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Provisions in the ACA concerning the MA and Part D programs largely focus on beneficiary protections, MA payments, and simplification of MA and Part D program processes. CMS implemented the MA and Part D provisions specified in the ACA through regulations at 42 CFR 422 and 423.
Part I of this chapter provides key information for Medicare Advantage Organizations (MAOs) regarding Medicare Advantage (MA) benefits for use in designing Plan Benefit Packages (PBP). Part II of this chapter, which begins at section 110, provides information on beneficiary protections, and includes topics such as rules for plan
Chapter 13 - Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and Health Care Prepayment Plans (HCPPs), (collectively referred to as Medicare Health Plans)
Medicare Managed Care Manual. Chapter 4 - Benefits and Beneficiary Protections. (Rev. , ) Table of Contents. 1 - Introduction. 10 - General Requirements. 10.1 - Basic Rule. 10.2 - Services of Non-contracting Providers and Suppliers. 10.3 - Types of Benefits. 10.4 - General Requirements for all MA Plans. 10.5 - Terms of MA Plans.
MAOs must cover the costs of Original Medicare benefits: • Benefits: MA plans must provide or pay for medically necessary Part A (for those entitled) and Part B covered items and services.
Each Medicare cost plan must offer at least all Part A benefits (other than hospice care) and all Part B benefits (or all Part B benefits to those entitled to only Part B) to all individuals residing in the area served by the plan in all benefit packages in its authorized geographic area.
Medicare Managed Care Manual. Chapter 4 - Benefits and Beneficiary Protections. Table of Contents (Rev. 87, 06-08-07) 1 - Introduction. 10 - General Requirements. 10.1 - Introduction. 10.2 - Basic Rule. 10.3 - Types of Benefits. 10.4 – Original Medicare Covered Benefits. 10.5 – Part D Rules for MA Plans. 10.6 – Anti Discrimination Requirements.
Manual, chapter 9 and in Pub. 100-16, Medicare Managed Care Manual, chapter 21, are identical and allow organizations offering both Medicare Advantage (MA) and Prescription Drug Plans (PDP) to reference one document for guidance.
This chapter discusses Medicare Advantage (MA) contract determinations and appeals as outlined in 42 CFR §422.641-696. Please also note, per 42 CFR §417.640, the rights,
The following sections set forth the requirements for apportionment of the allowable costs of physician services and other Part B services. In general, medical services are furnished through the HMO/CMP’s medical service facility or through arrangements with a medical group or IPA.