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Medicare Advantage: How is it Different from Traditional Medicare

As more Medicare beneficiaries choose to switch their medical coverage from traditional Medicare to Medicare Advantage plans (31% in 2015), I receive more and more questions regarding do the outpatient therapy rules and regulations that apply to traditional Medicare also apply to the Medicare Advantage plans. In this article, I will answer the following questions:

  1. Do Medicare Advantage plans have an annual therapy cap?
  2. Do Medicare Advantage plans provide the same coverage as traditional Medicare?
  3. Must Medicare Advantage plans follow National Coverage Decision and Local Coverage Decision policies?
  4. If a service in not covered by the Medicare Advantage plan, must I issue an Advance Beneficiary Notice of Noncoverage (ABN)?
  5. For Medicare Advantage plans, must a physician sign and date (ie. certify) my therapy plan of care?
  6. Do Medicare Advantage plans require functional limitation reporting?
  7. If I am not a provider with a Medicare Advantage plan, can I see the patient and collect cash for therapy services that would be covered by the Medicare Advantage plan?
  8. Do Medicare Advantage plans use the National Correct Coding Initiative Edits and modifier 59?

Lets begin!

Do Medicare Advantage plans have an annual therapy cap?

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Using the ABN for Medicare Advantage Plans

The Advance Beneficiary Notice of Non-Coverage (ABN) is used when normally the service(s) or item(s) would be covered by the Medicare program, but under the circumstance, a provider does not think their Medicare Administrative Contractor will pay for a service(s) or item(s). A question I have been receiving lately is can a provider of outpatient therapy services use an ABN for Medicare Advantage (MA) plans to indicate to the MA plan that they (the provider) believe the MA will not pay for a service(s) or item(s)?

The ABN is to be used

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CMS Releases NCCI Edits Version 24.1

The Centers for Medicare and Medicaid Services has released the National Correct Coding Initiative (NCCI) Edits Version 24.1. NCCI Edits Version 24.1 is applicable for dates of service April 1, 2018 – June 30, 2018. There are 2 versions of NCCI Edits Version 24.1; one version is for private practice and the second version is for all other outpatient therapy settings that would include rehabilitation agencies, skilled nursing facilities, home health agencies, comprehensive outpatient rehabilitation facilities and hospital outpatient departments. There are 15 new edits in both Versions of 24.1. To access NCCI Edits Version 24.1, click HERE and then select the applicable version based on your practice setting.

Home Health Services and Outpatient Therapy Simultaneously

A question I often receive is does the Medicare program pay for a Medicare beneficiary to receive outpatient therapy services while they are simultaneously receiving home health services under an open home health agency (HHA) plan of care? In this article, I will answer this question plus provide resources for the outpatient therapy provider to determine if the Medicare beneficiary is receiving home health services.

The answer is

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