CODING AND REIMBURSEMENT | Deciphering Medicare Advantage Hearing Benefits

By Anna Marie Jilla and Mariah Cheyney

This article is a part of the November/December 2020, Volume 32, Number 6,  Audiology Today issue.

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; Ch3.70.1.2).