Practical Tips for Settling Cases with Medicare Part C Enrollees

What is Medicare Advantage?

Medicare Advantage plans, also referred to as Part C plans, were established under Part C of Title XVIII of the Social Security Act as an alternative to traditional Medicare. [i] These plans allow Medicare entitled individuals to receive healthcare services through a non-governmental organization.  As a replacement to traditional fee-for-service Medicare, Part C plans must cover all of the services that traditional Medicare (Parts A and B) cover. [ii] This coverage is provided by organizations, primarily insurance companies, who contract with the Centers for Medicare and Medicaid Services (“CMS”) to administer Medicare benefits. In turn, the federal government pays the Part C plan a monthly per capita rate, determined on an annual basis, for providing Part C coverage.  Despite the contractual relationship between the Part C plan and CMS, any and all Part C reimbursement issues are handled exclusively by the Part C plan – both in terms of beneficiary identification and secondary payer recovery.