By Martine G. Brousse
"The Medical Bill Whisperer"
Patient Advocate, Certified Mediator
AdvimedPro
September 11, 2023
Watch the YouTube video: https://youtu.be/71pXfDDKo7w
Medicare has many parts: A,B,C,D
This blog addresses part C, a third blog in a serie of 4
In my blog on part A, I covered services considered “in patient’ or “facility”. This means hospital, skilled nursing facility, hospice etc.
In my blog on part B, I covered services considered “professional” (by individual medical care providers) as well as “outpatient” and others (labs, tests, durable medical equipment etc)
Part C does not refer to specific benefits, but to a different kind of Medicare plan that administers claims and delivers care outside of the traditional setting Original Medicare + Supplemental.
A. What is Part C
· Part C is “Medicare Advantage” or “MA”.
· Part C does not refer to specific benefits, but to plans that are administered by private insurance companies instead of Medicare and a Supplemental plan.
· While Part C must cover the same level of services as Part A + Part B, your Medicare premiums are paid to that company, which in turn pays your claims.
A Medicare Advantage (“MA”) policy works just as your previous Commercial plan did.
· While general Medicare guidelines for coverage apply, that private insurer now controls your access to care, regulates your use of medical services and can decide whether a claim should be paid…or not.
B. What is covered?
· Part C must cover the same level of services as Part A + Part B
· Exception: Hospice services are paid by Original Medicare even if you have a MA plan.
· Part D (Rx coverage) is usually included in a MA policy
· Many MA plans also include vision and dental benefits for an additional premium
C. Your cost
1. Like everything in healthcare, it depends…:
· On the type of plan you choose
· On the type of service you use
· On the status of the provider who performs the service
2. Although Medicare pays a fixed monthly amount for your care to the private insurance company holding your Medicare Advantage Plan, that company’s plan can charge different out-of-pocket costs and make its own different rules for how you get medical services. Just like for commercial plans.
3. You may be required to pay additional premiums for additional benefits (such as vision, dental and Rx)
D. The 5 Types of plans
1. HMO: Health Maintenance Organization.
· You must use a very limited local network of contracted providers
· A PCP (Primary Care Physician) manages and supervises all your medical needs and care
· That PCP issues (or denies!) referrals to specialists or to services he/she cannot render
· Out of Network services are not payable unless under special and specific circumstances
· An additional monthly premium to the one Medicare pays for Part A and B benefits is often at your charge
2. PPO: Preferred Provider Organization
· Patients should use this larger state-wide network to save $
· Out of network benefits are usually available, but at an additional cost to members
· There is no PCP requirement
· There is no pre-authorization or referral required, except for some specific services or items
· An additional monthly premium to the one Medicare pays for Part A and B benefits is often required
These 2 plans above are the most popular and widely available.
3. PFFS: Private Fee for Service
· Works almost the same as the PPO plan
· The plan may allow members to use the huge national Medicare network or have their own
· There is no PCP requirement
· There is no pre-authorization or referral required, except for some specific services or items
· Out of network benefits are usually available, but at an additional and higher cost to members
· An additional monthly premium to the one Medicare pays for Part A and B benefits is often required
4. MSA: Medical Savings Account
· Plan has 2 parts: a high deductible policy and a MSA account (similar to a HRA or HSA)
· Medicare funds the Savings account by a set amount per year. That amount is lower than the deductible.
· Once the deductible has been met (partially paid out of your pocket), your claims are paid @ 100% by the insurer
· Members can use the vast national Medicare network of providers
· Plan covers part A and B but not part D (Rx)
· Enrollment is restricted
· Savings account may be used to pay medical expenses (credited to yearly deductible) or non-medical expenses (not credited to yearly deductible)
· Funds used to pay non-medical expenses are taxable as income by the IRS
· An additional monthly premium to the one Medicare pays for Part A and B benefits is often required
5. SNP = Special Needs Plan
· Eligibility restricted to patients with specific severe or disabling chronic conditions (cancer, dementia, end-stage renal disease etc), certain health care needs while in an institution, or who also have Medicaid due to financial hardship
· Plans usually cover extra services including personalized care coordination services, provider choices and Rx formularies to best meet those specific needs
· All SNP plans must cover Rx (Part D)
· You will lose your plan if you no longer meet the plan's medical and financial conditions
· Access to care and size of available provider network will depend on the plan
E. Part C Advantages over Original Medicare:
1. Fixed yearly out of pocket max
· While Original Medicare has set deductible and co-pay amounts, your secondary/supplemental plan will determine whether you will have anything to pay out of pocket. The problem with the OM model is that it is open-ended, and stressful, especially when one faces a long or expensive treatment, does not have a supplemental plan (or has Medicaid which may not cover all expenses), or has a supplemental plan that does not cover 100% of the patient's liability.
· MA plans offer a pre-determined yearly share of cost max which can help members plan ahead of time, and gain some peace of mind
2. Supplemental policy
· It is not needed, and not available with a Medicare Advantage plan.
· Those premiums can be allocated to the MA vision, dental or Rx coverage
3. Rx (part D)
· Part D coverage is often included in the MA plan
· Those premiums can be allocated to a vision or dental coverage, or used to buy a better plan
4. Vision & Dental Coverage
· Usually included in the MA plan, probably at an additional cost
F. Medicare Advantage issues
1. Network sizes
· No network is as big in the country as the Medicare network. Well over 90% of all medical providers accept it. No MA network can even come close.
· Small networks can and will impede timely access to care, and restrict services to providers who may be sub-par, inexperienced or ill-suited.
· Many providers are reluctant to take on MA patients, due to administrative hassles and routine payment delays that do not happen with OM.
2. Timely access to care
· MA members routinely complain about delays in getting authorizations, appointments or treatments
· OM members have direct, easy, access to providers without requirements, delays or hoops to jump through
· OM requires no pre-authorization or referral, nor any approval from a Primary Care Physician or insurance Utilization Management department. If it is covered under Medicare guidelines, it is paid.
3. Premiums
· MA members usually must pay additional premiums, especially to receive Rx, dental and vision coverage.
· Whether one saves $ by bundling several types of policy under one MA plan is a question of math
4. Medical policies
· Private insurers’ policies are often only available to providers, or are based on recommendations from third-party cost-saving consultants such as Magellan or MCG
· Through its administrative parent CMS, Medicare guidelines are available to all on its medicare.gov website
· What is covered, and under what circumstance is also available in more detailed LCDs (local coverage determination) and NCDs (national coverage determination).
· Private insurers can comply with the Medicare requirement that they cover all that OM would cover, but can enforce stricter limits on how and when care is approved, and payment is made.
5. Claim processing
· The same delays, issues, denials, errors, willful rejections and hassles that plague the commercial (non-Medicare) billing world extend to MA plans
· While OM has a 14-day turnaround to process and pay claims – or explain clearly why it cannot be paid – private insurers can take months to issue a check
· The #1 issue reported by medical providers against MA plans is the difficulty in getting proper and prompt payments
6. Out of network claims
· MA plans will routinely penalize patients who often by no choice of their own, must rely on or have used out of network providers
· Medicare has strict rules regarding the protection of its members, which does not necessarily extend to MA insurers: if the provider is not contracted with Medicare, or if a service/item is likely to be denied, the patient must be warned in writing with an ABN (“Advanced Beneficiary notice”)
· Even non-contracted providers cannot bill OM members what they want, they must comply with Medicare guidelines and with how many $ might be assigned to the patient’s responsibility.
G. Important Facts to be aware of:
1. Joining a Medicare Advantage Plan might cause you to lose your employer or union coverage (commercial plan). By extension, your spouse and children would also lose coverage through that commercial plan
2. MA plan insurers are for-profit, meaning they use the same financial strategy and tactics to lower their cost and maximize their profits as they do for commercial plans.
3. You sign up in a MA plan for the while year and cannot switch unless it is Open Enrollment Period time (mid oct to beginning of Dec) or within the first 3 moths of your enrollment with Medicare.
In conclusion:
A MA plan may be best for you if:
· You are familiar with, and don’t mind, the confusing and frustrating world of private insurers
· You want one global policy for medical, dental, vision and Rx
· You want a limit on your yearly share of cost, and want to know what it is ahead of time
· You don’t really need many medical services, nor often require immediate or urgent access to care
· Your current treating physicians are also contracted with the MA plan you choose
Do visit medicare.gov for all the details about coverage, prices, plan comparisons you may have questions about.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
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@martine brousse 2023 @ the medical bill whisperer 2023