Medical Advantage Plans

Topics: Preferred provider organization, Health insurance, Health care Pages: 13 (2346 words) Published: January 27, 2013

Provider Participation in BCBSGA’s MA Plans3
Participation Procedures for Physicians and Physician Group(s)3 Terminating Participation with BCBSGA’s Medicare Advantage Plans4 Termination of a Provider Contract with Cause4
Termination of a Provider Contract without Cause5
Types of MA Plans:6
Who can join a Medicare Advantage Plan?9
When can you join, switch or drop a Medicare Advantage Plan?9 Considerations for Medicare Advantage Plans11

Provider Participation in BCBSGA’s MA Plans

Participation Procedures for Physicians and Physician Group(s)

BCBSGA’s MA plans must provide for the participation of individual health care professionals

through reasonable procedures that include:

(a) Written notice of rules of participation

(b) Written notice of material changes in participation rules before they become effective

(c) Written notice of adverse participation changes, and

(d) Process for appealing adverse physician participation decisions.Last update April 2, 2012 8

(These requirements also apply to physicians that are part of a subcontracted network.)

In addition, PROVIDER agrees that in no event, including but not limited to non-payment by

Plan, insolvency of the Plan or breach of their Agreement, shall the PROVIDER bill, charge,

collect a deposit from, seek compensation, remuneration or reimbursement from, or have any

recourse against a Covered Individual or persons other than the Plan acting on their behalf for

Covered Services provided pursuant to their Agreement. This provision does not prohibit the

collection of supplemental charges or Cost Shares on the Plan’s behalf made in accordance with

the terms of the Covered Individual’s Health Benefit Plan or amounts due for services that have

been correctly identified in advance as a non-Covered service, subject to medical coverage

criteria, with appropriate disclosure to the Covered Individual of their financial obligation. This

advance notice does not apply to services not covered due to a statutory exclusion from the

Medicare Advantage Program.

PROVIDER further agrees that for Covered Individuals who are dual eligible enrollees for

Medicare and Medicaid, that PROVIDER will ensure they will not bill the Covered Individual for

Cost Sharing that is not the Covered Individual’s responsibility and such Covered Individuals will

not be held liable for Medicare Parts A and B Cost Sharing when the State is liable for the Cost

Sharing. In addition, PROVIDER agrees to accept the Plan payment as payment in full or by

billing the appropriate State source.

Terminating Participation with BCBSGA’s Medicare Advantage Plans

In the event a provider wishes to terminate his/her participation in either of BCBSGA’s Medicare

Advantage networks or BCBSGA terminates a provider for reasons other than cause, a mandatory

60-day notification is required for the termination by either party. Please refer to your contract for

specific termination requirements.

Any provider requesting termination of his/her participation should send written notification to

the BCBSGA Network Management Department in his/her region. Upon receipt of the

termination request, BCBSGA will send a written, CMS-approved notification of the termination

to all affected members at least 30 calendar days before the effective date of termination. MA

organizations that suspend or terminate a contract due to deficiencies in the quality of care must

give notice of that action to the licensing or disciplinary bodies.

Termination of a Provider Contract with Cause

A Medicare Advantage organization that suspends or terminates an agreement under which the

health care professional provides service to the Medicare Advantage enrollees must give the

affected provider written notice of the following:

• Reason for the action

• Standards and the profiling data used to evaluate...
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