Medicare health plans, which include Medicare Advantage (MA) plans (such as Health Maintenance Organizations, Preferred Provider Organizations, Medical Savings Account plans and Private Fee-For-Service plans) Cost Plans and Health Care Prepayment Plans, must meet the requirements for grievance, organization determination, and appeals processing under the MA regulations found at 42 CFR Part 422, Subpart M.
Today, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would implement an order from the Federal district court for the District of Connecticut in Alexander v. Azar that would establish appeals processes for certain people with Original Medicare who are initially admitted to a hospital as an inpatient but subsequently reclassified by the hospital as an outpatient receiving observation services during their hospital stay and meet other eligibility criteria.
This page contains information on Medicare Part A and Medicare Part B eligibility and enrollment. For more information about Medicare for people who are still working, go to our Employer page or I’m 65 and Still Working page.
Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) are available to the individuals below:
- Age 65 or older
- Disabled
- End-Stage Renal Disease (ESRD)
The Relationship between Medicare and the Health Insurance Marketplace
This page contains a downloadable document listing frequently asked questions (FAQs) regarding the relationship between Medicare and the Health Insurance Marketplace. Topics include: general enrollment, End Stage Renal Disease (ERSD), and coordination of benefits.
This overview page provides links to important plan information on the Medicare Part D prescription drug benefit, first enacted under the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. Information about the Medicare Advantage and Part D plan offerings are included for each year, including plan premiums.
The Medicare Modernization Act (MMA) requires entities (whose policies include prescription drug coverage) to notify Medicare eligible policyholders whether their prescription drug coverage is creditable coverage, which means that the coverage is expected to pay on average as much as the standard Medicare prescription drug coverage. For these entities, there are two disclosure requirements:
As a condition of payment, all Part D plans must submit data and information necessary for CMS to carry out the payment provisions of the MMA. This section contains content on how CMS will implement the statutory payment mechanisms by collecting a limited subset of data elements on 100 percent of prescription drug “claims” or events.
The Retiree Drug Subsidy
The retiree drug subsidy (RDS) is one of several options available under Medicare that enables employers and unions to continue assisting their Medicare eligible retirees in obtaining more generous drug coverage. It is generally considered the easiest and most straightforward of the available options, and can often be implemented with little or no benefit design changes to current coverage. The primary web site for the RDS program, including the online tool for submitting subsidy applications, is hosted by the RDS Center (see link below under “Related Links Outside of CMS”). This page provides links to guidance and application instruction documents relating to the RDS, as well as overview documents.
This section contains information on eligibility for the Low-Income Subsidy (also called “Extra Help”) available under the Medicare Part D prescription drug program. It includes information on those who are automatically deemed eligible, as well as those who must apply to be determined eligible. There is also a section on how individuals are re-determined eligible for the low-income subsidy. Lastly, this section contains a notice to State Medicaid Directors informing them of the reassignment process impacting the Part D enrollment of certain low income individuals in their state.
This page discusses the enrollees right to request a Part D coverage determination, appeal or file a grievance/complaint.
Individuals who represent enrollees may either be appointed or authorized to act on behalf of the enrollee in filing a grievance, requesting an initial determination, or in dealing with any of the levels of the appeals process. For more information about appointing a representative, see section 20 in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, using the link in the “Downloads” section below.
A Health Care Pre-Payment Plan (HCPP) is an organization is a union or employer sponsored plan that provides or arranges for some or all of Part B Medicare benefits on a prepayment basis. Payment for Part A services is made on a fee-for-service basis.
Organizations that are interested in applying for a HCPP contract must download and complete all of the files below.
This section includes useful information to help Medicare Advantage Plans, Medicare Advantage Prescription Drug Plans, Prescription Drug Plans, and 1876 Cost Plans with marketing efforts.
Marketing questions should be directed to Account Managers, Marketing Reviewers, or the Marketing Mailbox at marketing@cms.hhs.gov.
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.
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.
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 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:
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.
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.
A SNP may be any type of MA CCP, including either a local or regional preferred provider organization (i.e., LPPO or RPPO) plan, a health maintenance organization (HMO) plan, or an HMO Point-of-Service (HMO-POS) plan. There are three different types of SNPs:
- Chronic Condition SNP (C-SNP)
- Dual Eligible SNP (D-SNP)
- Institutional SNP (I-SNP)
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.
The Quality Improvement program requirements for MA organizations are described in 42 CFR 422.152. Guidance may also be found in the CCIP Resource Document and in Chapter 5 of the Medicare Managed Care Manual. Both are available as downloads below.
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).
The Guidelines are for use by Medicare Advantage Plans (MAs), Medicare Advantage Prescription Drug Plans (MA-PDs), Prescription Drug Plans (PDPs) and 1876 Cost Plans. The guidelines allow organizations offering both Medicare Advantage and Prescription Drug Plans the ability to reference one document when developing marketing materials.
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