Medicare Advantage Medical Policy Frequently Asked Questions (FAQs)

Q. What is Medicare Advantage?

Medicare Advantage was established by the Balanced Budget Act (BBA) of 1997. The BBA expanded the health care options available since 1985 under the Medicare Risk contracts and established the Medicare Advantage products. Medicare Advantage allows eligible individuals to receive Medicare benefits through private health plans. These private plans provide all the benefits of Medicare, as well as benefits not available through Medicare, such as preventive care, routine hearing, vision and dental services and prescription drugs. Although most Medicare Advantage plans are HMOs, the plans that can be offered through Medicare Advantage include Provider Service Organizations, Preferred Provider Organizations, Private Fee-For-Service plans and Medical Savings Accounts.

Q. How does FreedomBlue relate to Medicare Advantage?

FreedomBlue is a Medicare Advantage PPO offered by Highmark Blue Shield through a contract with CMS. CMS pays a set amount each month to Senior Products for every enrolled Medicare Advantage member. The capitated amount paid to the plan is based on demographic and health status of the member. In return, SecurityBlue and FreedomBlue covers all Medicare Parts A and B benefits, as well as services not covered by Medicare such as routine physicals, as well as hearing and vision.

Q. Does Medicare Advantage offer the same coverage as Medicare?

As a replacement for traditional Medicare coverage, Medicare Advantage plans are required to cover at least all of the services that Medicare covers. However, most Medicare Advantage plans like FreedomBlue cover additional services, such as preventive care, routine hearing and vision, routine dental and prescription drugs

Q. What is "Medical Policy?"

Medical policies are documents that provide medical necessity and coverage guidelines.

Q. What, in general, do medical policies address?

Medical policies address numerous issues, such as anesthesia services, consultations, durable medical equipment and supplies, pathology, diagnostic medical services, radiology, nuclear medicine, surgery, cosmetic versus reconstructive surgery, therapies, and evaluation and management services.

Q. What does the term "medically necessary" mean?

Medically necessary means services or supplies determined by Medicare Advantage to be:

• appropriate for the symptoms and diagnosis or treatment of the Member's condition, illness, disease or injury;
• provided for the diagnosis or direct care and treatment of the Member's condition, illness, disease, or injury;
• not primarily for the convenience of you, your physician, hospital or health care provider;
  in accordance with standards of good medical practice; and
• the most appropriate supply or level or service that can safely be provided.