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CMS Guidelines for Medicare Advantage Plans

Medicare is a health care program for the elderly and disabled, overseen by the Centers for Medicare & Medicaid (CMS), a federal agency. CMS is responsible for creating regulations and manuals that set how Medicare is administered throughout the nation. Many Medicare enrollees opt to get their Medicare benefits through Medicare private health plans, known as Medicare Advantage plans. Even though these are private plans, they are still subject to guidelines set forth by CMS.

  1. Benefits Guidelines

    • Medicare Advantage plans must, at a minimum, provide the same benefits offered under Part A and Part B of traditional Medicare. This includes hospital coverage, medical services, durable medical equipment, some prescription drugs and more. Medicare Advantage plans have the option to provide additional benefits at an additional cost to the beneficiary, and they can also package Part D drug benefits with the Part A and B benefits.

    Enrollment Guidelines

    • Periods of time are limited in which a Medicare Advantage plan can enroll a beneficiary. These include the beneficiary's initial enrollment period, which is the seven months surrounding the first month he becomes eligible, the open enrollment period, which lasts from January 1 to March 31 each year (effective on the first day of the month following enrollment) and the annual coordinated election period, which lasts from November 15 to December 31 annually (effective on January 1 of the following year). Medicare Advantage plans can also enroll people during Social Security Administration approved special enrollment periods.

    Appeals Guidelines

    • If a Medicare Advantage plan decides to deny a beneficiary coverage of a service or drug, plan agents must provide the beneficiary written notice. The Medicare Advantage plan must adhere to CMS appeals process guidelines and must notify the beneficiary of her rights and with directions on how to appeal a denial. Beneficiaries who are being denied coverage in a hospital, skilled nursing facility or other care setting must be offered a quick appeals process, if necessary.

    Provider Relationship Disclosure Guidelines

    • Medicare Advantage plans that have incentive programs with providers must alert their members and beneficiaries according to CMS guidelines. They also must alert beneficiaries if any incentive programs affect referral services, or if provider relationships or contracts will affect the specialists or other doctors the beneficiary has access to in his network.

    Marketing Guidelines

    • Medicare Advantage plans must follow several strict guidelines in marketing their plans. Plan agents cannot make any phone calls or send any emails that are unsolicited. They also may not visit anyone in a home or nursing home without an invitation. If they are providing a gift to encourage enrollment, the gift may not be worth more than $15. They cannot use another plan's name in any advertising materials, use the term "Medicare Endorsed" or imply that they are a Medicare employee. Agents also may not market Medicare Advantage plans at any events that are educational, in any health care settings or anywhere where free food is available. Finally, they cannot ask for any financial or personal information if they call the beneficiary.

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