Medicare Advantage

If a patient disenrolls from a Medicare Advantage (MA) plan (also known as a Medicare HMO) and is eligible for Medicare home health benefits, a new start of care would begin as of the first billable visit after the termination date of the MA plan election. The home health agency (HHA) should confirm that the termination date has been updated on the Common Working File by the MA plan. This information is available in Palmetto GBA’s eServices Eligibility Tab, under “Plan Coverage”. If the termination date is not updated, final claims will reject.

Last Reviewed: 09/28/2023

When a patient who is receiving the Medicare home health benefit elects an MA Plan during a home health episode, the patient's Medicare coverage is put on hold for the duration of the MA Plan election. The HHA must discharge the patient from Medicare services before the effective date of the MA Plan using an "06" patient status code.

Last Reviewed: 09/28/2023

Information regarding Medicare patients whose status with a Medicare Advantage (MA) plan (also known as a Medicare HMO plan) changes within an episode of care may be found in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 10.1.23. This section of the manual also contains information regarding the OASIS requirements for Medicare patients who opt to enroll or disenroll from the MA plan during an episode of care. For additional questions or concerns regarding the OASIS requirements, providers may contact their state OASIS Education Coordinator. The CMS OASIS Educational Coordinators webpage contains the contact information for the state OASIS education coordinators.

Last Reviewed: 09/28/2023