Medicare Advantage Reimbursement of 99490 Leaves Much To Be Desired But Future Outlook Is Improving

Chronic Care Management (CCM) is a no-brainer for physicians looking to improve quality of care for traditional Medicare patients, but what about Medicare Advantage patients? Are these patients not entitled to the same level of support outside of the clinic as traditional Medicare?

The Center for Medicare and Medicaid Services (CMS) thinks so, according to statements by Kathryn Coleman, their director of the Medicare Drug & Health Plan Contract Administration Group. Unfortunately, the reality of the situation is quite different. A recap of her statements was posted by the American Academy of Family Practitioners (AAFP):

“Kathryn Coleman, director of the Medicare Drug & Health Plan Contract Administration Group, confirmed that the CCM was a covered Medicare Part B service ‘included in the basic benefit offered by every MA (Medicare Advantage) plan.’

However, Coleman noted that Medicare Advantage organizations ‘have wide latitude’ in terms of furnishing care coordination services to beneficiaries.

‘Medicare Advantage regulations … expressly preclude CMS from interfering in payment rates agreed to by an MA plan and its contracted providers,’ said Coleman. Whether such a plan pays physicians for furnishing care coordination via the CCM CPT code or some other mechanism ‘can vary depending on the contract agreement in place’”

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However, in our experience, some but not all Medicare Advantage plans are reimbursing for 99490. Unfortunately, for some Medicare Advantage reimbursement of 99490, the copay amounts are so high that it serves as a barrier to enrolling patients. However, there has been a strong push from the medical community to get CCM services reimbursed by the Medicare Advantage plans.

In fact, in 2015 the American Academy of Family Physicians (AAFP) Board Chair Reid Blackwelder, M.D., of Kingsport, TN sent a letter to the Senate Finance Committee outlining four recommendations for improving health outcomes for Medicare patients with chronic conditions. One of these four recommendations was:

“Require plans to implement and reimburse for the new Medicare chronic care management (CCM) code, CPT 99490”

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There has been feedback from organizations and influential individuals supporting similar policy changes. We will continue to monitor changes to Medicare Advantage Reimbursement of 99490 as there is support from many physicians that CCM is a critical part of caring for the Advantage patients – at CareHarmony we believe that no patient should be left behind.

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