NEW LEAF PRIMARY CARE
NEW LEAF BEHAVIORAL HEALTH PLLC
NEW LEAF BILLING, CODING, and AUDITING SOLUTIONS, LLC

Medicare Advantage Plans (Medicare age or eligible for Medicare coverage)

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A Medicare Advantage Plan, also known as Medicare Part C, is a type of health insurance plan offered by private companies that are approved by Medicare. It provides an alternative way to receive your Medicare Part A (hospital insurance) and Part B (medical insurance) benefits. Instead of getting care directly through traditional Medicare, you get your coverage through the Medicare Advantage plan. These plans are required to cover the same services as Original Medicare but may have different rules, costs, and provider networks. Some plans also include additional features like drug coverage or other services, but participation in a Medicare Advantage plan means your care is managed through the private insurer rather than directly through the federal Medicare program.

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At New Leaf Behavioral Health, we are not contracted with major Medicare Advantage plans such as Aetna, Blue Cross Blue Shield, Cigna, Essence, Humana, UnitedHealthcare, or Wellcare. This means we are considered out-of-network. But that does not mean you cannot be seen or that your care won’t be covered.  The insurance company will tell you that you are not able to be seen by an out of network provider which is unfortunately a lie. 

 

We are a Medicare participating provider.  This means as long as the service we provide is covered under traditional Medicare and we agree to accept Medicare’s rates (which we do) then your Medicare Advantage plan is legally required to process and pay the claim.

 

When you receive care from us:

 

• We bill your Medicare Advantage plan directly.

• Because we are out-of-network, your plan may process the claim differently and you may be responsible for a larger share of the cost.

• Once your plan yearly deductible is met:

  • Medicare pays 80% of the allowed amount.

  • You are responsible for 20% coinsurance, just like with traditional Medicare.

  • For example, if the Medicare-approved amount for a CPT code is $100, your plan pays $80, and you pay $20.

 

​While your plan is obligated to reimburse us, it may not do so promptly. In some cases, patients may be asked to pay upfront and submit for reimbursement. We always try to minimize this burden and advocate on your behalf. ​

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Also, don’t forget: your red, white, and blue Medicare card is no longer valid at appointments. You must present your Medicare Advantage insurance card at every visit, as that is now your actual insurance coverage.

 

Despite all of that, Medicare Advantage plans must comply with federal law and provide coverage for all the same medically necessary services as traditional Medicare. 

 

​Understanding Medicare Advantage Plan Obligations Under Federal Law which is mainly found under Title 42 of the Code of Federal Regulations (CFR), Part 422. 

 

Here’s what the law says:​

 

• 42 CFR § 422.100 and § 422.101 require Medicare Advantage plans to cover all basic benefits in a manner equivalent to Original Medicare.  This means that if a service is covered under traditional Medicare, the Medicare Advantage plan must also cover and reimburse it.

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• 42 CFR § 422.214 states that providers who are not contracted with the MA plan may still treat enrollees and be reimbursed at Medicare’s fee-for-service rates.  The MA plan must pay the provider directly at the traditional Medicare fee-for-service rate, and the provider does not have to be in-network or contracted.  As long as the provider agrees to accept Medicare rates and furnishes a covered benefit, the plan is legally obligated to process and pay the claim under the same rules as traditional Medicare. Any refusal to pay solely based on non-participation in the plan's network violates federal regulation and may constitute noncompliance subject to CMS enforcement.​

 

• 42 CFR § 422.504(g) affirms CMS’s authority to enforce compliance through audits and oversight.  CMS mandates compliance through sub-regulatory guidance and audit authority under 42 CFR § 422.504(g).​

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• 42 U.S.C. § 1395w-22(a)(1)(A) guarantees that MA enrollees are entitled to the same benefits as traditional Medicare beneficiaries.​

 

• Social Security Act § 1852(k)(1) mandates Medicare Advantage plans must provide for reimbursement for services provided by noncontracted providers in accordance with rules similar to those under Medicare Parts A and B.​

 

• CMS Medicare Managed Care Manual, Chapter 4 states MA organizations are required to provide enrollees, through the provision of benefits, access to all Medicare-covered services (as defined in Title XVIII of the Social Security Act), even if they are provided in an alternative manner.​

 

• CMS Medicare Managed Care Manual, Chapter 6 outlines that non-contracted providers must be paid based on the Medicare fee schedule minus applicable cost-sharing.​

 

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Please give us a call for proper insurance verification. 

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For the most up-to-date information on our accepted health insurance plans, contact our clinic directly at 618-416-7738.