Medicare Advantage Plans

Medicare Advantage Plans

Medicare Advantage (MA) plans must include the OTP benefit as of January 1, 2020 and contract with OTP providers in their service area, or agree to pay an OTP on a non-contract basis. In covering the OTP benefit, MA plans must use only Medicare-enrolled OTP providers. 

MA plans may:

  • Contract directly with a Medicare-enrolled OTP. Individual practitioners within an OTP don’t need to enroll separately.
  • Arrange for its enrollees to get the OTP benefit from non-contract Medicare enrolled OTPs. 

An MA plan may require its enrollees to get OTP services only through contracted OTP facilities.  In these cases, the MA plan will ensure equitable access to contracted OTPs throughout its service area.

If enrollees use non-contract OTPs, MA plans must contact those OTPs to coordinate plan benefits and timely payment to the OTPs consistent with federal regulations.

MA Plans & OTP Payment

Regardless of whether an OTP is under contract with an MA plan or providing services on a non-contract basis, the OTP must contact each specific plan with payment questions. MA plans pay OTPs on a non-contract basis at the Original Medicare payment rate.

Contacting MA Plans

OTPs should contact MA plans and ask for “provider services” to help with questions about payment for OTP services under that MA plan. 

If you’re not sure your Medicare patient is enrolled in an MA plan:

  • Ask for the patient’s insurance card, and look at the contact information on the back
  • Check your patient’s Medicare eligibility

Medicare Advantage Organizations

OTPs aren’t required to contract with Medicare Advantage Organizations (MAOs). When an OTP chooses to contract with an MAO, both parties negotiate the terms and conditions of payment.

Ensuring Continuity of Care for Dually Eligible Medicare Advantage Enrollees

Find Medicare-Enrolled OTPs

Page Last Modified:
09/06/2023 04:51 PM