How can Medicare Advantage plans (HMOs) affect your practice?

Answer: As a new calendar year approaches, beneficiaries may be electing different options for their Medicare. Some beneficiaries will choose to stay with Medicare fee-for-service for their Part B benefits, while others will choose a Medicare Advantage (MA) plan, such as an HMO.

Facts about MA Plans

  • MA plans are available to beneficiaries in all 50 states
  • As of April 2007, nearly 8.3 million beneficiaries are enrolled in MA plans
  • Many plans offer additional benefits not included in Medicare fee-for-service, such as prescription drug coverage, hearing aids, glasses and routine physical exams
  • Beneficiary enrollment in Medicare plans is handled through the Social Security Administration
  • When a patient enrolls in an MA plan, the MA plan replaces that beneficiary’s coverage through fee-for-service Medicare or traditional Medicare

How can MA Plans Affect your Practice?

  • Some patients do not realize that they have selected an MA plan and may still give you their red, white and blue Medicare card
  • Some patients think they should always give you their red, white and blue Medicare card even though they have a different plan
  • Some patients think their MA card is just for prescription drugs

Tips for Easy Claim Submission and Troubleshooting

  • Submitting a claim is not the best way to verify a patient’s enrollment. There can be a lag time between the effective date of a patient’s change in coverage (e.g., from traditional Medicare to an MA plan) and Medicare records being updated by Social Security.
  • Ask each patient to present all of his/her insurance cards at each visit. Alternatively, you can ask patients for their prescription cards, to ensure that you are getting the most accurate information possible.
  • If you cannot ascertain whether or not the patient has coverage through an MA plan, you should verify this information with a customer service representative in the provider contact center
  • If a patient insists that his Medicare coverage is wrong (he believes he should have traditional Medicare and not an MA plan), the patient must call 1-800-MEDICARE to correct his enrollment

eServices 
Palmetto GBA is pleased to offer eServices, our free Internet-based, provider self-service portal. This application provides information access over the Internet for the following online services:

  • Eligibility
  • Claims status
  • Remittances online
  • Financial information (payment floor and last three checks paid)
  • All providers that have an EDI Enrollment Agreement on file may register to use this tool. Simply access the introductory article to learn more. Select the 'eServices' link across the top of any of our site pages. The eServices User Manual (PDF, 7.85 MB) is a great guide on how to use the tool.

Note: One important consideration is that only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. Billing services and clearinghouses should contact their provider clients to gain access to the system.

Resource: To access the MA Plan Directory and CMS instructions for MA Plans, go to the CMS Medical Advantage (MA) Plan Directory page on the CMS website.

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Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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