UNRAVELLING THE CONFUSION OF MEDICARE ADVANTAGE PLANS
From time to time I receive questions regarding MA plans. Some pay the Medicare allowed amount, others pay more and some pay 80 percent of the allowed amount. Network participation rules can vary, as do some authorization requirements.
There are three basic types of MA plans with several options available within the first type of plan. All are required to offer at least the same level of benefits a beneficiary would receive under traditional Medicare. The three plan types and their options are summarized below.
Coordinated Care Plans Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) are the two most common types of coordinated care plans.
HMOs typically require a referral from a primary care physician and restrict the network of physicians from which a member can receive services.
However, some HMOs provide out-of-network options. These options can be restricted to a certain service(s) and may also limit the amounts that will be paid for those services.
Billers and those who check eligibility will want to check the specific procedure(s) for which they need coverage in order to determine the requirements for successfully billing this type of payer for services.
PPOs, according to the Medicare Managed Care Manual, include a network of providers that have agreed to a contractually specified reimbursement for covered benefits. The plan also provides reimbursement for all covered benefits regardless of whether the benefits are provided within the plans network of providers. PPOs can be local, consisting of a county, part of a county or multiple counties, or regional, covering multiple states. Benefits offered by a regional PPO must be uniform across the region.
Obvious benefits to billers of Medicare PPOs is that the facility is not required to be in-network in order to provide services and obtain reimbursement for patients with this type of policy.
Special Needs Plan (SNP) are offered under an HMO or PPO and limit enrollment to a targeted population of special needs individuals. These patients fall into one of three categories: “severe or disabling chronic conditions,” which includes patients with ESRD, according to CMS, dual-eligible, for those and ESRD PPS Updates who qualify for both Medicare and Medicaid and the third category includes institutionalized individuals and those outside of an institution which require a level of care equivalent those in long-term care facilities.
The final type of coordinated care plan is known as a Senior Housing Facility Plan. Enrollment in these plans is limited to residents of continuing care retirement communities where primary care services are provided onsite.
Medicare Medical Savings Account (MSA) Plans Medicare Medical Savings Account (MSA) plans combine a high deductible MA plan and a medical savings account. The MSA has a trustee assigned to manage the account. Under this type of plan, Medicare pays premiums for the insurance policies and makes a contribution to patient MSA accounts.
Patients pay for their health care from their MSA until their high deductible is reached. The annual maximum deductible is set by law and updated annually. The MA Plan is responsible for paying for covered services after the deductible is met.
For billers, in addition to billing the insurance company, the trustee or its representative will need to be billed until the plan’s high deductibles are met.
Private Fee-for-Service (PFFS) Plans A PFFS plan is defined by CMS as a MA Plan that pays providers of services at a rate determined by the plan on a fee-for-service basis. Patients can go to any Medicare provider who agrees to accept the plan’s rate-for-services before providing those services.
PFFS plans may be offered through an employer or a union or they may be offered by non-employer networks.
Additional Option for Religious Organizations In addition to the three basic type of MA plans, a Religious Fraternal Benefit (RFB) Plan can be offered by religious societies. Enrollment is limited to its members and the RFB may choose to offer any type of MA Plan.
For more information about Medicare Advantage Plans, go to http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c01.pdf
Do you have questions? Would you like to add your comments to a previously answered question? Do you have a funny experience with billing you would like to share? Please send your questions, comments and stories to me at firstname.lastname@example.org.
Rick Collins is the Chief Operating Officer of Sceptre Management Solutions, Inc., a company that specializes in billing for outpatient dialysis facilities and nephrology practices in the U.S.
NOTE: The information contained in this column is for informational purposes only and is not to be construed as payer policy or procedures. You should always verify information in this column with appropriate government or payer manuals and instructions and proceed as directed by your Medicare contractor or other appropriate payer representatives.