Saturday, September 30, 2017

Medicare offers more health coverage and decreased premiums in 2018

Medicare offers more health coverage choices and decreased premiums in 2018 

According to CMS

Medicare Advantage premiums decrease, choices increase, while enrollment hits an at all-time high

Today, the Centers for Medicare & Medicaid Services (CMS) announced that people with Medicare will have more choices and options for their Medicare coverage in 2018. As CMS releases the benefit and premium information for Medicare health and drug plans for the 2018 calendar year, the average monthly premium for a Medicare Advantage plan will decrease while enrollment in Medicare Advantage is projected to reach a new all-time high. Earlier this year, CMS announced new policies that support increased benefit flexibilities allowing Medicare Advantage plans the ability to offer innovative plans that fit the needs of people with Medicare.  

"More affordable choices lead to greater health security for those who need it most,” said Health and Human Services Secretary Tom Price, M.D. “Both Medicare Advantage and Medicare Part D are providing a higher level of health security for so many of America’s seniors precisely because they are built to be more responsive to their needs. Today's news, alongside the long-term trend of more folks choosing Medicare Advantage, is a testament to the power of a more patient-centered approach to healthcare.”

“The success of Medicare Advantage and the prescription drug program demonstrates what a strong and transparent health market can do—increase quality while lowering costs,” said CMS Administrator Seema Verma. “When Americans are empowered to choose the healthcare plans that fit their needs and the needs of their families, they demand more from their insurance plans and in turn healthcare plans, like any business, provide customers better service at a lower cost. 

CMS estimates that the Medicare Advantage average monthly premium will decrease by $1.91 (about 6 percent) in 2018, from an average of $31.91 in 2017 to $30. More than three-fourths (77 percent) of Medicare Advantage enrollees remaining in their current plan will have the same or lower premium for 2018.

Medicare Advantage enrollment is projected to increase to 20.4 million in 2018, a nine percent increase compared to 2017. More than a one-third of all Medicare enrollees (34 percent) are projected to be in a Medicare Advantage plan in 2018.

Access to the Medicare Advantage program remains strong, with 99 percent of people with Medicare having access to a Medicare Advantage plan. The number of Medicare Advantage plans available to individuals to choose from across the country is increasing from about 2,700 to more than 3,100– and more than 85 percent of people with Medicare will have access to 10 or more Medicare Advantage plans. In addition, more Medicare Advantage enrollees are projected to have access to important supplemental benefits such as dental, vision, and hearing benefits.

Medicare Part D prescription drug program access will also remain strong in 2018 with 100 percent of people with Medicare having access to a stand-alone prescription drug plan. Earlier this year, CMS announced that the average basic premium for a Medicare prescription drug plan in 2018 is projected to decline to an estimated $33.50 per month. This represents a decrease of approximately $1.20 below the average basic premium of $34.70 in 2017. The Medicare prescription drug plan average basic premium is projected to decline for the first time since 2012.

This fall, CMS is undertaking several consumer-friendly improvements for Medicare Open Enrollment so that people with Medicare can make an informed choice between Original Medicare and Medicare Advantage. Some of the improvements include:

Changes in the “Medicare & You” handbook to better explain coverage options;Establishing a help wizard on that will point to resources to help make informed healthcare decisions; andEstablishing a new email communication opportunity to improve the customer service experience through important messages and reminders.

Medicare Open Enrollment for 2018 Medicare health and drug plans begins on October 15, 2017, and ends December 7, 2017. Plan costs and covered benefits can change from year to year. People with Medicare should look at their coverage choices and decide the options that best fits their health needs. They can visit (, call 1-800-MEDICARE, or contact their State Health Insurance Assistance Program (SHIP). Those people with Medicare who do not wish to change their current coverage do not need to re-enroll in order to keep their current coverage.

For more information on the premiums and costs of 2018 Medicare health and drug plans, please visit:

For a fact sheet on Medicare Advantage and Part D in 2018, please visit:

For more information on Medicare Open Enrollment, including state-by-state fact sheets, please visit: 

Medicare beneficiaries and providers rights

Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Fee-for-Service (FFS) Medicare and the Medicare Advantage (MA) Programs.

These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers:

FFS Advance Beneficiary Notice of Noncoverage (FFS ABN)

FFS Home Health Change of Care Notice (FFS HHCCN)

FFS Skilled Nursing Facility Advance Beneficiary Notice (FFS SNFABN)

and SNF Denial LettersFFS Hospital-Issued Notices of Noncoverage (FFS HINNs)

FFS Expedited Determination Notices for Home Health Agencies, Skilled Nursing Facility, Hospice and Comprehensive Outpatient Rehabilitation Facility  (FFS Expedited Determination Notices)

MA Denial Notices (MA Denial Notices)

MA Expedited Determination Notices (MA Expedited Determination Notices)

Important Message from Medicare (IM)

and Detailed Notice of Discharge (DND)

(Hospital Discharge Appeal Notices)
FFS Notice of Exclusion from Medicare Benefits - Skilled Nursing Facility (FFS NEMB SNF

Biosimilar modifiers for payment

 the 2016 Physician Fee Schedule Final Rule, CMS updated the regulation text found at 42 CFR 414.904(j) to make clear that effective January 1, 2016, the payment amount for a biosimilar biological drug product is based on the average sales price of all NDCs assigned to the biosimilar biological products included within the same billing and payment code. In general, this means that CMS will group biosimilar products that rely on a common reference product’s biologics license application into the same payment calculation, and these products will share a common payment limit and HCPCS code.

In order to provide CMS with the ability to track claims payment and to develop a better understanding of the use of specific biosimilar products in Medicare Part B, claims for separately paid biosimilar biological products will be required to include a modifier that identifies the manufacturer of the specific product. Modifiers will be used to distinguish between biosimilar products that appear in the same HCPCS code but are made by different manufacturers. CMS will issue HCPCS codes for biosimilar biological products and will issue and assign modifiers to specific biosimilar products in each HCPCS code. The assignments will be published on this webpage. The use of the modifiers on claims for biosimilar products that appear on this webpage is mandatory. However, if a HCPCS code and corresponding biosimilar modifier(s) do not appear on the quarterly update, then a modifier is not required to appear on claims for the code. New biosimilar products that are not adequately described by an existing unique HCPCS code may be billed under a miscellaneous code or “not otherwise classified” code such as J3590. Similarly, a “not otherwise classified” code may also be used in situations where an existing biosimilar HCPCS code is associated with a corresponding modifier that is not yet in effect in the claims processing system. The manufacturer modifier is not required on claims that use a miscellaneous HCPCS code.

Please note that the determination of the payment amount for biosimilars is not affected by the use of a modifier.

The table below lists the current biosimilar HCPCS Codes, the product(s) that are associated with each code and the corresponding required modifier that is used to identify the product. The table will be updated quarterly when new permanent HCPCS codes and modifiers are available for biosimilar products that appear on the ASP price file.

Biosimilar HCPCS CodeProduct Brand namesCorresponding Required

ModifierQ5101 Injection, Filgrastim (G-CSF), Biosimilar, 1 microgramZarxioZA - Novartis/SandozQ5102 Injection, infliximab, biosimilar, 10 mgInflectraZB - Pfizer/HospiraQ5102 Injection, infliximab, biosimilar, 10 mgRenflexis

ZC –Merck/Samsung Bioepis           (see note below)

Note: The ZC modifier will become effective, that is, valid for claims submitted beginning October 1, 2017 and applies retroactively to dates of service on or after July 24, 2017.

Friday, September 29, 2017

Texas top claim submission / Reason code errors - August 2017

Texas Top Claim Submission / Reason Code Errors - August 2017


Explanation of Medicare Benefits Message





Non-covered charge.

Prior to performing or billing a service, ensure that the service is covered under Medicare. Please refer to the Centers for Medicare & Medicaid Services Internet Only Manual, 100-02, Chapter 16.



Claim not covered by this payer/contractor.

This denial indicates that the service is one that is processed or paid by another contractor.

Examples of these types of service are:

Durable Medical Equipment

Hospice related services

Medicare Advantage

You must send the claim to the correct payer/contractor.



Duplicate claim/service.

Please check claim status through the IVR to see if another claim was paid or is currently being processed. To prevent duplicate denials, allow us sufficient time to process a claim before submitting a second.



These are non-covered services because this is not deemed a 'medical necessity' by the payer.

Please ensure to follow Medicare guidelines, national and local coverage determinations for the service billed.


CMS Internet Only Manuals

CMS National Coverage Determinations Manual, Pub. 100-03

Novitas Local Coverage Determinations

Thursday, September 28, 2017

Important : BCBS New id format

All of the BCBS plans have been posting announcements about the new alpha/numeric prefixes that they’re going to be rolling out next year. Below is the announcement that Anthem put in a recent newsletter:

New member ID prefixes coming in 2018 The Blue Cross and Blue Shield Association (BCBSA) assigns member ID prefixes for all Blue Cross and Blue Shield branded Plans – Anthem Plans as well as non-Anthem Plans. There are a limited number of unused three-character, alpha only prefixes remaining, and they are expected to be exhausted in the 2nd or 3rd quarter of 2018. When that happens, the BCBSA will begin assigning prefixes that contain a combination of letters and numbers, or alpha-numeric prefixes.

What does this mean to you?

It will be even more important to ask your patients for their most recent identification (ID) card.When submitting claims, enter the identification number exactly as it appears on the member’s ID card.Check your EDI Software to make sure it can accept alpha-numeric prefixes.Check any internal documents you may have and update any references of “alpha prefix” to “prefix”.

Note: Current three-character, alpha-only prefixes will not be affected by this change. Current prefixes will still be valid once the new alpha-numeric prefixes are issued, unless there is another need to change or remove a prefix currently in use.

Tuesday, August 22, 2017

Propose new codes for telehealth Services

G0296 counselling visit for lung cancer screening
G0506 comprehensive assessment for CCM
CPT code 90785 interactive complexity
CPT code 90839 and 90840 psychotherapy for crisis
CPT codes 96160 and 96161 patient focused health risk assessment

Tuesday, August 15, 2017

Next Generation accountable care organization model (NGACO Model)

Next Generation Accountable Care Organization Model (NGACO Model)


The Centers for Medicare & Medicaid Services (CMS) has launched a new accountable care organization (ACO) model called the Next Generation ACO Model (NGACO Model). The twenty-one ACOs participating in the NGACO Model in 2016 have significant experience coordinating care for populations of patients through initiatives, including, but not limited to, the Medicare Shared Savings Program and the Pioneer ACO Model. Building on experience from the Pioneer ACO Model and the Medicare Shared Savings Program, through this new model, CMS will partner with ACOs that are experienced in coordinating care for populations of patients and whose provider groups are ready to assume higher levels of financial risk and reward. This is in accordance with the Administration’s goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to alternative payment models, such as ACOs, by the end of 2016 -- and 50 percent by the end of 2018.

Medicare ACOs have grown to over 477 nationwide, currently serving nearly 8.9 million beneficiaries since the Medicare Shared Savings Program and Pioneer ACO Model began in 2012. The results from the past 4 years have demonstrated that ACOs can provide better quality of care for beneficiaries while producing savings.

Selected Organizations

The NGACO Model organizations represent a variety of provider organizations and geographic regions, and were selected by fulfilling specific eligibility criteria outlined in the Request for Applications found at the Next Generation ACO Model web page. These organizations were selected through an open and competitive process from a large applicant pool that included many qualified organizations.

The 21 organizations participating in the NGACO Model in 2016:

NGACO Model Name Location
Accountable Care Coalition of Southeast Texas Inc. Houston, Texas
Baroma Accountable Care, LLC Miami, Florida
Beacon Health Brewer, Maine
Bellin Health DBA Physician Partners Green Bay, Wisconsin
Cornerstone Health Enablement Strategic Solutions (CHESS) High Point, North Carolina
Deaconess Care Integration Evansville, Indiana
Henry Ford Physician Accountable Care Organization Detroit, Michigan
Iowa Health Accountable Care West Des Moines, Iowa
Optum Accountable Care Organization Phoenix, Arizona
MemorialCare Regional ACO Fountain Valley, California
OSF Healthcare System Peoria, Illinois
Park Nicollet Health Services St. Louis Park, Minnesota
Pioneer Valley Accountable Care Springfield, Massachusetts
Prospect ACO CA Los Angeles, California
Regal Medical Group Northridge, California
River Health ACO Harrisburg, Pennsylvania
Steward Integrated Care Network Boston, Massachusetts
ThedaCare ACO Appleton, Wisconsin
Triad HealthCare Network Greensboro, North Carolina
Trinity Health ACO Livonia, Michigan
WakeMed Key Community Care Raleigh, North Carolina

The NGACO Model’s Core Principles

Protect Original Medicare beneficiaries’ freedom to seek the services and providers of their choice;
Engage beneficiaries in their care through benefit enhancements designed to improve the patient experience and reward seeking care from ACOs;
Create a financial model with long-term sustainability;
Utilize a prospectively-set benchmark that: (1) rewards quality; (2) rewards both improvement and attainment of efficiency; and (3) ultimately transitions away from an ACO’s recent expenditures when setting and updating the benchmark;
Mitigate fluctuations in aligned beneficiary populations and respect beneficiary preferences by supplementing a prospective claims-based alignment process with a voluntary process; and
Smooth ACO cash flow and support investment in care improvement capabilities through alternative payment mechanisms.
Medicare ACOs are comprised of groups of doctors, hospitals, and other health care providers and suppliers who come together voluntarily to provide coordinated, high-quality care at lower costs to their Original Medicare patients. ACOs are patient-centered organizations where the patient and providers are true partners in care decisions. Participating patients will see no change in their Original Medicare benefits and will keep their freedom to see any Medicare provider. Provider participation in ACOs is also voluntary. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

The goal of care coordination is to ensure that patients, especially those with chronic conditions, get the right care at the right time while avoiding medical errors and unnecessary duplication of services. Any patient who has multiple doctors has experienced the frustration of fragmented and disconnected care: lost or unavailable medical charts; duplicated medical procedures and tests; difficulty scheduling appointments; or having to share the same information repeatedly with different doctors. ACOs are designed to lift this burden from patients, while improving the partnership between patients and doctors in making health care decisions. Medicare beneficiaries will have better control over their health care, and providers will have better information about their patients’ medical history and better relationships with their patients’ other providers. For providers, ACOs hold the promise of realigning the practice of medicine with the ideals of the profession—keeping the focus on patient health and the most appropriate care.

Medicare beneficiaries whose doctors participate in an ACO will still have freedom of choice among providers and can still choose to see providers outside of the ACO. Patients choosing to receive care from providers participating in ACOs will also have access to information about how well their doctors, hospitals, or other caregivers are meeting quality standards.

Round 2 Application Process
Round 2 Letters of Intent and applications will be made available in spring 2016.

The CMS Innovation Center
The CMS Innovation Center was created by the Affordable Care Act to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care for Medicare, Medicaid and Children’s Health Insurance Program beneficiaries.

Working in concert with the Shared Savings Program, the CMS Innovation Center is testing a number of ACO models and has sponsored learning activities that help providers form ACOs and improve their results. More information on all of these initiatives is available on the CMS Innovation Center website at