Medicare Advantage - Questions and Answers

What if I have a problem with my Medicare Advantage plan?

Medicare Advantage is an option under the Medicare program. If you have a complaint regarding enrollment, disenrollment, coverage, or a claim, you must follow Medicare rules for resolving the problem. You should first contact the plan regarding your problem. If you are not able to resolve your problem with the plan, you should contact Medicare at 1-800-MEDICARE (1-800-633-4227).

State insurance departments, such as the Office of the Commissioner of Insurance (OCI), do not have jurisdiction over the Medicare program or Medicare Advantage plans. However, if your problem involves the acts of a licensed insurance agent, you should file a complaint with the OCI.

What happens if I am unhappy with my Medicare Advantage plan's claim decision?

A Medicare Advantage plan decision regarding the type of service and the amount to reimburse for the service is known as an organization determination. Medicare Advantage plans are required to respond in a timely manner to appeals of organization determinations. Medicare Advantage plans are also required to provide you with written information on how to file an appeal.

  • If you are unhappy with an organization determination, you must first file a request for reconsideration with the Medicare Advantage plan. The plan must issue its decision on your request within 60 calendar days and must issue an expedited decision within 72 hours.
  • If you are still unhappy with the decision, you may then appeal to an independent reviewer. The time frames are the same as those described above.
  • Additional reviews are conducted by an administrative law judge and also by the U.S. Department of Health and Human Service's appeals counsel. Finally, you may appeal the decision in federal court.
  • If the organization determination affects coverage of a continuing inpatient hospital stay, it may be immediately appealed to a Medicare peer review organization. You are not responsible for any costs incurred while this decision is pending.

If you are unhappy with a plan decision to not expedite an appeal or with the way you have been treated by plan providers, you should file a grievance with your Medicare Advantage plan. Grievances are separate and different from appeals. The plan is required to explain its grievance process to you and to respond to your grievance in a timely fashion.

Can my Medicare Advantage plan drop me?

Medicare Advantage plans can drop you at the end of the plan year if the plan does not renew its contract with Medicare. A plan that does not renew its contract with Medicare may decide to drop select geographic areas of service, or it may decide to nonrenew the entire plan. A plan may involuntarily disenroll you for failure to pay premiums timely, for causing a disruption in the plan's ability to deliver health care services, or if it cannot meet your medical needs. If you are involuntarily disenrolled, you are automatically returned to coverage under original Medicare at the beginning of the month following your involuntary disenrollment.

If I lose my Medicare Advantage coverage and return to original Medicare, can I get Medicare supplement coverage?

If you are involuntarily disenrolled from Medicare Advantage because the Medicare Advantage plan nonrenews its plan, you have the right to apply for a Medicare supplement policy, as long as you do so within 63 days of notice of the nonrenewal. If you voluntarily disenroll because you decide a Medicare Advantage plan is not right for you, you may have a right to Medicare supplement coverage as long as you have not been covered by a Medicare Advantage plan before and you disenroll from the Medicare Advantage plan within 12 months of your enrollment. This right is limited to the same Medicare supplement in which you were most recently previously enrolled, excluding any outpatient prescription drug coverage. If you do not have a right to get your same Medicare supplement coverage back, you will have to complete the medical questions on an application for Medicare supplement and the insurance company can deny your application.

How can I determine if a Medicare Advantage plan is a good choice for me?

Currently, the monthly premiums you will pay for a Medicare Advantage plan are less than the premiums you pay for a Medicare supplement policy. However, Medicare Advantage plans require that you pay a copayment each time you visit your doctor and for physicals, screening, vision and hearing exams, therapy, and rehabilitation services. You may be required to pay a $150 copayment for the 1st through the 5th day of inpatient hospital care and a $50 copayment for emergency room visits. You should compare not only the difference in the monthly premium between a Medicare supplement policy and a Medicare Advantage plan but also the copayment amounts you will pay for Medicare Advantage coverage. Your annual out-of-pocket expenses for a Medicare Advantage plan could range from approximately $500 to $5,900 depending on your health status. (2006 Medicare Advantage Costshare Report, Milwaukee Area Comparisons)

Can I keep my Medicare supplement policy and also have a Medicare Advantage plan?

Your Medicare supplement policy is designed to pay 20% of Medicare approved charges or to "supplement" the benefits payable under original Medicare. If you enroll in Medicare Advantage, you are no longer covered by original Medicare and your Medicare supplement policy will not pay any benefits toward Medicare Advantage out-of-pocket expenses. You should decide whether you want coverage under original Medicare with a Medicare supplement insurance policy or if you want coverage under a Medicare Advantage plan.

Am I entitled to the mandated benefits required by Wisconsin insurance law under Medicare Advantage plans?

Medicare Advantage policies are not subject to the mandated benefit requirements under Wisconsin insurance law. Insurance laws in Wisconsin mandate the coverage of specific services, including diabetic supplies, chiropractic care, limited home health care, and skilled nursing care. You can obtain a copy of the pamphlet, Fact Sheet on Mandated Benefits in Health Insurance Policies, that explains the benefits mandated under Wisconsin insurance law by contacting the OCI.

What happens under Medicare Advantage if I have a medical emergency?

All Medicare Advantage plans are required to use what is known as the "prudent layperson" standard in making coverage decisions about emergency care. Under this standard, if you have acute symptoms, such as severe pain, that would cause a reasonably prudent layperson to expect that delay in treatment would cause serious jeopardy to health or impairment of bodily functions, you are permitted to obtain emergency services without prior approval from your health plan. Emergency services must be provided by a qualified provider and are limited to services needed to diagnose and stabilize your condition. Urgent care is also required to be covered by a Medicare Advantage plan. An urgent care situation would include an accident or sudden illness while you are away from home. If you are a frequent traveler, you should inquire about the plan's guidelines for services when you are out of its geographic service area, including refills on prescription drugs and access to non-urgent or emergency medical services. Your Medicare Advantage plan may have a passport provision allowing you to see providers in other parts of the country. Under a PFFS plan your coverage is not limited by geographic service area. If you need medical attention, you may go to any doctor, specialist, or hospital that is approved for Medicare and accepts the plan's payment terms.

When can I join, switch, or drop my Medicare drug plan?

You can join a Medicare drug plan when you first become eligible for Medicare or if you get Medicare due to a disability. In addition, you are allowed to switch or drop your Medicare prescription plan during the annual election period (November 15 through December 31).

What happens after I join a plan?

You will get a letter from the plan telling you when your coverage begins. Once you enroll in a Medicare Advantage plan, you must show your plan ID card every time you visit a health care provider. You cannot use your red, white, and blue Medicare card to get health care because the original Medicare plan will not pay for your health care while you are enrolled in the Medicare Advantage plan. Read plan materials carefully to find out about the rules that can affect where you can get your care and what you will have to pay, including whether the plan has a network (certain providers you must use) and your share of the cost for services and supplies.