a. MA coordinated care plans

MA coordinated care plans include a network of providers that are under contract or arrangement with the organization to deliver the benefit package approved by CMS. The network must be approved by CMS to ensure that all applicable requirements are met including access and availability standards, service area requirements, and quality standards. MA coordinated care plans may include mechanisms to control utilization, such as referrals from a provider (also known as a “gatekeeper”) to receive services within the plan, and financial arrangements that offer incentives to providers to furnish high quality and cost-effective care.

MA coordinated care plans include, but are not limited to, HMO plans with or without point of service options, plans offered by provider sponsored organizations, preferred provider organizations, as well as the Religious Fraternal Benefits Society plan.

Definitions of the various types of MA coordinated care plans are as follows:

• An HMO is a public or private organization which provides (either directly or through arrangements with others) comprehensive health services to enrolled members who live within a specific geographic area. The beneficiaries pay a predetermined premium which covers the medical expenses without regard to the frequency or extent of covered services furnished.

• An HMO with a point-of-service plan is a plan in which a member may be reimbursed by the HMO for services received through non-network providers when network providers could have been used.

• A point of service (POS) plan is a benefit option that an MA plan can offer to its Medicare members as an additional, mandatory supplemental, or optional supplemental benefit. Under the POS benefit option, the MA plan allows members the option of receiving specified services outside of the MA plan’s provider network. In return for this flexibility, members typically have higher cost-sharing requirements for services received and, where offered as a mandatory or optional supplemental benefit, may also be charged a premium for the POS benefit option.

• A provider-sponsored organization is operated by providers, in which the substantial proportion of services are delivered through the sponsoring provider or affiliated providers.

• A preferred-provider organization (PPO) is a plan that has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; provides for reimbursement for all covered benefits regardless of whether the benefits are provided within the network of providers; and only for purposes of quality improvement requirements in §422.152(e) of the MA regulation is offered by an organization that is not licensed or organized under State law as an HMO.

• Religious and Fraternal (RFB) Society Plans are offered by a religious and fraternal society for members of the society. Only members of the society may enroll. The society must meet Internal Revenue Service and Medicare requirements for this type of organization.

• A Special Needs Plan (SNP) can be any type of coordinated care plan that meets CMS' SNP requirements and either exclusively enrolls special needs individuals or enrolls a greater proportion of special needs individuals. The MMA designated three specific segments of the Medicare population as special needs individuals: institutionalized individuals; those entitled to Medical Assistance under a State Plan under Title XIX (Medicaid) - “dual eligibles;” and other high-risk groups of chronically ill or disabled individuals who would benefit from enrollment in this type of plan.