MedAdvantage Frequently Asked Questions

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1. What is Medicare? How does it work?
   Medicare is a federal health care program managed by the Centers for Medicare & Medicaid Services (CMS) that provides health insurance to retired individuals and certain people with disabilities regardless of medical condition. Original Medicare is a fee-for-service plan with two components, Medicare Part A and Medicare Part B. Alternatives to traditional Medicare coverage include Medicare Advantage plans.
   
   Medicare Part A provides coverage for hospital bills (inpatient hospital care, hospice care, and home health care). This is financed by payroll taxes, with no premium to beneficiaries who have at least 40 quarters of Medicare-covered employment. The beneficiary pays a $912 deductible for up to 60 days, with additional copays required for stays longer than 60 days.
   
   Medicare Part B provides coverage for doctor bills (physician care as an inpatient at a hospital, at a doctor's office, or as an outpatient at a hospital or other health care facility) laboratory tests, physical therapy, and ambulance service. The Medicare Part B beneficiary premium is $78.20 per month. Medicare Part B has a $110 annual deductible, with 20% coinsurance after deductible is met.
   
2. What is a Medicare Advantage plan?
   The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) was signed into law on December 8, 2004. This allows plans that contract with CMS to offer options in coverage such as Medicare Managed Care Plans (HMO), Medicare Preferred Provider Organizations (PPO), Medicare Private Fee-for-Service Plan, (PFFS) and Medicare Specialty Plans. Essentially, these reduce out-of-pocket expenses and increase coverage. These plans provide all the benefits of Medicare Parts A and B, plus additional benefits. The beneficiary continues to pay the Medicare Part B premium as well as any additional premium charged by the Medicare Advantage plan. Regence BlueCross BlueShield of Oregon (BCBSO) is offering a Medicare Advantage PPO product called Regence BlueCross BlueShield of Oregon MedAdvantage.
   
3. What is the product name?
   Regence BlueCross BlueShield of Oregon MedAdvantage.
   
4. When is MedAdvantage available?
   MedAdvantage is effective for dates of service on or after June 1, 2005.
   
5. Who is eligible?
   Potential members need to be at least 65 years old or disabled as defined by Medicare. They must have Medicare Parts A and B, live within in the service area and not have end-stage renal disease (ESRD).
   
6. Why would a member choose MedAdvantage over an HMO or Medicare Supplement product?
   There are three types of health care plans that can protect members from unexpected costs. Health Maintenance Organizations (HMOs) are managed care plans that require the member to use only contracted physicians, other health care professionals and facilities and hospitals and, typically obtain referrals to see a specialist.
   
   Preferred Provider Organizations (PPOs) also have a contracted network of providers, but the member can see any provider and still receive coverage. The member has lower
   out-of-pocket costs if the member stays in-network, and no referrals are required.
   
   HMOs and PPOs typically offer extra benefits compared to Medicare such as routine physicals and vision care. HMOs and PPOs roll original Medicare benefits and supplemental benefits into one plan.
   
   Medicare Supplement (Medigap) plans are secondary policies to Medicare. They do not have a network of providers and usually cost more than HMOs and PPOs. Most Medicare Supplement plans do not offer coverage for routine physicals or vision hardware and exams,
   
   Medicare Supplement plans reduce out-of-pocket medical expenses for unexpected medical costs associated with Medicare deductibles and coinsurance. This coverage can include the Part A and Part B deductibles and coinsurance, the skilled nursing facility coinsurance, as well as other benefits.
   
7. What is meant by in-network and out-of-network providers?
   Physicians, other health care professionals and facilities who contract to accept MedAdvantage patients and accept MedAdvantage benefits and payment structures are considered "in-network" providers. Those who have not signed contracts with MedAdvantage are considered "out-of-network".
   
   With MedAdvantage, members are free to see any provider they wish. Our provider networks offer many qualified physicians, other health care professionals and facilities to choose from. A member may choose to see a provider outside our network, and pay higher out-of-pocket costs. Members are encouraged to see in-network providers to receive the best benefit from the plan and lower out-of-pocket costs. The MedAdvantage benefit summary details the differences in benefits when members see in-network and out-of-network providers.
   
8. What other Medicare plans do we offer?
   Our senior product portfolio includes options to meet the budget and service needs of Oregon and southwest Washington seniors. We continue to offer First Choice Sixty-Five, Preferred Choice Sixty-Five and Companion Plan Medicare Supplement (or Medigap) policies.
   
   
   
   Benefit Information
   
9. What are the contracted reimbursement rates for MedAdvantage?
   Contract addendums specifying reimbursement rates were sent to all network providers during our contracting process. For a copy of the addendum that applies to your office or facility, please call your professional relations representative.
   
10. What is the vision coverage?
    Members are eligible for routine vision exams once every two years. There is a $5 copay when utilizing in-network benefits. Vision hardware is covered up to $100 every two years.
    
11. What is the dental coverage?
    Members can go to any dentist and are covered up to $500 annually for preventive dental services such as cleanings, x-rays and exams. Dentists will be paid at billed charges up to the $500 annual maximum.
    
12. What about hearing services?
    For Medicare-covered hearing exams (diagnostic hearing exams), there is a $5 copay.
    
13. What other services does MedAdvantage provide?
    MedAdvantage provides access to discount programs for prescriptions, vision care services, hearing care services and fitness club memberships.
    
    
    
    Billing Information
    
14. Should providers bill Medicare or Regence BCBSO for services?
    Submit all claims to Regence BCBSO as you do for other products. Claims may be submitted electronically or on paper to PO Box 30805, Salt Lake City, UT 84130-0271.
    
15. What pre-authorization requirements does MedAdvantage have?
    The MedAdvantage Medical Pre-Authorization List is in this Welcome Packet mailing. It is also available on our Web site at www.or.regence.com/provider.
    
    
    Resources
    
16. Who do we contact for questions about MedAdvantage?

• For information on benefits, eligibility, or other customer service related issues:
  Customer Service: 1 (800) 541-8981
• For information related to your provider contract, fees, credentialing, specific medical, administrative, or reimbursement policies, billing and coding questions, contact your provider relations representative.