Medicare Advantage
What Audiologists and Speech-Language Pathologists Need to Know
Medicare Advantage (MA), also known as Medicare Managed Care or Part C, is a program where private health plans contract with the federal government to offer Medicare benefits. MA plans function differently from traditional Medicare, which is managed by Medicare Administrative Contractors (MACs) who administer both Medicare Part A (inpatient) and Medicare Part B (outpatient) benefits. In many cases, MA plans offer additional benefits traditional Medicare does not, such as hearing aids, at an additional monthly premium. Medicare beneficiaries can elect to enroll in traditional Medicare or join an MA plan. MA plans are required to cover all Part A and Part B Medicare benefits.
MA plans were created to determine if the private market would be more effective in delivering Medicare benefits than the federal government. Many Medicare beneficiaries elect to join an MA plan if they have specific health care needs the plan is tailored to address. MA plans also market their products to beneficiaries just like private health insurance companies, which encourages some beneficiaries to transition from traditional Medicare to MA.
On This Page
How MA Plans Work
MA plans function like private health plans with plan-specific enrollment and billing systems that are separate from each other and from traditional Medicare. MA plans are required to cover the same services and devices as traditional Medicare, but they can design their own enrollment and billing protocols. Both beneficiaries and providers need to go through the private insurance company to enroll in their MA plan. They also need to follow any billing requirements determined by that private insurance company.
Here are some examples of areas where MA plans may function differently from traditional Medicare:
- Documentation: MA plans may require documentation that is different from or is not required by traditional Medicare. For example, traditional Medicare requires a progress note completed every 10 treatment sessions and a discharge note, but MA plans may have different requirements. See our overview of traditional Medicare documentation to learn more.
- Payment Rates: MA plans can establish different payment rates for services that might be higher or lower than traditional Medicare payment rates. When enrolling as an MA plan provider, it is important to review your contract and the fee schedule for each individual payer.
- Coverage and Utilization Management (UM) Policies: Plans might also have different rules for coverage than traditional Medicare and may employ UM tactics, such as prior authorization for specific types of services. For example, an MA plan may require a referral from a physician before services can begin, or they may not cover services associated with a specific diagnosis. In other words, it is not safe to assume that services covered by MA plans are identical to services covered by traditional Medicare.
What MA Plans Must Cover
At a minimum, MA plans must cover Part A and Part B benefits at the same level as traditional Medicare. Audiologists and speech-language pathologists (SLPs) can find extensive resources on Medicare Parts A and B on ASHA’s Medicare webpage.
While coverage of services and devices must match that of traditional Medicare, payment to providers does not need to follow the Medicare fee schedule. The copays and deductibles in an MA plan will vary from traditional Medicare plans and may differ depending on the insurance company and selected plan (PPO, HMO, etc.). In addition, many MA plans offer supplemental benefits, such as hearing aids. To determine supplemental benefits, copays, deductibles, and documentation requirements, providers need to check with the plan directly using the number on the MA plan insurance card or ask the patient to review their explanation of benefits (EOB).
How to Identify an MA Plan
The beneficiary’s insurance card will indicate whether the plan is an MA plan. Here’s what to look for:
- An MA plan card typically looks very different from a traditional Medicare card, which is red, white, and blue. See medicare.gov for an example of the traditional Medicare card.
- For an MA plan, “Medicare” is indicated somewhere on the card along with the name of the insurance company managing the plan (e.g., “Arkansas Blue Medicare”).
- Look carefully! The card may or may not have the words “Medicare Advantage,” but it should show the type of plan (PPO, HMO, etc.). Many will also indicate copays or deductibles.
Out-of-Network Provider Rules
Unlike with traditional Medicare, providers are not required to enroll with the insurance company to see patients with an MA plan. There is a federal law that requires audiologists and SLPs to enroll with traditional Medicare if they want to provide covered services to Medicare Part B patients. In other words, audiologists and SLPs may not provide out-of-network services (called “opting out”) and accept out-of-pocket payment from Medicare Part B beneficiaries. This regulation does not apply to MA plans managed by private insurance companies.
Regulation 42 CFR 422.100(b) lists general MA requirements and indicates that MA beneficiaries seeing out-of-network providers will be responsible for full payment unless they seek proper authorization from their MA plan. There are a few exceptions to this rule:
- The beneficiary has an emergency where it is unreasonable or not possible to obtain in-network services
- The beneficiary receives out-of-area dialysis services
- The beneficiary’s specific MA plan authorizes the use of out-of-network providers.
Out-of-network providers can accept out-of-pocket cash pay from MA patients at their practice's usual and customary rate. Patients should be notified that they are responsible for payment and provided a good faith estimate of cost. The No Surprises Act requires that providers accepting cash pay must provide patients with a cost estimate prior to rendering the service.
Oversight of MA Plans
MA plan enrollment grew dramatically during and after the COVID-19 pandemic. Prior to the pandemic, roughly 30% of Medicare beneficiaries used an MA plan. Post-pandemic, that number doubled to approximately 60%. As MA has expanded, there have been a host of issues signaling the need for increased regulations. MA regulations are outlined in the Code of Federal Regulations Title 42 Chapter IV Subchapter B Part 422 (42 CFR 422). The program was established in 1997 and has been subject to a number of additions and revisions over the years.
Under rules finalized for contract year 2024, UM techniques have been strictly curtailed. ASHA is monitoring implementation to ensure our members and patients are not adversely impacted by violations of these policies.
Most regulations of MA plans are enforced at the federal level. State insurance commissioners currently do not have jurisdiction over MA plans even though they are entirely managed by private insurance companies. However, the commissioners are tracking and commenting on issues with MA plans. For example, they recently sent a letter to the U.S. Senate raising concerns about potentially abusive or inappropriate MA marketing techniques: State MA Marketing Authority Senate Letter [PDF].
How to Manage Issues With MA Plans
If providers or beneficiaries have coverage or benefit administration issues with an MA plan, they should start by contacting the plan directly.
If issues can’t be resolved directly with the plan, there is a Medicare Beneficiary Ombudsman (MBO) who receives and responds to complaints about all types of Medicare plans, including MA plans. Beneficiaries can call the MBO at 1-800-633-4227. TTY users should call 1-877-486-2048.
Beneficiaries can also contact their State Health Insurance Assistance Program (SHIP) for assistance.
Resources
ASHA Resources
- Medicare Coverage of Speech-Language Pathologists and Audiologists
- CMS Finalizes Policy Updates for Medicare Advantage Plans for Contract Year 2025 (May 3, 2024)
ASHA Comment Letters
- ASHA Comments to CMS on Medicare Advantage Proposed Rule [PDF] (April 3, 2020)
- ASHA Comments to CMS on Medicare Advantage Program [PDF] (February 9, 2023)
- ASHA Comments to CMS Regarding Medicare Advantage Plan [PDF] (January 3, 2024)
Other Important Resources
- CMS: Understanding Medicare Advantage Plans [PDF]
- CMS: Medicare Rights and Protections [PDF]
- CMS: Medicare Managed Care Manual
- NAIC Consumer Resource: Three Ways to Protect Yourself During Medicare and Medicare Advantage Open Enrollment
- Code of Federal Regulations: Medicare Advantage Program (42 CFR Part 422)
Questions?
Contact reimbursement@asha.org.
