Sage-Tips

Do Medicare Advantage plans have to follow LCDs?

Medicare Advantage plans are required to follow all Medicare laws and coverage policies, including LCDs (Local Coverage Decisions – coverage policies set by Medicare Fee-for-Service Contractors in your geographic area), when determining coverage for a particular service.

Do Medicare Advantage plans have to follow Medicare billing guidelines?

Medicare Advantage Plans Must Follow CMS Guidelines In the United States, according to federal law, Part C providers must provide their beneficiaries with all services and supplies that Original Medicare Parts A and B cover. They must also provide any additional benefits proclaimed in their Part C policy.

Does new insurance cover old medical bills?

Even if your insurance policy has been cancelled, old bills can still be sent to your insurance. The coverage still applies for care you received during the time the policy was in effect.

Which part of Medicare do NCDs and LCDs apply to?

These determinations outline the conditions in which a service is considered to be covered by Medicare. NCDs, which are developed through an evidence-based process, are applicable nationwide and to US territories. Conversely, LCDs are released by Medicare contractors, and apply only to the contractor’s region.

Do Medicare Advantage plans use ABNs?

ABNs aren’t valid for Medicare Advantage members The Original Medicare program uses ABNs — sometimes called “waivers.” But you can’t use them for patients in Aetna® Medicare Advantage plans, since the Centers for Medicare & Medicaid Services (CMS) prohibits them.

Is Medicare Advantage an HMO?

Most Medicare Advantage plans are structured as HMOs (health maintenance organizations) or PPOs (preferred provider organizations). If you’re interested in a Medicare Advantage plan, you’ll want to understand the difference between HMOs and PPOs, in both the care they cover and their costs.

What does it mean when a plan follows Medicare guidelines?

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.

What managed care plans require preauthorization for medical services such as surgery?

* All managed care plans, including HMOs, PPOs, and EPOs, require preauthorization for medical services such as surgery, expensive medical tests, and medication therapy.

What is a prior authorization for medication?

A prior authorization (PA), sometimes referred to as a “pre-authorization,” is a requirement from your health insurance company that your doctor obtain approval from your plan before it will cover the costs of a specific medicine, medical device or procedure.

How do I switch to a new Medicare Advantage plan?

To switch to a new Medicare Advantage Plan, simply join the plan you choose during one of the enrollment periods. You’ll be disenrolled automatically from your old plan when your new plan’s coverage begins.

Can I go out of network with an HMO plan?

In HMO Plans, you generally must get your care and services from providers in the plan’s network, except: Emergency care Out-of-area urgent care Out-of-area dialysis  In some plans, you may be able to go out-of-network for certain services. But, it usually costs less if you get your care from a network provider.

Do I need to choose a primary care doctor in HMO plans?

If you want Medicare Drug Coverage (Part D), you must join an HMO Plan that offers prescription drug coverage. Do I need to choose a primary care doctor in Health Maintenance Organization (HMO) Plans? In most cases, yes, you need to choose a primary care doctor in HMO Plans.

What is the difference between Medicare Advantage and HMO?

Medicare health plans (other than MA & MSA) Doctors, providers & hospitals in Medicare Advantage Plans Health Maintenance Organization (HMO) Plans In HMO Plans, you generally must get your care and services from providers in the plan’s network, except: Emergency care Out-of-area urgent care Out-of-area dialysis