Medicare Advantage Plans: Frequently Asked Questions

August 9, 2021
 / 
Rick Gawenda
 / 

There has been a lot of discussion on Medicare Advantage plans lately on several of the social media platforms. While social media can be a good place to seek information, the information that is shared is not always correct or perhaps, not correct for your specific situation and/or question. In this article, I will provide answers to the following questions I am routinely asked:

  1. Does the annual therapy threshold that applies to traditional Medicare beneficiaries also automatically apply to all Medicare Advantage plans and their beneficiaries?
  2. Does the 10th visit Progress Report that applies to traditional Medicare patients also apply to all Medicare Advantage plans and their respective beneficiaries?
  3. I know traditional Medicare requires a dated signature of the physician or nonphysician practitioner (NPP) whom the Medicare beneficiary is under their care while receiving outpatient physical, occupational and/or speech therapy services. Does this same requirement apply to Medicare Advantage plans whose beneficiaries are receiving outpatient physical, occupational and/or speech therapy services?
  4. Do the traditional Medicare supervision requirements of therapy students also apply to Medicare Advantage plans and their respective beneficiaries?
  5. Does traditional Medicare’s “8-minute rule” automatically apply to all Medicare Advantage plans?
  6. Must Medicare Advantage plans cover maintenance therapy in the same manner that traditional Medicare covers maintenance therapy?
  7. If I am not in-network (not enrolled) with a Medicare Advantage (MA) plan, can I charge the patient my cash rate and just provide them with a bill or invoice that they can then submit to the MA plan and obtain whatever reimbursement the MA plan will reimburse them?
  8. If a Medicare Advantage (MA) plan is an HMO and we are enrolled with traditional Medicare, is the MA plan required to allow Medicare enrolled providers to treat their clients and pay for those therapy services?
  9. Does the impending 15% payment reduction for services provided in part or in whole by a physical therapist assistant or occupational therapy for traditional Medicare also apply to Medicare Advantage plans?
  10. If I am not enrolled in traditional Medicare, can I treat Medicare Advantage patients whether I am in-network or out-of-network?

Lets begin!

Question
Does the annual therapy threshold that applies to traditional Medicare beneficiaries also automatically apply to all Medicare Advantage plans and their beneficiaries?

Answer

The content here is for members only log in here or sign up.

Question
Does the 10th visit Progress Report that applies to traditional Medicare patients also apply to all Medicare Advantage plans and their respective beneficiaries?

Answer

The content here is for members only log in here or sign up.

Question
I know traditional Medicare requires a dated signature of the physician or nonphysician practitioner (NPP) whom the Medicare beneficiary is under their care while receiving outpatient physical, occupational and/or speech therapy services. Does this same requirement apply to Medicare Advantage plans whose beneficiaries are receiving outpatient physical, occupational and/or speech therapy services?

Answer

The content here is for members only log in here or sign up.

Question
Do the traditional Medicare supervision requirements of therapy students also apply to Medicare Advantage plans and their respective beneficiaries?

Answer

The content here is for members only log in here or sign up.

Question
Does traditional Medicare’s “8-minute rule” automatically apply to all Medicare Advantage plans?

Answer

The content here is for members only log in here or sign up.

Question
Must Medicare Advantage plans cover maintenance therapy in the same manner that traditional Medicare covers maintenance therapy?

Answer

The content here is for members only log in here or sign up.

Question
If I am not in-network (not enrolled) with a Medicare Advantage (MA) plan, can I charge the patient my cash rate and just provide them with a bill or invoice that they can then submit to the MA plan and obtain whatever reimbursement the MA plan will reimburse them?

Answer

The content here is for members only log in here or sign up.

Question
If a Medicare Advantage (MA) plan is an HMO and we are enrolled with traditional Medicare, is the MA plan required to allow Medicare enrolled providers to treat their clients and pay for those therapy services?

Answer

The content here is for members only log in here or sign up.

Question
Does the impending 15% payment reduction for services provided in part or in whole by a physical therapist assistant or occupational therapy for traditional Medicare also apply to Medicare Advantage plans?

Answer

The content here is for members only log in here or sign up.

Question
If I am not enrolled in traditional Medicare, can I treat Medicare Advantage patients whether I am in-network or out-of-network?

Answer

The content here is for members only log in here or sign up.

I hope you found the answers to the questions helpful. If you have an additional question(s) regarding Medicare Advantage plans, email me at info@gawendaseminars.com and perhaps your question and my answer will be added to this article. Thank you for being a Gold Member!

All material posted on our website is intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be used, reproduced, or posted as your own material without prior written approval of Gawenda Seminars & Consulting, Inc.


All material posted on our website is the intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be used, reproduced, or posted as your own material without the prior written approval of Gawenda Seminars & Consulting, Inc.

This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

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  1. Great summary for those of us with measurable MA volume. My question relates to the PTA/OTA 15%reduction.

    With our Medicare @12% of visits and Tricare@47%, we will be taking a big hit with the PTA/OTA 15% reduction.
    Will the PTA/OTA 15% fee reductions also apply to Advantage plans–another 10+%?

    1. The law applies only to traditional Medicare, but could any insurance company, including MA plans, implement the reduction? Yes!

  2. Hi Rick,
    It has been announced that Humana will apply the PTA differential but none of the announcements verified that it included both commercial and MA plans. Have you been able to find out if Humuna MA plans are affected? Thanks

  3. Thanks for the information Rick – very helpful!

    Our office is a non-participating provider with traditional Medicare. However I have a part time PT employee who prefers not to apply for a Medicare provider # as she has her own part time cash practice. Is she allowed to treat MA patients?

    1. If she is not enrolled in Medicare, she can’t treat traditional Medicare patient’s in any practice, including her own. To treat Medicare Advantage patients, you do not have to enroll in traditional Medicare.

      1. And one more question..is this true also for Aetna Medicare – ie that she can see/treat those patients since she is not enrolled in traditional Medicare?
        Thank you.

        1. If she is not enrolled in Medicare, she can’t treat traditional Medicare patient’s in any practice, including her own. To treat Medicare Advantage patients, you do not have to enroll in traditional Medicare. I do provide consulting services if required.

  4. During benefit verification we are being told by several Medicare replacement plans as well as a few commercial payors including Aetna MCR, Humana MCR, United Healthcare Global and Tricare for Life, that they will not pay for therapy services provided by a PTA or a COTA. Is there more information available on whether this is a nationwide trend?

    1. All of those payers allow PTAs to treat their patients under the supervision of the PT. I will assume the person you are speaking to does not know.