Transitioning from PPO Plans to POS Plans

This year, we’re offering Medicare Advantage point of service (POS) plans rather than preferred provider organization (PPO) plans.

We’ve always believed medical care is at its highest quality when it’s guided by a primary care provider (PCP). Based on that and a national trend toward higher costs in PPOs, we are moving to plans that require PCPs. Both HMO and POS plans accomplish that.

Members on our 2016 PPO plans were sent letters telling them their PPO plan would be ending on December 31. These members must enroll in an HMO or POS plan to keep their coverage with Health Alliance Medicare. To help them make this transition, we:

• Sent them a retention kit, including a guide to their 2017 plan options.
• Will host several meetings to help highlight the differences in HMO and HMO-POS plans.
• Have enrollment forms pre-filled with their information from our system to make switching plans as easy as possible. They can use these at the meetings, or they’ll get them in the mail if they can’t make it to the meetings.
• Will make outbound calls to members throughout AEP to help them switch plans.

If your client enrolls into an HMO or POS plan for 2017, you will remain as the broker of record, unless we receive a written agent of record change from the member.

Our POS plans are a good alternative for these members. A POS plan is a blend of an HMO and PPO. Like an HMO, members get the comfort of having an in-network PCP to oversee their care, but like a PPO, they have the freedom to see out-of-network doctors.

Since members on HMO and POS plans need to designate a PCP, we’ve tried to match members up with a PCP based upon their claims history. Members can change their PCP and any time by contacting member services.

Service Area Reduction in Illinois

For 2017, we will not have any individual Medicare Advantage plans available in Jackson County, Illinois.

Each year we have one opportunity to submit our provider network to the federal Centers for Medicare and Medicaid Services (CMS) for review. CMS checks to see if there are enough providers and facilities in the network in terms of number and type to serve the needs of the Medicare beneficiaries in the county. This year, our network submission did not meet those requirements. We have since added the providers needed, but we cannot reapply for 2017. We expect to be back in 2018 for individuals purchasing Medicare plans, and we are sorry for the temporary disruption.

However, we will continue working with employer groups to serve their retiree coverage needs where benefit, network, and member premium regulations are more flexible.