For this brief, we define “value-added services” as additional services outside of the Medicare and Medicaid benefit package (i.e., State Plan and/or Medicaid managed care contract) that are delivered at managed care plans’ discretion and are not included in capitation rate calculations. Value-added services seek to improve quality and health outcomes, and/or reduce costs by reducing the need for more expensive care.7,8 In its May 2016 Medicaid managed care rule, the Centers for Medicare & Medicaid Services (CMS) recognized that a managed care organization may voluntarily provide additional services, although the costs of these services may not be included when determining payment rates.9 It also specifically refers to these as “value-added” services.10
Full Answer
What are the marketing guidelines for Medicare Advantage plans?
10 Introduction These Marketing Guidelines reflect the Centers for Medicare & Medicaid Service (CMS) current interpretation of the marketing requirements and related provisions of the Medicare Advantage (MA) and Medicare Prescription Drug Plan (PDP) rules (Chapter 42 of the Code of Federal Regulations, Parts 422 and 423).
How do Medicare Advantage private fee-for-service plans work?
“A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your doctor or hospital is not required to agree to accept the plan’s terms and conditions, and thus may choose not to treat you, with the exception of emergencies.
Why are the States selected for the Medicare Advantage program?
These states have been selected in order to be generally representative of the national Medicare Advantage market; they include urban and rural areas, areas with both high and low average Medicare expenditures, high and low prevalence of Low-Income Subsidies and areas with varying levels of penetration of and competition within Medicare Advantage.
How should I inform Medicare enrollee about Medicare Advantage plans?
Informing a potential enrollee about a Medicare Advantage or Medicare Prescription Drug Plan in an unbiased way that does not steer, or attempt to steer, that enrollee toward a specific plan or limited number of plans.
Which of the following is an allowable form of contact for prospecting for Medicare Advantage clients?
Due to a change reflected in the 2019 MCMG and now in the Medicare Advantage & Part D Communication Requirements, agents are permitted to make unsolicited direct contact with potential enrollees via email.
What must all Medicare Advantage sponsors have in place in order to meet CMS guidelines?
Medicare Advantage Plans Must Follow CMS Guidelines In the United States, according to federal law, Part C providers must provide their beneficiaries with all services and supplies that Original Medicare Parts A and B cover. They must also provide any additional benefits proclaimed in their Part C policy.
Is Medicare Advantage Value-based?
Medicare Advantage is built on a value-based system in which Medicare Advantage health plans receive a per-member, per-month payment for each beneficiary's care, and are tasked with using those dollars most effectively – incentivizing high quality, high-value care for the 24.2 million enrollees who trust Medicare ...
Which of the following areas is the marketing of Medicare health plans prohibited?
Participating in any marketing activity—such as distributing and accepting enrollment applications, conducting sales presentations, and soliciting beneficiaries—is not allowed in areas where individuals receive or wait to receive healthcare service. These areas include: Exam rooms.
Does CMS regulate Medicare Advantage plans?
The Centers for Medicare & Medicaid Services (CMS) released a regulation that clarifies the payment of compensation to agents and brokers who enroll beneficiaries in Medicare Advantage and Prescription Drug Plans. Copies of the new regulations and related documents can be downloaded from below.
Do Medicare Advantage plans have to follow LCDs?
Medicare Advantage plans are required to follow all Medicare laws and coverage policies, including LCDs (Local Coverage Decisions - coverage policies set by Medicare Fee-for-Service Contractors in your geographic area), when determining coverage for a particular service.
What are value based benefits?
Value based benefits design (VBBD) is an approach to improve employee health and productivity while better managing healthcare costs – particularly around high-cost chronic diseases.
What is value based enrollment?
This report describes HHSC valued-based enrollment methodology as an incentive program that automatically enrolls a greater percentage of Medicaid recipients who have not selected a managed care plan into a plan based on quality of care, efficiency and effectiveness of service provision, and performance.
What is the goal of Medicare Advantage?
One of the main goals of MA plans is to manage health care in order to reduce costs while also providing necessary care. An MA plan must provide enrollees in that plan with coverage of all services that are covered by Medicare Parts A and B, plus additional benefits beyond those covered by Medicare.
What marketing practices are allowed by Medicare Advantage companies?
Medicare Advantage Marketing to current patients Targeted mail and emails for patients 65+ Reminders for current patients during open enrollment. Informational blogs and social media posts. Posters in your office.
Which of the following must you not do when marketing UnitedHealthcare Medicare Advantage?
As an agent, you must not do which of the following when marketing UnitedHealthcare Medicare Advantage plans to consumers? Use providers or provider groups to distribute printed information comparing benefits of different health plans without approval.
What are the 3 main ways in which Medicare sales occur?
There are three different types of Medicare products sold by agents and brokers: Medicare Supplement plans (Also called Medigap plans), Medicare Advantage plans and Medicare Part D Rx plans.
What is value added services?
For this brief, we define “value-added services” as additional services outside of the Medicare and Medicaid benefit package (i.e., State Plan and/or Medicaid managed care contract) that are delivered at managed care plans’ discretion and are not included in capitation rate calculations . Value-added services seek to improve quality and health outcomes, and/or reduce costs by reducing the need for more expensive care.7,8 In its May 2016 Medicaid managed care rule, the Centers for Medicare & Medicaid Services (CMS) recognized that a managed care organization may voluntarily provide additional services, although the costs of these services may not be included when determining payment rates.9 It also specifically refers to these as “value-added” services.10
What is HCBS waiver?
Most HCBS waiver services are limited to individuals who would qualify for nursing facility placement (i.e., nursing home level of care). However, PRIDE plans have found significant unmet need for individuals at-risk of meeting nursing facility level of care criteria, and the plans believe that the provision of “low-level” HCBS waiver services could slow or deter functional decline. Examples of services often limited to individuals who meet nursing facility level of care criteria under fee-for-service but that could be extremely valuable to those at-risk populations include: limited personal care hours; minor home modifications (e.g., grab bars, shower stalls, or a safety assessment); nutritional supports and pest control; among others. For example, one PRIDE plan offered pest control for bed bugs to anyone with a demonstrated need, even though individuals must be enrolled in an HCBS waiver to receive this service under the fee-for-service program. This service cost to the plan is approximately $2,000-3,000/member and made a critical difference for keeping individuals in their homes. However, as noted above, capitation rates for these programs are based on the number of individuals who meet a level of care for HCBS waiver eligibility, not the unmet needs of individuals at risk of deteriorating. All plans were interested in expanding LTSS to at-risk individuals before they qualify for needing LTSS, but most do so on an ad hoc and limited basis because few plans have the means to provide these services on a larger scale.
Does Medicaid provide value added services?
At a high level, the structure of states’ Medicaid programs can influence the provision of value-added services. Many PRIDE plans reported that the decision to provide value-added services is related in part to how generous their state’s Medicaid benefit package is, particularly for LTSS. In states with robust LTSS offerings, plans often see less need for providing additional benefits.
What is a Value Add Service?
A value add service, by definition, is when you take a homogenous product or service and enhance it with more features or benefits. A simple example of this would be providing a car-buyer with a 10-year warranty.
Medical Billing, Coding, and Practice Management as a Value Add Service
Think as if you were your ultimate consumer, the patient. What does the patient see of your practice? Not much. They see a nurse, a doctor, a receptionist, a waiting room, and a patient room. That’s about it.
Logistics Value Add Services
By minimizing time consuming tasks and streamlining those techniques, Applied Medical Systems can decrease monthly overhead and increase efficiency. AMS can help reduce money spent on labor costs, transcription costs, paper and office space.
Make the Patients Feel
Simply put, make the patients feel as if the practice is running smoothly. How is this done? One such way is outsourcing your medical billing, coding, and practice management.
What happens if you get a health care provider out of network?
If you get health care outside the plan’s network, you may have to pay the full cost. It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed. In most cases, you need to choose a primary care doctor. Certain services, like yearly screening mammograms, don’t require a referral. If your doctor or other health care provider leaves the plan’s network, your plan will notify you. You may choose another doctor in the plan’s network. HMO Point-of-Service (HMOPOS) plans are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance. It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.
Do providers have to follow the terms and conditions of a health insurance plan?
The provider must follow the plan’s terms and conditions for payment, and bill the plan for the services they provide for you. However, the provider can decide at every visit whether to accept the plan and agree to treat you.
Can a provider bill you for PFFS?
The provider shouldn’t provide services to you except in emergencies, and you’ll need to find another provider that will accept the PFFS plan .However, if the provider chooses to treat you, then they can only bill you for plan-allowed cost sharing. They must bill the plan for your covered services. You’re only required to pay the copayment or coinsurance the plan allows for the types of services you get at the time of the service. You may have to pay an additional amount (up to 15% more) if the plan allows providers to “balance bill” (when a provider bills you for the difference between the provider’s charge and the allowed amount).
How to advertise Medicare?
Medicare private plans are allowed to conduct certain activities. For instance, companies can market their plan through direct mail, radio, television, and print advertisements. Agents can also visit your home if you invite them for a marketing appointment. However, insurance agents cannot: 1 Call you if you did not give them permission to do so 2 Visit you in your home, nursing home, or other place of residence without your invitation 3 Provide gifts or prizes worth more than $15 to encourage you to enroll (gifts or prizes that are worth more than $15 must be made available to the general public, not just to people with Medicare) 4 Disregard federal and state consumer protection laws for telemarketing, the National Do-Not-Call Registry, or do-not-call-again requests (you can register online for the National Do-Not-Call Registry or by calling from the number you wish to register) 5 Market their plans at educational events or in health care settings (except in common areas) 6 Sell you life insurance or other non-health products at the same appointment (known as cross-selling), unless you request information about such products 7 Use the term “Medicare-endorsed” or suggest that their plan is a preferred Medicare plan#N#Plans can use Medicare in their names as long as it follows the plan name (for example, the Acme Medicare Plan) and the usage does not suggest that Medicare endorses that particular plan above other Medicare plans 8 Imply that they are calling on behalf of Medicare
What are the rules for selling Medicare?
Insurance companies selling Medicare private plans must follow certain rules when promoting their products. These rules are meant to prevent plans from presenting misleading information about a plan’s costs or benefits, also known as marketing fraud. Medicare private plans are allowed to conduct certain activities.
Can Medicare agents visit my home?
For instance, companies can market their plan through direct mail, radio, television, and print advertisements. Agents can also visit your home if you invite them for a marketing appointment . However, insurance agents cannot:
Can Medicare be used in their name?
Plans can use Medicare in their names as long as it follows the plan name (for example, the Acme Medicare Plan) and the usage does not suggest that Medicare endorses that particular plan above other Medicare plans. Imply that they are calling on behalf of Medicare.
