| Service Category |
Payment Methodology |
| Acute Care Hospital - Inpatient Services |
Paid a Diagnosis Related Group (DRG) amount using the
Medicare Prospective Payment System (PPS) which includes
capital, disproportionate share hospital (DSH), capital
indirect medical education (IME), outliers and the new
technology add on. Pass-through payments for direct
graduate medical education (DGME), capital, certified
registered nurse anesthetists (CRNAs) for small rural
hospitals, and costs associated with nursing and allied health
education programs. Operating IME and DGME are not
required to be paid by Medicare Advantage plans since they
are paid by Fiscal Intermediaries, excluding capital IME. |
| Acute Care Hospital - Inpatient Outliers |
Payment is 80% of the excess of the cost of an admission
over the sum of the DRG payment (including IME and DSH)
and a threshold amount, updated annually. |
| Acute Care Hospital - Outpatient Services |
Services under the PPS are paid by the Ambulatory Payment
Class (APC) methodology, which are priced under the
outpatient code editor and the outpatient Pricer. |
| Ambulance |
Ambulance services will be reimbursed at 100% of the
national fee schedule. |
| Ambulatory Surgery Center |
Ambulatory Surgery Center (ASC) fee schedule. |
| Assistant surgeon (physician assistant) |
85% x 16% of the amount under the Medicare fee schedule |
| Assistant surgeon (physician) |
16% of the amount under the Medicare fee schedule |
| Bad Debt |
Acute Care Hospital, Critical Access Hospital, and Rural
Health Clinic -Independent and Provider Based: Plan will
reimburse hospital providers for bad debts on a retrospective
basis (Plan will not make interim payments for bad debt).
Debts resulting from cost sharing amounts that are
uncollectible from plan enrollees are reimbursed by plan if
reasonable collection efforts (as defined by Original
Medicare) have been made by the hospital. Reimbursement
will be at the same rate used by Original Medicare.
Requests with the supporting documentation should be
submitted to the plan claims address. |
| Home Health |
Payments made on a PPS Home Health Resource Group
(HHRG) basis which cover episodes of care up to 60 days
adjusting for short stays and outliers. DME reimbursed on
fee schedule |
| Swing Beds |
Paid on 100% SNF PPS unless Critical Access Hospital
swing beds which are exempt from SNF PPS and paid on a
reasonable cost basis. |
| Critical Access Hospitals |
Paid on a reasonable cost basis, generally 101%. |
| Physician Assistant |
85% MFS |
| Physician Services |
100% of the Medicare physician fee schedule plus 10%
bonus if service provided in a health professional shortage
area (HPSA) plus additional 5% bonus in physician scarcity
areas (PSA). Dentists, chiropractors, podiatrists, and
optometrists are not eligible for the physician scarcity bonus
as either primary care or specialty physicians.
Anesthesiologists payment depends on base and time units
including participation of CRNAs. |
| Nurse Practitioner |
85% MFS |
| Clinical Nurse Specialist |
85% MFS |
| Registered Dietician |
85% MFS |
| Clinical Psychologist |
100% MFS |
| Clinical Social Worker |
75% MFS |
| Audiologist, Chiropractor, Podiatrist, Optometrist, Dentist |
100% MFS |
| Co-Surgeons |
Medicare physician fee schedule increased by 25% then split
and paid 62.5% for each surgeon. |
| ESRD Facility |
Routine services paid a geographically adjusted composite
rate which varies depending on weather a facility is hospital
based or independent. Non-routine services are paid based
on a fee schedule. |
| Durable Medical Equipment |
100% of the Medicare Durable Medical Equipment,
Prosthetic, Orthotic and Supplies fee schedule. |
| Clinical Lab |
Generally paid on the lab fee schedule while certain small
hospitals are paid a higher rate. |
| Part B Drugs |
Drugs not paid on a cost or prospective payment basis will
be reimbursed under the average sales price (ASP) system
except blood, drugs delivered through DME, influenza,
pneumococcal and hepatitis B vaccines and certain new
drugs which are paid on 95% of the average wholesale price
(AWP). |
| Federally Qualified Health Centers |
80% of the lesser of an all inclusive rate or national per-visit
limit plus 20% of actual charge. FQHC for urban centers and
rural centers are based on Medicare limits.. |
| Rural Health Clinics |
80% of the lesser of the provider specific rate or national
per-visit limit plus 20% of actual charge based on Medicare
limits. Per visit limits do not apply to RHC's part of hospitals
with less than 50 beds or certain rural sole community
hospital based RHC's. |
| Long Term Care Hospitals |
100% PPS |
| Inpatient Rehabilitation Hospitals |
100% Inpatient Rehabilitation Facility Prospective Payment
System (IRF PPS) |
| Psychiatric Hospitals |
The new PPS system uses a federal per diem base amount
subsequently adjusted for one of 15 DRGs, co morbidities,
age, rural add-on, teaching add-on, outlier payments, wage
index, emergency department presence and
electroconvulsive therapy (ECT) therapy. |
| Medicare Dependant Hospitals |
100% PPS for hospitals that are in rural areas, have less than
100 beds and at least 69% of their patients are on Medicare.
If the hospital specific rate is larger than the PPS, the
hospital is paid 50% of the difference, calculated by
PRICER. |
| Sole Community Hospitals |
Generally paid the greater of PPS or the hospital specific rate
for a full year, calculated by PRICER. |
| Low Volume Hospitals |
Per CMS, hospitals under 800 discharges per year and more
than 25 miles from the closest acute care hospital may
qualify for an additional payment not to exceed 25%. |
| Cancer Hospitals |
Paid on the lesser of actual costs or their TEFRA limited
costs. Payment adjustments are subsequently made
dependent on the difference of above costs. |
| Children's Hospitals |
Paid on the lesser of actual costs or their TEFRA limited costs. Payment adjustments are subsequently made dependent on the difference of above costs. |
| Clinical Trials |
Per CMS requirements beginning in 2011 clinical trails will be
covered based on the updated CMS requirements. The plan
will reimburse beneficiaries for cost sharing incurred for
clinical trials services that exceed the MA plans’ in- network
cost sharing for the same category of service. In addition,
clinical trial cost sharing will be included in the out-of-pocket
maximum calculation. |
| Balance Billing |
A provider may collect only applicable plan cost sharing
amounts from plan members and may not otherwise charge
or bill members. Balance billing is prohibited by providers
who furnish plan-covered services to plan members. |
| Cost Settlement |
Critical Access Hospital: will reimburse Critical Access
Hospitals a cost settlement based on their most recent cost
report data. Requests with supporting documentation should
be sent to the plan claims address.
Rural Health Clinic -Independent and Provider Based: Plan
will reimburse rural health clinics on a retrospective basis for
encounters paid at less than the all-inclusive Medicare
allowable amount as determined after filing the cost report
with Medicare. Reimbursement will be at the same rate
allowed by Original Medicare. Requests with supporting
documentation should be sent to the plan claims address. |
