Handling Medicaid and HMO retroactive eligibility?

RETROACTIVE ELIGIBILITY

Providers should be aware that, since bills have to be incurred before the deductible amount is met, there is always a period of retroactive eligibility. This may be several days or up to a period of three months from the current month. In this situation, the local MDHHS office may apply these old bills to the past three months or may prospectively apply them to the next several months, depending on the DOS and the date the bill was presented to the MDHHS worker.


It is the provider's option to bill Medicaid if the beneficiary has paid the provider for services rendered. MDHHS encourages the provider to return the amount the beneficiary paid and bill Medicaid for the service. If the provider decides to bill Medicaid, he must return all money the beneficiary paid over and above the amount identified as the beneficiary's responsibility on the Medicaid deductible letter. If the beneficiary is accepted as a Medicaid beneficiary, he cannot be charged more than indicated on the letter from the local MDHHS office (plus applicable copayment amounts).

Retroactive Medicare Entitlement Involving State Medicaid Agencies

The time for filing a claim will be extended if CMS or one of its contractors determines that failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was not entitled to Medicare.

(b) The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.

(c) A State Medicaid Agency recovered the Medicaid payment for the furnished service from a provider or supplier 6 months or more after the date of the furnished service.

In these situations, at the time services were furnished the beneficiary was entitled to Medicaid but not to Medicare. After the date of the furnished services, the beneficiary is then notified that he or she is entitled to Medicare. Finally, sometime after the date of the furnished service, the State Medicaid Agency recoups the money it paid the provider or supplier. If the State Medicaid Agency recoups the money it paid the provider or supplier 6 months or more after the date the service was furnished, the provider or supplier may be given an extension to have those claims filed to Medicare.

In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with the following information:

• documentation verifying the date that the State Medicaid Agency recouped money from the provider/supplier;

• documentation verifying that the beneficiary was retroactively entitled to Medicare to or before the date of the furnished service (e.g., an official SSA letter to the beneficiary, or if an official SSA letter is not available, the contractor shall check the CWF database and may interpret the CWF date of accretion and the CWF Medicare entitlement date for a beneficiary in order to verify a beneficiary’s retroactive entitlement; see the example in section 70.7.2 above concerning the CWF for additional details regarding this contractor verification process); and,

• documentation verifying the service/s furnished to the beneficiary and the date of the furnished service/s.

If the contractor determines that all of the conditions described above for meeting this exception are met, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the State Medicaid Agency recovered its money.



 Retroactive Disenrollment from a Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) Provider Organization


The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was enrolled in a Medicare Advantage (MA) plan or Program of All-inclusive Care for the Elderly (PACE) provider organization.

(b) The beneficiary was subsequently disenrolled from the Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization effective retroactively to or before the date of the furnished service.

(c) The Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization recovered its payment for the furnished service from a provider or supplier 6 months or more after the service was furnished.

There may be situations where a beneficiary is enrolled in an MA plan or in a PACE provider organization, and later becomes disenrolled from the MA plan or PACE provider organization. And, if the MA plan or the PACE provider organization recoups the money it paid the provider or supplier 6 months or more after the service was furnished, the provider or supplier may be granted an exception to have those claims filed with Medicare.

In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with information that verifies:

• prior enrollment of the beneficiary in an MA plan or PACE provider organization;

• the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization;

• the effective date of the disenrollment; and,

• the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.

If the contractor determines that all of the conditions described above are satisfied, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the MA plan or PACE provider organization recouped its money from the provider or supplier.


 ELIGIBILITY

There are cases when beneficiaries have the medical need for Medicaid coverage but they have excess income. These beneficiaries are known as Medicaid deductible beneficiaries. Medicaid deductible means that the beneficiary must incur medical expenses each month equal to, or in excess of, an amount determined by the local MDHHS worker to qualify for Medicaid. Once the deductible amount has been incurred, the beneficiary becomes eligible for Medicaid benefits (Benefit Plan ID of MA). Providers must verify Medicaid coverage using the Benefit Plan ID(s) provided in the CHAMPS Eligibility Inquiry.

The process for a Medicaid deductible beneficiary to become Medicaid eligible is as follows:

** The beneficiary presents proof of any medical expenses incurred (e.g., insurance premiums, bills for prescriptions and/or office visits) to the MDHHS worker. Providers may estimate any other insurance or Medicare payment that may be applied to the incurred bill. If the exact charge is not immediately known, providers should estimate the charge on the incurred bill. This expedites the eligibility process.

** The local MDHHS worker reviews the medical bills incurred, and determines if the amount of beneficiary liability is met and the first date of Medicaid eligibility.

** It is fraud to provide beneficiaries with a notice of a bill incurred if no service has been rendered.

** Bills for services rendered prior to the effective date of Medicaid eligibility are the beneficiary's responsibility.

** For the first date of eligibility, the MDHHS worker sends letters to those providers whose services are:

** Entirely the beneficiary's responsibility.

** Partly the beneficiary's responsibility and partly Medicaid's responsibility.

** A letter is also sent to the beneficiary indicating which services are the beneficiary’s responsibilities for that first date of Medicaid eligibility.

** The beneficiary's Benefit Plan ID is changed to MA or MA-ESO to indicate the Medicaid eligibility period. The provider must verify eligibility using the CHAMPS Eligibility Inquiry when the beneficiary becomes eligible. Once the deductible amount is incurred, eligibility is established through the end of the month.

Providers may bill Medicaid for any covered services rendered during that eligible period. Before billing, providers should verify that the Benefit Plan ID of MA or MA-ESO is on file for the DOS. This will assure that the claims will not be rejected for lack of eligibility.

Filing claim to Medicare after offset from Medicare advantage plan (HMO)

Retroactive Disenrollment from a Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) Provider Organization


There may be situations where a beneficiary is enrolled in an MA plan or in a PACE provider organization, and later becomes disenrolled from the MA plan or PACE provider organization. And, if the MA plan or the PACE provider organization recoups the money it paid the provider or supplier 6 months or more after the service was furnished, the provider or supplier may be granted an exception to have those claims filed with Medicare.

In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with information that verifies:
• prior enrollment of the beneficiary in an MA plan or PACE provider organization;
• the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization;
• the effective date of the disenrollment; and,
• the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.

If the contractor determines that all of the conditions described above are satisfied, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the MA plan or PACE provider organization recouped its money from the provider or supplier.

The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was enrolled in a Medicare Advantage (MA) plan or Program of All-inclusive Care for the Elderly (PACE) provider organization.
(b) The beneficiary was subsequently disenrolled from the Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization effective retroactively to or before the date of the furnished service.
(c) The Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization recovered its payment for the furnished service from a provider or supplier 6 months or more after the service was furnished.

COORDINATION OF BENEFITS AND SUBROGATION - patient share

Coordination of Benefits and Patient’s Share



Members occasionally have two or more benefit policies. When they do, the insurance carriers take this into consideration and this is known as Coordination of Benefits.


Prompt Pay Legislation - Coordination of Benefits

Coordination of benefits is necessary when more than one plan is responsible for claim payment. Claims that involve coordination of benefits are subject to special rules under the Texas Prompt Pay Act.

When providers are aware of multiple plans potentially involved in claim payment, information related to all applicable plans must be submitted in order for the claim to be clean. The Provider must submit the claim first to the primary plan and then to any secondary or tertiary plans. The order of payer responsibility is determined by TDI guidelines, which have adopted the uniform rules of the National Association of Insurance Commissioners (NAIC).18

When Blue Essentials, Blue Advantage HMO and Blue Premier are the secondary payer of a claim submitted in non- electronic format, the amount paid by the primary plan is a required data element and must be submitted in field 54 for the claim to be clean.19 Thus, the applicable statutory payment period for a secondary plan does not begin unless and until it receives the primary plan’s adjudication information.

In some cases, Blue Essentials, Blue Advantage HMO and Blue Premier acts as both the primary and secondary payer on a single claim. A claim submitted to the primary plan that includes all required secondary plan information is sufficient to allow processing under both policies. The secondary plan’s Texas Prompt Pay Act payment period does not begin until the claim is adjudicated by the primary plan.

If Blue Essentials, Blue Advantage HMO and Blue Premier determines that a secondary plan has paid an amount owed by the primary plan in error, it may recover the amount of its overpayment from the primary plan or from the provider if it has already been reimbursed by the primary plan.20 For purposes of calculating Texas Prompt Pay Act penalties for secondary claims, the contracted rate and billed charges are reduced in proportion to the percentage of the claim owed after the primary plan’s payment.

Subrogation

Subrogation is a contract provision that allows healthcare insurers to recover all or a portion of claims payments if the member is entitled to recover such amounts from a third party. The third party’s liability insurance carrier normally makes these payments. A third party is another carrier, person or company that is legally liable for payment from the treatment of the claimant’s illness or injury. All claims you submit to Blue Cross must indicate if work-related injuries or illnesses are involved and if the services are related to an accident.

Providers should:

• Not require the Blue Cross member or the member’s attorney to guarantee payment of the entire billed charge.

• Not require the Blue Cross member to pay the entire billed charge up front.

• Not bill the Blue Cross member for amounts above the reimbursement amount/allowable charge.

• Charge the member no more than is ordinarily charged other patients for the same or similar service.

• Bill the member only for any applicable deductible, coinsurance, co-pay and/or noncovered service.

If amounts in excess of the reimbursement amount/allowable charge were collected, you should refund that amount to the member.


In the case of OGB claims, Blue Cross pursues recovery of claims payments and Blue Cross makes payments as applicable.

As  a  participating  provider  with  CarePlus  we  require  that  you  notify  the  Plan  of  any  third  party information  you  may  have  received  and  that  you  assist  the  Plan  in  complying  with  the  Medicare Secondary Payer rules.  In addition, if you are notified of a Medicare Set-Aside Plan please notify the Plan immediately.  You can contact the Plans COB / Subrogation department at 1-877-843-3870.  Please refer to the COB questionnaire located in the “Forms” section of this manual to assist you in submitting information to the Plan.  

CarePlus  is  subject  to  the  rules  and  regulations  as  defined  by  the  Social  Security  Act  and  the  CMS Medicare Secondary Payment (MSP) provision. Medicare Advantage Organizations are allowed four (4) provisions in which Medicare is considered a secondary payer. 

1.  Employer Group Health Plans (EGHP) and Large Group Health Plans (LGHP)
2.  Liability Insurance Plans
3.  No-fault Insurance Plans
4.  Workers’ Compensation Plans (WC)

Employer Group Health Plans (EGHP)

Policy:  Coverage under a health plan offered by an employer in which a Medicare beneficiary is covered as:

1.  An employee (age 65+) or
2.  As a dependent under another subscriber (of any change) covered under such plan

NOTE:  Medicare is the secondary payer for beneficiaries assigned to Medicare under the ESRD benefit for up to 30 months beginning when the individual becomes eligible for Medicare if the beneficiary was not otherwise eligible due to age or disability

Liability Insurance and No-Fault Insurance

Policy:  Types of liability include, but are not limited to automobile liability, malpractice, homeowner’s liability, product liability, and general casualty insurance.  Medicare is considered the secondary payer to all liability and no-fault insurance providers.

Workers’ Compensation (WC)

Policy:  Medicare  does  not  coordinate  benefits  with  Workers  Compensation  payers.  Workers’ Compensation assumes full liability for the payment of items and services related to a claim meeting their coverage requirements.

When  a  Member  has  coverage,  other  than  with  CarePlus,  which  requires  or  permits  coordination  of benefits from a third party payor in addition to CarePlus, CarePlus will coordinate its benefits with such other payor(s).  In  all cases, CarePlus  will coordinate benefits  payments  in  accordance  with  applicable laws and regulations and in accordance with the terms of its health benefits contracts. When permitted to do so by such laws and regulations and by its health benefits contracts, CarePlus will pay the lesser of: (i) the amount due under the prevailing agreement; (ii) the amount due under the prevailing agreement less the amount payable or to be paid  by the other payor(s); or (iii) the difference between allowed billed charges and the amount paid by the other payor(s). In no event, however, will CarePlus, when its plan is a secondary payor, pay an amount, which, when combined with payments from the other payor(s), exceeds the  rates  set  out  in  the  prevailing  agreement;  provided,  however,  if  Medicare  is  the  primary  payer, CarePlus  will,  to  the  extent  required  by  applicable  law,  regulation  or  Center  for  Medicare/Medicaid Services (CMS) Office of Inspector General (OIG) guidance, pay Provider an amount up to the amount CarePlus would have paid, if it had been primary, toward any applicable unpaid Medicare deductible or coinsurance. 

Recovery: Provider and CarePlus agree to use reasonable efforts to determine the availability of other benefits,  including  other  party  liability,  and  to  obtain  any  information  or  documentation  required  by CarePlus  and  Provider  to  facilitate  coordination  of  such  other  benefits.  Upon  request  by  CarePlus, Provider will provide CarePlus with a copy of any standard Provider forms used to obtain the necessary coordination of benefits information.

Payment Adjustment: Provider and CarePlus agree that retroactive adjustment to the payment including but not limited to claims payment errors, data entry and incorrectly submitted claims shall be submitted to Recovery of Over/Under Payment process.

Employment-related Injuries or Illness

There are generally three types of legal remedies available to members who sustain employment-related injuries or illnesses:

• Workers’ Compensation under state law – Workers’ Compensation under state law is a legal remedy whereby an employee who is injured within the course and scope of employment is usually entitled to certain benefits regardless of whether anyone was at fault.

• Longshore & Harbor Workers’ Compensation Act (LHWCA) - The LHWCA is a federal law that provides for the payment of medical care to employees who suffer “on the job” injuries that occur on the navigable waters of the United States or in adjoining areas used in loading, unloading, repairing or building certain vessels, regardless of whether anyone was at fault.

• Jones Act – The Jones Act is a federal law that provides protection only to “seamen” who are injured while working on a vessel.

Please understand that we do not make any coverage determinations as to which legal remedy would apply to a member’s injury.

We understand that it can be very difficult to determine which one of these legal remedies may cover a particular injury or illness; however, your patients may have medical benefits available to them under their Blue Cross contract. All claims for covered services, including those claims for which a third party may be liable, must be filed directly to Blue Cross. Please understand that services for injuries and illnesses that arise under the Jones Act, like any other covered services that do not fall under any workers’ compensation guideline, are not considered contractual exclusions, and therefore, must be filed with Blue Cross. Although services that fall under a workers’ compensation guideline are, in most circumstances, typically excluded under the terms of the member contracts/certificate of coverage, we strongly encourage our providers to file claims for these services with us. If the service is determined not to be covered by workers’ compensation or the particular contract does not exclude these types of services, you risk any future consideration by failing to meet administrative filing requirements. The current administrative claims process may deny an initial claim for employment related injuries however, please contact Customer Service so that we can work with your office to apply the appropriate member benefits.

Coordination of benefits does not apply in any of these scenarios.


Coordination of Benefits Guidelines from BCBS

The availability of benefits specified in this Contract is subject to Coordination of Benefits (COB) as described below.

This COB provision applies to This Plan when a Participant has health care coverage under more than one Plan.

If this COB provision applies, the order of benefit determination rules should be looked at first. Those rules determine whether the benefits of This Plan are determined before or after those of another Plan. The benefits of This Plan shall not be reduced when This Plan determines its benefits before another Plan; but may be reduced when another Plan determines its benefits first.

Coordination of Benefits – Definitions

1. Plan means any group insurance or group-type coverage, whether insured or uninsured. This includes:

a. group or blanket insurance;
b. franchise insurance that terminates upon cessation of employment;
c. group hospital or medical service plans and other group prepayment coverage;
d. any coverage under labor-management trustee arrangements, union welfare arrangements, or employer organization arrangements;

e. governmental plans, or coverage required or provided by law.

Plan does not include:
a. any coverage held by the Participant for hospitalization and/or medical-surgical expenses which is written as a part of or in conjunction with any automobile casualty insurance policy;
b. a policy of health insurance that is individually underwritten and individually issued;
c. school accident type coverage; or
d. a state plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the United States Social Security Act, as amended).

Each contract or other arrangement for coverage is a separate Plan. Also, if an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate Plan.

2. This Plan means the part of this Contract that provides benefits for health care expenses.

3. Primary Plan/Secondary Plan
The order of benefit determination rules state whether This Plan is a Primary Plan or Secondary Plan covering the Participant. A Primary Plan is a Plan whose benefits are determined before those of the other Plan and without considering the other Plan's benefit. A Secondary Plan is a Plan whose benefits are determined after those of a Primary Plan and may be reduced because of the other Plan's benefits.

When there are more than two Plans covering the Participant, This Plan may be a Primary Plan as to one or more other Plans, and may be a Secondary Plan as to a different Plan or Plans.

4. Allowable Expense means a necessary, reasonable, and customary item of expense for health care when the item of expense is covered at least in part by one or more Plans covering the Participant for whom claim is made.

5. Claim Determination Period means a Calendar Year. However, it does not include any part of a year during which a Participant has no coverage under This Plan, or any part of a year before the date this COB provision or a similar provision takes effect.

6. We or Us means Blue Cross and Blue Shield of Texas.



Order of Benefit Determination Rules

1. General Information

a. When there is a basis for a claim under This Plan and another Plan, This Plan is a Secondary Plan which has its benefits determined after those of the other Plan, unless (a) the other Plan has rules coordinating its benefits with those of This Plan, and (b) both those rules and This Plan's rules require that This Plan's benefits be determined before those of the other Plan.

b. If this Contract contains any dental or vision benefits, the benefits provided by the health portion of this contract will be the Secondary Plan.

2. Rules
This Plan determines its order of benefits using the first of the following rules which applies:

a. Non-Dependent/Dependent. The benefits of the Plan which covers the Participant as an Employee, member or subscriber are determined before those of the Plan which covers the Participant as a Dependent. However, if the Participant is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is

(1) secondary to the Plan covering the Participant as a Dependent and

(2) primary to the Plan covering the Participant as other than a Dependent (e.g., a retired Employee), then the benefits of the Plan covering the Participant as a Dependent are determined before those of the Plan covering that Participant other than a Dependent.

b. Dependent Child/Parents Not Separated or Divorced. Except as stated in Paragraph c below, when This Plan and another Plan cover the same child as a Dependent of different parents:

(1) The benefits of the Plan of the parent whose birthday falls earlier in a Calendar Year are determined before those of the Plan of the parent whose birthday falls later in that Calendar Year; but

(2) If both parents have the same birthday, the benefits of the Plan which covered one parent longer are determined before those of the Plan which covered the other parent for a shorter period of time.

However, if the other Plan does not have the rule described in this Paragraph b, but instead has a rule based on gender of the parent, and if, as a result, the Plans do not agree on the order of benefits, the rule in the other Plan will determine the order of benefits.

c. Dependent Child/Parents Separated or Divorced. If two or more Plans cover a Participant as a Dependent child of divorced or separated parents, benefits for the child are determined in this order:

(1) First, the Plan of the parent with custody of the child;
(2) Then, the Plan of the spouse of the parent with custody, if applicable;
(3) Finally, the Plan of the parent not having custody of the child.

However, if the specific terms of a court decree state that one of the parents is responsible for the health care expense of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. The Plan of the other parent shall be the Secondary Plan. This paragraph does not apply with respect to any Calendar Year during which any benefits are actually paid or provided before the entity has that actual knowledge.

d. Joint Custody. If the specific terms of a court decree state that the parents shall share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the Plans covering the child shall follow the order of benefit determination rules outlined in Paragraph b.


e. Active/Inactive Employee. The benefits of a Plan which covers a Participant as an Employee who is neither laid off nor retired are determined before those of a Plan which covers that Participant as a laid off or retired Employee. The same would hold true if a Participant is a Dependent of a person covered as a retired Employee and an Employee. If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this Paragraph e does not apply.

f. Continuation Coverage. If a Participant whose coverage is provided under a right of continuation pursuant to federal or state law is also covered under another Plan, the following shall be the order of benefit determination:

(1) First, the benefits of a Plan covering the Participant as an Employee, member or subscriber (or as that Participant's Dependent);

(2) Second, the benefits under the continuation coverage.

If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits this Paragraph f does not apply.

g. Longer/Shorter Length of Coverage. If none of the above rules determine the order of benefits, the benefits of the Plan which covered an Employee, member or subscriber longer are determined before those of the Plan which covered that Participant for the shorter period of time.

Effect on the Benefits of This Plan

1. When This Section Applies

This section applies when This Plan is the Secondary Plan in accordance with the order of benefits determination outlined above. In that event, the benefits of This Plan may be reduced under this section.

2. Reduction in this Plan's Benefits
The benefits of This Plan will be reduced when the sum of:

a. The benefits that would be payable for the Allowable Expense under This Plan in the absence of this COB provision; and

b. The benefits that would be payable for the Allowable Expense under the other Plans, in the absence of provisions with a purpose like that of this COB provision, whether or not claim is made exceeds those Allowable Expenses in a Claim Determination Period.

In that case, the benefits of This Plan will be reduced so that they and the benefits payable under the other Plans do not total more than those Allowable Expenses.

When the benefits of This Plan are reduced as previously described above, each benefit is reduced in proportion.

It is then charged against any applicable benefit limit of This Plan.

Right to Receive and Release Needed Information

We assume no obligation to discover the existence of another Plan, or the benefits available under the other Plan, if discovered. We have the right to decide what information we need to apply these COB rules. We may get needed information from or release information to any other organization or person without telling, or getting the consent of, any person. Each person claiming benefits under This Plan must give us any information concerning the existence of other Plans, the benefits thereof, and any other information needed to pay the claim.

Facility of Payment

A payment made under another Plan may include an amount that should have been paid under This Plan. If it does, We may pay that amount to the organization that made that payment. That amount will then be treated as though it were a benefit paid under This Plan. We will not have to pay that amount again.



Right to Recovery

If the amount of the payments We make is more than We should have paid under this COB provision, We may recover the excess from one or more of:

1. the persons We have paid or for whom We have paid;
2. insurance companies; or
3. Hospitals, Physicians, or Other Providers; or
4. any other person or organization.

Aetna US Healthcare (Medicare HMO)

Aetna US Healthcare (Medicare HMO)

Aetna has been one of the leading providers of quality health insurance in the United States for the last 150 years. There dedication to providing families with safe, cost effective health insurance plans places this provider amongst the crème de la crème of customer service firms. They maintain their position as a leader in the health industry through the practice of these core values:

    * Integrity.
    * Quality service and value.
    * Excellence and accountability.
    * Employee engagement.

Aetna US Healthcare provides effective service and easy to understand information regarding the benefits involved with choosing one of their many, high quality health insurance plans. This is a smart choice when it comes to health insurance.


Available in certain areas of California, New Jersey, New York and Pennsylvania, the Golden Medicare is a managed care plan like an HMO. This plan doesn’t allow for as much flexibility as a fee-for-service plan, only offering coverage within an established network of doctors, specialists and hospitals. A PCP, or primary care physician, is selected. This PCP will have access to all your medical history and manage your care. To be eligible for Aetna US Healthcare's Golden Medicare plan you must, first and foremost, live in the designated area: you need to qualify for Medicare Part A, and enrolled in Medicare Part B. Aetna US Healthcare's Golden Choice plan allows for a little more flexibility. This is a Medicare + Choice plan with out of the network benefits. These benefits include: visit any licensed out-of-network physician, and pay applicable deductible and coinsurance, visit any in-network physician and pay applicable specialist copay, or visit your PCP and pay the applicable PCP copay.

Medicare HMO - cigna healthcare review and coverage

Cigna Health care (Medicare HMO)

Cigna Healthcare offers you customized Healthcare plans that are perfectly molded to the specific needs of your company, whilst at the same time allowing the flexibility that is needed in this constantly changing industry. Cigna Healthcare provides a wide variety of healthcare options ranging from HMO plans and flex care plans, to open access plans, indemnity plans and preferred provider plans. A few examples of these plans follow below:

PPO Plus ( Preferred Provider Plan )

Key Features:

    * Access to a wide range of physicians, specialists and hospitals across the company, all providing quality care and service.
    * 450,000 available physicians to choose from.
    * Nationwide emergency care coverage. (24-hour service)
    * Customized cost-sharing options readily available - copayments, deductibles and coinsurance.

Advantages:

    * No primary care physicians required.
    * Simple "away-from-home" care, through a toll free number, offering nearby participating physicians.
    * 24-hour health information line offering all the answers to your health insurance related queries.
    * A large network of quality physicians across the country.

Indemnity Basic and Extensive Medical Coverage ( Indemnity Plan )

Key Features:

    * Unlimited choice of providers for members.
    * Hospital Savings Program offers discounts for hospitalization.
    * Lifesource Transplant service for transplant services that are specialized.
    * Discounts towards health products and services made available through Healthy Rewards program.

Advantages:

    * Available services in all 50 states.
    * Can be grouped with numerous other options to allow for a "complete benefits program."

For more information regarding Cigna Healthcare and their many services and plans, visit their website at www.Cigna.com.

Indemnity Plans

The benefit of choosing an indemnity plan as your type of health insurance plan, otherwise known as a fee-for-service plan, is that it doesn't bog you down into a single network of physicians. Indemnity plan holders are given the freedom to choose/visit the doctor of their choice. In the case of indemnity plans, the remaining bill is then submitted to the insurance provider who pays the covered expenses. (Typically this consists of approx. 80% of the bill, leaving indemnity plan holders to pay the other 20%) This type of health insurance plan generally has what is called an "out-of-pocket" maximum. After this kicks in, your health plan provider pays for all covered benefits.

What you should know prior to purchase?



Although the most expensive type of health insurance policy, indemnity, or Fee-for-service insurance gives you the most flexibility and freedom to go to the doctor / medical facility / health care specialist of your choice. After receiving treatment, you must submit a claim to your insurance company (doctor or facility generally handles submissions) in order to receive reimbursement. Indemnity plans are customized so as to fit the needs of each unique policyholder, and as such, you will only be reimbursed for healthcare expenditures specified by your policy.

what is HMO

HMO (health maintenance organization)

Out of the four categories of health insurance, HMO plans are the least expensive option. The downside to the lowered cost is restricted access to health care. Plans have a set monthly fee, covering doctors within the plan. If you visit a doctor outside of the plan, you are then responsible for the bill. Within a given plan, you are responsible for choosing a Primary Care Physician (PCP) who will coordinate your care. This includes:

• Routine and preventive care.
• Referrals to a network specialist or facility when necessary.
• Treatment for injuries and illness.

With some plans, you may need to pay a coinsurance, however with other HMO plans, there is no fee for doctor visits.