Medicare and Medicare Advantage (MA) plans have similar structures, because MA plans are required to (at minimum):

  • offer the same benefits that traditional Medicare provides to its beneficiaries, and
  • adhere to all CMS National and Local Coverage Determinations.

However, there are some significant differences between the two. And that makes sense given that traditional Medicare is government-operated, while Medicare Advantage plans are operated by Medicare-approved private companies. Thus, many of the core Medicare requirements don't automatically apply to Medicare Advantage plans.

That said, private payers can—and often do—adopt Medicare's rules and regulations. So, when in doubt about a particular Medicare Advantage plan requirement, reach out to the payer directly before providing services to the beneficiary. That way, you'll know exactly how to proceed so your patient receives the treatment he or she needs—and you get paid (just another reason to implement a thorough insurance verification step in your intake process).

With all that in mind, let's discuss some of the main differences between Medicare and Medicare Advantage rules (adapted from a presentation that compliance expert Rick Gawenda, PT, gave at Ascend 2018):

Occupational Therapist Salary Guide - Regular BannerOccupational Therapist Salary Guide - Small Banner

Medicare requires providers to adhere to the 8-Minute Rule; MA plans may not.

As we explained here, “The 8-Minute Rule governs the process by which rehab therapists determine how many units they should bill to Medicare for the outpatient therapy services they provide on a particular date of service.” In short, the 8-Minute Rule requires that therapists provide direct, one-on-one therapy for at least eight minutes to bill Medicare for a time-based code. While some commercial insurance companies also require that providers adhere to the 8-Minute Rule, others use the Substantial Portion Methodology (SPM), and still others allow for either. While both calculation methods require at least eight minutes of direct treatment per code, there is no cumulative component to SPM, so “if your leftover minutes come from a combination of services, you cannot bill for any of them unless one individual service totals at least eight minutes.” That said, in some cases, you might be able to bill for more units using SPM, so if the MA plan doesn't have a preference, then it may behoove you to run the calculations for both.

Medicare requires rehab therapists to obtain a physician-certified POC; MA plans may not.

As we discussed here, Medicare requires that all patients receiving physical, occupational, or speech therapy treatment be under the active care of a physician, which means therapy providers must “obtain a signed [and dated] plan of care certification within 30 days of a Medicare patient's initial therapy visit.” Now, Medicare does not require that the certification come from the patient's primary care physician—nor does it require that therapists obtain certification prior to initiating treatment. That said, to ensure that you'll receive payment, you'll want to be confident that you can obtain POC certification in a timely manner before providing services. Because MA plans are run by commercial companies, some may adhere to Medicare's POC certification rule—and some may not. In fact, while Medicare does not require patients to obtain prior authorization before receiving therapy services, some MA plans do. So, to ensure you're always in compliance, check with the specific MA plan provider—as well as your state practice act—before providing services. As a reminder, if an insurance company and your state practice act have different requirements, you should always adhere to the most stringent rule.

Medicare has an annual therapy threshold and modifier requirements; MA plan providers may not.

In February 2018, Medicare repealed the hard therapy cap and replaced it with a soft cap—also known as the therapy threshold. That means that providers must continue to track their Medicare beneficiaries' progress toward the soft cap and affix the KX modifier to claims for medically necessary services that exceed the threshold. While some commercial payers have also instituted a threshold, others have not. So, you'll want to follow up with each plan provider to learn its stance on the threshold—and modifier use. And speaking of modifier use, you'll also want to confirm whether you must include the therapy-specific modifiers that Medicare requires (i.e., GP, GN, and GO) on claims you submit to the MA plan provider.

Medicare requires providers to complete its reporting programs; MA plans may not.

Medicare programs such as the now-defunct PQRS, the soon-to-be-discontinued functional limitation reporting, and the soon-to-be-in-effect-for-therapists MIPS are—or were—Medicare musts. However, MA plans may not have the same reporting requirements as their traditional counterparts. If you're ever unsure about the requirements for a certain plan, double-check with the plan provider.

Medicare requires providers to use ABNs to communicate patient financial responsibilities; MA plans do not.

Medicare requires that providers use Advance Beneficiary Notices of Noncoverage (ABNs) to notify Medicare beneficiaries that Medicare may not cover the therapy services that they are electing to receive. As this is a Medicare-only form, it's only appropriate for original Medicare patients. For patients with MA coverage, you'll want to reach out to the payer to learn its requirements for handling patient responsibility.


There you have it: the rules for Medicare vs. Medicare Advantage. If you're wondering how all the Medicare variants—original (Parts A and B), Advantage, Supplemental (Part C), and Prescription (Part D)—work, check out this post.

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