Introduction to the Medicare Advantage Program
The Medicare Part C Program was developed following passage of the Balanced Budget Act of 1997 and went into effect in January of 1999. With identified gaps in coverage for Medicare beneficiaries, the addition of an optional Medicare program permitted the Centers for Medicare and Medicaid Services (CMS) to contract with private or public agencies to provide additional Medicare options for beneficiaries who wished to seek coverage in addition to original Medicare’s Part A and B benefits.
In 2003, Part C of the Medicare program was renamed the Medicare Advantage Program (Centers for Medicare and Medicaid Services, 2020) and currently provides private coverage for one-third of Medicare beneficiaries (Sung and Noel-Miller, 2019).
Most Medicare Advantage (MA) plans are administered by private insurance companies. The two most common types of MA plans are health maintenance organization (HMO) plans and preferred provider organization (PPO) plans. HMOs typically provide access to benefits through a pre-defined network of providers, while PPOs allow a beneficiary to see an in- or out-of-network provider.
The MA enrollment periods occur throughout the year and provide opportunities for enrolling, renewing, or dis-enrolling from MA plans. Prospective and current beneficiaries can view and compare the plan benefits using the summary of benefits and/or evidence of coverage documents.
The summary of benefits provides a high-level overview of coverage. The evidence of coverage (EOC) document is a more detailed document containing specific language on how the benefits will be accessed through the plan. By law, MA organizations are required to provide both evidence of coverage and summary of benefits documents on their website for prospective and current beneficiaries to download and review. (CMS, 2020; Ch188.8.131.52).
Medicare Advantage plans include all services as defined under original Medicare Part A and B. In other words, MA organizations must provide coverage for Medicare-covered services as defined under Part A or B. For example, if an MA plan beneficiary receives a tinnitus evaluation, this procedure is covered under Part B as a diagnostic audiology service. Therefore, it must also be covered under the MA plan. For a list of covered audiology services under traditional Medicare Part B, see the CMS Audiology Code List (CMS, 2016).
The covered Part B services are typically reimbursed through the insurance plan, so it is important to understand whether there is a provider in-network restriction. For in-network services, the audiologist must be a contracted provider for the Medicare Advantage plan.
Premiums and Payments
Each MA plan will have different cost structures for beneficiaries. However, MA plan descriptions must use uniform terminology in describing expected costs. Each of these items should be explicitly outlined in the plan description documents (CMS, 2020; Ch4.10.2). TABLE 1 provides a summary of terminology used in the plan description documents.
|PREMIUM||This is the price paid to enroll in the insurance plan. Plan premiums vary, are typically paid monthly, and are paid in addition to Part B premiums.|
|COST-SHARING||This is a broad term used to describe the agreed-upon cost responsibilities of the beneficiary and insurer. Generally, this term includes descriptions of deductibles, copayments, and coinsurance.|
|DEDUCTIBLE||This is a fixed amount that the beneficiary must pay each year before their insurance benefits begin to cover costs.|
|COPAYMENT (COPAY)||This is a fixed amount that the beneficiary pays for covered services. The remaining balance past the copayment is covered by the plan.|
|COINSURANCE||After meeting the deductible, beneficiaries pay coinsurance, a certain percentage of total costs for covered services under the plan.|
|OUT-OF-POCKET MAXIMUM||This is the maximum out-of-pocket amount that beneficiaries will pay in coinsurance after the deductible has been met.|
An MA supplemental benefit is defined by CMS as “an item or service not covered by original Medicare, that is primarily health related and for which the MA plan must incur a […] direct medical cost” (CMS, 2020; Ch4.30.1). Examples of supplemental benefits in an MA plan are vision care, hearing aids and routine hearing testing, home care, and/or transportation to medical appointments.
As many audiology services are not covered through traditional Medicare Part B, supplemental hearing benefits in MA plans can include provisions for items and services beyond that of Part B provisions. These items may include routine hearing tests, hearing aids, and other hearing aid accessories. When seeking information about the specific details of supplemental hearing benefits, health-care professionals should refer to the evidence of coverage document for a given MA plan and not rely on the summary of benefits document.
Part B-covered diagnostic audiology services are accessed by submitting directly to the MA payer. Many MA plans, which provide beneficiaries with access to supplemental hearing care, may do so through a contracted third-party vendor network. Thus, it is important not only to reference the MA coverage policies, but also the coverage policies of the third-party hearing-care contractor responsible for providing the supplemental benefits.
Examining the Evidence of Coverage Document
All Medicare Advantage evidence of coverage documents follow a specific format. You will be able to locate the information for hearing care in Chapter 4 of the EOC under “Hearing Services.”
In TABLE 2, we provide a hypothetical example of the hearing-services benefit for an MA plan. It is important to thoroughly review language in evidence of coverage documents and identify whether additional information on hearing-care coverage policies is referenced in other parts of the document (appendices, footnotes, etc.).
|SERVICES THAT ARE COVERED FOR YOU||WHAT YOU MUST PAY WHEN YOU GET THESE SERVICES IN-NETWORK||WHAT YOU MUST PAY WHEN YOU GET THESE SERVICES OUT-OF-NETWORK||WHERE THE BENEFIT IS DEFINED|
Diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider.
|$0 copayment for each Medicare-covered exam.
Your provider must follow prior authorization requirements.
|$20 copayment for each Medicare-covered exam.
You pay these amounts until you reach the out-of-pocket maximum.
|Traditional Medicare Part B coverage policies for diagnostic hearing and balance tests|
|ADDITIONAL ROUTINE HEARING EXAMS
Limited to one exam every year
|$0 copayment||$20 copayment||Plan-specific supplemental MA coverage policies|
Through our agreement with XYZ Hearing Care, you can choose from a selection of hearing aids.
Limited to 2 hearing aids every 3 years. Before receiving hearing services, contact XYZ Hearing Care to register. You can find a list of in-network providers on our website.
|Hearing aids are provided through a third party, XYZ Hearing Care. Additional fees apply for provider follow-up visits.
$600 copayment for each brand name ‘Entry’ level hearing aid.
$1,500 copayment for each brand name ‘Standard’ level hearing aid.
|Hearing aids ordered through providers other than XYZ Hearing Care are not covered and are the responsibility of the beneficiary.||Plan-specific supplemental MA coverage policies|
|HEARING AID ACCESSORIES
Hearing aid accessories are not covered by the plan and are the responsibility of the member.
|$2,000 copayment for each brand name ‘Premium’ level hearing aid.
Covered services that do not count toward your maximum out-of-pocket amount.
|NOTE: The benefits and prices outlined in this example are for illustrative purposes only and do not represent an actual Medicare Advantage plan.|
MA organizations are required to provide all Medicare Part A and B benefits under MA plans. In the present example, the hearing services section outlines these coverage provisions for diagnostic hearing evaluations, as they would be provided through original Medicare Part B benefits. These Medicare-covered benefits must be included in MA plans and will follow Medicare guidelines for payment. A full list of Part B-covered audiology services that should be included in all MA plans is detailed elsewhere by the CMS (2016).
Supplemental Benefits and Services
Routine hearing exams can be included in MA plan provisions that provide supplemental coverage beyond traditional Medicare Part B benefits. This example MA plan provides coverage for routine or annual hearing examinations once per year. Beneficiaries are simply responsible for the agreed-upon copayments for in- and out-of-network services.
Here, hearing aids are covered, but are provided exclusively through XYZ Insurance’s partner organization, XYZ Hearing Care. This third party serves as a contracted entity that provides MA supplemental hearing care benefits to beneficiaries through a defined network of contracted providers. The XYZ Hearing Care organization provides beneficiaries with options for different types and brands of hearing aids and allows for the provision of two hearing aids every three years.
In this hypothetical case, some stipulations on hearing benefits would apply, as follows:
- For hearing aids to be covered, they must be obtained through the third party, XYZ Hearing Care.
- The hearing aids available to beneficiaries under this plan are limited.
- Copayments for hearing aids do not count toward the out-of-pocket maximum.
- Hearing aid accessories and follow-up visits are not covered and are the financial responsibility of the beneficiary.
To determine payment (revenue) for such services would require facility-specific review of third-party contracts or contracted fee schedules.
Practitioners are encouraged to first verify that original Medicare Part B benefits are adequately reflected in MA plan coverage documents, specifically those for diagnostic hearing, tinnitus, and balance evaluations. Additional benefits, such as routine hearing evaluations and hearing aids, may be covered by MA plans, but may also be subject to certain restrictions or different cost-sharing structures. Beneficiaries and providers should thoroughly review evidence of coverage documents as a first step in understanding the hearing-care coverage policies of MA plans.
The purpose of the information provided above by the American Academy of Audiology Coding and Reimbursement Committee is strictly for educational guidance to audiologists. Action taken with respect to the information provided is an individual choice. The American Academy of Audiology hereby disclaims any responsibility for the consequences of any action(s) taken by any individual(s) as a result of using the information provided, and reader agrees not to take action against, or seek to hold, or hold liable, the American Academy of Audiology for the reader’s use of the information provided. As used herein, the “American Academy of Audiology” shall be defined to include its directors, officers, employees, volunteers, members, and agents.
Centers for Medicare and Medicaid Services. (2020) Medicare Managed Care Manual. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326 (accessed September 6, 2020).
Centers for Medicare and Medicaid Services. (2016) Audiology Code List. www.cms.gov/Medicare/Billing/TherapyServices/Downloads/Audiology_Codes.pdf (accessed September 3, 2020).
Sung JE, Noel-Miller C. (2019) https://blog.aarp.org/the-meaning-of-medicare-advantage-new-flexibility-in-supplemental-benefits (accessed August 26, 2020).