“Medicare Quick Bites” is your weekly treat of Medicare information. Hawaii SHIP has created these bite-sized lessons to help you understand this complex federal health insurance, thus “Making Medicare Digestible!” Follow us on Facebook or Twitter to get your weekly delivery of Medicare Quick Bites! This week’s treat is Pre-Service Organization Determination.
This prior authorization for Part C Medicare Advantage (MA) plans is similar to the Advanced Beneficiary Notice of Noncoverage posted in last week’s blog. A beneficiary, or their representative or provider, can request a decision from the MA plan to find out if the plan will or will not cover a service, drug, or supply. A fast decision can be requested based on the beneficiary’s health needs.
If a plan provider refers the beneficiary outside the network for a service or to a provider and doesn’t get an organization determination in advance, this is known as “plan directed care.” In most cases the beneficiary won’t have to pay more than the plan’s usual cost sharing. Check with the plan for more information about this protection.