Medicare Advantage (MA) Plans For CCM Reimbursement

By Sudeep Bath | March 16, 2024

Medicare Advantage (MA) is a third-party insurer required to provide the same coverage for healthcare services as original Medicare does. Chronic care management (CCM) is covered as part of Medicare Part B and is reimbursable under Medicare Advantage as long as a patient meets the eligibility requirements.

A Medicare Advantage plan is required to provide it’s enrolling patients with at least traditional Medicare coverage, including the CCM. This means an MA plan will reimburse or pay for CCM just like it does for other physician and healthcare services.

In this blog post, we’ll explore more about MA plans for CCM reimbursement.

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Medicare Advantage Is Similar To Medicare Part C

Medicare Advantage is also known as Medicare Part C, and used interchangeably referring to each other. It’s an alternative to getting Medicare Parts A, B, and D through a third party, where Medicare Part A covers inpatient stays and hospital visits, Medicare Part B covers outpatient services including doctor’s office visits, and Medicare Part D covers prescription medicines.

Medicare Advantage Coverage For Chronic Care Management (CCM)

Chronic care management is covered by Part B of Original Medicare (OM), which is add-on coverage to Medicare Part A. Patients who add this coverage will have to pay an extra monthly fee for Part B. If an individual opts for an MA plan, Part A and Part B coverage are automatically covered. Some Medicare Advantage plans cover the Part B premium, while others ask the insured to pay it in addition to their MA monthly premium.

The Centers for Medicare and Medicaid Services (CMS) pay a fixed monthly amount to the company providing an MA plan to an individual. This means individuals who choose an MA plan continue to receive the same financial compensation from Medicare as those having an Original Medicare.

Original Medicare (OM) and Medicare Advantage (MA) differ primarily in the entity providing health insurance coverage. In MA, a third-party insurance provider utilizes monthly Medicare payments to cover expenses, while OM directly administers coverage. Despite this distinction, MA plans are mandated to adhere to uniform regulations and provide comparable protection to Original Medicare.

If a patient is eligible for both Medicare and Medicaid, Medicaid will cover the premiums and coinsurance for chronic care management. When opting for dual insurances, individuals receiving CCM service will not be subject for cost sharing as this service will be covered by Medicaid.

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Frequently Asked Questions (FAQs)

What is Chronic Care Management (CCM)?

Chronic Care Management (CCM) is a term that describes a series of services that can assist healthcare providers in managing patients with multiple chronic diseases outside of the traditional office visit. The services include care planning, medication management, patient communication, and monitoring health outcomes.

Does Medicare Advantage (MA) cover CCM services?

Yes – Many Medicare Advantage plans include coverage for CCM services. However, this can vary depending on the Medicare Advantage plan. Unlike Original Medicare, Medicare Advantage plans offer more flexibility and value-added services in terms of care management.

How is CCM payment made under Medicare Advantage?

Medicare Advantage plans cover CCM services using approved CCM CPT codes (such as 99490, 99487, and so on) and pay providers for their time and efforts in managing patients on their behalf.

Is patient consent and documentation necessary in CCM billing?

Yes. Regardless of whether the patient receives services through Original Medicare or Medicare Advantage, providers must obtain patient consent for CCM services and ensure accurate records that show time spent and services provided.

Is it possible for patients to receive both CCM services and additional care management services through Medicare Advantage?

In most cases, CCM services can be planned with other care services, but there are still some limits. For instance, providers can’t bill Medicare Advantage for CCM services at the same time as other services. Providers should follow the rules to avoid denials, which is an important point to make.

What is the difference between Original Medicare and Medicare Advantage plans when it comes to paying for CCM services?

There are certain billing rules and fees for CCM codes in Original Medicare. Medicare Advantage plans may also follow the same codes, but some plans may offer more help, reimbursement, and eligibility criteria based on their benefits.

Who are the best candidates for Medicare Advantage CCM services?

CCM services are best for people who have two or more long-term health problems that will last at least a year and need ongoing medical care. Medicare Advantage plans put more emphasis on preventative care to help these patients get better health outcomes.

Do Medicare Advantage plans need more reports for CCM reimbursement?

Yes. Medicare Advantage plans may need more information to make sure that CCM services were provided as promised. Care plans, time logs, and notes may be part of the report. Providers must make sure they follow the rules of the Medicare Advantage plan.

Are CCM services reimbursed monthly?

Yes. CCM services are reimbursed monthly as long as the time spent and care activities are met. The services are reimbursed accordingly.

How can providers be reimbursed accurately for CCM services under Medicare Advantage?

To be reimbursed accurately for CCM services, the following should be done to maximize reimbursement for CCM services:

Verify the patient’s eligibility for the MA plan
Obtain the consent of the patient
Monitor the time spent by the clinical staff for the activities of CCM services every month
Use the CPT codes for CCM correctly
Familiarize yourself with the Medicare Advantage plan requirements for CCM services