AHIP Medicare - Module 2 - Other types of Medicare Health Plans

The other types of Medicare health plans include:

– Medicare Cost Plans
– Programs of all-inclusive Care for the Elderly (PACE) plans
–Medicare-Medicaid Plans (MMPS)
–Other Demonstration Plans
-Other Medicare health plan demonstrations include state-specific demonstrations such as the Minnesota Senior Health Care Options (MSHO) program.

Medicare Cost Plans are Medicare health plans that are not Medicare Advantage (Part C) plans and are not Original Medicare.

Medicare Cost Plans:
– may offer Part D prescription drug coverage as an optional benefit but are not required to do so.

– May offer other optional supplemental benefits.

–are available in certain areas in the United States. IN 2023 they were offered in 11 states including some counties in Illinois Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, Oklahoma, South Dakota, Wisconsin, and Wyoming.

Medicare Cost Pans are Medicare health plans that are not Medicare Advantage (Part C) plans and are not Original Medicare.

Cost plan enrollees can choose to receive Medicare-covered services:
– Under the plan’s benefits by going to plan network providers
- The plan’s cost-sharing applies when the enrollee gets services from network providers.

– Under Original Medicare by going to non-network providers.
- Original Medicare cost-sharing applies when the enrollee gets services from non-network providers. This amount is generally higher than the plan cost-shring.

The following individuals are eligible to enroll in a Medicare cost plan:
– Those with Medicare Part A and Part B; or

– Those with only Part B. Enrollees with Part B only will not have Part A coverage under the plan unless they purchase it. The plan may adjust the enrollee premium for individuals with Part B only.

NOTE: Regarding Premiums: Enrollees must pay their Part B premiums and any plan premium.

PACE Plans are Programs of All-Inclusive Care for the Elderly (PACE):

– are Medicare plans for frail, elderly beneficiaries certified as needing a nursing home level of care but still living in the community (i.e., not in a nursing home).

– PACE Plans are available in most states but tend to have small service areas, and thus may only be available in a few counties.

– PACE Plans offer an adult day health center, where enrollees can get care, meals, and other services.

– PACE Plans include comprehensive medical and social service delivery systems using an interdisciplinary team approach in the adult day health center, supplemented by in-home and referral services.

Eligibility for PACE: Participants must be
- age 55 or older.
- reside in the PACE organization’s service area,
- be certified as eligible for nursing home care by their state.
- be able to live safely in a community setting at the time of enrollment.

Under a PACE Plan:
– there’s no deductible or copayment for any drug, service, or care approved by the PACE team of health care professionals.

– Beneficiaries with Medicaid pay no premiums

– Beneficiaries with only Medicare pay a monthly premium to cover the long-term care portion of the PACE benefit and a premium for Part D (in addition to the Part B premium).

Medicare-Medicaid Plans (MMPs):
- are established under demonstration authority; and
- are available only in certain counties in Rhode Island, South Carolina, Texas, California, Illinois, Massachusetts, Michigan, New York, and Ohio.

Only certain individuals eligible for both Medicare and Medicaid may enroll in MMPs.
- Eligibility varies by state.

MMPs financially integrate and provide both Medicare and Medicaid benefits.
- In some states, MMPs may offer additional benefits.

All MMPs include Part D benefits.
MMPs are NOT Medicare Advantage plans.