Medicare Advantage Plans

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Medicare Advantage Plans

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Presentations text content in Medicare Advantage Plans


Medicare Advantage Plans


What are Medicare Advantage Plans?

1. Required by law to provide their members the same or greater coverage as regular Medicare.

2. Medicare Advantage (MA) plans must follow national coverage determinations (


) and generally follow written local coverage determinations (LCDs) applicable to the geographic area in question.

3. MA plans must generally be organized and licensed under state law as a risk bearing entity.


3 Basic Types of MA Plans

1. Coordinated Care Plans

HMOs (with or without point-of-service option), local


, regional


, and special needs plans.

2. Medical Savings Accounts (




3 Basic Types of MA Plans

3. Private Fee for Service (


) Plans

A. Do not restrict enrollee’s choices among providers as long as the providers are authorized to provide services & agree to accept plan’s terms & conditions of payment.

B. Pay providers at a rate determined by the plan on a fee-for-service basis without placing the provider at financial risk.

C. In certain areas, they are not required to meet standards for network adequacy if the plan provides for payment in at least the amount the provider would have received under regular Medicare.

D. Providers without network contracts are known as “deemed providers”. Deemed providers are obligated to comply with the plan’s terms and conditions for payment when they choose to furnish services to a plan member.


Deemed Contracted Providers



plan insured may see any provider willing to accept the plan’s terms & conditions regardless if the provider has a written contract with the plan. Provider is considered “deemed”:

A. If he/she knew that the insured was a member of a



B. Provider had an opportunity to review the plan’s terms & conditions of participation

C. Provider furnished services to the insured


plans are required to make their terms/conditions available on plan’s website and through telephone number on patient’s card. Thus, provider is considered to have had the opportunity to review plan’s terms & conditions.


General MA Payment Information

The requirement to cover same services as regular Medicare does


mean that plans must pay the same amount as regular Medicare. Medicare law does not address the amount a MA plan must pay a contracting provider for furnishing covered services.

Payment arrangements are considered a private contractual matter between MA plan & provider.

MA plans are free to adopt their own coding & editing policies consistent with payment terms set forth in the contract.


General MA Payment Information

4. MA plans


pay non-contracted providers the same amount they would have received from regular Medicare for furnishing covered services to their members. This includes services provided on an emergency basis or out-of-area urgently needed services. The plan must also follow regular Medicare coding policies, including modifiers, in these situations.

5. All MA plans are obligated to maintain a process

under which non-contracted providers may appeal payments they consider inaccurate.


Providers Rights & Responsibilities

The DPMs rights & responsibilities under MA Plans will depend on the nature of the relationship with the plan, i.e., whether he/she is a contracting provider to the plan, an out-of-network provider or a “deemed” provider under a PFFS plan.

Certain rights & obligations depend on what type of coverage the patient has. It is extremely important that the patient provide all of his/her insurance cards upon check-in. Patients frequently provide the wrong information which results in billing frustration. MA insurance cards specify the plan type, thus providing the DPMs office the necessary information to determine his/her rights.


Providers with Written Contracts

If the DPM has a written contract with the MA plan, the contract will define rights & obligations of both parties.

Per CMS requirements, the contract must include a hold harmless clause, record retention requirements, confidentiality terms, prompt payment terms, and clause requiring the provider to comply with the plan’s policies and procedures.


Providers with Written Contracts

MA plans have a great deal of flexibility in selecting providers to participate in their plan. MA law contains a provision that prohibits the plan from discriminating, in terms of participation, reimbursement, or indemnification, against any provider who is acting in the scope of his/her license, solely on the basis of that license.

The law explicitly specifies that this prohibition does


preclude a MA plan from using different reimbursement amounts for different specialties or for different practitioners of the same specialty.


Providers with Written Contracts

It does not prohibit a MA plan from refusing to grant participation to a practitioner in excess of the number needed or from implementing measures quality & control costs.

Per MA law, if the organization, declines to include a provider or group of providers in the plan, it must furnish written notice to the affected provider(s) of the reason for the decision.


Non-contracted providers and coordinated care plans

Except in emergencies, any non-contracted provider can decline to provide services to members of a MA plan.

Under a


plan, a provider without a written contract who furnishes routine services to a member is considered a “deemed provider”. Deemed providers have different rights than non-contracted providers.

If the DPM provides out-of-network services to a member of a MA coordinated care plan that covers such services, the DPM must accept, as payment in full, the amount that the he/she would have received under regular Medicare. Therefore, the DPM may balance bill the patient up to the Medicare allowable for the service. The amount paid by the MA plan will be the Medicare allowable minus the member’s cost sharing obligation.


Non-contracted providers and coordinated care plans

While the law does not set forth a specific prompt payment period for contracted providers, it does specify a prompt payment requirement for non-contracted providers. The plan must pay the non-contracted provider within 30 days of receipt of a clean claim or it must pay interest on the claim.

A non-contracting provider who furnishes services to a plan member that covers out-of-network services should bill the plan. If payment is denied, the provider may bill the member.

A MA PPO may not impose prior authorization rules for services rendered by non-contracted providers, but may deny services if they are not medically necessary.


Trying it out

Because a provider can choose to be a “deemed provider” on a case by case basis, he/she can give participation a “trial” run.


who provide services to non-network


members should review their payments to ensure they are consistent with regular Medicare payments.

A provider can decide to no longer be a “deemed provider” at any point. The DPM should not furnish services to a


member if they do not wish to be considered a “deemed provider” with regard to that patient visit.



This presentation is intended to provide the podiatrist with basic information regarding Medicare Advantage plans and to assist the practitioner in making educated decisions as it pertains to his/her practice.

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