Medicare Advantage

Medicare Advantage Plans

Patients who are eligible for Medicare Benefits can elect to contract with a private health insurance company offering Medicare Advantage or Part C plans, rather than sign up for traditional Medicare. These plans are offered by private health insurance companies that contract with Medicare to provided eligible beneficiaries with Part A and B services. Most of these plans also offer prescription drug coverage.

There are five types of MA plans: HMOs (can include HMO point of service plans)
                                                     Private Fee for Service (PFFS)
                                                     Special Needs Plans (SNP)
                                                     Medical Savings Account (MSA)

MA plans cover all traditional Medicare services, but the MA plans can charge different out-of-pocket costs and may have different rules for access to services, such as coverage only if services are provided by in-network providers. Patients cannot have supplement insurance (Medigap) if they have MA.

Medicare pays these plans a fixed amount per month per beneficiary. (If the beneficiary doesn’t need medical care, the plan comes out ahead). The MA Plans follow National and Local Coverage Determinations. These plans can offer coverage for additional services, such as dental care, which is not covered under traditional Medicare, but they cannot offer fewer services than traditional Medicare. They are not obligated to pay according to the Medicare Physicians Fee Schedule or the DME fee schedule and they usually pay less than the fee schedule (another reason these plans are attractive to insurance carriers). Most have not adopted the MPPR reductions, but could modify their plans to do so at any time. A provider should always verify benefits for a MA patient to determine if the provider is in-network as many plans do not provide out of network benefits. A provider’s participation in traditional Medicare does not guarantee payment from the MA plan. If a patient elects to pay out of pocket, the provider is not obligated to fill out an ABN and will not file a claim; they will bill the patient directly.

If a provider is considering contracting with a Medicare Advantage Plan, be sure to obtain a fee schedule for services and DME in advance to determine if your participation is cost effective.

Therapy Cap
MA plans are not mandated to follow the therapy cap. The provider should contact the plan to determine in advance if the plan has implemented a cap and exceptions process. A signed physician referral may not be necessary depending on the rules of the plan.

Medicare Part C beneficiaries are not included in PQRS reporting.

Functional Limitation Reporting
Medicare does not require Functional Limitation Reporting for Medicare Advantage Plans; however, individual Medical Advantage Plans may choose to require this reporting. Providers should check with their plan to determine if the plan imposes requirements.

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