Medicare Advantage
Medicare Advantage
Medicare Advantage
Administered by CMS and also referred to as Part C of the Medicare program, insures beneficiaries 65 and older as well as the disabled. Unlike traditional Medicare which covers only Part A and B and utilizes a fee-for-service reimbursement model to providers and health systems, Part C allows for Medicare Advantage Organizations (MAOs) to receive per-member-per month (PMPM) capitation.
Based on the diagnoses submitted along with other factors such as the enrollee’s age and gender, CMS calculates a risk score, or risk adjustment factor (RAF) for each beneficiary. A higher RAF reflects a patient with higher acuity and more severe and chronic conditions. Subsequently, CMS reimburses the MAO more for these patients.
MAOs are provided higher payments when their beneficiaries are anticipated to incur higher healthcare costs, and conversely are provided lower payments when their beneficiaries are expected to incur lower healthcare costs.
Commercial ACA
Medicare Advantage
Medicare Advantage
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Medicaid
Medicare Advantage
Medicaid
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