What is "deeming" under Medicare Advantage?
When an enrollee in a private fee for service (PFFS) plan offered by a Medicare Advantage (MA) Organization obtains services from a provider, then for those services, that provider is classified into one of the following three mutually exclusive provider types:
- A provider is a direct-contracting provider if that provider has a direct contract (that is, a signed contract) with the MA Organization
- A provider is a deemed-contracting provider if:
- The provider is aware in advance of furnishing services, that the person receiving the services is enrolled in a PFFS plan
- The provider has reasonable access to the plan's terms and conditions of payment; and the service provided is covered by the plan
- A provider is non-contracting provider if that provider does not have a direct contract and is not deemed
A provider is "aware in advance" of enrollment if notice of enrollment for this enrollee was obtained from:
- The enrollee (e.g., presentation of an enrollment card)
- A Medicare intermediary
- A carrier
- The MA Organization itself
A provider has "reasonable access" to the plan's terms and conditions of payment if the
plan makes accessible its terms and conditions of payment through:
- A plan Web site
It is then the provider's responsibility to call or fax the PFFS plan or to visit the PFFS Web site to obtain the plan's conditions of participation. However, announcements in newspapers, journals, or magazines or on radio or television are not considered communication of the terms and conditions of payment.
It is important to emphasize that although a provider who does not have a direct contract with the plan may choose to provide, or not to provide services, the provider does not have the option of becoming non-contracting. Rather, once the provider provides services, the provider automatically becomes deemed-contracting provided the deeming conditions listed above have been met.
Any provider who was aware in advance of furnishing services, that the person receiving the services is enrolled in the PFFS plan and had reasonable access to the plan's terms and conditions of payment becomes a deemed contracting provider for the services they furnish that enrollee.
The following examples illustrate typical situations in which the provider becomes deemed contracting:
- An enrollee walks into a physician's office for the first time, advises the physician that he or she is a member of the PFFS plan and presents his or her plan enrollment card. Since the provider had the opportunity to call the plan phone number on the enrollee card, the provider is considered deemed contracting as soon as s/he provides services, even though the provider did not actually check the terms and conditions of payments.
- An enrollee enters a hospital for non-emergency care, advises the hospital that he or she is a member of the PFFS plan and presents his or her plan enrollment card. All providers that contract with this hospital, or are employed by this hospital, are considered deemed contracting as soon as they provide services, even though hospital providers typically do not themselves verify plan enrollment.
The following examples illustrate when a provider is considered non-contracting:
- A provider who provides care in an emergency to an unconscious enrollee is non-contracting if the provider did not know prior to furnishing services that the enrollee belonged to a PFFS plan;
- A provider who, prior to furnishing services, did not have "reasonable access" to the PFFS plan's terms and conditions of payment, is also considered non-contracting.
Source: CMS MMCM Chap. 4 150