Medicare Advantage Program. Michael Taylor, PhD Medicare Advantage Manager

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1 Medicare Advantage Program Michael Taylor, PhD Medicare Advantage Manager

2 Objectives General Overview of Medicare Advantage CMS 5 Star Ratings Medicare Part C & D Audit Process Coping with Contract Terminations Post Pay Audits 2

3 Medicare Choices 1. Original Medicare May add Medigap (Medicare supplement insurance) May add Medicare prescription drug coverage 2. Medicare Advantage Plans With or without Medicare Prescription Drug Coverage 3. Other Medicare Health Plans Like Cost Plans, Medicare Medical Savings Accounts and Programs of All-Inclusive Care for the Elderly (PACE) Plans 3

4 Part A Hospital Insurance Part B Medical Insurance Part C Medicare Advantage Plans Medicare has Four Parts Helps cover inpatient care in hospitals & skilled nursing facility, hospice, and home health care. Helps cover doctors services, outpatient care, home health care and some preventive services. Another way to get Medicare benefits. Includes Parts A & B. Usually includes prescription drug coverage. Run by private insurance companies approved by and under contract with Medicare. You have choices in how you get your Medicare health and drug coverage Part D Medicare Prescription Drug Coverage Helps cover the cost of prescription drugs. Run by private insurance companies approved by and under contract with Medicare. 4

5 What Are Medicare Advantage (MA) Plans? Health plan options approved by Medicare Run by private companies Part of the Medicare program Sometimes called Part C Available in many areas of the country Medicare pays a set amount to plan 5

6 Medicare Advantage Eligibility Requirements You must live in plan s service area You must have Medicare Part A and Part B You must not have ESRD at time of enrollment 6

7 Types of Medicare Advantage Plans Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Regional Preferred Provider Organization (RPPO) Private Fee-for-Service (PFFS) Special Needs Plan (SNP) Medicare Medical Savings Account (MSA) 7

8 Other Plan Types 1876 Cost Plan Health Care Pre-payment Plan Medicare Demonstration Medicare-Medicaid Demonstration Plans Program of All-inclusive Care for the Elderly Qualified Health Plans 8

9 How Medicare Advantage Plans Work You get Medicare-covered services through the plan All Part A and Part B covered services Some plan may provide additional benefits Most plans include prescription drug coverage Part D May have to go to network doctors or hospitals Different than in Original Medicare Benefits and cost-sharing 9

10 Medicare Advantage Plan Costs Must still pay Part B premium Some plans may pay all or part of the premium Some people may be eligible for state assistance Pay additional monthly premium to plan Pay deductibles, coinsurance and copayments Different from Original Medicare Varies from plan to plan 10

11 Medicare Prescription Drug Coverage Available for all people with Medicare Provided through Medicare Prescription Drug Plans Medicare Advantage Plans Other Medicare plans 11

12 Who Can Join You must have Medicare Part A and/or Part B You must live in plan service area You must enroll in a Medicare Rx plan You can t live outside the U.S. or be incarcerated 12

13 Application Review Request for a Medicare Advantage Organization contract Request to expand an existing Medicare Advantage Organization contract (service area) 13

14 Monitoring and Oversight Allows CMS to work with MAOs to resolve problems before they escalate into a compliance or enforcement action. A day to day activity aimed at managing a MAO s contract. Use of various internal controls activities. Complaints Tracking Module. Marketing Material Review. Data Driven Analysis. 14

15 Program and Compliance Audits Audits are conducted routinely with Part C and D plans. Audits are conducted on an annual basis with the plans. The audits are based upon plan performance in the prior year. Audit review areas vary from year to year. 15

16 5-Star Special Enrollment Period Enroll one time any time during the year in a 5-Star Medicare Advantage Plan 5-Star Medicare Advantage with Prescription Drug Plan 5-Star Prescription Drug Plan Even if already in a 5-Star Plan New plan starts first of month after enrolled Star ratings on Plan Finder October 8 Updated yearly 16

17 Low-Performing Medicare Plans Plans that receive a summary rating of less than 3-Stars for at least 3 years in a row Ratings are on Medicare Plan Finder Medicare & You doesn t have full, updated ratings Low-performing plans No online enrollment for low-performing plans No enrollment through MEDICARE Must contact plan directly to enroll Enrolled beneficiaries can call MEDICARE and ask to move to a higher quality plan 17

18 Contracting with Medicare Advantage Orgs Provider Networks can change depending on contract terms between provider and MAO. Contract terms vary based upon the healthcare market. Members stay with MAOs during contract terminations. 18

19 Dealing with Contract Terminations MAOs can terminate contracts with providers dependent on contract terms and conditions. CMS collaborates with partners to communicate next steps to impacted Medicare beneficiaries. CMS works with State Insurance departments to close MAO. Impacted providers should work with State Insurance departments to receive payment for services rendered prior to termination. 19

20 Provider Appeals (Non Contract Providers) Non-contract providers have 60 calendar days from the remittance notification date to file the reconsideration; Providers must include a signed Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal. Should include documentation such as a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that supports the provider s argument for reimbursement. Must mail the reconsideration to the plan.

21 Post Pay Audits In general, MA plans can conduct retroactive reviews up to one year. If there is good cause MA plans can conduct retroactive reviews for claims past a year CFR , CFR, CFR , and CFR CMS is currently reviewing the current post pay regulations

22 Private Fee for Service Plans Additionally, if the plan is a PFFS plan a the ability of the MAO to conduct post pay audits has to be disclosed in the PFFS plans terms & conditions of payment.

23 Contact Information 23

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