Medicare Advantage

Medicare Advantage (MA) or Medicare Part-C covers about one third of all Medicare beneficiaries. MA plans are sometimes referred to as Medicare private health plans in that they are sold by private insurance companies (e.g. United Healthcare, Blue Cross Blue Shield) that provide Medicare benefits. MA plans offer an alternative way of receiving Medicare-related health care benefits through common private vehicles such as HMOs, PPOs, and PFFS. MA plans must offer occupational therapy services as a benefit that, at a minimum, meet the level of Medicare Part A and Part B services offered through “Original” Medicare (or Medicare that is administered by the federal government through the Centers for Medicare & Medicaid Services (CMS).

When considering whether to contract as a network provider with an MA plan, occupational therapy practitioners must remember that the patient’s benefits and your billing, coverage, and payment processes will all be administered directly under your MA plan rather than under CMS. You as the practitioner must check with your MA payer prior to providing the service if you’re unsure whether a service is covered. Each MA plan can charge patients different out-of-pocket costs or require prior authorization for therapy services, for example. For these reasons, it is important that you understand the workings of your individual MA plan’s network rules, restrictions, and costs.

AOTA strongly recommends that occupational therapy practitioners research the MA plan offerings in their region and assess how each plan covers occupational therapy before contracting as a network provider.  

CMS General Information on Medicare Advantage Health Plans

CMS Resources on Medicare Advantage

Medicare Managed Care Appeals & Grievances

Medicare Advantage Consumer Website