Reminders about caring for our Medicare Advantage members

12/01/2020

Please keep the following in mind as you provide care and services to our Medicare Advantage members:

  • Follow the Medicare Outpatient Observation Notice (MOON) requirements. Hospital providers must give written and verbal notice to Medicare Advantage members when they are receiving observation services as outpatients for more than 24 hours.

    MOON informs Medicare beneficiaries (including Medicare Advantage plan members) that they are receiving outpatient observation services and are not admitted as an inpatient of a hospital or critical access hospital (CAH).

    All hospitals and CAHs have been required to provide this notice since March 2017. For more information, visit the Centers for Medicare & Medicaid Services (CMS) website.

  • Do not bill patients who are designated as Qualified Medicare Beneficiaries (QMBs). Federal law prohibits all Original Medicare and Medicare Advantage providers and suppliers from billing individuals enrolled in the QMB program for Medicare Part A and Part B cost-sharing under any circumstances. Providers who inappropriately bill individuals enrolled in QMB are violating their Medicare Provider Agreement and may be subject to sanctions.

    This applies to all Medicare providers, regardless of whether they accept Medicaid.

    The QMB program is a Medicare savings program that exempts Medicare beneficiaries from having to pay their Medicare cost-shares. If providers want to get paid a patient’s cost-share, the bill of service may be submitted to Medicaid for reimbursement.

    For more information, check out this Medicare Learning Network resource.

  • Also, as a reminder: 
    • Our contracts require all our Medicare providers to see all our Medicare Advantage members, including those who are eligible for both Medicare and Medicaid (often called “dual eligible”).
    • CMS forbids Medicare providers from discriminating against patients based on “source of payment.” That means providers cannot refuse to serve members because they receive assistance with Medicare cost-sharing from a state Medicaid program.
  • Preventive annual physical exams are only covered when performed by primary care providers (PCPs). ConnectiCare will only cover CPT codes 99381 through 99397 if the services are performed by PCPs. Obstetricians and gynecologists will only be reimbursed for the Medicare-covered annual pap/pelvic exam (CPT code G0101) to stay consistent with CMS reimbursement guidelines. Check out this 2019 provider headline for more details.
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