Dual Eligibles Participating in Medicare Advantage Plans

December 1, 2007

Author: Cathy Roberts

Some low-income Medicare beneficiaries participate in Medicare Advantage (“MA”) plans, where Medicare Part A (hospitalization), Part B (outpatient) and sometimes also Part D (prescription drug) services are provided through a private health insurance plan, rather than through the traditional or original Medicare model.

MA plans must offer all the services that traditional or original Medicare provides, but are not required to offer the same level of cost-sharing.  MA plans may offer additional services not provided by original Medicare, such as routine dental or vision coverage.  However, MA plans may limit their services to a fixed provider network and/or subject their participants to HMO-type or other additional requirements. 

Dual eligibles may encounter unexpected problems when they enroll in an MA plan.  Advocates should be on the lookout for:

• Aggressive or misleading marketing practices.  Because dual eligibles can enroll in MA plans at any time, unlike non-dual eligibles who are generally limited to the annual open enrollment period, they are particularly vulnerable to marketing abuses, particularly during those months outside of the annual open enrollment period.  A dual eligible may be eligible for retroactive disenrollment from their MA plan if they were the victim of misleading marketing.  Dual eligibles can always prospectively disenroll – even if no marketing abuse occurred -- due to their continuous enrollment period.
• Situations in which the dual eligible is WORSE off being in the MA plan rather than original Medicare. MA plans may restrict rather than expand a dual eligible’s options.  Under original Medicare, a beneficiary goes to any health care provider who accepts Medicare.  In an MA plan, a dual eligible may be limited to the doctors who participate in the plan.
• Ensuring coordination of coverage with Medicaid. The beneficiary should be able to receive medically necessary services like transportation through Medicaid if they are not covered by the plan.  However, some beneficiaries have simply been told “we don’t cover that service” by their MA plan without being directed to their local Medicaid worker.
• Confusing cost-sharing rules and, depending on the dual eligible’s status, increased payment liability.  Unlike Part D, where dual eligibles receiving the full Low Income Subsidy have the same level of cost sharing, cost-sharing is NOT necessarily the same for all dual eligibles enrolled in MA plans.  CMS issued a memo in the spring of 2007 to state Medicaid directors entitled “Cost Sharing in Medicare Advantage Plans” which stated:  “To properly determine Medicaid liability for Part C [Medicare Advantage] cost sharing for a dual eligible it is necessary to determine the individual’s Medicaid coverage group and the type of Part C cost-sharing.”  What follows is part of the cost-sharing matrix contained in the memo:

Medicare Part C Cost Sharing Chart

 As you can see from the chart, beneficiaries receiving QMB -- the Qualified Medicare Beneficiary program which pays for individuals’ Part B monthly premiums and any premiums, deductibles and co-pays not covered by Part B – should not have any cost sharing in Medicare Advantage plans.  However, other dual eligibles may have to cover the cost of co-pays, premiums and deductibles on their own if they want to stay in the MA plan.  You can get the entire CMS memo and full cost-sharing matrix on the Center for Medicare Advocacy’s website at www.medicareadvocacy.org.

For Medicare beneficiaries receiving full Medicaid coverage, there are usually more disadvantages, rather than advantages, to enrolling in an MA plan.  If you encounter a dual eligible who is having problems with an MA plan, remember that the beneficiary can disenroll at any time.  For questions about this article or Medicare Part C or Part D issues affecting dual eligibles, please contact Cathy Roberts in the Albany office at (518) 462-6831 x 23 or croberts@empirejustice.org.