Medicare Advantage Providers are not Required to be Enrolled in Medicare

by  Wyn Staheli, Director of Content - innoviHealth
Dec 18th, 2018

There was a ruling that was requiring providers to be enrolled in Medicare in order to provide services for Part C (Medicare Advantage (MA)) and/or Part D. However, on April 2, 2018, CMS released the 2019 Final Rules for MA and Part D which changed this previous ruling. According to a CMS press release (see References below), as part of the  “Patients Over Paperwork” Initiative, effective January 1, 2019, they are “eliminating enrollment requirements for healthcare providers and prescribers that bring value to Medicare Advantage and Part D beneficiaries.” This is only for Part C and Part D plans. For Part A and Part B, it is still necessary to be enrolled as a Medicare provider. Healthcare providers who have opted out of Medicare may now provide services to beneficiaries under Medicare Part C or prescribe Part D covered drugs.

This doesn’t mean that ANY provider can now start providing services for Part C beneficiaries. Medicare Advantage plans will utilize a “Preclusion List” to ensure that excluded providers are not eligible to provide services to Medicare beneficiaries. This list is not the same thing as the OIG Exclusion List. However, if a provider is already on the OIG Exclusion List, there’s a high probability they will also be on this new “Preclusion List”.

Also, in many cases, Medicare Advantage (e.g., HMO, PPO) plans require providers to be enrolled in their plan to be an in-network provider before they will cover services. Be aware of individual payer policies.