Medicare Advantage plans: What psychologists need to know

Medicare Advantage (MA), also sometimes referred to as Medicare Part C, provides patients with an alternative to traditional, fee-for-service Medicare. Patients can choose from a variety of MA plans offered by private insurance companies. In return for a monthly per capita payment from the Centers for Medicare and Medicaid Services, MA plans must provide hospital (Part A) and professional (Part B) services just as traditional Medicare does. Many MA plans also cover prescription drugs (Part D) as well as supplemental benefits such as dental and vision care.

According to the Kaiser Family Foundation, MA plans have been surging in popularity over the past 10 years and as of 2020, they represent almost 40% of all Medicare patients. Assuming this growth continues, psychologists should anticipate that some patients who initially signed up for traditional Medicare may switch, or already have switched, to MA plans.

Ask to see documentation of their enrollment in Medicare. MA plan patients will have two cards from Medicare. The first is the standard red, white, and blue Medicare card that shows the date they became eligible for Parts A and B. The second is a plan-specific MA card. The MA card has contact information, including phone numbers, for providers with questions such as whether their services will be covered.

At a minimum, MA plans must provide the same benefits as traditional Medicare. MA plans also have the flexibility to offer additional benefits such as dental, vision, hearing aids, transportation, etc.

MA plans must offer the same telehealth services as traditional Medicare. While traditional Medicare expanded telehealth coverage during the Covid-19 public health emergency (PHE), MA plans can offer greater telehealth coverage independent of the PHE, if they choose to.

All Medicare beneficiaries, whether on traditional Medicare or covered by an MA plan, should receive services from Medicare, possibly, depending on the circumstances and/or the MA plan’s requirements. An out-of-network provider who is not part of the Medicare program may be able to treat an MA patient if they are eligible to enroll as a Medicare provider. This excludes anyone who is ineligible, has been suspended, or had their Medicare enrollment revoked. There are also exceptions for patients to receive emergency and urgent services from non-Medicare providers.

No. If you opt out of Medicare, neither you nor the patient may seek reimbursement from Medicare for your services. You must privately contract with any Medicare patients, including those covered by MA plans.

It depends on what type of MA plan the patient has. MA plans fall into the following categories:

Health Maintenance Organization (HMO) plans typically require that patients see providers who are part of the HMO’s network. Depending upon the HMO, it may limit reimbursement to services furnished by in-network providers. HMO plans require a referral from a primary care provider in order to see a specialist. HMO plans are typically the least expensive of all the MA plans.

One subset, known as HMO Point of Service plans, allows patients to see providers out of network.

Preferred Provider Organization (PPO) plans allow patients to see out-of-network providers but at a higher cost than if they used an in-network provider. PPOs do not require referrals for specialty care.

Private Fee-For-Service (PFFS) plans originally were loosely structured, but over the past 10 years have shifted to having a network of providers. While PFFS plans allow patients to see providers that are out of network, providers must agree to accept the plan’s terms for reimbursement.

Special Needs plans (SNPs) fall into one of three categories:

• Chronic care SNPs are only available to patients who have one or more severe or disabling chronic conditions.
• Institutional SNPs are available to patients who live in an institution (e.g., skilled nursing facility, assisted living, etc.).
• Dual-eligible SNPs are for patients covered by both Medicare and Medicaid.

SNPs are structured as either an HMO with network providers or a PPO that has some flexibility for patients to see providers who are not in the SNP’s network. It is very important to know the terms and conditions of the SNP before a patient receives treatment.

MA plans that limit patients to in-network providers allow for limited exceptions if patients need emergency care, out-of-area urgent care, or out-of-area dialysis.

MA plans must reimburse out-of-network providers at least as much as what traditional Medicare pays.

There are limited exceptions under which a provider can directly bill a Medicare patient. When a patient is covered by an MA HMO plan, services are typically limited to those furnished in-network and the plan may not pay for out-of-network services except in an emergency.

A psychologist treating an MA HMO patient must inform the patient that because they are choosing to go out-of-network they will be responsible for the entire cost of the service. The psychologist may bill the patient for no more than the amount that traditional fee-for-service Medicare pays for the service.

Low-income seniors and patients with disabilities may be enrolled in both Medicare and Medicaid. Medicare is the primary payer for these patients who are referred to as “dual eligible.” Once the Medicare claim is processed, any remaining charges (e.g., copayments, deductibles) are transferred to Medicaid.

This is where the process gets tricky. Some state Medicaid plans cover “cross-over payments” to providers, but others do not if the amount paid to a provider by Medicare is equal to or exceeds the amount Medicaid pays the provider for the service. State Medicaid plans that cover the cross-over may have restrictions, such as requiring that the provider be enrolled in the state Medicaid program.

No, you cannot balance bill a dual-eligible patient.

MA plans can change annually. The insurance companies offering the plans send patients a letter each September, known as the Annual Notice of Change, alerting them to upcoming plan changes. Plan changes may involve key components such as premiums, copays, deductibles, and provider networks.

Yes, each year there is an open enrollment period from January 1 to March 31 for patients in MA plans. During the MA open enrollment period, patients can switch from one MA plan to another or they can join traditional Medicare.