APMA News - April 2013 - (Page 22)

A Medicare Advantage: Answering Questions about Coverage PMA receives numerous member questions about the requirements applicable to Medicare Advantage (MA) organizations. The two most frequent questions are whether an MA organization can refuse to pay for items or services covered by Medicare fee-for-service (original Medicare), and how to appeal MA organization coverage denials or other adverse claims decisions. In this article, we discuss the rules concerning MA coverage. Because the rules vary based on the nature of a provider’s relationship with the plan in question, specifically whether the provider is a contracting provider, an out-of-network provider, or a deemed provider, we begin with a few basics on physician participation with MA organizations and the types of MA plans. Watch for your May issue of APMA News in which we will cover questions about MA appeals. Background Medicare law authorizes three basic types of MA plans: coordinated care plans, medical savings account plans, and private fee-for-service (PFFS) plans. An MA organization may offer more than one type of plan. The most common types of MA plans are coordinated care plans and PFFS plans. Therefore, we focus on these types of plans in our discussion below. The coordinated care plan category is made up of a number of different types of plans, including HMOs (with or without a point-of-service [POS] option), local PPOs, regional PPOs, and special needs plans, which may be HMOs or PPOs. Coordinated care plans can have closed networks (e.g., HMOs) or open networks (e.g., PPOs or HMOs with a POS option). Under an open network plan, providers may have written contracts with the MA organization or may be non-contracting but entitled to payment from the plan for furnishing covered services to the plan’s members. PPOs may not require non-contracting providers to obtain prior authorization, furnish prior notification, or obtain a referral as a condition of coverage. PFFS plans do not restrict enrollees’ choices among providers as long as the providers are lawfully authorized to provide services and agree to accept the plan’s terms and conditions of payment. PFFS plans are not required to meet standards for network adequacy if the plan provides for payment to providers in at least the amount the provider would have received under original Medicare. Those plans that do not meet network adequacy standards through contracted providers are known as “non-network” PFFS plans. PFFS plans that maintain a network of providers with which they have written contracts are known as “network” PFFS plans. 22 APMA News April 2013 In most instances when a provider furnishes services to a member of a PFFS plan with which the provider does not have a written contract, the provider is deemed to have agreed to the plan’s terms and conditions.i Thus, these providers are known as deemed providers rather than non-contracting providers. PFFS plans may not vary member cost sharing based on whether a provider has a written contract with the organization or is a deemed provider. In addition, PFFS plans must pay their contracted and deemed providers on a fee-for-service basis without placing the provider at financial risk and cannot require prior authorization, prior notification, or referral as a condition of coverage. The type of MA plan in which a patient is enrolled is clearly stated on his or her membership card. Benefits and Payment MA plans are required by law to provide their members the same (or greater) coverage as original Medicare. In determining whether a service is covered, an MA plan must follow national coverage determinations (NCDs) and general Medicare coverage guidelines, and it must generally follow the written local coverage determinations (LCDs)ii applicable to the geographic area in which the services were furnished. Notwithstanding, MA plans may also impose utilization management requirements that do not apply under original Medicare.iii For example, they may review the medical necessity of an item or service in instances in which original Medicare automatically pays for the item or service. If a physician believes that an MA plan is not covering services that are covered under original Medicare, the physician should look at the reason for non-coverage stated on the applicable explanation of benefits (EOB). A statement that the item or services are not covered services would indicate that the plan may not be meeting its obligation to cover original Medicare benefits. A statement that the service is not medically necessary would require further research to determine whether the decision is consistent with any applicable NCDs or LCDs. Contracting Providers Medicare law addresses neither the manner in which the MA organization must pay a contracting provider for furnishing covered services nor the amount it must pay. Thus, the requirement to cover the same services under original Medicare does not mean that plans must pay their contracting pro-

Table of Contents for the Digital Edition of APMA News - April 2013

APMA News - April 2013
President’s Message
Contents
Beat Bunion Blues: APMA’s Spring PR Campaign
Matthew G. Garoufalis, DPM: Presidential Inaugural Speech to the APMA House of Delegates
Nuts and Bolts of the House of Delegates and Resoultions Outcomes
State Advocacy in Focus: Building Relationships
Medicare Advantage: Answering Questions about Coverage
2012 Podiatric Practice Survey: Corporation Type
Podiatric Medical Assistants’ Program at The National Promotes Team Learning
Annual Scientifi c Meeting Registration Forms
Annual Scientifi c Meeting Sponsors
Team APMA 5K Run/Walk
Seeking Award Nominations
Reimbursement
Federal Advocacy Forum
APMAPAC Chair Report
IT Consultant
Inside APMA’s Social Media
Website Wisdom
On the Road with APMA
Small Business 101
CPME Update
In Short
Worthy of Note
Insurance Advisor
New Members
Death Notices
APMAPAC Update
Development Update
Classifi ed Advertising
Dates to Remember
Advertising Index
10 Questions
Your APMA

APMA News - April 2013