Medicare Advantage Plan Contracts

Medicare Advantage (MA) is Medicare managed care, administered by a private health insurer. Thus, physicians should approach MA contracts in much the same way as they do any managed care contract.

From the patient’s perspective, all MA plans offer similar benefits to those covered by traditional Medicare, and many offer additional services, such as vision or wellness benefits. Beneficiaries covered by MA plans cannot purchase a Medigap policy to help with cost-sharing. This means that physicians treating patients enrolled in MA plans have to collect any patient cost-sharing amounts, which vary by plan, directly from their patients.

Under the MA program, Medicare beneficiaries may select their health care coverage from several types of plans, including Private Fee-For-Service (PFFS), Health Maintenance Organizations (HMOs), Regional and Local Preferred Provider Organizations (PPOs), Medical Savings Accounts (MSA), and Special Needs Plans (SNPs).

The AMA offers resources for you, your patients and staff:

• “Attention Medicare beneficiaries: Which plan is right for you?”  describes the different types of MA plans.

Important information about Private Fee for Service (PFFS) plans
In response to the AMA’s request, the Centers for Medicare and Medicaid Services (CMS) has posted on its website contact information for most of the major Medicare Advantage PFFS plans, to allow physicians easier access to the plans terms and conditions.Visit the CMS website for contact information for all PFFS plans.

Risk Adjustment Data Validation (RADV) Audits
The Centers for Medicare and Medicaid Services (CMS) reimburses Medicare Advantage plans based on risk-adjusted scores. The goal of this program is appropriate payment to plans with medically complex members. Establishing the medical complexity of a patient for a CMS RADV audit involves gathering the diagnostic coding derived from the medical record, which the plans regularly request from physician practices. Meanwhile, Medicare Advantage plans often conduct their own audits that also involve collection of medical records from physician offices.

The AMA regularly hears from physicians who have received unreasonable requests from insurers for medical records. The financial and administrative burden these audits place on physician practices cannot be underestimated. The AMA continues to work with CMS, Medicare Advantage plans, and Federation staff to help alleviate this burden.

AMA Letter to CMS on RADV Audits (September 9, 2011)

Prescription Drug Information
Medicare beneficiaries may obtain prescription drug coverage through their choice of either a stand-alone prescription drug plan that works with traditional Medicare, or an MA plan that offers drug coverage and other benefits. You can visit the CMS website for information on this benefit.