- Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance
- Unprecedented Efforts to Increase Transparency of Nursing Home Ownership
- CMS Proposes Benefit Expansion for Mobility Devices, Advancing Health Equity for People with Disabilities
- CMS Addresses Inequities in Rural Health in Medicare
- Medicare Shared Savings Program: Application Deadlines for January 1, 2024, Start Date
- HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing: April 2023 Update
- ICD-10 & Other Coding Revisions to National Coverage Determinations: July 2023 Update
News
Billing Medicare Part B for Insulin with New Limits on Patient Monthly Coinsurance
Starting July 1, 2023, Part B coinsurance for a month’s supply of insulin used in an insulin pump covered under the DME benefit can’t exceed $35.
CMS will adjust payments to suppliers and pharmacies to account for the balance of the reduced coinsurance. Suppliers will continue to get the Medicare payment amount for the insulin (average sales price plus 6%) minus any applicable coinsurance, which is capped at $35 for a month’s supply.
Don’t bill for supplies of insulin for July or subsequent months before July 2023. We’ll complete the system updates to make sure patients aren’t charged more than the $35 maximum allowed for the month of July. Your DME Medicare Administrative Contractor will also educate you about billing during the May – June transition period.
We’re adding 2 new modifiers to the April 2023 HCPCS quarterly update file:
- JK - Short Descriptor: Drug 1-month supply or less; Long Descriptor: One month supply or less of drug/biological
- JL - Short Descriptor: Drug 3-month supply; Long Descriptor: Three month supply of drug/biological
Split Billing:
- Before July 2023: For “from date of service” in May or June 2023, don’t bill a 3-month supply of insulin. Instead, bill a 1-month supply of insulin with the JK modifier.
- Starting July 2023: For “from date of service” in July and later, bill a 3-month supply of insulin with the JL modifier or a 1-month supply with the JK modifier.
For more information, see the fact sheet (PDF).
Get information for your patients:
- 7 Things to Know About Medicare Insulin Costs
- Saving money with the Inflation Reduction Act
- Information about Insulin Costs and Coverage
Unprecedented Efforts to Increase Transparency of Nursing Home Ownership
HHS announced additional action to increase the transparency of nursing home ownership and management. The Department issued a proposed rule to require nursing homes to disclose to CMS and states additional ownership and management information. The rule also includes private equity and real estate investment trust definitions, setting the stage for the disclosure of whether nursing home owners are private equity investors or real estate investment trusts. The proposal marks an important step in continuing to implement President Biden’s initiative to improve the quality and care available at nursing homes. By making facility ownership and oversight more transparent, nursing home residents and their families will be more empowered to make informed decisions about care.
More Information:
CMS Proposes Benefit Expansion for Mobility Devices, Advancing Health Equity for People with Disabilities
On February 15, CMS released a proposed national coverage determination (NCD) decision that would, for the first time, expand coverage for power seat elevation equipment on certain power wheelchairs to Medicare individuals. The proposed NCD is open for public comment for 30 days.
Read the full press release.
CMS Addresses Inequities in Rural Health in Medicare
On February 10, CMS posted a blog on addressing rural health inequities in Medicare, a cornerstone of CMS’ effort to improve health equity. Compared to urban Americans, rural Americans are more likely to have heart disease, stroke, cancer, unintentional injuries, suicide risk, and chronic lung disease. The authors advance a 3-pronged approach of supporting rural providers, making rural health care more effective, and transforming the rural health delivery system to improve access to high-quality, coordinated care in rural areas.
Medicare Shared Savings Program: Application Deadlines for January 1, 2024, Start Date
Accountable Care Organizations (ACOs): See Medicare Shared Savings Program Application Types & Timeline to learn about key dates to start January 1, 2024. CMS will accept applications starting May 18 through the ACO Management System. Apply no later than noon ET on June 15.
We offer a new advance investment payments (PDF) option to encourage health care providers in rural and underserved areas to join together as ACOs. Learn about:
- Advance shared savings payments to build infrastructure
- Recouped funds from earned shared savings
- Roles for community-based organizations (PDF)
More Information:
- Shared Savings Program
- Application Toolkit
- Email questions to SharedSavingsProgram@cms.hhs.gov
Events
Medicare Home Health Prospective Payment System CY 2023 Webinar — March 29
Wednesday, March 29 from 1:30–3 pm ET
Register for this webinar.
CMS experts provide an overview of several provisions from the CY 2023 Home Health Prospective Payment System final rule related to behavior changes, the construction of 60-day episodes, and payment rate development.
Visit Home Health Agency Center for more information. We’ll post materials soon.
MLN Matters® Articles
HCPCS Codes Used for Skilled Nursing Facility Consolidated Billing: April 2023 Update
Learn about codes excluded from skilled nursing facility consolidating billing (PDF), including:
- HCPCS Codes
- Codes for blood clotting factors
ICD-10 & Other Coding Revisions to National Coverage Determinations: July 2023 Update
Learn about this quarterly update (PDF):
- New codes
- Recent changes
- How to find coding information
Multimedia
Expanded Home Health Value-Based Purchasing Model: First Performance Year Quick Guide Materials
CMS posted materials from the First Performance Year Quick Guide webinar in January:
Learn more about the Expanded Home Health Value-Based Purchasing Model. Download your January 2023 Pre-Implementation Performance Report from iQIES. See instructions for accessing reports.
Information for Patients
Options When ESRD Coverage with Medicare Ends
Patients with Medicare because of ESRD currently lose coverage 36 months after a kidney transplant unless otherwise eligible for Medicare. When their coverage is about to end, CMS will mail them a letter to explain other coverage options, including:
- Employer coverage
- Health Insurance Marketplace®
- Medicaid and the Children’s Health Insurance Program
- Continuing Medicare coverage
If your patient doesn’t have or expect to get other health insurance, they may qualify for the new Part B immunosuppressive drug benefit. It only covers immunosuppressive drugs and no other items or services.
When your patient gets this letter, they need to:
- Think about how they want to get their health coverage
- Act to make sure they have health coverage when their Medicare coverage ends
Get information for your patients:
- Medicare.gov/ESRD
- Medicare Coverage of Kidney Dialysis & Kidney Transplant Services booklet
- Medicare’s Coverage of Dialysis & Kidney Transplant Benefits fact sheet
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