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Last Modified: 11/27/2024 Location: FL, PR, USVI Business: Part B

Eligibility FAQ -- Medicare Advantage plans

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"With our snowbirds, we have to stay on top of their eligibility status," said one Medicare billing manager who uses First Coast's SPOT to access eligibility information. "Having fast access to Medicare eligibility and secondary payer information helps us file clean, accurate claims and get reimbursed sooner."
Click here to find out what SPOT can do for you.
Q: For a patient enrolled in a Medicare Advantage, can a Medicare participating Part B provider ask for payment at the time of service (at the standard Medicare fee schedule rate) and instruct the patient to file the claim with the Medicare Advantage for direct reimbursement? Regarding original Medicare vs. Medicare Advantage plans, what fee schedule can we bill?
A: If the patient is enrolled in a Medicare Advantage plan, contact the Medicare Advantage plan prior to rendering services to determine what amount the patient is responsible for out of pocket. This will provide you guidance on whether to treat or bill the patient. Medicare does, however, limit the amount providers can bill patients for services. Refer to Medicare & You handbook external pdf file for more information.
When a patient enrolled in a Medicare Advantage plan uses out-of-network providers, their out-of-pocket expenses for covered services may be higher. It is important to verify with the patient (and confirm through First Coast’s Part B interactive voice response (IVR) system at 1-877-847-4992 or through SPOT) if the patient is enrolled in a Medicare Advantage plan.
The CMS IOM Pub. 100-16, Medicare Managed Care Manual, Chapter 4 - Benefits and Beneficiary Protections, Section 110.1.3 external pdf file states:
• Medicare Advantage plans must reimburse non-participating providers for emergency care, ambulance services sought through 911 calls, and for medically necessary dialysis services from a non-participating provider when the patient is out of the service area.
The CMS IOM Pub. 100-16, Medicare Managed Care Manual, Chapter 6 - Relationships with Providers, Section 100 external pdf file further states:
• Non-contracted providers must accept as payment in full no amount greater than what original Medicare would pay and cannot bill the patient more than their normal cost-sharing amounts (coinsurance).
There are numerous potential scenarios and the answer may change dependent upon terms of the plan. In general, if a Medicare Advantage plan enrollee seeks care outside of the Medicare Advantage plan network in which he or she is enrolled and the Medicare Advantage organization sponsoring the plan has no legal liability for reimbursement, then yes, the provider can bill the Medicare Advantage plan enrollee. However, the provider shouldn't bill the patient more than the original Medicare amount for what would otherwise be covered A/B services.
There is no specific guidance for collecting payment from the patient at the time services are rendered.
Source: CMS IOM Pub. 100-16, Medicare Managed Care Manual, Chapters 4 and 6 external pdf file
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.