How would a Medicare Advantage Plan handle this . . . . ?

[GailL1]

How would a Medicare Advantage plan, of whatever type - HMO, PPO, PFFS - handle payment to an out of network provider like a (medically needed) Air Ambulance or Medi-Helicopter?

Does CMS provide them with some standard guidance for situations like this?

[john258]

The Medicare Adv plan I am looking at covers air ambulance and covers all in and out of network providers payment the same. I pay no difference when I use either. The plan is set up that way and works the same as group Insurance does when you are employed. The provider just has to agree to accept the Insurance as they do with employer group Insurance.

Where I live air ambulance is used all the time since the hospital serves  an area that can be about a 100mile drive from some service areas. They send the Air Amb to auto accidents in the far out areas.

[somarco]

The provider just has to agree to accept the Insurance as they do with employer group Insurance.

It's a bit more involved than you elude to.

Accepting the insurance is not the same as agreeing to accept the reimbursement as "paid in full".

Non-par providers will take what the carrier offers but, as a non-par provider, they are under no contractual obligation to adhere to the fee schedule. If they choose to bill the patient for the difference in their charge vs the carrier payment, it is up to the patient to pay the difference or negotiate and amount the provider is willing to accept.

Barring a local statute prohibiting balance billing, providers are allowed to collect their normal fee for services rendered.

[john258]

When the Carrier pays what Medicare pays there is no problem, and that is true with many including mine. The provider gets one Remib, and bills once since the Carrier settles the full claim.

[MaVolta]

Interesting. My MA plan didn’t even cover ground ambulance coming to my house during Covid. I developed chest pain after surgery and was told by the ER to hang up and dial 911 for the EMTs to check me out. I was stable but they said I still needed to go to the ER. My husband drove me to the hospital a short distance away. About six weeks later I received a bill from emergency services that my insurance didn’t cover it. That was a surprise. 

[GailL1]

So that was a "Surprise" Medical bill for you - If I am understanding your correctly, you had to pay for the EMT's to just check you out - but since it was not deemed at that point to be an "emergency" - no payment from your MA.  Did they pay for the services that you received in the ER once your husband got you there???  

[MaVolta]

Yes, I was surprised that ambulance service was not covered, especially during a pandemic. With the ER, I was only required to pay the $90 co-pay. The hospital claim was denied payment for some services or they had to refile and challenge parts of the claim. Some benefits were covered as “bundled” though billed separately. I cannot begin to understand it, but I didn’t have to pay for it. I don’t even know how the eventually got it settled.

This was a new plan, and they seem to deny a lot of things.It’s been a real headache for the providers, many of whom are dropping them in 2022. I will be dropping them also. The insurance was through WellCare and it was terrible. 

[somarco]

@GailL1 MA plans typically apply a copay . . . $250 - $300 for emergency medical transport.

Air transport claims can be dicey, especially where an insurance carrier, not Medicare, is adjudicating the claim. Air ambulance is most often considered a life or death situation but you are expecting a non-medical claims examiner to decide if you really needed air transport or if ground transport would have been good enough.

Medical personnel on the scene are making the judgement about what type of transportation the individual needs.

Challenging a claim denial after the fact is difficult, especially in a managed care policy. The carrier will either pay the claim or not. There is no middle ground.

Personally, if I were in a life or death situation I would not want a managed care plan making decisions about the type of care they would cover.

[GailL1]

Thanks for your incite & knowledge - the reason I am asking is I wondered if this would be one areas which would be similar to other health insurance plans and the NO Surprise Act  that passed Congress last year and is now in the rule making stage with implementation Jan 01, 2022.

So I am not asking so much about who determines the need or any challenge along that line but more about how it is paid.  

As I understand your post, even if this type of emergency transport might be with an out of network provider on a MA plan, it is, pending no need challenge, pretty much paid according to the MA contract - that is to say, the beneficiary pays a copay, maybe some co-insurance and the MA plan pays their part - but can the provider balance bill the beneficiary for more money?

For that matter, how would traditional Medicare pay for this type of emergency service if medically necessary?  Would the beneficiary be balanced billed?  

Are these type of emergency air transports covered under the regular terms of Traditional Medicare - I don't think they are but I could be wrong.

[somarco]

@GailL1 a non-par provider may "balance bill" the patient for the difference in their "normal" fee for service vs the amount paid by the carrier.

Original Medicare does not have networks, thus there is no such thing as a non-par provider. Once a provider agrees to accept Medicare patients they also agree to accept the Medicare approved charge and are prohibited from balance billing.

One exception is in the case of a provider that does not take assignment. They are within their right to balance bill what amounts to roughly 12% above the Medicare approved amount.

Medical transport, ground or air, is a covered charge by Medicare subject to medical necessity guidelines.

https://www.medicare.gov/coverage/ambulance-services

[GailL1]

@somarco 

So these type of emergency air transports are covered by Medicare(Part B) when needed - but a person may have to sign an ABN under the traditional program. Try as I might I could find no listing for emergency air transports that actually accept assignment under the Traditional program so a beneficiary could be balanced billed.

https://www.medicare.gov/coverage/ambulance-services 

Medicare will only cover ambulance services to the nearest appropriate medical facility that’s able to give you the care you need.

The ambulance company must give you an " Advance Beneficiary Notice of NONcoverage (ABN)" when both of these apply:

• You got ambulance services in a non-emergency situation.
• The ambulance company believes that Medicare may not pay for your specific ambulance service.

My initial query in this thread is IF there is any instance in Medicare where there maybe some "Surprise bills".  I think there are and therefore these should be covered within the new legislation of "Surprised Bills" which will go into effect for the private insurance market in January 2022. 

[ReTiReD51]

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I would think as long as its a medical necessity, Medicare wouldn't object to paying their share for transportation of this type. As far as how a MA plan would treat this if Medicare approves they would have to pay minus your copays and deductibles. 

[GailL1]

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@ReTiReD51 wrote:

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I would think as long as its a medical necessity, Medicare wouldn't object to paying their share for transportation of this type. As far as how a MA plan would treat this if Medicare approves they would have to pay minus your copays and deductibles. 

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Is there a Medicare share?  I don't know that these types of emergency services accept Medicare rates or if they accept them as fully paid (well with the 20% that is the beneficiary's responsibility).  Would they balance bill the beneficiary?

[ReTiReD51]

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I’ve got one for you @GailL1 

If you decide to donate any of your organs when you pass, who pays for the removal and transportation of your organs.

Will Medicare pay for that? If they do will your supplement then pay their 20%? Same goes for MA will they pay a portion?

I read once where your insurance would pay for those costs so I called the Organ donor center in my state to ask them who pays for the removal of your organs after you die and l didn’t get past a young confused phone receptionist who didn’t know who to connect me with so I could ask.

After that I have never checked the box on my state drivers license to donate any of my organs when time comes for me to enter those Pearly Gates.

[GailL1]

The donor pays nothing - the recipient's insurance or the Organ Procurement Organization pays for it.

Medicare (CMS) has a policy.

Medicare Department of Health & Human Services (DHHS)
Centers for Medicare & Provider Reimbursement Manual Medicaid Services (CMS) Part 1 - Chapter 31, Organ Acquisition
Payment Policy  

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R471PR1.pdf