The following information describes services provided by Medicare+Choice (M+C) plans, and then RDs' opportunities with these plans.
Medicare+Choice plans are offered by certain private insurance companies or managed care organizations (MCOs) who contract with the government to provide at least the same benefits as Medicare Part A and B. RDs who are employed, or under contract with HMOs or private plans who offer M+C plans have opportunities for providing and receiving payment for MNT services for diabetes and non-dialysis kidney disease.
Medicare+Choice plans, also called Medicare C, are health coverage plans that are offered by private insurance companies or managed care organizations (MCOs). The companies/organizations that offer Medicare+Choice (M+C) plans are state licensed and are certified by the Centers for Medicare & Medicaid Services (CMS) as meeting the M+C contract requirements (Federal Register: 42 C.F.R. § 422.2.). The most common types of M+C plans are coordinated care plans or private-fee-for-service plans. Coordinated plans are offered by managed care organizations (MCOs), such as HMOs, preferred provider organizations and provider-sponsored organizations.
The HMO's contract with the government requires that they have at least the same benefits as Medicare Part A and Part B coverage, and some may offer additional benefits. Because coverage for diabetes and non-dialysis kidney disease is new to the benefits HMO M+C plans must be offering, some HMOs may not have recognized this in their plan services. RDs can provide information to HMO administrators and physicians that MNT should be covered and accessible to Medicare+Choice clients with diabetes and non-dialysis kidney.
Medicare+Choice plans frequently offer Medicare benefits at a lower overall cost to seniors than the "traditional" fee-for-service Medicare plan. However, recent rising health care costs have forced many MCOs to increase their premiums or discontinue the M+C plan altogether. In 2001, around 5.6 million seniors were enrolled in Medicare+Choice plans (Mathematica Policy Research). Seniors enroll in these programs seeking protection from the costs that traditional Medicare does not cover (such as prescription drugs, or other preventive services such as vision or hearing care).
Medicare+Choice HMOs; Beneficiaries enrolled in a Medicare+Choice plan offered by an HMO generally must use doctors, hospitals, and health care providers (such as RDs) under contract with the HMO. These providers are in the HMO´s "network." Some HMOs have an option called "point of service" that allows clients to go to doctors and other providers who aren´t in the HMO´s network if they are willing to pay an extra amount. Each HMO beneficiary has a primary care physician who provides or oversees all of the beneficiary's health care. To enroll in an HMO or HMO with the POS option, the beneficiary must live in the HMO´s service area, be eligible for Medicare Part A and Part B, and not have end-stage renal disease.
Payment arrangements to the Medicare+Choice programs; Medicare+Choice plans are paid a flat monthly fee (capitated amount) by the government for the services included in the plan. The MCO contracts with physicians or other non-physician practitioners, such as RDs, to provide the services in the program. Practitioners may be either an employee or independent contractor with the MCO. Payment for RDs' services is made directly from the HMO or MCO, not the government. The practitioner does not need to be enrolled in Medicare as a Medicare provider, since they are bound by the contract/work relation with the MCO, not the government who offers the traditional Medicare program.
Since Medicare+Choice programs must provide the same covered services as those that are included in Medicare Part B program, including MNT for diabetes and non-dialysis kidney disease, RDs have opportunities to expand their services to these plans. RDs would need to establish a business relation with the MCO who offers the Medicare+Choice plan. RDs who provide MNT services as part of a Medicare+Choice plan do not need to be enrolled as Medicare providers. However, practitioners who are enrolled as Medicare providers, and who choose to expand their business by pursuing contracts with HMOs, may find the Medicare provider designation helpful in establishing the HMO M+C contract. For good business practice, RDs should follow the Medicare MNT benefit requirements, such as use of evidence-based MNT protocols, MNT codes, appropriate documentation, communicate with physician and other healthcare practitioners.
RDs can determine the Medicare+Choice plans in your area through several sources including CMS or your state department of insurance. From CMS' Web page, www.medicare.gov/mphCompare/home.asp , through a search by zip codes, RDs can view all Medicare plans (traditional Medicare and Medicare+Choice plans) in your area. This search compares the programs, and includes the company name, plan name, service area and phone information.
Ellen Pritchett, RD, CPHQ and Pam Michael, MBA, RD ADA Quality Management and Health Care Financing Team