What's new

Medicare providers and suppliers, including pharmacies, must not bill Qualified Medicare Beneficiaries (QMBs) for Medicare Part A or Part B cost-sharing. This includes Medicare Part A and Part B deductibles, coinsurance and copayments.

The QMB eligibility group is a Medicaid eligibility group through which states pay Medicare premiums and cost-sharing for certain low-income QMBs. The group is part of the Medicare Savings Programs.

Compliance reminder

All Original Medicare (also called Fee-for-Service Medicare) and Medicare Advantage providers and suppliers must:

• Ensure that QMBs are not billed for Medicare cost-sharing
• Take action to remedy any QMB billing or collections

To comply with these requirements, Medicare providers and suppliers should:

• Implement processes that avoid QMB billing prohibitions
• Make sure their office staff and vendors are using systems to identify the QMB status of Medicare beneficiaries

Read the MLN fact sheet for reminders and to learn how to be compliant.

11/7/2024

We previously announced plans to begin using the Optum’s Emergency Department Claim (EDC) Analyzer to review ED claims pre-payment beginning November 1, 2024. We are delaying implementation of this tool and will announce a new implementation date in our December 2024 provider newsletter.

The EDC Analyzer will support our Emergency Department Visits: Level of Service (Facility #110) reimbursement policy.

11/5/2024

Fall brings with it an increase in respiratory viruses that can affect people of all ages. As a health care provider, you play a key role in educating patients, parents and caregivers about vaccinations.

The fall respiratory virus season typically peaks between September and November, with a surge in cases of COVID-19, influenza and respiratory syncytial virus (RSV).

While there is no cure for these viruses, there are steps your patients can take to prevent their spread and alleviate symptoms:

• Get vaccinated: Encourage your patients to stay up to date on their vaccinations.
• Practice good hygiene: Teach patients to wash their hands frequently with soap and water, cover their mouth and nose when coughing or sneezing, and avoid close contact with people who are sick.
• Stay home when sick: Emphasize the importance of staying home from work or school when experiencing symptoms to prevent the spread of illness.
• Antiviral medications: For high-risk patients, antiviral medications may be prescribed to help alleviate symptoms and shorten the duration of illness.

By promoting prevention strategies and providing timely treatment, you can make a significant impact in reducing the spread of these viruses. We appreciate you prioritizing patient education, staying up to date with the latest information, and taking a proactive approach to keeping our communities healthy and safe.

Resources

Our Quality Improvement Toolkit includes materials in English and Spanish to share with your patients about influenza immunizations. Other helpful resources include:

• Centers for Disease Control and Prevention (CDC)
• World Health Organization (WHO)
• American Academy of Pediatrics (AAP)

9/4/2024

We’re excited to announce that our medical policies, Clinical Position Statements and online forms are now live. We have migrated them to the same platform as our public websites, bringing a host of exciting changes and innovations, including increased security, design and navigation changes.

The following content is now available on the same platform as the rest of our public websites:

• Commercial medical policies
• Medicare medical policies
• Clinical Practice Guidelines

• Provider forms

With this migration, you’ll enjoy a seamless user experience, complete with:

• A fresh, modern design that’s consistent with our provider website
• Streamlined navigation for medical policies, making it easier to find what you need
• Advanced search functionality that supports searches by line of business, keywords, CPT or HCPCS code
• All medical policies on a single page, sortable by name, policy ID number or effective date
• A convenient drop-down menu for browsing policies by category or section, reducing clicks and saving time

• Enhanced forms functionality

We hope the enhancements we’ve made make using this content even easier.

8/26/2024