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Linda Collins Blogger

Medicare Advantage Open Enrollment Period

Posted by Linda Collins | October 27, 2015

Every year the open enrollment period for Medicare Part C, known as Medicare Advantage, is October 15 – December 7th. During this time your patients are inundated with mailings, calls and TV ads about the various Medicare Advantage plans available to them. In order to help you and your patients understand the choices presented, here are a few facts about Medicare Advantage programs:

  • The Medicare Advantage (MA) program provides Medicare beneficiaries coverage through private insurance companies that contract with Medicare. The Medicare Advantage plan must offer the same standard benefit package and cover everything covered by traditional Medicare.
  • Most Medicare Advantage plans are either health maintenance organizations or preferred provider organizations that allow you to use specific doctors or facilities within a certain network. This means patients may be restricted to certain providers within a geographic area.
  • Medicare Advantage members generally pay a fixed amount (a copayment of $20, for example) every time they see a doctor as opposed to meeting a deductible and paying a coinsurance (typically 20%) under traditional Medicare. This means the patient may have lower out-of-pocket costs for high dollar items, but the provider must agree to accept the fee schedule offered by the Medicare Advantage plan.
  • A member of a Medicare Advantage plan cannot also use Medicare Supplemental Insurance ("Medigap") to pay for out-of-pocket expenses. Patients can only use Medigap policies with traditional Medicare.
  • Many Medicare Advantage plans offer additional benefits such as gym membership, as a way to induce healthy members to join their plan.
  • Medicare Advantage plans may require a provider to sign a participation contract outlining utilization responsibilities and fee schedules that are below the standard Medicare payment.
  • Typically, Medicare Advantage plans have timely filing requirements of 60-90 days versus the 365 days allowed by traditional Medicare.
  • The availability of Medicare Advantage plans varies by geographic region. Not all plans are equal and not all plans are available in every location.

What does this mean for you?

Make sure that you inform any patients who are considering enrolling in a Medicare Advantage plan to research all options and consult with you before making a decision.

They should both compare the cost of the plan to the cost of traditional Medicare and check the provider directory for provider preference. An important trend to follow is the increasingly narrow networks that many private insurance companies like those in the Medicare Advantage program use. You don't want your patient to lose the ability to see you for treatment simply because they didn't understand that you're not part of the insurer's narrow provider network.

If you have an ongoing relationship with the patient, you should also take the time to review their historical health care costs and treatment. You should explain how both might be impacted by switching from traditional Medicare to a Medicare Advantage plan and vice versa.

Medicare Advantage programs must follow the established Medicare coverage criteria as outlined in the LCDs and Policy Articles. You may be subject to payer processes such as pre-authorization, but the actual coverage criteria must be the same as traditional Medicare. If you experience denials that do not match the LCDs, then you can immediately appeal to the payer. You and your patient may also contact the Medicare Ombudsman’s Office for assistance in these situations. (Medicare Complaint Form)

Medicare Advantage plans are becoming increasingly attractive to Medicare beneficiaries. Some experts predict that Medicare Advantage enrollees will represent 30 percent or more of all Medicare beneficiaries by 2016.

For more information about the Medicare Advantage program for you or your patient, visit

The difference in both a patient’s out-of-pocket costs and the amount a supplier gets reimbursed by a Medicare Advantage plan versus traditional Medicare can be significant! So take the time to educate your patients and yourself before making a decision that could have a big impact on that relationship.

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