Medicare Advantage: How is it Different from Traditional Medicare

April 9, 2018
Rick Gawenda

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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  1. Attended Ascend in AZ – awesome! You mentioned at the conference about Advantage plans not utilizing the 8-min rule. I am researching this by individual plan(s) as recommended but it would also be by state as well, correct?

    1. Whether or not a Medicare Advantage (MA) plan follows the Medicare “8-minute rule” is MA specific per your contract with them. Your contract may differ from another practices contract in the same or different state.