2005 MEDICARE FEE SCHEDULE

This booklet/CD contains your 2005 Medicare Fee Schedule. We are sending the Fee Schedule to help you make an informed decision on Medicare participation.

This Fee Schedule lists physician and practitioner services by code number as published in the Physician’s Current Procedural Terminology (CPT) or HCPCS National Level II Codes. For each service, it gives the Medicare participating fee amount, non-participating fee amount and the limiting charge. These rates are effective for dates of service on or after January 1, 2005 and after. According to our records, this Fee Schedule is appropriate for the locality where you practice.

A number (#) sign in front of the procedure code indicates the facility rate. The facility rate is applied when the service is performed in an Inpatient Hospital Setting (21), an Outpatient Hospital Setting (22), a Hospital Emergency Room (23), an Ambulatory Surgical Center (24), a Military Treatment Facility (26), a Skilled Nursing Facility (31), a Hospice Setting (34), Land Ambulance (41), Ambulance Air and Water (42), an Inpatient Psychiatric Facility (51), a Psychiatric Facility-Partial Hospitalization Setting (52), a Community Mental Health Center (53), a Psychiatric Residential Treatment Center (56), or a Comprehensive Inpatient Rehabilitation Facility (61).

The column headed “Procedure Code/Mod” lists the procedure code and the modifier when applicable. When a modifier is listed, it indicates that the service is broken into professional (-26) and technical (-TC) components. For example, diagnostic tests and radiology services may be split into separate professional (physician services) and technical (staff and equipment) components. Where these procedures appear in the Fee Schedule, the global procedure is listed first without a modifier. The professional and technical components are on the next two lines.

The column headed “Par Fee” (Participating Fee Amount) lists the allowances for physicians and suppliers who agree to accept assignment on all covered services rendered to Medicare patients. The participating fee includes the Medicare Part B payment (before coinsurance is deducted). A participating practitioner or supplier may not ordinarily collect from the beneficiary more than the deductible and coinsurance for covered services.

The “Non-Par Fee” (Non-participating Fee Amount) applies to assigned and unassigned services performed by non-participating physicians and suppliers. The non-participating fee equals 95% of the participating fee amount and is the basis for calculating the Medicare Part B payment as well as the beneficiary’s coinsurance.

The “Limiting Charge” represents the maximum amount a non-participating physician or supplier may bill on unassigned claims. The limiting charge is 115% of the non-participating fee amount. Unassigned claims for all services and suppliers paid under the physician fee schedule are subject to the limiting charge rules when billed by any non-participating physician or supplier, including x-ray suppliers, diagnostic laboratories and occupational or physical therapists.

Localities for Northern California are:

· Area 03 (Marin, Napa, Solano Counties)

· Area 05 (San Francisco County)

· Area 06 (San Mateo County)

· Area 07 (Alameda, Contra Costa Counties)

· Area 09 (Santa Clara County)

· Area 99 (Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado, Fresno, Glenn, Humboldt, Inyo, Kern, Kings, Lake, Lassen, Madera, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Nevada, Placer, Plumas, Riverside, Sacramento, San Benito, San Bernardino, San Joaquin, Santa Cruz, Shasta, Sierra, Siskiyou, Sonoma, Stanislaus, Sutter, Tehama, Trinity, Tulare, Tuolumne, Yolo, Yuba Counties)

Localities for Southern California are:

· Area 17 (Ventura County)

· Area 18 (Los Angeles County)

· Area 26 (Orange County)

· Area 99 (San Luis Obispo, Santa Barbara, San Diego, Imperial Counties)

Localities for New England are:

· Area 01 (Massachusetts - Middlesex, Norfolk, Suffolk Counties)

· Area 99 (Rest of Massachusetts Counties)

· Area 03 (Maine - York, Cumberland Counties)

· Area 99 (Rest of Maine Counties)

· Area 40 (New Hampshire – entire state)

· Area 50 (Vermont – entire state)

Listed below are the Participating, Non-Participating and Limiting Charge amounts for Anesthesiology Conversion Factors for 2005:

California

Locality Par Amount Non-Par Amount Limiting Charge

03 18.27 17.36 19.96

05 19.30 18.34 21.09

06 19.20 18.24 20.98

07 18.61 17.68 20.33

09 19.25 18.29 21.03

17 18.11 17.20 19.78

18 18.72 17.78 20.45

26 18.68 17.75 20.41

99 17.55 16.67 19.17

New England

Locality Par Amount Non-Par Amount Limiting Charge

01 18.66 17.73 20.39

99(MA) 17.89 17.00 19.55

03 17.22 16.36 18.81

99(ME) 16.96 16.11 18.53

40 17.74 16.85 19.38

50 16.96 16.11 18.53

If you have any questions about the Fee Schedule or about becoming a participating physician, please call our Customer Service Representatives or write to the Medicare Provider Enrollment Department at the phone numbers and addresses listed below.

Northern California: Southern California: New England:

P.O. Box 602 P.O. Box 60560 P.O. Box 3434

Marysville, CA. 95901 Los Angeles, CA. 90060-0560 Hingham, MA. 02044

(877) 591-1587 (866) 502-9054 (877) 567-3129 Maine

(877) 567-3130 Massachusetts

(866) 539-5595 New Hampshire/Vermont

KEY NEWS FROM MEDICARE FOR 2005

FOR PHYSICIANS AND OTHER PROVIDERS

Billing and business staff: Share this with physicians and other providers.

Physician Fee Schedule Information

In the August 5, 2004, Federal Register, the Center for Medicare & Medicaid Services (CMS) published the following proposed rule: Revisions to Payment Polices Under the Physician Fee Schedule for Calendar Year 2005. This proposed rule contained a number of changes affecting physicians that result from the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Included among these MMA provisions are: the “Welcome to Medicare” preventive physical examination for new beneficiaries; a new cardiovascular screening blood test benefit; a new diabetes screening benefit; incentive payment improvements for physicians practicing in physician shortage areas; and changes to the drug payment methodology. We also proposed other non-MMA policy changes. Our final polices will be published in the final rule in early November.

General Medicare News

1. The Centers for Medicare & Medicaid Services (CMS) is Trying to Make Your Life Easier

The CMS has two initiatives focusing exclusively on physician and provider/supplier issues concerning the Medicare program. The Open Door initiative conducts monthly conference calls open to everyone in which providers discuss their issues with senior Medicare officials, questions are answered and problems are addressed in real time. More information is available at http://www.cms.hhs.gov/opendoor/. The Physicians Regulatory Issues Team (PRIT) is another initiative with a single task, to address the regulatory burden which providers may confront in dealing with Medicare. The PRIT welcomes issues and input from physicians and other providers. The team can be reached by sending an email to http://www.PRIT@cms.hhs.gov.

2. Medicare-Approved Drug Discount Card Program

Medicare beneficiaries, who don’t have outpatient prescription drug coverage through Medicaid, can still get help with their outpatient prescription costs through a Medicare-approved drug discount card. The program, which started in the Spring of 2004, will continue through December 31, 2005. Medicare’s new prescription drug benefit begins on January 1, 2006. For a small annual enrollment fee, these cards can help your Medicare patients save 11-18 percent over national average retail prices for drugs commonly used by the Medicare population. Low-income beneficiaries receive additional assistance and can save 32 to 86 percent when both the discounts and $600 in transitional assistance is taken into account. Several brand name pharmaceutical manufacturers have additional programs for low-income beneficiaries that can provide substantially more savings.

To obtain more information, please refer your patients to:

· Call 1-800-MEDICARE (1-800-633-4227) and ask about drug savings. TTY users should call 1-877-486-2048; or

· Access www.medicare.gov on the web (select “Prescription Drug and Other Assistance Programs.”).

3. Competitive Acquisition Program for Medicare Part B Drugs

Section 303(d) of the MMA of 2003 requires the implementation of a competitive acquisition program for Medicare Part B drugs not paid on a cost or prospective payment system basis. Under the new program, which is scheduled for implementation on January 1, 2006, physicians will be given a choice between buying and billing these drugs under the average sales price (ASP) system, or selecting a Medicare-approved vendor that will supply these drugs. If the physician elects to obtain drugs through the competitive acquisition program, the vendor will bill Medicare for the drug. The vendor will also bill the beneficiary for any applicable coinsurance and deductible.

Annual physician enrollment in the program is anticipated to begin in the fall of 2005. The following web site is being constructed in order to keep physicians informed about enrollment procedures, drug vendors, and drugs that may be obtained through the program: www.cms.hhs.gov/providers/drugs/compbid. The CMS is also interested in receiving public comments about the competitive acquisition program; general comments may be submitted to the following e-mail address: MMA303dDrugBid@cms.hhs.gov

4. New Medicare Preventive Services

Effective January 1, 2005, under the MMA, Medicare will provide coverage for three new preventive services. These new preventive services include coverage for an initial preventive physical examination, coverage for cardiovascular screening blood tests, and coverage of diabetes screening tests. While Medicare already provides coverage for many different preventive services, these new services expand the scope of beneficial medical screening services to Medicare beneficiaries.

The CMS will launch an educational campaign to inform you and other providers about these new benefits, ask for your assistance with informing beneficiaries about these services, and direct you and your patients to resources as they become available. Information about coverage, billing, and coding procedures for these new services are also forthcoming.

5. Incentive Payment Improvements for Physicians in Shortage Areas

Effective January 1, 2005, Section 413 of the MMA provides for an additional payment to physicians in counties where there is a scarcity of physicians (Physician Scarcity Area—PSA). The MMA also provides for improvements to the health professional shortage area (HPSA) incentive payment.

The CMS has created a user friendly Web page for the provider community that addresses the changes to the HPSA bonus payment program and describes the new PSA bonus payment program. The Web page provides a high level overview of both bonus payment programs, complete instructions on determining eligibility for the automated payments, and helpful resources with links to further assist physicians in completing a bonus payment claim. The new procedures are effective for claims submitted with dates of service on and after January 1, 2005. The Web site is http://www.cms.hhs.gov/providers/bonuspayment.

6. Payment for Influenza and Pneumococcal Vaccines

The CMS increased the Medicare payment rate for influenza and pneumococcal vaccines. The influenza vaccine payment increased to $10.10 and the pneumococcal vaccine payment increased to $23.28. The new vaccine payment amounts were effective September 1, 2004. As always, the CMS urges you to place your vaccine orders early to ensure timely receipt.

7. HIPAA Message for Medicare Providers:

As you are aware, October 16, 2003, was the deadline for compliance with the electronic transaction and code set standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). While the vast majority of Medicare providers are in compliance with the HIPAA standards, there still remains some work to be done to get all electronic billing Medicare providers into compliance. To be in compliance with the law, it is critical that every Medicare electronic billing provider be submitting HIPAA compliant claims.

If you need assistance with submitting HIPAA compliant claims, we welcome the opportunity to work with you. Contact your Medicare contractor for assistance or you may contact your regional office for help.

In our efforts to keep you informed about HIPAA issues, we encourage you to visit the following Web pages for the latest news affecting you. To access our national educational articles, distributed as part of the Medlearn Matters process, visit http://www.cms.hhs.gov/medlearn/matters/. To access a variety of issues related to HIPAA policies affecting Medicare providers, visit http://www.cms.hhs.gov/providers/edi/.

8. HIPAA Security Compliance Deadline

By April 21, 2005, all covered entities under the HIPAA (except small health plans) must ensure the security of electronic protected health information. Small health plans have until April 21, 2006, to meet the HIPAA security standards. The CMS has released the HIPAA Security Rule which outlines the administrative, physical and technical safeguards that a covered entity must implement to be in compliance with the HIPAA security standards. A copy of the rule may be downloaded from the CMS Web site at: http:/www.cms.hhs.gov/hipaa/hipaa2.

The security requirements were designed to be technology neutral and scalable from the very largest of health plans to the very smallest of provider practices. Covered entities will find that compliance with the Security Rule will require an evaluation of what security measures are currently in place, an in-depth risk analysis, and a series of documented solutions derived from a number of complex factors unique to each organization.

The CMS is eager to help you understand and implement the strategies for complying with the Security Rule and is developing a wealth of educational materials that will be available on the CMS Web site, located at http://www.cms.hhs.gov/hipaa/hipaa2. In addition, there are a number of professional and standard setting organizations that offer listservs, white papers, and other helpful resources on security implementation.

9. Medicare and You 2005

The national edition of Medicare and You 2005 is available for order after October 4, 2004. Call 1-800-MEDICARE (1-800-633-4227) to request up to 25 copies, or fax an order to 410-786-1905 for more than 25 copies.

10. Advance Beneficiary Notices (ABNs)

The ABN standard form, CMS-R-131, is available on the Beneficiary Notices Initiative (BNI) Web site. For replicable ABN forms and information on how to properly use the ABN, please visit the BNI Web site at http://cms.hhs.gov/medicare/bni.

11. Relevant Medicare Patient Brochures That May Be Of Interest To Physicians

There are a variety of new and revised brochures that physicians might find helpful to address frequently asked coverage-related questions. These include: Does Your Doctor or Supplier Accept Assignment? (CMS Publication # 10134); How to Read Your Medicare Summary Notice (CMS Publication # 11055); Medicare Coverage of Durable Medical Equipment (CMS Publication # 11045); Medicare Coverage of ambulance Services (CMS Publication #11021); Women with Medicare: Visiting Your Doctor for a Pap Test, Pelvic Exam, and Clinical Breast Exam (Publication #02248); Guide to Medicare Preventive Services (Publication #10110); and Medicare Coverage of Diabetes Supplies and Services (Publication #11022). A complete listing of all beneficiary publications is available at http://www.medicare.gov/ on the Web. Select “Publications” under “Search Topics”. Many publications are available in different languages and formats including: Braille, Spanish, Audiocassette, and Large Print. To order copies for your office, fax your request to (410) 786-1905, and include the name of a contact person, phone number, and mailing address (no P.O. boxes please).

12. Medicare Learning Network

The Medicare Learning Network (MLN) is the brand name for official CMS provider educational products and is designed to promote national consistency of Medicare provider information developed for CMS initiatives. The MLN products are available on the Medlearn Web page, which gives easy access to Web-based training courses, comprehensive training guides, brochures, fact sheets, CD-ROMs, and videos, as well as educational Web guides, electronic listservs, and links to other important Medicare Program information. All educational products are available free of charge and can be ordered and/or downloaded from the Medlearn Web page. The Medlearn Web page is located at http://www.cms.hhs.gov/medlearn. As always, we welcome your comments and suggestions for Medicare educational products.

13. Medicare Physician Web Site

A Web page designed to meet the Medicare information needs of physicians is available on the CMS Web site at http://cms.hhs.gov/physicians/. The page includes links to general information on enrollment, billing, conditions of participation, publications, education, data, and statistics. A special feature link on the page is the Medicare Physician Fee Schedule Look‑up, an application that allows the user to look up physician service information regarding fee schedule amounts and geographic practice cost indices for every carrier and locality. The Web page also includes links to National Correct Coding Initiative (NCCI) edits and to specific information on the Practicing Physicians Advisory Council (PPAC), the PRIT, Medicare payments, and the participating physician directory. The CMS continues to work on improving the Web page to make it as comprehensive and easy to navigate as possible. The CMS welcomes feedback on information to include and other suggestions for improvement.

We have added a new heading titled “Specialty Web Pages” to the main Physicians Web page. Under this heading we will be adding links to pages of special interest to specific physician groups. The first specialty page “Medicare Information for Anesthesiologists” is available at http://www.cms.hhs.gov/physicians/anesthesiologist/default.asp. Check the “Specialty Web Pages” section for additional pages to be added during the year.

14. “Medlearn Matters…Information for Medicare Providers”

One of the best sources for the latest Medicare information is “Medlearn Matters…Information for Medicare Providers.” These national articles, which are written in consultation with clinicians and billing experts, are designed to give providers and their staff easy-to-understand information related to new and recently-changed Medicare rules and policies and to focus on how these changes impact a provider’s Medicare business functions. The articles also serve to enhance and support Medicare carrier and intermediary local provider education efforts by promoting the availability of nationally consistent educational materials. Medicare carriers and intermediaries publish Medlearn Matters articles in their bulletins and post them on their Web sites. There is also a searchable table on the Medlearn Matters Web page. The Web page that contains links to each article and its corresponding program instructions, if applicable. The Medlearn Matters Web page is located at http://www.cms.hhs.gov/medlearn/matters.

15. Medicare-Approved Drug Discount Cards and Transitional Assistance Web Page

The Medicare-Approved Drug Discount Cards and Transitional Assistance Web page contains information and a variety of educational products that have been designed to assist physicians, pharmacists, and other health care providers in understanding Medicare prescription drug provisions in the MMA. The Web page has links to helpful information about the MMA, State Health Insurance Assistance Programs, and beneficiary materials, as well as links to a drug price comparison Internet tool and a Web-based training tool. Educational brochures, posters, and articles can be downloaded from the Medicare-Approved Drug Discount Cards and Transitional Assistance Program Web page located at http://www.cms.hhs.gov/medlearn/drugcard.asp. Physicians, pharmacists, and other health care professionals may display the Medicare-Approved Drug Discount poster at their offices to assist Medicare patients in finding out where to find information about the Medicare-approved drug discount card. The poster is available in both English and Spanish versions, and may be ordered free of charge from the Medlearn Web page located at http://www.cms.hhs.gov/medlearn.

16. Medicare Resident & New Physician Training Program

As the aging population continues to increase, it is more important than ever that the physicians who are providing care to our seniors have a good understanding of the workings of the Medicare program. Therefore, the CMS is pleased to report that the Medicare Resident & New Physician Training (MRNPT) Program Facilitator’s Kit is now available from the Medlearn Web site Product Ordering System at www.cms.hhs.gov/medlearn. The Facilitator’s Kit includes everything that is needed to conduct training sessions for finishing residents, new physicians, and other health care providers who are seeking Medicare information as it relates to physician services. New products in the Facilitator’s Kit include a copy of our latest resident training video and a CD-ROM version of our newly developed Web-based training course that is based on the Medicare Resident & New Physician Guide publication. We have also significantly revised the Facilitator’s Guide, which contains all the information and instructions needed to prepare for and conduct the MRNPT Program, so that it is a more user-friendly and concise product that can be utilized by Medicare contractors, regional offices, medical schools, teaching hospitals, and other provider education training partners.

17. Medicare Contractor Provider Satisfaction Survey (MCPSS)

Recognizing the important role that provider perceptions have of the CMS and the role that fee-for-service contractors play in representing the Medicare program to providers, the Agency is taking steps to obtain and evaluate provider satisfaction with services provided by our Medicare contractors. The survey will be pilot tested in 2005 with 7,000 providers of all types. If you are asked to participate in this survey, your timely comments will be very much appreciated!

18. Exhibit Program

The CMS continues to depend upon its Exhibit Program to help ensure that we provide enhanced customer service and satisfaction to our Medicare physician and provider community. Fiscal Year 2004 marked a significant increase in the number of CMS exhibits at national conferences -- 92 conferences in all. The Exhibit Program represents a unique opportunity for CMS central and regional office staff to have direct contact with physicians and providers to share timely and relevant information and to hear directly from you about the issues, concerns, and challenges you face in the Medicare program.

19. Listserv Messages

The CMS has a number of listservs for Medicare providers that are used to transmit up-to-the-minute information specific to the providers who have subscribed. (A listserv is an electronic mailing list service for those interested in receiving Medicare news.) Listservs have been established for physicians and DMEPOS-suppliers. To view the entire menu of available listservs and to subscribe to one or more listserv, view the link at http://www.cms.hhs.gov/mailinglists/ and follow the directions. Important notices and reminders will be automatically sent to your email address via the Internet.

20. Medicare Contractor Web Sites and Listservs

In addition to the CMS Web sites and listservs, each Medicare contractor has its own Web sites and listservs. Make sure to subscribe to the listservs that your contractor has available and visit the Web site regularly to stay up-to-date on Medicare changes. Links to all contractor Web sites can be found at http://www.cms.hhs.gov/medlearn/tollnums.asp.

21. The CMS Quarterly Provider Update

The CMS Quarterly Provider Update is an Internet-only document and is released quarterly (January, April, July, and October.) It provides a single source for you to turn to and will give you advance notice on instructions that affect you at least 90 days before they are implemented.

It is organized by provider type and contains the following information:

· Regulations and major policies currently under development during the quarter.

· Regulations and major policies completed or cancelled.

· New/revised manual instructions.

The CMS Quarterly Provider Update can be accessed from the Internet at: http://www.cms.hhs.gov/providerupdate/.

22. The CMS Manual System

As you may know, as of October 1, 2003, the CMS transitioned from a paper-based manual system to a Web-based system. This system is called the online CMS Manual System and is located at http://www.cms.hhs.gov/manuals/.

The online CMS Manual System is organized in six parts: Internet-Only Manuals (IOMs), Future IOM Updates, Program Transmittals, Crosswalks, Paper Based Manuals, and Program Memoranda. The IOM manuals themselves are organized by functional area (e.g., eligibility, entitlement, claims processing, benefit policy, program integrity) as opposed to the old paper manuals, that were organized by audience. The functional orientation of the new manual has eliminated significant redundancy within the manuals, and has streamlined the updating process. It has also made information available sooner.

The CMS manual system is still evolving and we welcome any comments or suggestions on its improvement. Please send these comments or suggestions via our site Feedback form:

http://www.cms.hhs.gov/feedback/.

23. Medicare Coverage Information

The Medicare Coverage Database, which is on the http://www.cms.hhs.gov/ Web site, includes the local medical review policies (LMRPs) and the National Coverage Determinations (NCDs). This database allows users to search across NCDs, LMRPs, and contractor articles/FAQs from a single point of entry. The database can be accessed by going to http://www.cms.hhs.gov/mcd/search.asp.

24. The CMS Publishes Nursing Home Quality Measures

The CMS provides quality data about nursing homes on their beneficiary Web site http://www.medicare.gov. The quality data enables beneficiaries, their caregivers, and families to choose a nursing home based on information relevant to both long-stay (chronic) and short stay (typically Medicare‑covered). The measures represent the best available science and include a risk adjustment methodology. This quality data is one source of information for consumers to use in choosing a nursing home. We encourage consumers to review the other data on the nursing home site, which includes nurse staffing, health inspections and compliancy findings. Consumers should visit nursing homes in person before selection. Additionally, quality improvement organizations in each state are assisting nursing homes to use the data to implement quality improvement strategies. Users can search for nursing homes by State, county, city, zip or name. Proximity searches from 0-500 miles are also available when searches are made on city or zip code.

25. The CMS Publishes Home Health Quality Measures

The CMS launched Home Health Compare Nationally on its beneficiary Web site, http://www.medicare.gov/, in October 2003. Home Health Compare contains information about Medicare‑certified home health agencies. Specific information includes the name, address and phone number of the agency; Medicare‑covered services offered by the agency; the agency's initial date of Medicare certification; and type of ownership. Home health quality measures are available for all Medicare certified home health agencies in the nation.

26. Coming Soon – The CMS to Publish Hospital Quality Measures

The CMS will launch Hospital Compare nationally on its beneficiary Web site, http://www.medicare.gov/, in February 2005. Hospital Compare will contain information about Medicare-certified hospitals. Specific information will include the name, address, telephone number, and accreditation status. For hospitals that have submitted data for three clinical conditions; heart attack, heart failure, and pneumonia, quality measures will be available on the Medicare.gov site.

27. Online Participating Physician Directory

As part of the ongoing effort to provide Medicare beneficiaries with information to help them make health care choices, the CMS has a participating physician directory at www.medicare.gov, the CMS’ beneficiary Web site. The directory can be accessed from the home page under the Participating Physician Directory. Initially, the directory contained only names, addresses, and specialties of Medicare participating physicians who agreed to accept assignment for all covered services. In May 2003, the Participating Physician Directory added several features including information about physicians, such as their medical school and year of graduation, any board certification in a medical specialty, gender, and hospitals at which the physician has admitting privileges. The directory, which is updated monthly, also includes the participating physician’s office phone number and any foreign language capabilities. In the future, the directory will contain information on whether a physician is accepting new Medicare patients.

The information in the database comes from the Unique Physician Identification Number (UPIN) Registry. The directory is updated monthly. Corrections or changes to the information will be reflected on the Web site, the month after an update is made to the UPIN registry.

28. Medicare Advantage Private Fee For Service Plans

The Balanced Budget Act of 1997 allowed for a new type of Medicare Advantage (MA) plan, Private Fee For Service (PFFS). A MA PFFS plan may be designed without a provider network. In order to offer a PFFS plan without provider contracts, the PFFS organization must agree to pay all Medicare eligible providers the current Medicare allowable rates (including original Medicare deductibles and coinsurance) minus any plan specific enrollee cost sharing. This payment rate is mandated via specific regulation as well as the contract that the CMS holds with the PFFS organization. Further, depending on the PFFS plan design, providers may balance bill enrollees of PFFS plans. However, even if the plan design allows this balance billing, it is limited to an amount of 15 percent of the PFFS plan payment amount. Currently, there are no PFFS contracts that allow balance billing. Other than this balance billing amount (if included in the plan's design), providers may only bill Medicare beneficiaries for co-payments, deductibles or coinsurance which are described in the MA plan’s terms and conditions of payment and the enrollee's Evidence of Coverage. All other bills must be sent to the PFFS organization. For additional information, including frequently asked questions, please visit the CMS web site at http://www.cms.hhs.gov/healthplans/pffs.

29. Changes to the Medicare Appeals Process

Effective October 1, 2004, all first level Medicare appeals will be called redeterminations. This will include those appeals now known as reviews and reconsiderations. In addition, contractors must complete all redeterminations within 60 days. These new timeframes will apply to redeterminations requested on or after October 1, 2004. You will be notified of the redetermination decision with the new Medicare Redetermination Notice (MRN). The new model letter was developed using feedback provided during extensive consumer testing with both providers and beneficiaries. The new notice provides information in a user-friendly manner that will be more consistent across Medicare contractors than current decision letters. There are further important changes on the horizon for the Medicare appeals process, beginning in 2005. The major benefits will be more accurate and timely appeals decisions. The changes include:

· A uniform process for Medicare Part A and Part B appeals,

· New timeframes for appeal determinations,

· Expanded appeal rights for providers and suppliers, and

· The establishment of a new independent review entity, called a Qualified Independent Contractor (QIC), to perform reconsiderations of redetermination decisions.

30. The Voluntary Chronic Care Improvement Program (MMA Section 721)

The Chronic Care Improvement Program is an important component of the Medicare Modernization Act and demonstrates a commitment to improving and strengthening the traditional fee-for-service Medicare program. This program is the first large-scale chronic care improvement initiative under the Medicare FFS program. The CMS will select Chronic Care Improvement Organizations (CCIOs) that will offer self-care guidance and support to chronically ill beneficiaries. CCIOs will help beneficiaries manage their health, adhere to their physicians’ plans of care, and assure that they seek or obtain medical care that they need to reduce their health risks.

· Initially, the programs will be focused on beneficiaries who have Congestive Heart Failure (CHF), Complex Diabetes, or Chronic Obstructive Pulmonary Disease (COPD) because these beneficiaries have heavy self-care burdens and high risks of experiencing poor clinical and financial outcomes.

· The new programs are NOT single-disease focused. They will be designed to help participants manage all their health problems.

· Participation will be entirely voluntary. Eligible beneficiaries do not have to change plans or providers or pay extra to participate.

For additional information on this initiative, please go to www.cms.hhs.gov/medicarereform/ccip

11/10/04