The Real-World Trouble with Medicare “Advantage” Plans & HME Coverage

Medicare advantage (MA) Plans were always required to provide the same coverage as traditional Medicare, and on April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) clarified Medicare Advantage and the Part D Final Rule (CMS-4201-F), requiring that MA plans MUST comply with National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and general coverage and benefit conditions included in traditional Medicare regulations.

But what we’re seeing is most MA plans are NOT complying and are instead restricting access to medically necessary equipment and services that traditional Medicare would otherwise approve. So, first I’d like to propose that we stop using the word “Advantage,” as that conveys to beneficiaries that these plans are better than traditional Medicare. And in many cases, what we are seeing is they are not better, as they are not complying with NCDs, LCDs, and general coverage and benefit conditions included in Traditional Medicare regulations.

Instead, I’d suggest the names Part C, Replacement… or even DIS-Advantage would be more accurate.

Celebrity Endorsements & Promises

The main concern with this is beneficiaries are being lured in record numbers with misleading — I’d say deceptive — advertising by hearing that word (“Advantage”) and being promised by likable celebrities that you are missing out if you don’t have one of these plans. In fact, these plans are denying items that traditional Medicare would, and in some cases has, approved through prior authorization (PA) already.

I’ve been working with a supplier recently on a case where the beneficiary has traditional Medicare and in September 2022 received a prior authorization (PA) for a Group 3 single-power wheelchair with tilt. By the time the supplier was ready to deliver in mid October, the beneficiary had switched to a Part C plan. Therefore, the supplier couldn’t deliver the wheelchair without getting a PA from that plan.

The supplier submitted the exact same documentation and the PA affirmation letter from traditional Medicare, and the Part C plan denied the request, stating they’d approve a Group 3, no power. They stated the beneficiary didn’t qualify for tilt.

Appealing to the ALJ

The supplier appealed this decision. At the first two levels, the denial was upheld. So they requested an Administrative Law Judge (ALJ) hearing. Keep in mind this is a PA, so the beneficiary can’t receive the item without a PA approval.

In March 2023 — yes, March — there was an ALJ hearing, and the PA approval from traditional Medicare was submitted as well as all the original documentation. The physical therapist who performed the wheelchair evaluation was there (virtually) to point out where the medically necessary documentation was for the tilt.

In April, the ALJ overturned the denial and approved the K0856 Group 3 single-power wheelchair with tilt. The supplier was ready to deliver… but wait, there’s more. The Part C plan appealed the ALJ’s decision with the Medicare Appeals Council, so as of this writing, the beneficiary still doesn’t have the medically necessary power chair that traditional Medicare approved back in September 2022.

Unfortunately, this is not an isolated case. This practice is widespread, and most give up or worse. These Part C plans are not covering what traditional Medicare would cover, and the challenge is how to fix this, as there is very little oversight from CMS to enforce compliance.

I’ll leave with hope, as we won’t give up advocating for the Medicare beneficiary.

As an industry, we need to attack this from every angle. First, document when this happens so it can be presented to CMS and Congress that some Part C plans are restricting access to medically necessary equipment and supplies.

Second, stop accepting beneficiaries with a Part C plan that doesn’t comply with traditional Medicare policies and regulations, and explain the reason to beneficiaries. Educate them on their choice to select the plan (traditional Medicare/Part C) that is best for their needs and how they can advocate for themselves by contacting their Part C plan about inappropriate denials.

Finally: These plans want and expect you to give up as they wear you down. I know this is easier said than done, but don’t give up and allow Goliath to win.

About the Author

Dan Fedor is the Director of Reimbursement and Education for U.S. Rehab, a division of The VGM Group.

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