Legal: Make sure MA plans mirror Medicare

Monday, November 21, 2011

A. With few exceptions, coverage guidelines under a Medicare managed care plan must mirror those applied under original Medicare (Parts A and B) for the same items or services in the same geographic area. For example, a plan cannot establish more restrictive coverage criteria and attempt to reduce access to durable medical equipment covered under Medicare Part B.

Medicare Part C, also known as the Medicare Advantage (MA) program or Medicare managed care, allows Medicare beneficiaries to elect to receive their benefits through private health insurance plans instead. CMS contracts with private insurers to provide these benefits based on a fixed monthly payment amount. 

MA plans are required to provide beneficiaries with at least the same basic benefits otherwise available to them under original Medicare. To meet this requirement, MA plans must follow (1) Medicare National Coverage Determinations (NCDs); (2) general coverage guidelines included in original Medicare manuals and instructions; and (3) written coverage guidelines of local Medicare contractors, such as Local Coverage Determinations (LCDs), with jurisdiction for claims in the geographic area covered by the plan. In cases of conflicting local coverage policies in the geographic area covered by a plan, the plan may apply one policy uniformly across the plan's entire covered area.

Despite these requirements, MA plans have some flexibility in how they deliver care to enrolled beneficiaries. Depending on the type of plan, this may include the ability to limit the number of participating providers.

Katie Salsbury is an attorney with Eastwood & Azia. Reach her at or 202-296-7775.