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Replacement Plans in Medicare

Replacement Plans in Medicare

Not all Medicare coverage is the same. In fact, as healthcare expenses increase and coverage decreases many qualified Medicare beneficiaries are making the choice to put aside their traditional Medicare and enroll in a Medicare Part C plan also known as a Medicare Advantage Plan (i.e., replacement plan).


Replacement Plans in Medicare

What is a Medicare Advantage Plan?

According to, a Medicare Advantage Plan (like an HMO or PPO) is a Medicare health plan that qualified beneficiaries may choose as part of their Medicare package. These plans are very similar to traditional Health Management Organizations (HMOs), Preferred Provider Organizations (PPOs) and Private Fees for Service (PFFS) plans. These plans have their own rules for both treating and billing patients.

Medicare Advantage Plans (i.e., “Part C” or “MA Plans”) are offered by private companies approved by Medicare. If your patient joins a Medicare Advantage Plan, the plan automatically includes Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. This means that your patient does not have traditional Part B Medicare! In addition, Medicare Advantage Plans may offer other coverage such as: vision, hearing, dental, and/or health and wellness programs. Most also include Medicare Part D (Prescription Drug Coverage).

Medicare pays a fixed monthly amount to the companies offering Medicare Advantage Plans. These companies must follow the rules set by Medicare. However, each Medicare Advantage Plan may have different out-of-pocket costs and different rules for how patients obtain services (e.g., Is a referral required for specialists like chiropractors? Are they limited to doctors, facilities, or suppliers that belong to the plan?) Note: These rules may change yearly.

Don’t Be Fooled!

Unfortunately, most patients do not understand that Medicare Advantage plans replace their traditional (original) Medicare. There is no need for patients to provide the clinic a copy of their traditional Medicare card. They should provide a copy of their Medicare Advantage insurance card. We encourage you to train your staff on how to identify these cards properly during the intake process.

You will immediately see that the cards are not red, white and blue like traditional Medicare cards. The key is to look for the words Medicare Advantage on the front of the card. Most major payers will offer a Medicare Advantage plan option each year. In some cases, your office may be annexed into the plan as a preferred provider if your office participates in the payor’s commercial plans. Below you can see a Sample BC BS Medicare Advantage Plan Card:


Medicare Part C or Advantage Plans

Once you’ve identified the card you will need to know what is required prior to billing a Medicare Advantage Plan. What you need to know can be found at “The Ins and Outs of Billing Medicare Advantage Plans”.


The Ins and Outs of Billing Medicare Advantage Plans


What is a Deemed Provider in a Medicare Replacement Plan?


Your Compliance Plan and FDR
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...KMC University is extremely well structured, organized, knowledgeable and efficient. The KMC Library is stuffed full of everything one would ever need to become educated in the world of HIPAA while still being user friendly by providing informational sheets, videos etc. Each section in the Library provides a flow chart as to how it should be followed and implemented. Everything is easily comprehensible for executives and staff to be trained. It is all very impressive...

Neomi Hunt, M.S.