Medicare Advantage Plans

Medicare Advantage Plans (MAPs) are plans offered by private companies that provide Part A, Part B, and Part D coverage in one plan. These plans are also referred to as Part C. MAPs cover all Medicare services and most also offer extra coverage like vision, hearing, and dental coverage. A list of MAPs by zip code can be found at Medicare.gov.

Medicare Advantage Plan Prompt Pay

  • For non-contracted providers, the MAP must follow CMS prompt pay regulations. See the Medicare Managed Care Manual and the dispute resolution web page for information.
    • The contract between CMS and the MAP must provide that the MAP will pay 95% of the "clean claims" within 30 days of receipt if they are submitted by, or on behalf of, an enrollee of an MAP private fee-for-service plan or on claims for services that are not furnished under a written agreement between the MAP and the provider;
    • The MAP must pay interest on clean claims that are not paid within 30 days (interest rates); and
    • All other claims from non-contracted providers must be paid or denied within 60 calendar days from the date of the request for payment.
  • For contracted providers, prompt pay terms are governed by the physician’s contract with the plan.

Where to File Complaints

MAPs (Part C) and Prescription Drug Plans (Part D): Complaints may be mailed, faxed, or emailed. Emailed complaints must be sent securely via encryption or password protection. Follow the instructions on how to file a complaint and how to encrypt or password protect an emailed complaint on the Where to File Complaints guide. 

Sequestration Guidelines for Medicare Advantage Plans

In 2013, CMS released information regarding the mandatory payment reductions (sequestration) in MAP and stand-alone Part D plans indicating that whether or not a MAP applies sequestration to claims or not is governed by the physician's contract with the MAP. As such, a MAP may or many not take sequestration from claims payment when CMS imposes sequestration. More information can be found in the CMS notice.

QMB/Dual Eligible Demonstration Project

The Dual Eligible project is a Medicaid program that helps very low-income dual eligible beneficiaries with Medicare cost-sharing. Dual eligible or QMB (Qualified Medicare Beneficiary) are terms used to identify Medicare beneficiaries who also receive Medicaid assistance, ranging from beneficiaries who receive the full range of Medicaid benefits to beneficiaries who receive assistance only with Medicare premiums or cost sharing. See our Medicaid and CHIP page for more information.

Quicklinks

AARP (UHC) Aetna Medicare BCBS Medicare Advantage PPOHMO, UT Care Cigna/Healthspring Devoted Health Humana Gold  Memorial Hermann Advantage
Molina
Scan Health
Verda
Wellcare/TexanPlus Wellpoint (Amerivantage)

Resources