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Who Are Dually Eligible Beneficiaries?

Dually eligible beneficiaries are those who qualify for Medicare Part A (hospital insurance), Part B (medical insurance), or both, and receive full Medicaid benefits or assistance with Medicare premiums and cost-sharing through specific Medicare Savings Programs (MSPs). The primary MSP categories include:

• Qualified Medicare Beneficiary (QMB): Covers Part A and Part B premiums, deductibles, coinsurance, and copayments.
• Specified Low-Income Medicare Beneficiary (SLMB): Covers only Part B premiums.
• Qualifying Individual (QI): Covers only Part B premiums for individuals who are not eligible for any other Medicaid benefits.
• Qualified Disabled Working Individual (QDWI): Covers Part A premiums for certain individuals under 65 who have returned to work.

Medicare is generally the primary payer for services, with Medicaid covering additional costs that Medicare does not, such as long-term care or home-based services.

Billing Prohibitions and Requirements

Healthcare providers must be particularly mindful when billing dually eligible beneficiaries, especially those under the QMB program. Key points include:

• Billing Prohibitions: Providers cannot bill QMB beneficiaries for Medicare Part A and B cost-sharing, such as deductibles, coinsurance, and copayments. Even if Medicaid does not fully cover these amounts, the provider must accept the Medicare and Medicaid payments as payment in full.
• Assignment Requirement: Providers must accept assignment, meaning they agree to accept the Medicare-approved amount as full payment for services provided to dually eligible beneficiaries.
• Advance Beneficiary Notice (ABN): In some cases, providers may issue an ABN if they expect Medicare to deny a service as not medically necessary. However, providers cannot charge the beneficiary up front and must follow specific guidelines if they plan to shift financial responsibility to the patient.

Important Resources

For further details and guidelines, healthcare providers can refer to:

• Medicare Claims Processing Manual, Chapter 1
• Medicare & Medicaid Basics

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Chronic Care Management (CCM) services are essential in the ongoing care of patients with multiple chronic conditions, offering continuous support and coordination of care to improve health outcomes and reduce healthcare costs. The Centers for Medicare & Medicaid Services (CMS) recognizes CCM as a critical service and provides reimbursement for these non-face-to-face services under the Medicare Physician Fee Schedule (PFS).

What Are Chronic Care Management Services?

CCM services focus on the comprehensive management of patients with two or more chronic conditions that are expected to last at least 12 months or until the patient’s death. These conditions place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline. Examples of chronic conditions include diabetes, hypertension, heart failure, asthma, and chronic kidney disease.

CCM services typically include:

• Structured Recording of Patient Health Information: Maintaining accurate and up-to-date patient health records is vital for ongoing care.
• Comprehensive Care Plan: Developing, implementing, and updating a patient-centered care plan that addresses all health issues, with a focus on managing chronic conditions.
• Care Coordination: Ensuring that all healthcare providers involved in a patient’s care are informed and coordinated, including referrals, transitions between healthcare settings, and communication with community-based services.
• Access to Care: Providing patients with 24/7 access to care and health information, ensuring continuity of care and addressing urgent needs promptly.

Who Can Provide CCM Services?

CCM services can be provided by a variety of healthcare practitioners, including:

• Physicians
• Nurse Practitioners (NPs)
• Physician Assistants (PAs)
• Clinical Nurse Specialists (CNSs)
• Certified Nurse Midwives (CNMs)

These services are often provided by clinical staff under the general supervision of a billing practitioner, meaning the practitioner oversees the services but does not need to be physically present when they are delivered.

Billing and Coding for CCM Services

CCM services are billed using specific Current Procedural Terminology (CPT) codes that correspond to the complexity and duration of the services provided. Some of the relevant CPT codes include:

• 99490: Non-complex CCM services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
• 99487: Complex CCM services, first 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
• 99491: CCM services provided personally by a physician or other qualified healthcare professional, first 30 minutes, per calendar month.

Healthcare providers must ensure accurate and compliant billing practices, as improper billing can lead to denied claims or audits.

Patient Eligibility and Consent

Before initiating CCM services, healthcare providers must confirm that patients meet the eligibility criteria—having two or more chronic conditions—and obtain the patient’s consent. This consent must inform the patient of the nature of CCM services, their cost-sharing responsibilities, and their right to stop services at any time.

The Role of CCM in Reducing Healthcare Disparities

CCM services are particularly important in addressing healthcare disparities, especially for patients in rural or underserved areas. By providing continuous care and support, CCM can help manage chronic conditions more effectively, reducing the need for more costly interventions such as emergency room visits or hospital admissions.

For more detailed information on billing and guidelines, healthcare providers can refer to the CMS Chronic Care Management Services Guide.

Image Prompt Suggestion:

“A healthcare provider in a clinical setting, reviewing a patient’s comprehensive care plan on a computer. The scene shows the provider focusing on detailed patient information, with a calendar and medical charts in the background, emphasizing the continuous and coordinated nature of Chronic Care Management services.”

• H1: Comprehensive Guide to Chronic Care Management (CCM) Services
• H2: What Are Chronic Care Management Services?
• H2: Who Can Provide CCM Services?
• H2: Billing and Coding for CCM Services
• H2: Patient Eligibility and Consent
• H2: The Role of CCM in Reducing Healthcare Disparities

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Key Points of CR 13610:

1. Manufacturer Exit Scenarios

This update addresses situations where a wheelchair manufacturer discontinues operations—whether through business closure or bankruptcy—resulting in the wheelchair no longer being available on the market. When aftermarket parts are unavailable, making the existing equipment inoperable, beneficiaries may need to replace their wheelchairs entirely. This update allows Medicare to consider such equipment as “lost” under federal regulations, thus permitting the issuance of replacement equipment.

2. Replacement Equipment and Claims Processing

Under the new guidelines, when a manufacturer exits the business and no aftermarket parts are available, Durable Medical Equipment (DME) suppliers can process claims for replacement wheelchairs. Suppliers must include the appropriate Healthcare Common Procedure Coding System (HCPCS) code for the replacement equipment along with specific HCPCS modifiers such as RA (Replacement of a DME Item) and KH (Initial Claim, Purchase, or First Month Rental) when applicable. This ensures that the claim is processed correctly and the replacement equipment is provided under the new 13-month capped rental period, starting from the date the new equipment is furnished.

3. Prior Authorization Requirements

Suppliers are required to submit a Prior Authorization Request (PAR) before furnishing the new wheelchair to the beneficiary and submitting a claim for processing. This step is crucial to ensure that the replacement equipment meets Medicare coverage criteria and that the claim will be reimbursed. Suppliers must include a narrative stating that the replacement is due to the manufacturer exiting the business, which should be submitted through the proper electronic claim formats or noted on the CMS-1500 claim form.

4. Exemptions and Clarifications

It’s important to note that this replacement policy does not apply if repair parts are available from sources other than the original manufacturer. The policy also does not apply if the wheelchair does not yet require repairs or replacement parts. Suppliers must ensure that these conditions are met before processing a replacement claim under this new directive.

Impact on Beneficiaries and Providers

This update is significant for both beneficiaries who rely on power or manual wheelchairs and the providers who supply and maintain this equipment. By allowing for the replacement of wheelchairs when the manufacturer exits the market and no parts are available, CMS is ensuring that beneficiaries continue to have access to the mobility aids they need. For providers, this update clarifies the process for submitting claims in these specific circumstances, helping to avoid claim denials and ensuring timely reimbursement.

Conclusion

CMS’s CR 13610 provides clear and essential guidance for managing the replacement of wheelchair equipment in scenarios where the manufacturer exits the business. By adhering to these guidelines, DME suppliers can ensure compliance with Medicare requirements while continuing to meet the needs of their patients.

For more detailed information and to stay updated on further changes, DME suppliers should consult the official CMS documentation or contact their Medicare Administrative Contractor (MAC).

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Key Updates for FY 2025:

1. Hospice Payment Rates

For FY 2025, the hospice payment update percentage is based on the inpatient hospital market basket, which is set at 3.4%. However, this percentage must be reduced by a multifactor productivity (MFP) adjustment of 0.5 percentage points, resulting in a final hospice payment update of 2.9%. This update applies to the payment rates for all levels of hospice care, including Routine Home Care, Continuous Home Care, Inpatient Respite Care, and General Inpatient Care.

Hospice providers who do not submit the required quality data will face a reduction in their payment rates. Specifically, the payment update percentage for these providers will be reduced by 4 percentage points, resulting in a net decrease, with an update rate of -1.1%. This emphasizes the importance of timely and accurate quality data submission to avoid significant financial penalties.

2. Hospice Cap Amount

The hospice cap amount for FY 2025 has been updated to $34,465.34, reflecting a 2.9% increase from the FY 2024 cap amount of $33,494.01. This cap applies to the aggregate amount that a hospice provider can be reimbursed for services rendered within the cap year, which spans from October 1, 2024, to September 30, 2025.

3. Hospice Wage Index

The hospice wage index is adjusted annually to account for local variations in wages. For FY 2025, CMS continues to implement a 5% cap on any decreases to a geographic area’s wage index. This cap helps mitigate significant negative impacts on hospice providers in areas where wage index adjustments could otherwise result in substantial payment reductions. CMS has also incorporated revised delineations from the Office of Management and Budget (OMB) into the hospice wage index, ensuring that wage index values are reflective of current geographic and economic realities.

4. Labor and Non-Labor Shares

The labor and non-labor shares used to wage-adjust hospice payments for each level of care have been revised. For instance, the labor share for Routine Home Care (days 1-60) is now 66.00%, with the corresponding non-labor share at 34.00%. These adjustments ensure that hospice payments more accurately reflect the cost of providing care.

Importance for Hospice Providers

These updates underscore the necessity for hospice providers to remain vigilant in their billing practices, particularly in the areas of wage index coding and quality data submission. Failure to comply with CMS requirements can result in significant payment reductions, which could impact the financial viability of hospice services.

Conclusion

CMS’s CR 13707 brings several critical changes for FY 2025, with a focus on ensuring fair and accurate payment adjustments for hospice services. By staying informed and compliant with these updates, hospice providers can optimize their reimbursement processes and continue delivering high-quality care to their patients.

For more detailed information and guidance on these changes, hospice providers should refer to the official CMS documentation or consult their Medicare Administrative Contractor (MAC).

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Key Changes Introduced by CR 13241:

1. 2% Payment Reduction for Non-Submission of Quality Data

Since the Deficit Reduction Act (DRA) of 2005, CMS has implemented a pay-for-reporting requirement for Medicare home health services. Beginning in calendar year 2007, and continuing each subsequent year, HHAs that fail to submit required quality data are subject to a 2% reduction in their Annual Payment Update (APU). This reduction is a significant penalty, intended to enforce compliance with quality data submission requirements.

The quality data that must be submitted includes:

• OASIS Data: This data must be submitted for all episodes beginning on or after July 1 of the previous year and before July 1 of the current year. OASIS data is crucial for evaluating patient outcomes and ensuring high standards of care.
• HHCAHPS Data: Monthly data collection and submission for HHCAHPS must be completed from April 1 of the prior year through March 31 of the current year. This data reflects patient experiences and satisfaction with the care provided by HHAs.

2. Exemption Criteria for HHCAHPS Data Submission

CMS acknowledges that not all HHAs have a large enough patient base to submit HHCAHPS data. Therefore, HHAs that have served 59 or fewer HHCAHPS-eligible patients in the year immediately prior to the data collection year are exempt from the HHCAHPS submission requirement. These agencies must submit a Participation Exemption Request form to CMS to be granted this exemption. It is important for agencies to accurately count their patients and submit the exemption form if eligible, to avoid the 2% payment reduction.

3. Notification and Reconsideration Process

CMS will issue Technical Direction Letters (TDLs) to Medicare contractors, providing lists of HHAs that have not complied with the quality data submission requirements. Contractors are then responsible for notifying these agencies about the impending 2% reduction. The notification must clearly state whether the non-compliance pertains to OASIS, HHCAHPS, or both, and include the necessary steps to request reconsideration if the HHA believes it has been wrongly identified.

HHAs wishing to dispute the reduction have 30 days from the date of the notification letter to submit a reconsideration request. This request must be accompanied by documentation that supports compliance with the quality data submission requirements. It is crucial that HHAs provide clear and relevant documentation, as CMS will not contact the agency for additional information if the initial submission is incomplete.

4. CMS Review and Final Determination

Once CMS reviews the reconsideration request and supporting documentation, they will issue a final determination. If CMS upholds the 2% reduction, the HHA has the option to appeal the decision through the Provider Reimbursement Review Board (PRRB). If the reduction is reversed, the HHA will receive their full APU for the upcoming year.

Implications for Home Health Agencies

This update reinforces the importance of timely and accurate submission of quality data for HHAs. The 2% payment reduction is a significant financial penalty that can impact the operational sustainability of an agency. Therefore, HHAs must be diligent in their data collection, submission processes, and compliance with CMS requirements to avoid penalties.

For agencies that find themselves subject to the payment reduction, the reconsideration process offers a crucial opportunity to contest the decision. However, this process requires careful preparation and documentation to successfully overturn the penalty.

Conclusion

CMS’s CR 13241 represents a continued effort to enforce quality standards in home health care by linking payment updates to the submission of essential quality data. HHAs must take these requirements seriously and ensure compliance to avoid financial penalties that could adversely affect their operations.

For more information and detailed guidance on compliance, HHAs should consult the official CMS documentation or contact their Medicare Administrative Contractor (MAC).

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