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Medicare Advantage Contractor Requirements

For people who need government medical insurance, but prefer private sector service and approaches, the Center for Medicare and Medicaid Services created the Medicare Advantage plan. Medicare participants have the right to elect to have their benefits administered by private insurance companies in the form of a health maintenance organization or preferred provider organization. However, when handling government money, contracted insurers aren't free to run their programs in just any way. CMS requires contracted insurers to follow certain guidelines and procedures in order to receive Medicare funds.

  1. Rates

    • Each year, CMS sends a list of reimbursement rates to Advantage plan participants and applicants. In order to be an Advantage provider for the next calendar year, insurers must accept the service reimbursement schedule Medicare offers. Insurers who have been Advantage participants but who do not want Medicare's annually revised rates are dropped from the program and their Medicare insured must choose a new Advantage insurer.

    Data Reporting

    • Starting in 2011, Medicare Advantage organizations must report statistics regarding health-care outcomes to CMS via the Health Effectiveness Data Information Set (HEDIS) system. Medicare requires its health-care providers such as hospitals and physicians' offices to report to CMS on patients' conditions and progress via a standardized set of health measures. Advantage insurers must also submit this data accompanying their claims.

    Disputes

    • When Medicare patients on a Medicare Advantage plan have a dispute with their Advantage insurer over a denied claim coverage, the patient has the right to bring their grievance to Medicare. Advantage providers must agree to allow CMS Administrative Law Judges be the final arbiters of disputes over claims and patient issues.

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