CMS Requirements for Medicare Advantage

Medicare is the federally-administered health care program available to the elderly and disabled, and overseen by the agency called Centers for Medicare & Medicaid Services (CMS). Many Medicare beneficiaries prefer to get their benefits through Medicare private health plans known as Medicare Advantage plans. These plans often offer benefits that traditional Medicare does not. The Medicare Advantage market also gives the beneficiary many options. However, CMS does not let the market go free. CMS imposes regulations to ensure that beneficiaries get quality coverage.

Health Coverage

• CMS requires that all Medicare Advantage (MA) plans offer all Medicare-covered services. The plan must offer Part A hospital services and Part B medical services. While the plans must offer this coverage, CMS does not regulate how the MA plan charges for these services or any regulations placed on services. For example, a beneficiary may visit a specialist under traditional Medicare without prior authorization, and Medicare will pay for 80 percent of the bill. An MA plan must cover that specialist visit, but may require prior authorization and may only pay for 60 percent of the bill.

Drug Coverage

• CMS requires that each insurance company offer at least one MA plan bundled with a Part D prescription drug plan.

Notification

• CMS regulations require MA plans to notify beneficiaries of any formulary (a list of covered drugs) or services changes. They may do this annually if the change happens at the beginning of the year, or they may send out a letter if the change happens in the middle of the benefit year.

Marketing

• CMS strictly regulates how a Medicare Advantage insurance company can market its plan in an effort to reduce marketing fraud. Plans may not contact beneficiaries without their consent. This means they cannot call anyone unless that person gave them permission to do so, and they may not send out unsolicited emails. Further, there are certain places that an MA provider may not market its plan. This includes nursing homes, places serving free meals or in other health care settings. They also may not make themselves out to be Medicare. They cannot say they are with Medicare, claim their plan is Medicare-endorsed, or compare their plan to others by name.

Emergency and Urgent Care

• Many MA plans restrict their beneficiaries to a network of providers. This means you can only see local network doctors for the plan to provide coverage. However, CMS requires that MA plans cover any out-of-network care received by a beneficiary in the event of emergency or urgent care.