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.
- 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.
- 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.
- Novitas online appeals and appeals status - Appeals can be done 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.
- Where to File Complaints - After you have exhausted the payer’s appeal and complaint process, you can file a complaint with the CMS Regional Administrator in Dallas. Provide a detailed account of the issue with supporting documentation, if any, and your efforts to resolve the issue with Novitas or other payer. The complaint form is used to file all complaints, not just Part C (managed care) or Part D complaints as indicated on the form. The form will not be accepted, nor any attachments, if they are not encrypted or password protected. Send the password in a separate email immediately after sending the complaint by going to your “sent” folder, open the email with the complaint, and “reply all”. Simply provide the password in the body of the email. Fax the form if you can’t send the complaint encrypted or password protected.
Mail or email securely (emails not sent securely will not be processed) to the following:
Centers for Medicare and Medicaid Services
Dallas Regional Office
1301 Young Street, Room 833
Dallas, TX 75202
Phone: (214) 767-4463
Fax: (443) 380-8886
Email (securely) the complaint to RODALFM@cms.hhs.gov.