Medicare Advantage Plans are typically known as Medicare Part C or MA Plans. These plans are offered by private companies that have been approved by the Center for Medicare & Medicaid Services (CMS). The plans are funded by the Medicare benefit and administered by the private companies, technically, Medicare Advantage Organizations (MAO). The plans will provide all of the beneficiary’s Medicare Part A and Part B coverage and in some cases Medicare Part D is included in the plans.


Beneficiaries must be enrolled in both Medicare Part A & Part B to be eligible to select a Medicare Advantage Plan for their coverage.  Beneficiaries must permanently reside in the service area of the MA Plan.  Beneficiaries must be US citizens or lawfully present in the USA.  Beneficiaries or legal representatives must complete enrollment forms.  Premiums for the coverage vary widely and the supplemental benefits could be varied as well.

Beneficiaries have the option of selecting a MA Plan when they become eligible for Medicare coverage based on their age (typically, 65 years old).  The beneficiary then has the right to change their coverage dependent on their specific circumstance, but the following times are the most common:

Medicare Advantage Open Enrollment Period (MA OEP) – Oct 30 – Dec 7 of each calendar year with an effective date of January 1 the following year.

Special Election Periods – The following reasons may apply:

  • Change in Residence
  • Employer/Union Group Health Plan (EGHP)
  • Disenroll from Part D to Enroll in Creditable Coverage
  • Full Dually Eligible for Other Low-Income Subsidy
  • Retroactive Notice of Medicare Entitlement
  • PACE
  • CMS/State Assignment
  • Change in Dual/LIS Status
  • Change to Enroll in a MA Plan, PDP or Cost Plan with a Plan Performance Rating of Five Stars – can ONLY happen once in an enrollment year and can happen if switching from one 5 Star plan to another 5 Star plan.

The most frustrating part of this is the changes during the year with no notification to providers. This causes the providers to implement excessive checking of eligibility files to try to ensure the changes are accounted for.  In many cases, the changes are not current and may cause agencies not to receive payment due to lack of authorization from the new plan.

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There are currently ~43 Medicare Advantage Plans available for the average beneficiary to select from. This is more than double the number of available plans in 2018. Greater than 51% of all Medicare beneficiaries are enrolled in a Medicare Advantage Plan in 2023. Approximately one-third of Medicare beneficiaries live in counties where at least 60% of the beneficiaries in the county are on Medicare Advantage plans. Having said that, the emphasis here is that your agency strategy regarding Medicare Advantage will depend on your specific service area and the Medicare Advantage saturation found there.


Medicare Advantage Plans must cover all services that Original Medicare covers. The reality is, that even though the Medicare Advantage Plans are to replace the beneficiary’s Original Medicare coverage, most Home Health Agencies would agree that this is not the case. The plans primarily require prior authorization to provide care to the patient and the prior authorization process lacks authorization for the number of visits that agencies need to provide the highest standard of care, in most cases. Due to this, the patient’s quality of care outcomes often suffers.


If an agency is considering contracting with a MA Plan the following are a few things to consider:

  • What is the saturation in the agency coverage area based on statistics regarding the number of enrollees in the MA Plan in the agency coverage area?
  • How many referrals did the agency receive in the last 3 months from the MA Plan, and likely refuse, because the agency was not contracted?
  • What kind of relationship does other agencies have with the MA Plan, if currently contracted with the MA Plan?
  • How does the MA Plan compare to other MA Plans in the agency coverage area?
  • What contracts will be most beneficial to the agency and patient care?


Some of the key elements of a MA Plan contract that should be fully understood by the agency prior to signing includes payment terms, contract length & renewal terms, renegotiating rates timeline, authorization process, clean claim clauses and definitions, update distribution method, timely filing clauses, access to provider manuals and more.

When contracts are signed that look only at the rates, agencies will struggle to get started effectively. The billing department should have immediate access to all contracts and be involved in the new payer setup in the agency software system.


The reality is that Medicare Advantage Plan participation is growing daily. As beneficiaries turn age 65 and as they are bombarded by the advertising material, they are made to believe that they must pick a plan with little to no information being provided that Original Medicare with a Supplement is even an option. This harsh reality being the case, home health agencies must learn the best ways to evaluate plans and determine how they can best present themselves as the agency of choice to the MA Plans and how they can effectively benefit from the relationship.

The implementation of a new contract must be precise and effective so that both the beneficiary and the agency benefit. Opposite of the days when Original Medicare was 80% of the Medicare population, we are faced with greater than 60% being Medicare Advantage participants in the next few years. Many have relied on profits from the Original Medicare program to supplement losses from Medicare Advantage Plans, this must change.

In our next blog we will discuss some of the intricate details of implementing a new Medicare Advantage contract, including authorization, effective billing and collections and how agencies can survive and thrive in a Medicare Advantage environment.

Healthcare Provider Solutions stands ready to assist your agency in any way necessary. Start a conversation today!