MANAGED CARE

Medicare Advantage, (MA) the Medicare managed care program, allows Medicare beneficiaries to join one of a variety of regional and local health plans, which, while based on the Medicare fee-for-service coverage rules, also offer coverage and payment options not available in traditional Medicare. 

Generally providers establish payment and review guidelines through contracts with MA plans, but there are also fee-for-service MA plans that pay providers off contract for covered services at the same rates established by the Centers for Medicare & Medicaid Services (CMS).

In general, non-contract providers must accept as payment-in-full the amount they would have received from CMS for the same admission, service or procedure, and are not permitted to bill the Medicare beneficiary beyond the MA cost sharing amount. In case of emergency care, an MA plan is required only to pay a non-contract provider the lesser of what CMS would have paid or the provider’s billed charge.

NEWS

4/08/2008:: The Centers for Medicare & Medicaid Services (CMS) released the calendar year 2009 Medicare Advantage (MA) capitation rates and MA and Medicare Part D payment policies on April 7.  MA capitation rates for aged and disabled beneficiaries will increase an average of 3.6%. CMS also announces it will audit medical records from a sample of MA plans to determine the accuracy of the diagnosis codes. As coding errors are identified, CMS states it will reconcile payments at the plan level. CMS also states the results will help it determine whether differences in risk scores between MA plans and Medicare fee-for service claims can be attributed to differences in coding patterns and whether an adjustment to capitation rates is appropriate in 2010.