APMA News - September/October 2020 - 16

Medicare Advantage:

ANSWERING QUESTIONS ABOUT
COVERAGE AND APPEALS

PMA receives numerous member questions about the
requirements applicable to Medicare Advantage (MA)
organizations. The two most frequently asked 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 around MA coverage and appeals. Because the rules vary based on the nature of a provider's relationship with the plan in question, specifically whether the
provider has a contract with the plan or is non-contracting
(i.e., an out-of-network provider), we begin with a few basics
on physician participation with MA organizations and the
types of MA plans.

Background
Medicare law authorizes three basic types of MA plans: coordinated care plans, medical savings account plans, and private fee-for-service plans. One MA organization may offer
more than one type of plan. By far, the most common types
of MA plans are coordinated care 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 (SNPs), 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
16 APMA News September/October 2020

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.
The type of MA plan in which a patient is enrolled is clearly stated on their 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 must generally follow the written local coverage determinations (LCDs) 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. 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 explanation of benefits (EOB) denying payment for the service.
A statement that the item or service is not a covered service
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. A statement concerning how
the service was coded or billed, or how the organization's
continued on page 18

APMA News - September/October 2020

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