Medicare

The Medicare program provides healthcare coverage for people 65 or older, people under the age of 65 with certain disabilities, and people of all ages with End-Stage Renal Disease. Medicare has three components: Part A for hospital coverage, Part B for physician services, and Part D for prescription coverage. Individuals may opt out of Medicare and enroll in a Medicare Advantage Plan, referred to as Part C. For more information on Part C visit our Medicare Advantage web page.

***CMS releases the 2023 Medicare physician fee schedule (MPFS) proposed rule. Review the announcement for a summary and links to the rule. ***

• Alternative Payment Programs/ACOs - Medicare has several alternative payment programs and opportunities for physicians that focus on quality, cost, and pay for performance.

• Billing for Dual Eligibles - The Qualified Medicare Beneficiary (QMB) program is a Medicaid program that helps very low-income dual eligible beneficiaries (individuals who are enrolled in both Medicare and Medicaid) with Medicare cost-sharing. Federal law protects QMBs from any cost-sharing liability and prohibits all original Medicare and Medicare Advantage providers, including those who do not accept Medicaid, from billing QMB individuals for Medicare deductibles, coinsurance, or co-payments. All Medicare and Medicaid payments that physicians receive for furnishing services to a QMB individual are considered payment in full. For additional information, see the  MLN Matters notice and MLN Booklet.

QMBs may obtain benefits through Medicare and Medicaid, or they may choose to select a Medicare Advantage plan that is designed for dual eligibles. These plans combine the Medicare and Medicaid benefits into one plan and often offer additional benefits not available with Medicare such as case management and wellness programs. In Harris county, HHSC and CMS have set up a Demonstration Project blending Medicare and Medicaid benefits into a managed care plan, referred to as a Medicare-Medicaid Plan (MMP), for people who have both Medicare and Medicaid coverage, known as dual eligibles. In these plans, Medicare and Medicaid benefits work together to better meet the member’s health-care needs and the MMPs must provide the full array of Medicaid and Medicare services.
     - TMA Dual Eligible resources
     - CMS Medical Learning Network Booklet
     - CMS Medical Learning Network notice

• Chronic Care Management - This section provides information on how to bill for the Chronic Care Management codes, patient eligibility how to get started and more.

• CMS Proposed and Final Rules

• Enrollment, Provider Record Changes and Opt-out Procedures

• Part B Immunization Billing, Seasonal Influenza Vaccines Pricing - These resources provide guidance on immunization billing and seasonal payment rates. 

• Physician Directory - The Medicare Participation Physicians/Suppliers Directory (MEDPARD) contains the names, addresses, telephone numbers and specialties of Medicare Participating physicians and suppliers.

• Preventive Services Chart - Guidance on properly furnishing and billing Medicare preventive services with information by service.

• Medicare Reimbursement - The Medicare Part B Physician's Fee Schedule is available for download on the Novitas website.
       - Novitas online Fee Schedule Look-up
       - Medicare deductible and coinsurance information
     - Patient billing protections - Medicare Interactive, KFF 

• Medicare Secondary Payor guide - Guidance on determining when Medicare is primary or secondary.

• Merit-based Incentive Payment System (MIPS) - MIPS is a quality reporting program that consolidates the previous quality reporting programs and began its first performance year in 2017.

• Novitas online appeals and appeals status - Appeals can be submitted online through Novitasphere. The appeals inquiry tool allows you to determine the status of appeals and reconsiderations. Go to the Novitas website. Click on Jurisdiction H. On the left-hand side menu, hover over Appeals, then select Status of My Appeal.

• Quality Payment Program - The Medicare Access and CHIP Reauthorization Act of 2015 repealed the Sustainable Growth Rate (SGR) and replaced it with the Medicare Quality Payment Program (QPP).

• Revalidation

• Where to File Complaints - Complaints may be mailed, faxed, or emailed. Emailed complaints must be sent securely via encryption or password protection. Follow the instructions on how to file a complaint and how to encrypt or password protect an emailed complaint on the Where to File Complaints guide.