Ask the Expert: If Medicare pays for a procedure, does a Medicare Advantage plan also have to pay?

May 20, 2015
Area(s) of Interest: Payor Issues and Reimbursement Practice Management Public Payors 

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  • The specific service is specifically identified in the Act (section 1861) (unless superseded by written CMS instructions or regulations regarding Part C of the Medicare program);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.



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