MA HMO - Out of Network Coverage

[yogooglethis]

Same rights. Same or additional benefits. Not the same charges.

I was referring to the fact that a medicare provider who accepts assignment rates for a medicare covered service.i.e office consultation cannot be more for an out of network ppo member compared to someone on original medicare.Of course the portion of that charge that the oon ppo member is responsible to pay is greater but the total charged billed for medicare covered service cant be.On the other hand In network provider rates can be and usually are lower then original medicare rates.

 

[MBSC]

I was referring to the fact that a medicare provider who accepts assignment rates for a medicare covered service .i.e office consultation cannot be more for an out of network ppo member compared to someone on original medicare. Of course the portion of that charge that the oon ppo member is responsible to pay is greater but the total charged billed for medicare covered service cant be. On the other hand In network provider rates can be and usually are lower then original medicare rates.

The OP was asking about out of network MA HMO. Can those OON providers charge more even if they are Original Medicare participating? Yes.

If they do charge more, is the MA HMO member responsible for the entire charge or only the Original Medicare allowable? The entire charge for non-emergency non-approved care. There is no adjustment down to Original Medicare rates for HMO OON providers. It would be up to the member to negotiate down, such as a prompt payment discount. The MA member would need a POS or PPO plan to have their financial liability limited.

For OON MA PPO, the provider can bill/charge more but must accept the Original Medicare rate as payment in full. They write off the difference.

42 CFR 422.214 - Special rules for services furnished by noncontract providers.
(a) Services furnished by non-section 1861(u) providers.
(1) Any provider (other than a provider of services as defined in section 1861(u) of the Act) that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare.

(d) Regional PPO payments in non-network areas. An MA Regional PPO must pay non-contract providers the Original Medicare payment rate in those portions of its service area where it is providing access to services by non-network means.

Reference: https://www.law.cornell.edu/cfr/text/42/422.214

 

[somarco]

MBSC, thanks again for the clarification.

I was under the impression a provider that accepts Medicare assignment was limited to the Medicare allowable charge irrespective of the type of insurance (or lack thereof) the Medicare beneficiary has in place.

For purposes of discussion, a Medicare beneficiary is effectively no longer considered a beneficiary once they leave the original Medicare system. There are no protections against balance billing except as allowed by the MA contract?

If this is the case, then there are some serious holes in HMO MA plans.

 

[MBSC]

There are no protections against balance billing except as allowed by the MA contract? If this is the case, then there are some serious holes in HMO MA plans.

My previous post was in response to the MA HMO member being denied authorization to the OON provider.

Balance billing protections are in place for MA HMO members seeking care at in-network providers and also at OON providers for emergencies and services approved by the MA plan. If the MA plan denied the member's request to see the OON provider, the care is not "MA plan covered" so there is no protection. MA members must follow the MA plan's rules.

Medicare Managed Care Manual
Chapter 4 - Benefits and Beneficiary Protections
Section 180 – Balance Billing

When enrollees obtain plan-covered services in an HMO, PPO, or RPPO, they may not be charged or held liable for more than plan-allowed cost-sharing. Providers who are permitted to ‘balance bill’ must obtain the amount in excess of the enrollee’s cost-sharing (the balance) for services, directly from the MAO and not from the enrollee.

 

[somarco]

Thanks again for the clarification, but you answered my question in your earlier post.

If I understand correctly, the patient is protected against OON balance billing (xs of the Medicare allowable charge) for non-emergency care when they are covered by:
- original Medicare
- MA PPO
- MA POS
- MA PFFS
- MA HMO with POS option

but not with a "pure" HMO as in the case of Kaiser. It is as if they are deserted by Medicare in the HMO model.

Still seems odd to me the rules for providers that accept Medicare assignment apply in every case EXCEPT the MA HMO model.

If you enroll in an HMO you are SOL when it comes to non-emergency OON treatment.