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Old 02-11-2019, 10:39 PM
Diesel Diesel is offline
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Default Medicare Advantage Question

Question is there a place on the CMS website or Medicare website the goes over what limits a MA plan must heve. Like home health has to be covered at 100% down to 95% if that make since. When creating a MA plan how do I know what benefits can be changed.
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Old 02-12-2019, 08:11 PM
Bassooner Bassooner is offline
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The final call letter each year has some of the benefit limits. Here's the 2019 announcement: https://www.cms.gov/Medicare/Health-...cement2019.pdf

Page 196: Shows ranges of acceptable maximum out-of-pocket limits.

Page 198: Shows some actuarial equivalence tests that inpatient, SNF, DME, and Part B Rx are required to pass.

Page 201: Shows in-network cost-sharing requirements for a number of different benefit categories. These are sometimes contingent on the plan's MOOP limit. For instance, home health has to be covered with zero cost-sharing for mandatory MOOP ($3401-$6700) plans, but there can be cost-sharing of up to 20% or $35 for voluntary MOOP ($0-$3400) plans.

For benefits without a specific cost-sharing requirement, CMS generally interprets anti-discrimination provisions to mean that you can't have cost-sharing higher than 50% for in-network Medicare-covered benefits.

This isn't an exhaustive list, just what first came to mind. In addition to the call letter, the Medicare Managed Care Manual (in particular Section 50 of Chapter 4) has more detail around cost-sharing requirements.
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