Medicare Advantage
Medicare Advantage (Part C) plans provide Medicare coverage through private health insurance companies approved to participate in the Medicare program. These plans include all benefits covered under Original Medicare—Part A (hospital insurance) and Part B (medical insurance)—and often offer additional services, such as wellness programs and other supplemental benefits. Most Medicare Advantage plans also include prescription drug coverage (Part D).
Compared to Original Medicare, Medicare Advantage plans typically feature lower overall cost sharing and include an annual maximum out of pocket limit, helping protect members from high healthcare expenses.
Medicare Advantage Cost Components
Medicare Advantage costs generally fall into the following categories:
- Premiums: Members must continue to pay their Medicare Part B premium and may also pay a separate monthly premium for the Medicare Advantage plan.
- Deductibles: Some plans require members to pay a deductible before the plan begins to cover healthcare services or prescription drugs.
- Copayments: Copayments are fixed amounts members may pay for certain services, such as office visits, outpatient care, or prescription medications.
- Coinsurance: Coinsurance is the percentage of costs a member may be responsible for after meeting any applicable deductible.
- Out of Pocket Limit: All Medicare Advantage plans include an annual maximum out of pocket limit—a feature not available with Original Medicare.
Star Ratings and Quality Improvement
Each year, the Centers for Medicare & Medicaid Services (CMS) publishes Medicare Star Ratings to help beneficiaries choose high quality health care coverage. Plans are rated on a one to five star scale, with five stars indicating excellent performance. Ratings are based on measures such as patient satisfaction, preventive care, medication adherence, access to care, and administrative effectiveness. Your partnership as a provider is essential to achieving strong Star Ratings and ensuring members receive timely, appropriate, and coordinated care.
BlueCross BlueShield of South Carolina supports Medicare Advantage providers with dedicated resources, including a Quality Navigator—a registered nurse who visits your practice to collaborate on improving health outcomes. The Quality Navigator shares information on clinical programs, quality initiatives, financial incentive opportunities, and new benefits available to Medicare Advantage members.
As part of the Medicare Advantage quality program, BlueCross BlueShield of South Carolina is required to annually collect and review medical records to track the completion of key health services. We appreciate your prompt response to medical record requests. To reduce administrative burden, practices may grant the Quality Navigator direct EMR access to obtain necessary documentation.
Together, we can improve health outcomes and deliver a positive, high quality experience for every Medicare Advantage member.
Local Coverage Determinations and National Coverage Determinations
BlueCross BlueShield of South Carolina applies both Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) when adjudicating Medicare claims to ensure services meet Medicare coverage requirements.
LCDs are region‑specific coverage policies developed by Medicare Administrative Contractors (MACs). They define whether particular services, procedures, or technologies are reasonable and necessary for Medicare beneficiaries within a specific geographic area. LCDs may include detailed criteria such as covered indications, documentation requirements, limitations, and coding guidelines.
NCDs are issued by CMS and apply nationwide. These determinations establish uniform coverage rules for specific services or items across all states and take precedence over LCDs when applicable. NCDs are typically based on national evidence reviews and set consistent standards for coverage, indications, and utilization.
When processing claims, BlueCross BlueShield of South Carolina follows applicable NCDs first. If no NCD exists for a service, the appropriate LCD is applied. Providers are encouraged to review relevant LCDs and NCDs when ordering or performing services to confirm coverage requirements, support accurate documentation, and help reduce claim denials or delays.