Skip navigation

Linda Collins Blogger

‘Tis the Season….for enrollment in Medicare Advantage plans

Posted by Linda Collins | October 31, 2012

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

  • Medicare Advantage (MA) is a health insurance program that provides an eligible person with the United States' Medicare benefits. In other words, the Medicare Advantage plan must offer the same standard benefit package and cover everything covered by Original Medicare.

  • Most Medicare Advantage plans are either health maintenance organizations (HMOs) or preferred provider organizations (PPOs), which allow you to use specific doctors or facilities within a certain network. This means the patient 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 Original 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 a Medicare Supplement Insurance (Medigap plan) to pay for out of pocket expenses. Medigap policies can only be used with Original Medicare programs.

  • 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 Original Medicare.

  • The availability of Medicare Advantage plans vary by geographic region. Not all plans are equal and not all plans are available in every location.

What does this mean to you?

Make sure that you inform any patients who are considering enrolling in a Medicare Advantage plan to research all options before making a decision. They should compare the cost of the plan to the cost of Original Medicare and check the provider directory for provider preference. Providers who are considering participating in a Medicare Advantage network need to be aware of pre-authorization/utilization reviews, fee schedules and claims filing timelines.

The difference in both a patient’s out-of-pocket costs and the amount a supplier gets reimbursed by a Medicare Advantage plan versus Original 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.

Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at [email protected]