The Marketing guidelines reflect CMS’ interpretation of the marketing requirements and related provisions of the Medicare Advantage and Medicare Prescription Drug Benefit rules (Chapter 42 of the Code of Federal Regulations, Parts 422 and 423).
This webpage contains information related to the MA Quality Improvement program. Within this site, we provide the Quality Improvement program requirements and relevant HPMS memos and resource information.
What is a Special Needs Plan? A special needs plan (SNP) is a Medicare Advantage (MA) coordinated care plan (CCP) specifically designed to provide targeted care and limit enrollment to special needs individuals. A special needs individual could be any one of the following: An institutionalized individual, A dual eligible, or An individual with a severe or disabling chronic condition, as specified by CMS.
Medicare Advantage (MA) organizations offering coordinated care plans, network-based private fee-for-service (PFFS) plans, and network-based medical savings account (MSA) plans, as well as section 1876 cost organizations, must maintain a network of appropriate providers that is sufficient to provide adequate access to covered services to meet the needs of the population served. The contracted network of providers must be consistent with the pattern of care in the network service area.
PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) INFORMATION RESOURCE. This page provides important information about PACE.
A Private Fee-For-Service (PFFS) plan is a Medicare Advantage (MA) health plan, offered by a State licensed risk bearing entity, which has a yearly contract with the Centers for Medicare & Medicaid Services (CMS) to provide beneficiaries with all their Medicare benefits, plus any additional benefits the company decides to provide. The PFFS plan:
A Medicare Medical Savings Account (MSA) plan is a type of Medicare Advantage plan that combines a high-deductible health plan with a medical savings account. Enrollees of Medicare MSA plans can initially use their savings account to help pay for health care, and then will have coverage through a high-deductible insurance plan once they reach their deductible. Medicare MSA plans provide Medicare beneficiaries with more control over health care utilization, while still providing coverage against catastrophic health care expenses. In Demonstration MSA plans, some MSA provisions are waived to make the plans more like other consumer-directed health plans, such as health savings accounts (HSAs) available in the private sector.
A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will each pay its share of covered health care costs.
Information on payment methodology Advance notices and announcements Studies
A Cost Contract provides the full Medicare benefit package. Payment is based on the reasonable cost of providing services. Beneficiaries are not restricted to the HMO or CMP to receive covered Medicare services, i.e. services may be received through non-HMO/CMP sources and are reimbursed by Medicare intermediaries and carriers.
