Medicare Advantage Plans: They Say They Follow Medicare Guidelines, But…

Many Medicare beneficiaries are being solicited by private insurance companies offering Medicare Advantage Plans via TV commercials. These Medicare Advantage Plans pose as Medicare and some of them even use celebrities to pitch their product. Read the fine print, as they are not affiliated with Medicare.

They are trying to convince Medicare beneficiaries to select their “Advantage Plan” over original Medicare Fee for Service (FFS) by stating they offer all the standard benefits of Medicare with a lower out-of-pocket cost.

But wait there’s more: These plans often state they provide additional benefits, such as gym memberships, transportation and eyeglasses. How can they provide more benefits with a lower cost? How can these private, for-profit insurance companies run all these TV commercials and pay celebrities and make a profit?

While some of these plans are good for the beneficiary’s needs and are fair to suppliers with reimbursement, many are not. Some are able to offer more for less due to an increased number of members, thus spreading the costs over a larger pool; however, many others are able to do this by not actually providing the same benefits as original Medicare.

Many of these plans don’t follow Medicare’s payment rules, and some attempt to pay for Complex Rehab Technology (CRT) wheelchairs on a rental basis, deny expensive electronics that are necessary to operate power positioning, and deny payment, thus plunging the CRT supplier into the labyrinth of appeals.

Do Medicare Advantage Plans Really Follow Medicare Payment Rules?

When suppliers encounter a customer who has a Medicare Advantage Plan, they must determine if they have to be in network if required, and they have to figure out the coverage policies. Many plans say “We follow Medicare” — and most would take this to mean that the Medicare Advantage Plan will cover and process claims the same as original Medicare would.

However, while these plans are required at a minimum to furnish all medically necessary Medicare-covered DME (policy), they are not required to follow Medicare's payment rules (prices, rental/purchase, modifiers, clean claim timeliness, etc).

Suppliers need to be aware of this so they can take this into consideration when determining if they can accept a contract or customer with one of these Medicare Advantage Plans. If you’re a CRT or DME supplier, is vital to obtain the Medicare Advantage Plans’ policies and payment rules in writing prior to accepting a customer so you know what you are getting in to. If the Medicare Advantage Plan says, “We follow Medicare,” ask what that means. Ask if they follow Medicare’s policies (coverage) and payment rules. And get their policies and payment rules in writing prior to agreeing to provide DME to these customers.

What CMS Actually Says About Medicare Advantage Plans

Here is what the Centers for Medicare & Medicaid Services (CMS) says regarding requirements for Medicare Advantage Plans:

“While Medicare Advantage Plans are required to furnish all medically necessary, Medicare-covered DME, they are not required to follow original Medicare payment rules in furnishing those services. Medicare Advantage Plans will generally furnish Medicare Advantage enrollees with all medically necessary DME through contracted DME suppliers. Since Medicare Advantage plans are capitated by CMS, the Medicare Advantage plan is financially responsible for furnishing all medically necessary, Medicare-covered services, which of course includes DME items and supplies. In addition to their financial and coverage responsibilities, Medicare Advantage plans have the ability to negotiate prices with its contracted providers and also to use utilization management tools consistent with Medicare coverage standards.”

What this means is if a Medicare Advantage plan determines that it is best for them to rent Complex Rehab power wheelchairs rather than extending the purchase option that is available to original Medicare beneficiaries, they can do that. They can negotiate reimbursement prices as well, and judging by what suppliers are experiencing, some Medicare Advantage Plans are also denying accessories that original Medicare allows per policy. A recent widespread example: Electronics E2377, E2311 and E2313 are frequently being denied as not medically necessary.

The point of this article is to ensure providers are aware of these other ways Medicare Advantage Plans can provide more for less while incurring the costs of all those commercials with celebrities. This other way squeezes the CRT supplier, and it is impacting access as more and more suppliers are saying no to contracts or customers with one of these plans.

What Can You Do?

First, review all contracts thoroughly and make sure they’re clear regarding what the Medicare Advantage Plans will pay and how they pay (rental/purchase). Don’t just accept “We follow Medicare” assertions; that doesn’t mean the Medicare Advantage Plan follows Medicare’s payment rules, since they are not required to per CMS. If you can’t accept what they offer, don’t accept it. Try to negotiate a fair contract, and if the Medicare Advantage Plan won’t accept your terms, don’t accept the plan.

Second, assist your customers (current and new) about where they can obtain unbiased information on the differences between original Medicare and these Medicare Advantage private plans. If you can’t accept customers with Advantage Plans, tell them why. Beneficiaries are only hearing from celebrities promoting their plans and saying how great they are — they’re not hearing about how these plans negatively impact beneficiaries’ true medically necessary benefits with unsustainable prices and payment methods (such as 13-month rentals for Complex Rehab power wheelchairs and accessories). While the Medicare Advantage Plan customer may be able to get a gym membership and eyeglasses, they may not be able to obtain the wheelchair they need. And tell them that they can select original Medicare FFS (or switch back) if they find that the Medicare Advantage plan isn’t as good as those celebrities made it appear.

Finally, please tell Medicare recipients struggling to make sense of all these plans and sales pitches from insurance companies that they can call 1-800-633-4227 (1-800-Medicare) to speak to an actual Medicare representative for accurate, unbiased information about selecting the best plan for them.

About the Author

Dan Fedor is the Director of Reimbursement and Education for U.S. Rehab, a division of The VGM Group.