CMS proposes 1.84% Medicare Advantage payment increase The Centers for Medicare and Medicaid Services (CMS) has proposed increasing baseline Medicare Advantage payment rates for 2019 by an average of 1.84 percent. According to CMS, the proposed payment increase is based on better use of encounter data and changes to the risk adjustment model used to pay for aged and disabled beneficiaries. Medicare Advantage is at an all-time high, with approximately one-third of all Medicare beneficiaries enrolled in a Medicare managed care plan. Enrollment has more than doubled over the past decade. CMS is accepting comments on the proposal until March 5, with the final rates posted on April 2. For more information, see the CMS fact sheet. February 5, 2018 Medicare Medicare Advantage 0 0 Comment Read More »
Anthem Blue Cross rescinds termination of Medicare Advantage agreement with Brown and Toland Anthem Blue Cross has reached an agreement to extend its Medicare Advantage contract with Brown & Toland Physicians. Although Anthem Blue Cross previously announced the contract would be terminated effective October 1, 2017, the parties have since signed a contract extension through December 2018. The termination would have affected approximately 1,900 Medicare Advantage enrollees in San Francisco. Click here to see the letter sent from Brown & Toland. Physicians with questions can contact Brown & Toland Physician Services at physicianservices@btmg.com. August 17, 2017 Managed Care, Medicare Anthem Blue Cross, Medicare Advantage, San Francisco Medical Society 0 0 Comment Read More »
Anthem Blue Cross terminates Medicare Advantage agreement with Brown and Toland Effective October 1, 2017, Anthem Blue Cross will terminate its contract with Brown & Toland Physicians for its Medicare Advantage product. The termination will affect approximately 1,900 Medicare Advantage enrollees in San Francisco. Affected patients will be reassigned to Asian American Medical Group, Jade Health Care Medical Group or Imperial Health Holdings Medical Group. The termination was reportedly due to a failure to reach a contractual agreement with Brown & Toland. Physicians with questions can contact Brown & Toland representative Stephanie Mamane at (415) 972-4282 or smamane@btmg.com. August 9, 2017 Managed Care, Medicare Anthem Blue Cross, Medicare Advantage, San Francisco Medical Society 0 0 Comment Read More »
Ask the Expert: If Medicare pays for a procedure, does a Medicare Advantage plan also have to pay? The California Medical Association (CMA) has received this question from physician practices many times over the past few years. The answer is – it depends. Title XVIII of the Social Security Act established regulations for the Medicare program, which includes provisions affecting Medicare Advantage (MA) plans. The Centers for Medicare and Medicaid Services (CMS) has interpreted these provisions through the Medicare Managed Care Manual (Chapter 4 – Benefits and Beneficiary Protections). The Manual provides guidance for MA plans under Internet-only manual (IOM) 100-16. These guidelines reflect CMS’ current interpretation of the provisions of the MA statute and regulations (Chapter 42 of the Code of Federal Regulations, part 422) pertaining to benefits and beneficiary protections. In general, the Act lists categories of items and services covered by Medicare. Congress occasionally adds specific services to be covered by Medicare. The MA plans are required to provide enrollees with all basic categories of benefits under Original Medicare. Some examples of services that are specifically defined in the Act and that MA plans would be required to cover are prostate cancer screening tests for a man over 50 years of age who has not been tested in the preceding year, as well as pneumococcal, influenza and hepatitis B vaccines and administration. While MA plans are required to provide coverage for the same basic categories of benefits as Original Medicare would provide, MA plans are not necessarily required to pay for all of the same procedures that Medicare would have paid. So, how can you determine when an MA plan is required to pay? According to the CMS Internet Only Manual 100-16, Chapter 1 (page 4), an item or service classified as an original Medicare benefit must be covered by an MA plan if: The specific service is specifically identified in the Act (section 1861) (unless superseded by written CMS instructions or regulations regarding Part C of the Medicare program); CMS has a National Coverage Determination specifically listing that CPT code as medically necessary/payable; or A local Medicare Administrative Contractor with jurisdiction for claims in your geographic region has a Local Coverage Determination that specifically lists that CPT code as medically necessary/payable. In other words, if the service in question doesn’t fall into one of the above categories, the MA plan may have its own medical policy and deem a procedure experimental, investigational or not medically necessary and deny payment. For this reason, it’s important to be familiar with the medical policies of the plans for which you contract. May 21, 2015 Medicare Medicare Advantage, Medicare 0 0 Comment Read More »
Medicare Advantage plans to see a modest increase in payments The Centers for Medicare and Medicaid Services (CMS) announced this week that Medicare Advantage plans would see a 0.4 percent boost in payment rates for 2015. This small payment boost is a change from CMS's February proposal that would have reduced Medicare Advantage plans payment rates by 1.9 percent. This announcement comes on the heels of new data that predicts falling Medicare costs due to healthier baby boomers aging into the system. Healthier beneficiaries in Medicare have led to a downward drop in risk adjustment for the program. CMS has also proposed an improved risk adjustment methodology to account for patient’s health status (severity of illness) and demographics. Plan bids will be based on these criteria. Along with this modest payment increase for Medicare Advantage plans, CMS announced that it plans to discontinue a three-year quality bonus demonstration project that shielded some plans from cuts required by the Affordable Care Act. CMS also said it will limit how much Medicare Advantage plans are allowed to increase beneficiaries’ premiums in 2015. This proposal limits these increases to the equivalent of $32 per month annually in 2015, down from $34 in 2014. With Congress’s recent passage of a bill that will update California's outdated Medicare localities, the Medicare Advantage rates in the 14 affected counties will see an even greater increase because the rates are partially built on the Medicare fee-for-service rates. Contact: Elizabeth McNeil, (800) 786-4262 or emcneil@cmanet.org. April 16, 2014 Medicare Medicare, Medicare Advantage, GPCI 0 0 Comment Read More »
