Access our secured site
Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

View requirements for Local Plan and BlueCard Out-of-Area members.

Search our online provider directory when you need a doctor, hospital, or other health care provider.

Medicare Advantage Overview

“Medicare Advantage” is the new program alternative to standard Medicare Part A and Part B fee-for-service coverage (generally referred to as “traditional Medicare”). The Medicare Advantage program is an outgrowth of the former Medicare + Choice program. It offers Medicare beneficiaries several product options (similar to those available in the commercial market), including health maintenance organization (HMO), preferred provider organization (PPO), point-of-service (POS) and private fee-for-service (PFFS) plans. All Medicare Advantage plans must offer beneficiaries at least the standard Medicare Part A and B benefits, but many offer additional covered services as well (e.g., enhanced vision and dental benefits). Beginning January 1, 2006, many Medicare Advantage plans will be offering Medicare prescription drug coverage for their members under the new Medicare Part D benefit program.  
Medicare Advantage plans may allow in-and out-of-network benefits, depending on the type of product selected.  For instance, Medicare Advantage HMO plans typically require members to obtain health care services through in-network providers, except in urgent or emergency care situations. By contrast, Medicare Advantage PPO and POS plans offer added flexibility by allowing members to select out-of network providers at additional member cost. While POS plans may limit available out-of-network benefits to those services specified by the plan, PPO plans must offer all covered services through both in and out-of-network providers. As a result, coverage for out-of-network claims may vary depending on the Medicare Advantage product type and plan selected by the member. Providers should confirm the level of coverage for all Medicare Advantage members prior to providing service since the level of benefits, and coverage rules, may vary depending on the Medicare Advantage plan. 
Several Blue Plans offer Medicare Advantage products of the type mentioned above (e.g, HMO, PPO, POS and PFFS plans). The Blue Plan is typically (but not always) the primary payer for health care services provided to their Medicare Advantage members. Since Medigap policies are designed to supplement benefits under traditional Medicare (and not Medicare Advantage plans), such policies generally have no applicability in the Medicare Advantage context. 
Types of Medicare Advantage Plans
Medicare Advantage HMO
A Medicare Advantage HMO is a Medicare managed care option in which members typically receive a set of predetermined and prepaid services provided by a network of physicians and hospitals.  Generally (except in urgent or emergency care situations), medical services are only covered when provided by in-network providers.  The level of benefits, and the coverage rules, may vary by Medicare Advantage plan.  
Medicare Advantage POS
A Medicare Advantage POS program is an option available through some Medicare HMO programs. It allows members to determine – at the point of service – whether they want to receive certain designated services within the HMO system, or seek such services outside the HMO’s provider network (usually at greater cost to the member). The Medicare Advantage POS plan may specify which services will be available outside of the HMO’s provider network.    
Medicare Advantage PPO
A Medicare Advantage PPO is a plan that has a network of providers, but unlike traditional HMO products it allows members who enroll access to services provided outside the contracted network of providers.  Required member cost-sharing may be greater when covered services are obtained out-of-network. Medicare Advantage PPO plans may be offered on a local or regional (frequently multi-state) basis. Special payment and other rules apply to regional PPOs. 
Medicare Advantage PFFS
A Medicare Advantage PFFS plan is a plan offered by an organization that pays physicians and providers on a fee-for-service basis. Enrollees can obtain services from any licensed physician or provider in the United States who is qualified to be paid by Medicare and accepts the plan’s terms of payment.  The Plan must provide the same coverage as Medicare Part A and Part B, but may offer additional services.   
Medicare Advantage Claims
Members who enroll in Medicare Advantage products may on occasion seek services out-of-network. As noted, coverage rules are likely to vary by product type and Medicare Advantage plan. When you furnish services to an enrollee in a Medicare Advantage Plan:  
Ask for the member ID card. Members will not have a standard Medicare card; instead, a Blue Cross and/or Blue Shield logo will be visible on the ID card. The following examples illustrate how the different products associated with the Medicare Advantage program will be designated on the front of the member ID cards: 
Verify eligibility by contacting 1-800-676-Blue (2583) and providing the alpha prefix. Be sure to ask if Medicare Advantage benefits apply.  If you experience difficulty obtaining eligibility information, please record the alpha prefix and report it to BCBSGa.  
Submit claims to BCBSGa..  Do not bill Medicare directly for any services rendered to a Medicare Advantage member.  Payment will be made directly by a Blue Plan. 
Based upon the Centers for Medicare and Medicaid Services (CMS) regulations, if you are a provider who accepts Medicare assignment and you render services to a Medicare Advantage member for whom you have no obligation to provide services under your contract with a Blue Plan, you will generally be considered a non-contracted provider and be reimbursed the equivalent of the current Medicare payment amount for all covered services (i.e., the amount you would collect if the beneficiary were enrolled in traditional Medicare). This amount may be less than your charge amount. Special payment rules apply to hospitals and certain other entities (such as skilled nursing facilities) who are non-contracted providers. Providers should make sure they understand the applicable Medicare Advantage reimbursement rules. 
Other than the applicable member cost sharing amounts, reimbursement is made directly by a Blue Plan. In general, you may collect only the applicable cost sharing (i.e. co-payment) amounts from the member at the time of service, and may not otherwise charge or balance bill the member. Special rules apply, however, in the PFFS context where balanced billing may be permitted under some plans. 
Reminders for Remittance Advice:
Please review the remittance notice concerning Medicare Advantage plan payment, member’s payment responsibility and balance billing limitations.  
If you have any questions, please contact us at 1-800-628-3988 or by mail at BCBSGa P.O. Box 9907 Columbus, Ga 31908.   
© 2016 BlueCross BlueShield of Georgia
Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.