Medicare Advantage Plans
What are Medicare Advantage
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 (NCDs) 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
A. HMOs (with or without point-of-service
option), local PPOs, regional PPOs, and
special needs plans.
2. Medical Savings Accounts (MSAs)
3 Basic Types of MA Plans
3. Private Fee for Service (PFFS) 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
1. PFFS 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 PFFS
B. Provider had an opportunity to review the plan’s terms &
conditions of participation
C. Provider furnished services to the insured
PFFS 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
1. The requirement to cover same services as regular
Medicare does NOT 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.
2. Payment arrangements are considered a private
contractual matter between MA plan & provider.
3. MA plans are free to adopt their own coding & editing
policies consistent with payment terms set forth in the
General MA Payment
4. MA plans MUST 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 &
• 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
• The law explicitly specifies that this prohibition does
NOT 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 PFFS 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 noncontracted 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.
• DPMs who provide services to non-network PFFS
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 PFFS 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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