Medicare Advantage
Medicare Advantage (MA) or Medicare Part C plans are sometimes referred to as Medicare private health plans because 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 to receive Medicare-related health care benefits through common private vehicles such as HMOs, PPOs, and PFFS.
About Medicare Advantage
MA covers about one third of all Medicare beneficiaries. 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 (i.e., 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, remember that the patient’s benefits and your billing, coverage, and payment processes will be administered directly under the MA plan, not CMS. You must check with the MA payer before providing services if you’re unsure whether something is covered. MA plans vary and can charge patients different out-of-pocket costs or require prior authorization for therapy services, so it is important to understand the 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.
Additional resources
CMS General Information on Medicare Advantage Health Plans
CMS Resources on Medicare Advantage