Medicare Advantage

Medicare Advantage (“MA”) is an alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.  MA plans often operate like commercial managed care plans, such as health maintenance organizations, preferred provider organizations or point of services organizations.  MA plans have the flexibility in offering benefits and establishing terms and conditions of payment and participation, but there are numerous regulatory and program restriction that apply. Such restrictions include, but are not limited to, mandatory provider contracting terms and policy requirements.

A MA organization is a public or private entity organized and licensed by a State as a risk-bearing entity (with the exception of provider-sponsored organizations receiving waivers) that is certified by CMS as meeting the MA contract requirements.   HDJN advises MA organizations and participating providers on the following types of issues related to MA plans:

  • Plan design, terms and conditions.
  • Enrollment and eligibility issues.
  • Provider network adequacy.
  • Provider contract development, review and negotiation.
  • Compliance
    • MA compliance program review and adequacy.
    • Mandatory provider contracting terms and conditions.
    • Policies and procedures.
    • Marketing guidelines.
  • State insurance filings.
  • Preemption issues.

Contact:

James (Jim) M. Daniel
James (Jim) M. Daniel