MEDICARE ADVANTAGE
Synergy’s Medicare experts know the law surrounding Medicare reimbursement and will hold Medicare Advantage Plans to their statutory requirements. We correspond with the private insurance carriers representing MAP plans on a regular basis and know their tricks.
A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice as part of Medicare. Medicare Advantage Plans, sometimes called “Part C” or “MAP” are offered by private insurance companies approved by Medicare. This includes Aetna, Kaiser, United, Cigna etc. The MAP provides all of Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. MAP may also offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs.
Obtaining a copy of your client’s insurance benefit card is always the best way to identify the appropriate entity with a possible lien interest on the settlement funds. For Medicare, your client may have traditional Medicare or a Medicare Advantage plan.
Medicare Advantage plans allow Medicare entitled individuals to receive healthcare services through a non-governmental organization, commercial insurance companies, who contract with the Centers for Medicare and Medicaid Services (“CMS”) to administer Medicare benefits. These MA plans must handle all aspects of benefit administration, including the recoupment of benefits paid that should have been paid by another party. These companies must follow rules set by Medicare.
If your client is of Medicare age, on SSDI for more than 2 years or otherwise believes they have Medicare coverage, a MAP is always possible. If traditional Medicare through CMS does not show that claims were paid by traditional Medicare, then investigating a private MAP policy is a must.
The Medicare Act allows a Medicare beneficiary to select a private insurance carrier to provide healthcare coverage instead of healthcare obtained through original Medicare. This elected healthcare plan is known as “Medicare Advantage.” Medicare Advantage is governed by the Medicare Act (42 U.S.C. § 1395w -21 to -29) and funded by CMS, usually on a capitated basis.
The federal statutes and regulations that allow for a Medicare Advantage plan to subrogate or seek reimbursement in these situations are analogous to CMS’ right of recovery under the Medicare “secondary payer” provisions. The provisions governing the administration of Medicare Advantage plans expressly state that Medicare Advantage plans are required to act as CMS would under MSP regulations. “MAOs will exercise the same rights to recover from a primary plan, entity, or individual that the Secretary exercises under the MSP regulations in subparts B through D of part 411 of this chapter.” 42 CFR 422.108(f).
Depending on the circuit, a Medicare Advantage Plan likely has a private cause of action and can collect double damages from a primary payor if their interest is not satisfied at the time of settlement. Humana Inc is a large insurance carrier providing Medicare Advantage coverage that has been an active proponent of establishing Medicare Advantage Plans rights and penalties against non-complying injured parties, attorneys, or insurance carriers.
When it comes to MAO liens there is a good chance you may be unaware that a lien exists without your own research. A good practice is to obtain copies of all government assistance program cards and any health insurance cards to see just what the injury victim is receiving in terms of benefits/insurance coverage. Make sure a thorough investigation is done if the client is a Medicare beneficiary for the existence of Part C/MAO liens. The investigation and inquiry should start upon intake and continue throughout representation with the final check occurring before disbursement of settlement proceeds. Failing to do so may expose you and your firm to personal liability for double damages to a Part C Plan or Medicare itself. Once a Part C/MAO lien is identified, you must aggressively pursue reduction methods either using traditional lien reduction arguments if the MAO doesn’t insist upon adherence to the MSP or using the MSP’s compromise or waiver provisions.