Medicare Advantage

A type of Medicare plan offered by private insurance companies that contracts with CMS to provide Medicare Part A and Part B benefits, often including additional coverage like dental and vision.

Medicare Advantage, also called Medicare Part C, is a private insurance alternative to traditional fee-for-service Medicare. Over 30 million Americans are enrolled in Medicare Advantage plans, and that number grows every year. If you see patients over 65, you are almost certainly seeing Medicare Advantage members. From a credentialing perspective, Medicare Advantage plans are separate from traditional Medicare. Being enrolled in Medicare through PECOS does not automatically make you a participating provider with Medicare Advantage plans. Each MA plan has its own provider network and its own credentialing process. UnitedHealthcare Medicare Advantage, Humana Medicare Advantage, and Aetna Medicare Advantage are all separate enrollments. MA plans are required by CMS to maintain adequate provider networks to serve their members. This means they need primary care physicians, specialists, hospitals, and ancillary providers in every county where they operate. Network adequacy requirements create opportunities for providers to negotiate favorable contract terms, especially in underserved areas. Reimbursement rates for Medicare Advantage plans are not the same as traditional Medicare rates. Each MA plan negotiates its own fee schedule with providers. Some MA plans pay more than traditional Medicare for certain services. Others pay less. The rates are specified in your participation agreement with each MA plan. One important distinction: MA plans can apply utilization management tools like prior authorization that traditional Medicare does not use. An MA plan might require prior authorization for an MRI that traditional Medicare would pay without prior auth. This adds administrative burden but is part of the MA plan's cost management approach. If you are evaluating which Medicare Advantage plans to join, look at their enrollment in your area, their fee schedule compared to traditional Medicare, their prior authorization requirements, and their claims processing efficiency. Not all MA plans are worth the administrative effort of enrollment.