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Proposed Rule for Payment under the Ambulance Fee Schedule (AFS) published 5/26/06 (See AFS Regulations and Notices link.) Section 4531 (b) (2) of the Balanced Budget Act (BBA) of 1997 added a new section 1834 (l) to the Social Security Act which mandated the implementation of a national fee schedule for ambulance services furnished as a benefit under Medicare Part B. The fee schedule is effective for claims with dates of service on or after April 1, 2002, and it applies to all ambulance services, including volunteer, municipal, private, independent, and institutional providers, i.e., hospitals, critical access hospitals (except when it is the only ambulance service within 35 miles), and skilled nursing facilities.

Section 1834 (l) also requires mandatory assignment for all ambulance services. Ambulance providers and suppliers must accept the Medicare allowed charge as payment in full and not bill or collect from the beneficiary any amount other than any unmet Part B deductible and the Part B coinsurance amounts.

A cover sheet is provided with every year’s PUF giving detailed information concerning the amounts payable and any special circumstances pertinent for that year’s payments.

NATIONAL BREAKOUT OF GEOGRAPHIC AREA DEFINITIONS BY ZIP CODE

In response to several requests from the ambulance community for a national breakout of the geographic area definitions (rural, urban, and super rural) by zip code, we have prepared a table (see Downloads section below).  Please note that it is arranged by State (using each State’s two-letter postal abbreviation), and, within each State, all zip codes are listed.  There are two sides to the table – the current geographic area breakout on the left and the geographic area breakout under the Proposed Rule, which was published on May 26, 2006 on the right.  The Medicare contractor number and the locality are also included.  Please note that, in the far right column for each side of the table, R = Rural, Blank = Urban, and B = Super Rural.  None of the Super Rural areas has changed.  Please search for your State, then zip code within the State, and compare the two sides of the table to determine if your geographic area definition changes under the Proposed Rule discussion.

AMBULANCE SERVICES CENTER
For a one-stop resource web page focused on the informational needs and interests of Medicare Fee-for-Service (FFS) ambulance suppliers, go to the Ambulance Services Center (see under “Related Links Inside CMS” below).

Instructions on the Submission of OPPS ASP Data for Nonpass-Through Separately Payable Therapeutic Radiopharmaceuticals and Radiopharmaceuticals with Pass-Through Status. CMS has posted guidance for manufacturers who will be submitting ASP for radiopharmaceuticals in CY 2010.  These instructions can be viewed by clicking on the document.  Please note that in light of the imminent deadline for submitting ASP data for OPPS payment beginning on January 1, 2010, we encourage manufacturers wishing to submit ASP data for the January 2010 OPPS update to contact us immediately through the OPPS mailbox at OutpatientPPS@cms.hhs.gov (see Related Links Inside CMS below) so we can facilitate the submission process.

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Section 4523 of the Balanced Budget Act of 1997 (BBA) provides authority for CMS to implement a prospective payment system (PPS) under Medicare for hospital outpatient services, certain Part B services furnished to hospital inpatients who have no Part A coverage, and partial hospitalization services furnished by community mental health centers. The provisions of this section were further modified by sections 201 and 202 of the Balanced Budget Refinement Act of 1999 (BBRA).

All services paid under the new PPS are classified into groups called Ambulatory Payment Classifications or APCs. Services in each APC are similar clinically and in terms of the resources they require. A payment rate is established for each APC. Depending on the services provided, hospitals may be paid for more than one APC for an encounter.

Section 4523 of the BBA also changed the way beneficiary coinsurance is determined for the services included under the PPS. A coinsurance amount will initially be calculated for each APC based on 20 percent of the national median charge for services in the APC. The coinsurance amount for an APC will not change until such time as the amount becomes 20 percent of the total APC payment. In addition, Section 204 of the BBRA provides that no coinsurance amount can be greater than the hospital inpatient deductible in a given year.

Both the total APC payment and the portion paid as coinsurance amounts will be adjusted to reflect geographic wage variations using the hospital wage index and assuming that the portion of the payment/coinsurance that is attributable to labor is 60 percent. CMS’s final rule for the new system was published in the Federal Register on April 7, 2000 (65 FR 18434). The new system went into effect on August 1, 2000.

Source: http://www.cms.hhs.gov/HospitalOutpatientPPS/

Many seniors do not receive recommended preventive and primary care, leading to less effective and more expensive treatments. For example, 20 percent of women aged 50 and over did not receive a mammogram in the past two years, and 38 percent of adults aged 50 and over have never had a colonoscopy or sigmoidoscopy. Seniors in Medicare must pay 20 percent of the cost of many preventive services on their own. For a colonoscopy that costs $700, this means that a senior must pay $140 — a price that can be prohibitively expensive. Under health insurance reform, a senior would not pay anything for a screening colonoscopy or other preventive services. Reform will eliminate any deductibles, copayments, or other cost-sharing for obtaining preventive services, making them affordable and accessible.

Source: http://www.hhs.gov/news/press/2009pres/09/20090923b.html

The federal government pays private insurance companies on average 14 percent more for providing coverage to Medicare Advantage beneficiaries than it would pay for the same beneficiary in the traditional Medicare program. There is no evidence that this extra payment leads to better quality for Medicare beneficiaries, and all Medicare beneficiaries pay the price of these excessive overpayments through higher premiums — even the 78 percent of seniors who are not enrolled in a Medicare Advantage plan. A typical couple in traditional Medicare will pay on average nearly $90 next year to subsidize private insurance companies that do not provide their Medicare benefits. Health insurance reform will eliminate excessive government subsidies to Medicare Advantage plans, which could save the federal government, taxpayers, and Medicare beneficiaries well over $100 billion over the next 10 years.

Medicare is a health insurance program for:

• people age 65 or older,
• people under age 65 with certain disabilities, and
• people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).

Medicare has:

Part A Hospital Insurance – Most people don’t pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.

Part B Medical Insurance – Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.

Prescription Drug Coverage – Most people will pay a monthly premium for this coverage. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.

Beneficiary Notices Initiative

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.

Use the navigation tool on the left side of this page to link to the following financial liability notices and their instructions:

• FFS Revised Advance Beneficiary Notices (FFS Revised ABN)

• FFS Home Health Advance Beneficiary Notice (FFS HHABN)

• FFS Skilled Nursing Facility Advance Beneficiary Notice (FFS SNFABN) and SNF Denial Letters

• FFS Hospital-Issued Notice of Noncoverage (FFS HINNs)

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

• MA Denial Notices (MA Denial Notices)

• MA Expedited Determination Notices (MA ED Notices)

• Important Message from Medicare

• FFS Notice of Exclusion from Medicare Benefits (FFS NEMB)

• FFS Notice of Exclusion from Medicare Benefits – Home Health Agency (FFS NEMB HHA)

• FFS Notice of Exclusion from Medicare Benefits – Skilled Nursing Facility (FFS NEMB SNF)

 Related Links Inside CMS

 Medicare Program – General Information

Medicare Prescription Drug Creditable Coverage Notices

Manufacturer reporting of Average Sales Price (ASP) data: A manufacturer’s ASP must be calculated by the manufacturer every calendar quarter and submitted to CMS within 30 days of the close of the quarter.  Each report must be certified by one of the following: the manufacturer’s Chief Executive Officer (CEO); the manufacturer’s Chief Financial Officer (CFO); an individual who has delegated authority to sign for, and who reports directly to, the manufacturer’s CEO or CFO.

Manufacturers must report the ASP data to us in Microsoft Excel using the template provided in Addendum A, the ASP Data Form.  Both this and the ASP Certification Form (Addendum B), are available in the ‘Downloads’ section below.

When sending ASP data to CMS via first class mail, federal express mail, or overnight delivery, please use the following address:

Centers for Medicare & Medicaid Services
Hospital and Ambulatory Policy Group
Division of Ambulatory Services
ATTN: Medicare ASP Data
Mail Stop No. C4-01-26
7500 Security Boulevard
Baltimore, MD 21244
Phone: 410-786-0548

Please send any questions to: sec303aspdata@cms.hhs.gov.

Medicare Contractor Reporting Template for Medicare Part B Drugs – (Located in the “Downloads” section below)

As indicated in CR 4140, dated February 15, 2006, Medicare contractors shall use the Medicare Contractor Reporting Template for Part B drugs to report information on all Medicare Part B drugs not paid on a cost or prospective payment basis when payment limits are not listed in the quarterly drug pricing files, or in the OPPS Pricer. Contractors shall also use the template to report pricing information for the NOC drug billing codes. This information must be sent to CMS on a monthly basis to e-mail address: sec303aspdata@cms.hhs.gov.

New Information Regarding Medicare Payment and Coding for Drugs and Biologics (See Downloads section below for the message)

Section 303(c) of the Medicare Modernization Act of 2003 (MMA) revised the payment methodology for Part B covered drugs that are not paid on a cost or prospective payment basis. In particular, section 303(c) of the MMA amended Title XVIII of the Act by adding section 1847A, which established a new average sales price (ASP) drug payment system.  Beginning January 1, 2005, drugs and biologicals not paid on a cost or prospective payment basis will be paid based on the ASP methodology, and payment to the providers will be 106 percent of the ASP.  There are exceptions to this general rule which are listed in the latest ASP quarterly change request (CR) document.  The ASP methodology uses quarterly drug pricing data submitted to the CMS by drug manufacturers.  CMS will supply contractors with the ASP drug pricing files for Medicare Part B drugs on a quarterly basis.

Persons with Disabilities: The term “disability” refers to limited physical or cognitive capacity. It includes people with neurological and neuro-developmental conditions, such as disorders of the brain, spinal cord, peripheral nerve, and muscle (e.g., cerebral palsy, epilepsy/seizure disorders, stroke, intellectual disability/mental retardation); moderate to severe developmental delay; muscular dystrophy; and spinal cord injury. These chronic conditions interfere with functional capacity. “Disability” also includes people with other chronic health conditions that interfere with functional capacity.

Having a disability alone may not place someone at higher risk for complications from the H1N1 virus, but other factors may put a person with disabilities at higher risk.  You may be at risk if you are a:

• Young child
• Pregnant woman
• Person with arthritis
• Person with asthma
• Person with cancer
• Person with diabetes
• Person with heart disease
• Person with HIV/AIDS

Among people with disabilities, the following groups are at higher risk of acquiring the H1N1 infection:

• People who have difficultly breathing – (ventilator users and individuals with asthma and other respiratory conditions – this could include individuals with a range of disabilities such as intellectual and developmental disabilities, cerebral palsy, spinal cord injury, seizure disorders, and metabolic conditions).
• People who have difficulty fighting infections or who are immunocompromised – (individuals with HIV, cancer, and other types of immune suppression, or individuals using immunosuppressive medications).
• People of any age who have chronic health conditions (heart disease, metabolic [i.e., diabetes], renal, hepatic, hematological [i.e. sickle cell anemia], pulmonary, or neurological disorders).
• People who have pharmacological dependency.
• People younger than 19 years of age who are receiving long-term aspirin therapy due to their risk of developing Reye’s Syndrome.
• Children prone to dehydration from poor nutritional and fluid intake caused by prolonged vomiting and diarrhea, or underlying metabolic conditions.

More information for people with disabilities and their caregivers

CMS ANNOUNCES MEDICARE PREMIUMS, DEDUCTIBLES FOR 2010

CMS uses five different provider and supplier enrollment applications. In general, Part A providers are required to use the CMS-855A to enroll or update their enrollment information; Part B suppliers (except suppliers of Durable Medical Equipment, and Prosthetics, Orthotics, and Supplies (DMEPOS)) are required to use the CMS-855B to enroll or update their enrollment information; physicians and non-physician practitioners are required to use the CMS-855I to enroll or change their enrollment information; and DMEPOS suppliers are required to use the CMS-855S to enroll or update their enrollment information.  In addition to these four enrollment applications, individual practitioners who would like to reassign their benefits to an eligible provider or supplier or terminate an existing reassignment agreement would use the CMS-855R.

To ensure timely processing of your application, make certain to completely fill out the application and provide all required supporting documentation at the time of filing. Section 17 of the Medicare enrollment application lists the supporting documentation that you will need to submit with your enrollment application. Once you have completed the application, you should mail it to the Medicare contractor servicing your state.  A contractor can generally process your application within 60 days if you submit a complete application with all required supporting documentation.  It will take longer to be enrolled if you are a provider or supplier that requires a State survey or accreditation.  If you have any questions about the enrollment process, please contact your Medicare contractor.

Source: https://questions.cms.hhs.gov

Extra Help for People with Limited Income and Resources

If you are not sure if you qualify for extra help paying for Medicare Prescription Drug Coverage, visit these two online resources:

1. Apply Online for Extra Help with Medicare Prescription Drug Plan Costs

If your resources are less than $11,710 (single) or $23,410 (married) and your income is limited, you may qualify for extra help paying for Medicare Prescription Drug Coverage. These resource limits are for 2007 and may increase each year. The resource limits include $1,500 per person for burial expenses. Resources include your savings and stock, but not your home or car. If you haven’t received an application or information about the extra help, and you think you may qualify, you should apply.

Remember, as Department of Health and Human Services Secretary Leavitt says, “If in doubt, fill it out!” You can apply Online by visiting the Help With Medicare Prescription Drug Plan Costs section on the Social Security Administration website.

2. Find Out if You Should Apply for the Extra Help

Visit the BenefitsCheckUpRx website to learn about and join valuable federal, state and private programs that can save you money on health care and prescription drugs including the new Medicare Prescription Drug Coverage.