MEDICARE/MEDICAID

Medicare Managed Care Information
Medicare beneficiaries who are enrolled in the Medicare Contracting Managed Care/HMO Program are expected to receive care and services from the HMO’s participating physicians and providers. The plan’s physician or provider in turn receives payment from the HMO for the services provided to the Medicare beneficiary. But what happens when the beneficiary receives emergency or urgently needed care services (outside the HMO service area) by a non-participating physician or provider of the Medicare Managed Care Plan or HMO?

Under the Medicare Managed Care/HMO Program, a provider may collect payment from a Medicare beneficiary whose HMO has made an initial determination to deny payment. However, if the type of HMO contract (i.e.: Risk or Cost) is unknown to the physician, it is strongly advised that a claim be filed with the local Medicare Part-B carrier (if this action was not previously taken). If the patient is enrolled in an HMO with a “COST” Contract, the local Medicare carrier will provide benefits for covered Medicare services. If the patient is enrolled in a “RISK” Contract, the local Medicare Carrier will, regretfully, deny benefits for the Medicare covered services.

If both the local Medicare carrier and the patient’s HMO deny claim payment, Medicare participating providers may charge the beneficiary up to 100% of the Medicare fee schedule amount for participating providers. Non-participating providers in New York State may charge the patient for the Medicare fee schedule amount for non-participation, plus the Federal or New York State limiting charge (i.e.: 115% or 105%, respectively).

Please note, there should be no balance billing to a Medicare beneficiary beyond the appropriate fee schedule amount for participating Medicare physicians nor beyond the limiting charge for non-participating Medicare physicians. When initially receiving an adverse determination from the Medicare Contracting HMO, the Medicare beneficiary is advised of the right to appeal. Physicians may wish to reiterate to their patients that right to appeal when receiving an initial determination that payment is being denied.

The foregoing information advises you of the recourse to be taken for denials under Medicare Managed Care. The following will provide information for Medicare Contracting Managed Care Plans in New York State.


For your information, we have listed the contract typed (i.e.: RISK or COST) associated with each Medicare Managed Care Plan. We have also provided each of the entities’ Plan Name, Plan Number, the Plans’ address and telephone number. Health Maintenance Organizations (HMOs) and Competitive Medical Plans (CMPs) with Medicare contracts must provide the full range of all Medicare covered services. Medicare beneficiaries enrolled in a risk contract are “locked-in” to receiving all covered care from the Plan, except for emergency or urgently need care away from the Plan’s service area. If the member goes outside the Plan for unauthorized care, neither the Plan nor Medicare will pay. In this instance, the patient is at “risk” for payment.

Conversely, beneficiaries are not “locked-in” to receiving services from a Plan with a Cost contract. While the Plan will not pay if the member uses non-plan providers, Medicare will still pay its share for covered services. In such instances, the member would be responsible for paying Medicare’s coinsurance and deductible, just as if the member was receiving care under the traditional fee-for-service system.

In addition to risk and cost contracts, Medicare has agreements with health care prepayment plans (HCPPs). They are unlike other plans in that they may only provide a limited range of Part B services. Medicare enrollee’s can go outside the HCPP for any medical or hospital services and are responsible for paying coinsurance and deductibles as in fee-for-service Medicare.

Prepared by:

Regina McNally
MSSNY Senior Ombudsman
Division of Socio-Medical Economics 
January 24, 1997