Tuesday, October 13, 2020

Medicare Advantage Must Pay for Services Covered Under FFS Medicare A/B

Medicare Advantage plans must pay for services covered by local or national decisions and articles of Medicare A/B.


https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c04.pdf





As discussed in section 10.2 of this chapter, an item or service classified as an original

Medicare benefit must be covered by every MA plan if:

• Its coverage is consistent with general coverage guidelines included in original

Medicare regulations, manuals and instructions (unless superseded by written CMS

instructions or regulations regarding Part C of the Medicare program);

• It is covered by CMS’ national coverage determinations (see sections 90.3 and 90.4,

below); or

• It is covered by written coverage decisions of local Medicare Administrative

Contractors (MACs) with jurisdiction for claims in the geographic area in which

services are covered under the MA plan, as described in section 90.2 below.


90.4.1 – MAC with Exclusive Jurisdiction over a Medicare Item or Service 


(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15) In some instances, one Medicare A/B MAC processes all of the claims for a particular Medicare-covered item or service for all Medicare beneficiaries around the country. This generally occurs when there is only one provider of a particular item or service (for example, certain pathology and lab tests furnished by independent laboratories). In this situation, MA plans must follow the coverage policy reflected in an LCD issued by the A/B MAC that enrolled the provider and processes all of the Medicare claims for that item or service.


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