Mental Health-Related Policies & Resources
- Outpatient Mental Health Treatment Limitation — Description of the phased-in elimination of the limitation in the portion of reimbursement covered by Medicare for mental health services, and the application of this to coverage for Alzheimer’s related disorders.
- Table showing reimbursement rate example with the elimination of the mental health limitation from before 2010 through 2014 and beyond
- Medicare Improvements for Patients and Providers Act of 2008 — To amend titles XVIII and XIX of the Social Security Act to extend expiring provisions under the Medicare Program, to improve beneficiary access to preventive and mental health services, to enhance low-income benefit programs, and to maintain access to care in rural areas, including pharmacy access, and for other purposes. Includes ‘SEC. 102. ELIMINATION OF DISCRIMINATORY COPAYMENT RATES FOR MEDICARE OUTPATIENT PSYCHIATRIC SERVICES,” the scheduled phase-in of patient copayments reaching parity with other treatments at 20% by 2014.
- Original language as published in Federal Register April 1998 describing implementation of outpatient treatment limitation
General Medicare Policies
- Medicare Manual on Private Contracting_Opting Out - Retrieved 9/24/11 at http://www.cms.gov/manuals/Downloads/bp102c15.pdf. This is the “source document” that provides the definitive Medicare requirements.
- CMS Manual 2008 June 27 Transmittal 92 on Private Contracting/Opting out of Medicare
- Medicare Learning Matters (MLN) 6//27/2008 on Private Contracting/Opting out of Medicare
- “Provider Inquiry Assistance” on Private Contracting/Opting out of Medicare
- Psychologists and other eligible health care professionals may contract privately to provide services to Medicare beneficiaries without first having to become Medicare providers: Medicare guidance on private contracting
- OIG study Impact of Physicians Opting Out of Medicare finds MACs collect insufficient data: http://goo.gl/3NpgZ
- Listings of practitioners who have opted out may be found here for
- Local Coverage Determination (LCD) and National Coverage Determination (NCD)
- What is a Local Coverage Determination?
- “…a decision by a fiscal intermediary (FI) or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (e.g., a determination as to whether the service or item is reasonable and necessary),” based on Section 522 of the Benefits Improvement and Protection Act (BIPA).
- Fiscal Intermediaries, Carriers, and Medicare Administrative Contractors (MACs) are Medicare contractors that develop and/or adopt LCDs.
- Medicare contractors develop LCDs when there is no National Coverage Determination (NCD) or when there is a need to further define an NCD (National Coverage Determination).
- A local policy may consist of two separate, though closely related documents: the LCD and an associated article. The LCD only contains reasonable and necessary language. Any non-reasonable and necessary language a Medicare contractor wishes to communicate to providers may be done through the article. At the end of an LCD that has an associated article, there is a link to the related article and vice versa.
- What is a National Coverage Determination?
- Originates from from the Centers for Medicare & Medicaid Services (CMS)
- Applies to all Medicare jurisdictions.
The comprehensive CMS “Medicare Coverage Database” with links to all NCDs and LCDs may be found here: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx
Additional source: http://www.wpsmedicare.com/part_b/policy/active/index.shtml
Fees and Medicare Financing
- Physician Fee Schedule Lookup: This website is designed to provide information on services covered by the Medicare Physician Fee Schedule (MPFS)…provides more than 10,000 physician services, the associated relative value units, a fee schedule status indicator and various payment policy indicators needed for payment adjustment…the geographic practice cost index (GPCI) has been…applied in the calculation of a fee schedule payment amount by multiplying the RVU for each component times the GPCI for that component. The Physician Fee Schedule look-up website is designed to take you through the selection steps prior to the display of the information. The site allows you to:
- Search pricing amounts, various payment policy indicators, RVUs, and GPCIs by a single procedure code, a range and a list of procedure codes.
- Search for the national payment amount, a specific Carrier/Medicare Administrative Contractor (MAC) or a specific Carrier/MAC locality. Each page has associated Help/Hint available to complete your selections.
- This link shows the Medicare Conversion Factor from 1992-2012 I have compiled from various sources. The graph shows what would happen to Medicare reimbursement if the amount required by law would go into effect as of 1/1/12. This is the value that has been halted temporarily by the 2-month extension signed into law 12/23/2011.
- Medicare Conversion Factor: “Section 1848(d)(1)(E) of the Social Security Act (the Act) requires the Secretary to make available to the Medicare Payment Advisory Commission (MedPAC) and the public, by March 1, an estimate of the Sustainable Growth Rate (SGR) and conversion factor applicable to Medicare payments for physicians’ services for the following year and the data underlying these estimates.”
Enrollment
- “How to Enroll as a Medicare Psychologist.” (2006). Gordon Herz. Independent Practitioner: Bulletin of Psychologists in Independent Practice.
- The Basics of Medicare Enrollment for Physicians and Other Part B Suppliers: “Provider-Supplier Enrollment Fact Sheet Series”
- Medicare Provider-Supplier Enrollment: Overview page with links to essential information, forms.
