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. 

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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:

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• 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.

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• 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.

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• 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.

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• 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.

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• 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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Bottom line: Even if we are not in-network with your MA plan, if the service is covered under traditional Medicare, your plan must cover and pay for it.