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Healthcare Landscape

What’s a Medicare Advantage Plan?

Eligible Medicare beneficiaries receive Medicare benefits through either Medicare or a Medicare Advantage Plan. Medicare Advantage Plans are offered by private companies approved by Medicare, who contracts with these companies to cover Medicare benefits.

A Medicare Advantage Plan for a beneficiary may cover additional benefits that are not covered by Part A and Part B, such as vision or dental coverage and low or no deductibles. However, preferred medical service & product coverage can be limited, premiums and co-pays can change annually and high co-pays may occur.  Beneficiaries may also be required to pay the full cost for any services received from providers that are outside of the plan’s network.

Approximately one third of Medicare participants are enrolled in managed Medicare Advantage plans. These numbers are expected to increase, up to approximately 7%.

Managed care organizations set their own rules for paying providers. For example, some organizations want to receive off-cycle PPS MDS assessments, some want a RUG every 30 days, and some don’t use RUGs at all. Most managed care contracts pay levels instead of RUGs.  Levels are based on how many disciplines are provided and how much therapy is provided per day.  Managed Care plans will not have to follow the CMS Patient Driven Payment Model (PDPM).

Paragon Rehabilitation strives to focus on efficient, quality services for our customers. This means finding a way to focus on both quality clinical outcomes and efficient services to ensure we can achieve our goals in a shorter period of time. We believe communication with our partners is one of the keys to success when understanding Medicare Advantage Plan payment provision models.

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