Recently, the Center for Medicare and Medicaid Services (CMS) authorized the sale of a Medicare Plus Choice Private Fee For Service Plan in Wisconsin. While the Plan is required by federal law to have its benefits, disclosures, premiums, and advertising material reviewed and approved by CMS, the Office of the Commissioner of Insurance (OCI) believes that Wisconsin's Medicare-eligible consumers need to be well informed when they are deciding what coverage is best for them.

The Medicare Plus Choice program was enacted in 1997 to foster a Medicare program that relies on health maintenance organizations and managed care plans to lower the costs of the Medicare program. The Medicare Plus Choice program is completely voluntary and consumers do not have to leave traditional Medicare unless they care to do so. Should one select a Medicare Plus Choice Plan, the Medicare program will, at your direction, purchase a health insurance policy on your behalf.

There are a number of different Medicare Plus Choice plans authorized by federal law. The most common of which has been Medicare Plus Choice Managed Care offered by an HMO. HMOs generally have more restrictions on the providers you may use than any other type of health plan you can enroll in, although they often provide benefits, such as preventative care, that are not available from other types of health plans. The Medicare Plus Choice Private Fee For Service Plans are offered by private insurance companies. These plans generally do not restrict provider choice as do the Medicare Plus Choice Managed Care Plans. Medicare Plus Choice may provide "additional" benefits for which they may charge a premium.

Medicare and Medicare Plus Choice plans are regulated by the Center for Medicare and Medicaid Services (CMS), a federal agency in the Department of Health and Human Services. State insurance laws do not apply to traditional Medicare, are largely preempted by federal law, and apply on a very limited basis to Medicare Plus Choice plans. For example, Wisconsin's mandated coverage of specific services, such as diabetic supplies, limited home health care, and skilled nursing care would not be mandated in a Medicare Plus Choice plan.

The cheapest policy may not always be the best option for you. Therefore, if you are looking at purchasing, for example, a Medicare Plus Choice Private Fee For Service plan, here are some questions you should ask:

1. Since the agreement between the insurer and the federal government is annually renewable, what assurance can you give me that this plan will be available to me over the long haul?
2. What rights do I have if I decide to cancel the plan?
3. What rights do I have if I decide that I don't like the plan and cancel it?
4. Can you show me how the coverages you provide and the premium you are charging compare to traditional Medicare with a typical Medicare supplement insurance policy?
5. How often can you raise the premium?
6. How often can you change the benefits? How often will you change the benefits?
7. Could you please explain to me, in very clear terms, the providers I can see and still be covered under the plan?
8. What are you getting paid to sell me this plan?

Make informed decisions about your health care coverage. It is always better to know what you're buying before you actually need it so that there are no surprises when you really do need it. Don't be afraid to ask questions.

For more information visit OCI's Web site at http://oci.wi.gov, or call 1-800-236-8517. On the site, there is fact sheet on Medicare Plus Choice along with contact information for any questions you may have about the plans and those insurers who provide the coverage.

Medicare Plus Choice Considerations - Part 1

By Guenther Ruch, Administrator
Division of Regulation and Enforcement
Office of the Commissioner of Insurance