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Medicare Advantage Plans With Benefits Like Flat Out-of-Network Copays | Presbyterian Health Plan

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HealthSun Health Plans is an HMO plan with a Medicare Contract and a Medicaid contract with the State of Florida Agency for Health Care Administration. Enrollment in HealthSun Health Plans depends on contract renewal. Every year, Medicare evaluates plans based on a 5-star rating system. Star rating is for contract years 2018, 2019, 2020, 2021, 2022 and 2023. HealthSun complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-336-2069. . ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-877-336-2069. .

Do you need to file a complaint? File your complaint online via CMS by submitting the Medicare Complaint Form. Should you need to file a complaint with Medicare you may do so by calling CMS at 1-800-Medicare.

You can report suspected fraud or any other non-compliance activity by calling our Member Services Department at 877-336-2069 or TTY at 877-206-0500.

H5431_WEB_M Last Updated On 12/31/2022

About Half Of All Medicare Advantage Enrollees Would Incur Higher Costs Than Beneficiaries In Traditional Medicare For A 7

Medicare Advantage plans have the flexibility to modify cost sharing for most services, subject to limitations. Total Medicare Advantage cost sharing for Part A and B services cannot exceed cost sharing for those services in traditional Medicare on an actuarially equivalent basis. Further, Medicare Advantage plans may not charge enrollees higher cost sharing than under traditional Medicare for certain specific services, including chemotherapy, skilled nursing facility care, and renal dialysis services.

Medicare Advantage plans also have the flexibility to reduce cost sharing for Part A and B benefits, and may use rebate dollars to do so. According to MedPAC, in 2022, about 43 percent of rebate dollars were used to lower cost sharing for Medicare services.

In the case of inpatient hospital stays, Medicare Advantage plans generally do not impose the Part A deductible, but often charge a daily copayment, beginning on day 1. Plans vary in the number of days they impose a daily copayment for inpatient hospital care, and the amount they charge per day. In contrast, under traditional Medicare, when beneficiaries require an inpatient hospital stay, there is a deductible of $1,556 in 2022 with no copayments until day 60 of an inpatient stay .

How Does Medicare Reimbursement Work

The Centers for Medicare and Medicaid sets reimbursement rates for all medical services and equipment covered under Medicare. When a provider accepts assignment, they agree to accept Medicare-established fees.

Providers cannot bill you for the difference between their normal rate and Medicare set fees. The majority of Medicare payments are sent to providers of for Part A and Part B services.

Keep in mind, you are still responsible for paying any copayments, coinsurance, and deductibles you owe as part of your plan.

Next, well review how reimbursement works with each part of Medicare.

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How Do You File A Medicare Reimbursement Claim

As we mentioned earlier, it is rare for you to have to file a claim if you have original Medicare and the service provider is a participating provider.

  • Once you see the outstanding claims, first call the service provider to ask them to file the claim. If they cannot or will not file, you can download the form and file the claim yourself.
  • Go to Medicare.gov and download the Patient Request of Medical Payment form CMS-1490-S.
  • Fill out the form by carefully following the instructions provided. Explain in detail why you are filing a claim , and provide the itemized bill with the providers name and address, diagnosis, the date and location of service and description of services.
  • Provide any supporting information you think will be helpful for reimbursement.
  • Be sure to make and keep a copy of everything you are submitting for your records.
  • Mail the form to your Medicare contractor. You can check with the contractor directory to see where to send your claim. This is also listed by state on your Medicare Summary Notice, or you can call Medicare at 1-800-633-4227.
  • Finally, if you need to designate someone else to file the claim or talk to Medicare for you, you need to fill out the form.
  • You can view any outstanding claims by checking your Medicare Summary Notice or by going to MyMedicare.gov.

    Most Medicare Advantage Enrollees Have Access To Some Benefits Not Covered By Traditional Medicare In 2022 And Special Needs Plan Enrollees Have Greater Access To Certain Benefits

    Medicare Advantage Plans Costs

    Medicare Advantage plans may provide extra benefits that are not available in traditional Medicare. The cost of these benefits may be covered using rebate dollars paid by CMS to private plans. In recent years, the rebate portion of federal payments to Medicare Advantage plans has risen rapidly, totaling $432 per enrollee annually for non-Medicare supplemental benefits, a 24% increase over 2021. The rise in rebate payments to plans is due in part to incentives for plans to document additional diagnoses that raise risk scores, which in turn, generate higher rebate amounts that make it possible for plans to provide extra benefits. Plans can also charge additional premiums for such benefits, but most do not do this. Beginning in 2019, Medicare Advantage plans have been able to offer additional supplemental benefits that were not offered in previous years. These supplemental benefits must still be considered primarily health related but CMS expanded this definition, so more items and services are available as supplemental benefits.

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    Medicare Advantage In 202: Premiums Out

    Medicare beneficiaries have the option of receiving their Part A and Part B Medicare benefits through a private Medicare Advantage plan. The federal government contracts with private insurers to provide Medicare benefits to enrollees, and plans are required to meet federal standards. For example, Medicare Advantage plans are required to provide an out-of-pocket limit, and may provide additional benefits or reduced cost sharing compared to traditional Medicare. They are also permitted to limit provider networks, and may require prior authorization for certain services, subject to federal standards. This brief provides information about Medicare Advantage plans in 2022, including premiums, cost sharing, out-of-pocket limits, supplemental benefits, prior authorization, and star ratings, as well as trends over time. A companion analysis examine trends in Medicare Advantage enrollment.

    Do Reimbursement Policies Affect The Reimbursement Amount

    Reimbursement for out-of-network providers is subject to Uniteds reimbursement policies. Application of our reimbursement policies typically result in a decrease to the allowed amount. Uniteds reimbursement policies are generally based on national reimbursement rules and determinations, along with state government program reimbursement policies and requirements. Examples of the most common reimbursement rules include:

    • If a single code describes a procedure and the provider bills several procedure codes, we may apply one inclusive amount rather than a separate amount for each billed code.
    • If a surgery involves several different procedures, coverage for some or all of the procedures may be made through a single inclusive amount for the primary procedure. Some secondary procedures may be eligible for reimbursement at 50%.
    • When services are received from a health care professional who is not a physician, such as a physician’s assistant, the reimbursement amount will be less than what is allowed for a physician.

    Our reimbursement policies can be found at UHCprovider.com/policies.

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    What Else Do I Need To Know About Original Medicare

    • You generally pay a set amount for your health care before Medicare pays its share. Then, Medicare pays its share, and you pay your share for covered services and supplies. There’s no yearly limit for what you pay out-of-pocket.
    • You usually pay a monthly premium for Part B.
    • You generally don’t need to file Medicare claims. The law requires providers and suppliers to file your claims for the covered services and supplies you get. Providers include doctors, hospitals, skilled nursing facilities, and home health agencies.

    How Does Medicare Affect My Plan

    Mayo Clinic (Rochester) stops scheduling out-of-network Medicare Advantage patients in Minnesota.-ST

    Some types of plans, like a PPO or POS, cover some portion of your care if you receive services from providers outside your plan’s provider network. Since Medicare is such a large, established plan, many insurers use the programs payment schedules to help determine what they will pay out-of-network providers.

    Medicares payments are usually lower than payments from commercial health insurers. So, some insurance plans use Medicare’s fee for a specific medical procedure as a base, and then multiply it by a certain percentage to develop the maximum amount that they will pay for that procedure.

    For example, if you visit an out-of-network doctor, your insurer may agree to pay 130 percent of the rate Medicare would normally pay for the visit. This means that if Medicare would normally pay $100 for an office visit, your insurer would agree to pay up to $130.

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    New Protections For You

    What are surprise medical bills?

    If you have health insurance and get care from an out-of-network provider or at an out-of-network facility, your health plan may not cover the entire out-of-network cost. This can leave you with higher costs than if you got care from an in-network provider or facility.

    In the past, in addition to any out-of-network cost-sharing you might owe , the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid . This is called balance billing.

    An unexpected balance bill from an out-of-network provider is called a surprise medical bill.

    What are the new protections if I have health insurance?

    If you get health coverage through your employer, the Health Insurance Marketplace®, or an individual health insurance plan you purchase directly from an insurance company, these new rules will:

    If you have a health insurance plan with an out-of-network benefit, like a Preferred Provider Organization , you can choose to go to an out-of-network provider. But you cant be billed more than in-network cost sharing amounts for items or services provided by an out-of-network provider at in-network facilities unless you consent to getting care out-of-network by signing a notice and consent form.

    What are the new protections if I dont have health insurance or choose not to use it?

    They also allow you to file a dispute if you are charged more than $400 above the estimate.

    Your Action Plan: Understand Your Plan

    There are times when you cannot avoid going outside your network for care. But, you should know what to expect and be prepared for the bills you receive. Its very important to understand how your plan calculates its reimbursement rates before your visit.

    Follow these tips to help manage your out-of-pocket costs:

    • Ask your provider to refer you to in-network providers first unless there is a specific reason why you want to go out-of-network. If you are having a complex procedure, ask if all of your providers are in the network.
    • If you choose to go out-of-network, ask the providers staff how much he or she will charge before your visit. Then, talk to your insurer to find out how much of the service your plan will cover.
    • If your plan tells you they will pay a percentage of the charge based on Medicares fee schedule, ask how that will translate into a dollar amount.
    • If your plan reimburses out-of-network care based on a percentage of Medicare, look up your out-of-pocket costs in advance by selecting the Medicare-based button on the results page of the FH Medical Cost Lookup.
    • If youre unclear about how your plan calculates out-of-network rates, or what services are covered, look on your insurers website, check your plan documents or call your insurer and ask!

    And most importantly remember that you are your own best resource. Speaking up and asking your provider and insurer these questions up front will help you manage your out-of-pocket expenses.

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    Things To Know About Medicare Advantage Plans

  • You’re still in theMedicareProgram.
  • You still have Medicare rights and protections.
  • You still get complete Part A and Part B coverage through the plan. Plans may offer some extra benefits that Original Medicare doesnt cover like vision, hearing, and dental services.
  • Yourout-of-pocket costsmay be lower in a Medicare Advantage Plan. If so, this option may be more cost effective for you. Note: You may be charged copayments during the first 20 days.
  • You cant buy and dont need Medigap.
  • You can only join a plan at certain times during the year. In most cases, you’re enrolled in a plan for a year.
  • You can join a Medicare Advantage Plan even if you have apre-existing condition
  • You can check with the plan before you get a service to find out if it’s covered and what your costs may be.
  • Following plan rules, like getting aReferralto see a specialist in the plan’sNetworkcan keep your costs lower. Check with the plan.
  • Go to a doctor, other health care provider, facility, or supplier that belongs to the plan’s network, so your services are covered and your costs are less. In most cases, this applies to Medicare Advantage HMOs and PPOs.
  • Providers can join or leave a plans provider network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you may need to choose a new provider.
  • If the plan decides to stop participating in Medicare, you’ll have to join anotherMedicare Health Planor return to Original Medicare.
  • A Small Share Of Medicare Advantage Enrollees In Individual Plans Have Access To Special Supplemental Benefits For The Chronically Ill But A Larger Share Of Enrollees In Snps Have Access To These Benefits

    Medicare Advantage vs. Original Medicare

    Beginning in 2020, Medicare Advantage plans have also been able to offer extra benefits that are not primarily health related for chronically ill beneficiaries, known as Special Supplemental Benefits for the Chronically Ill . The majority of plans do not yet offer these benefits. Fewer than half of all SNP enrollees are in plans that offer some SSBCI. The share of Medicare Advantage enrollees who have access to SSBCI benefits is highest for food and produce , meals , transportation for non-medical needs , and pest control .

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    Nearly 7 In 10 Medicare Advantage Enrollees Are In Plans With No Supplemental Premium In 2022

    In 2022, nearly 7 in 10 beneficiaries are in zero-premium individual Medicare Advantage plans with prescription drug coverage , and pay no premium other than the Medicare Part B premium . The MA-PD premium includes both the cost of Medicare-covered Part A and Part B benefits and Part D prescription drug coverage. In 2022, 87% of Medicare Advantage enrollees in plans open for general enrollment are in plans that offer prescription drug coverage.

    Altogether, including those who do not pay a premium, the average enrollment-weighted premium in 2022 is $18 per month, and averages $11 per month for just the Part D portion of covered benefits, substantially lower than the average premium of $40 for stand-alone prescription drug plan premiums in 2022. Higher average PDP premiums compared to the MA-PD drug portion of premiums is due in part to the ability of MA-PD sponsors to use rebate dollars from Medicare payments for benefits covered under Parts A and B to lower their Part D premiums, which according to the Medicare Payment Advisory Commission , are $300 per enrollee annually in 2022.

    For the remaining 31% of beneficiaries who are in plans with a MA-PD premium , the average premium is $58 per month, and averages $35 for the Part D portion of covered benefits slightly lower than the $40 monthly PDP premium.

    What Is A Medicare Doctor Network

    Generally, a network is an interrelated group or system. A Medicare doctor network is a group of doctors who have agreed to work with your health insurance plan. A network can be a good thing in the way that you know your plan has screened the network Medicare doctors. A network can also be a bad thing in the way that it can limit the doctors that you can see.

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    When Is My Prescription Covered

    Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. If you cannot use a network pharmacy, we could cover your prescriptions filled at an out-of-network pharmacy if you will be traveling out of the service area. Please contact the Part D Services Department at 1-877-336-2069 for information concerning vacation supplies and authorizations.

    In these situations, please check first with the Member Services Department to see if there is a network pharmacy nearby. You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.

    How Do I Submit A Claim

    Out of Network Physical Therapy Billing – Deductibles and CoInsurance

    Submit claims electronically via Change Healthcare EDI Systems, payer ID number 72126.

    Submissions must be in accordance with the Medicare Claims Processing Manual 100-4, Chapter 24 and any other CMS guidance that governs claims handling and the filing of claims. Peoples Health reserves the right to use the claims procedures issued by CMS to adjudicate claims, specifically the procedures contained in the Medicare Claims Processing Manual and all other CMS-issued payment guidance, as well as to make use of the reconciliation processes and other remedies contained therein.

    For more information about Change Healthcare, visit or call 1-866-924-4634.

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