Medicare Advantage Plan (Part C) and Prescription Drug Plan (Part D) Liens

Over the past few years, the reimbursement rights of Medicare Advantage Plans and Medicare Prescription Drug Plans have become a very hot topic. With more litigation arising across the country, clients must pay special attention to these plans when settling cases.

Under "traditional" Medicare, beneficiaries receive coverage through Part A (hospital insurance) and Part B (medical insurance). Medicare beneficiaries may choose to enroll in a Medicare Advantage Plan under Part C as an alternative to traditional Medicare. Medicare Advantage Plans are offered by private health insurers as a replacement for coverage under traditional Medicare. If a beneficiary is enrolled in a Medicare Advantage Plan, the plan pays for the beneficiary's treatment that would otherwise be covered under Parts A and B. In addition to benefits that are otherwise payable under traditional Medicare, some Advantage plans also provide prescription coverage. Medicare beneficiaries may also receive prescription drug coverage by enrolling in a Prescription Drug Plan under Part D. Like Medicare Advantage Plans, Prescription Drug Plans are offered by private health insurers.

It is important to keep in mind when resolving conditional payment claims, that the conditional payment letters issued by the new Benefits Coordination Recovery Center (BCRC), formerly the Medicare Secondary Payer Recovery Contractor (MSPRC), ONLY apply to payments made under Parts A and B of traditional Medicare. They do NOT include information concerning Medicare Advantage or Prescription Drug plan liens. If a beneficiary is enrolled in a Medicare Advantage or Prescription Drug plan, the identity of that plan should be determined and the plan should be contacted individually to determine whether it intends to assert a lien.

The problem with Medicare Advantage and Part D Plans is the difficulty associated with discovering their existence, particularly if a beneficiary has changed plans. Unfortunately, although we are usually able to determine a beneficiary's current plan and see how long he or she has been enrolled, determining the existence of any prior plans is much more difficult. It requires significant additional research along with communication with the beneficiary. Once the lien information is received, we advocate aggressively to obtain the lowest claim possible. This entire process involves a great deal of time and effort.

Since Advantage and Part D Plans are clearly legally entitled under the MSPA to recover payments made on behalf of a Medicare beneficiary, the existence of such plans and any potential claims for reimbursement should be determined before a settlement is finalized. Given the current split in court decisions concerning Advantage plans' right to sue primary plans directly in federal court, Advantage plans are filing more lawsuits now seeking recovery than ever before. Whether they can sue a primary payer directly in federal court or not, their right to recover is undisputed and should not be ignored.

If you have any questions concerning Medicare Advantage Plans or Medicare Prescription Plans, please do not hesitate to contact us. We will be more than happy to discuss this important issue with you and help ensure that you are protected.