Yes, Medicare Advantage (MA) does reimburse for chronic care management (CCM). Medicare Advantage is a third-party insurer that is required to provide the same coverage for services that Original Medicare does. Because Original Medicare chronic care management is covered as part of Medicare Part B, it will be covered by Medicare Advantage as long as a patient meets the required conditions.
Because Medicare is such an important part of providing care for many patients, this article will explore more about how MA works with the different elements of chronic care management. This will include topics like:
- Requirements and guidelines for MA
- Comparison of MA to Original Medicare
- How the Centers for Medicare and Medicaid Services (CMS) pay for MA
- The role of Medicaid in Medicare chronic care management coverage
All information is accurate as of time of writing, in 2023. Please refer to links provided as coverage is subject to change.
Is Medicare Part C the Same as Medicare Advantage?
Yes, MA is also known as Medicare Part C and the terms are used interchangeably in the literature. Here is a quick review of CMS Medicare Advantage Guidelines compared with other parts of Original Medicare.
- Medicare Part A – Covers inpatient stays and hospital visits
- Medicare Part B – Covers outpatient services and doctor’s office visits
- Medicare Part C (Medicare Advantage) – Provides an alternative to receiving Medicare Parts A, B, and usually D through a third party
- Medicare Part D – Covers prescription drugs
- Medigap – Provides coverage for some of the healthcare costs not paid for by Original Medicare, like deductibles, copayments, and coinsurance. It is provided through private companies and cannot be used in conjunction with Medicare Advantage.
What Are the CMS Medicare Advantage Contract Requirements?
In order for a private third-party to become an MA provider, they must meet certain criteria and provide specific required services. Some of the largest Medicare Advantage plans providers include well-known health insurance providers like Kaiser Permanente, Humana, Aetna, and Cigna Healthcare.
The requirements for these organizations to become MA providers include:
- Signing a contract with CMS. One MA provider can use one contract to cover multiple different MA plans that they offer to consumers.
- Obtaining authorization from any state they operate in to provide health benefits as a risk bearing entity.
- Meeting the minimum enrollment numbers of 5,000 individuals. This requirement can be adjusted or waived, especially in rural areas.
- Showing competent organizational and administrative abilities needed to provide quality health services. These include:
- A managerial board for overseeing policies and best practices.
- A CEO or executive manager who is elected and can be removed by this managerial board.
- Appropriate staff to run the offered programs.
- Fidelity bonds of at least $100,000 per employee, to protect against fraudulent activity by staff.
- Reasonable insurance policies protecting the organization from losses due to fire, theft, or professional liability claims.
- Demonstrable commitment to ethical practice and compliance.
How Does CMS Pay Medicare Advantage Plans?
The Centers for Medicare and Medicaid Services (CMS) pay a fixed dollar amount every month to the company providing an individual their MA plan. In 2019 that amount was around $1,000 per month, per patient. This means individuals who choose an MA plan are still receiving an equivalent financial compensation from Medicare as individuals who choose Original Medicare. The only difference is that MA individuals are having their health insurance provided by a third party that uses monthly payments from Medicare to pay expenses.
MA plans are required to follow the same rules and provide the same protections as Original Medicare. This means they will pay for the same treatments and care an individual would have covered under standard Medicare, although out-of-pocket costs, pre-approval requirements, and in-network provider options will vary.
Chronic care management is covered by Part B of Original Medicare, which is an optional extra that an individual choosing Original Medicare can add on to Medicare Part A. Patients will pay an additional monthly premium for Part B if they add this coverage. If, on the other hand, an individual chooses an MA plan instead, Part A and Part B coverage is automatically included. There are some Medicare Advantage plans that pay the part B premium, while others require the insured person to pay this premium in addition to their MA monthly premium.
Does Medicaid Pay for Chronic Care Management Under Medicare Advantage Plans?
Yes, in most cases if a patient is dually eligible for both Medicare and Medicaid, Medicaid will pay for the premiums and coinsurance needed for chronic care management. There are around 12 million dually eligible individuals in the USA, and most are able to choose a Medicare Advantage plan for their Medicare coverage. In these cases, patients receiving chronic care management will not be responsible for cost sharing for this service, since it will be paid for by Medicaid.
TimeDoc: Make Providing Chronic Care Management to Medicare Advantage Patients Easier
As any healthcare provider administrator knows, staying compliant with Medicare documentation regulations can feel like a full time job. That’s why TimeDoc Health created a platform to provide care management solutions at scale. Our platform lets you:
- Spend less time on billing
- Automate planning for care management
- Document time with ease
- Stay compliant with Medicare requirements
- Improve staff efficiency
- Increase return-on-investment with chronic care programs
To learn more about how we can help with your Medicare Advantage patients, as well as those with other insurance, get in touch today.