" accept a certain plan. That is not always the case. Typically, insurance companies reimburse providers on a contracted rate agreed upon by both the company and the provider. Such agreements periodically come up for renewals, and sometimes providers may be removed or opt out of the network. Consumers should double check with their physician's office and hospital to ensure a contractual agreement is in place before signing up. For further information about insurance plans accepted by Sarasota Memorial, please call our Customer Service Center at (941) 917-1540.

2. What are the out-of-pocket costs, including maximum lifetime out of pocket, co-payments and deductibles? While premium costs are very important, consumers also should take note of a particular health plan's coverage of physician office visits, outpatient services, hospital services, in- and out-of-network providers, etc. Sometimes consumers select a plan with a lower premium only to find that the insurance provides only minimal coverage of a service or has a high co-payment or deductible.

3. What kind of plan are you considering? Take time to understand the differences and limitations of non-traditional Medicare and supplemental plans. Following is a brief summary of options available in today's market:

Original Medicare Plan vs. Medicare Advantage Plan

Medicare Advantage Plans are offered by private companies that contract with Medicare to provide all of your Medicare Part A and Part B benefits. When you join a Medicare Advantage Plan, you are still in Medicare. In many cases, the premiums or costs of services (co-pays) can be lower in a Medicare Advantage Plan than they are in the Original Medicare Plan or the Original Medicare Plan with a supplemental Medigap policy. Medicare services are covered through the plans, and are not paid for under Original Medicare.

There are four kinds of Medicare Advantage Plans:

• HMO (Health Maintenance Organizations) – HMOs are network plans. In most cases, members can only go to doctors, specialists or hospitals on the the plan’s list, except in an emergency. If members use doctors or hospitals out-of-network, they may be responsible for 100% of the bill.

• PPO (Preferred Provider Organization) – PPOs are another type of network plan that generally offers members a larger network of providers. Generally, you can use doctors, hospitals and providers outside of the network for an additional cost.

• POS (Point of Service Plans) – POS plans are managed care plans that allow members to go to any physician or hospital that accepts the terms of the plan, and requires a contract between your insurance company and healthcare providers.

• PFFS (Private Fee for Services) – PFFS have no networks. Members can go to any Medicare-approved doctors or hospitals that accept the plan's payment terms. The insurance company, rather than Medicare, decides how much it will pay and what you pay for the services you get. PFFS plans are different from HMOs, PPOs,and POS plans. With PFFS plans, there are no contracts to sign. Providers are "deemed" acceptable if they accept the terms of the company's plans. It is at the provider’s discretion to accept the plan.

Medicare Supplemental Plans

Standard vs. Select Supplemental Plans

Insurance companies sell Medicare supplemental policies, sometimes referred to as Medigap policies, to fill the "gaps" and help pay some of the health care costs that the original Medicare Plan does not cover. You can choose from up to 12 different supplemental policies, each offering “standard” or “select” benefits and coverage options.

If you are enrolled in the original Medicare Plan and choose a “standard” Medigap/supplemental policy, you can go to any doctor, hospital or other health care provider who accepts Medicare. The insurance company typically pays the Part A deductible.

If you are enrolled in the original Medicare Plan and choose a “Medicare Select” supplemental policy, you may be asked to use specific hospitals and doctors to get full insurance benefits (except in an emergency). Deductibles may be waived at specified hospitals. For this reason, Medicare Select policies generally cost less than other supplemental policies.

Medicare Select members may seek care at Sarasota Memorial, even though it may not be listed as a network provider. However, depending on your plan benefits, members may be responsible for the Part A deductible for non-emergency hospital care. Check with your insurance company as some will, on a case-by-case basis, choose to pay that deductible when providers are not in its network.

For further information about insurance plans accepted by Sarasota Memorial, please call our Customer Service Center at (941) 917-1540.

To learn more about Medicare, get a free copy of the “Medicare & You” handbook (CMS publication No. 10050), visit www.medicare.gov on the web. Select “Search Tools” at the top of the page. This website also includes information on what Medicare health plans, Medicare drug plans and Medigap policies are available in our area. Or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

08/03/07