2021 Medicare Changes & Resources
Mental Health-Related Policies & Resources
***NEW*** 2015 April: Medicare’s main page about MAC Parts A and B Jurisdictions is here: A/B MAC Jurisdictions
***NEW*** 2015 January: Map of Medicare Administrative Contractors (MAC) Jurisdictions: Current MAC Jurisdiction Map
2013 December 13: FOR WI PSYCHOLOGISTS: NGS’s LCD For Psychology and Psychiatry Services (L26895)
2013 December 8: Psychological and Neuropsychological Tests. Document’s Medicare reimbursement for testing including tests performed by technicians and computers.
Policy interpretation: Documentation Timelines: “There are several provisions that may affect “timeliness” when talking about documentation.”
2013 Feb 12: Medicare proposes to add 8 services to Telehealth Services for 2013 and updates telehealth psychotherapy codes to match new CPT codes.
2013 Jan 18 Update: Phase-in of Outpatient Mental Health Treatment Limitation. Includes information about services for individuals with Alzheimer’s Disease and Related Disorders.
***NEW*** 2013 Update on Medicare Conversion Factor: “What the ‘Fiscal Cliff’ means to doctors and our patients with Medicare”
2012 Nov 21: Changes in Medicare Reimbursement for Psychological Services — See what has been happening to amounts psychologists receive to provide basic services.
- 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
- 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.
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 websiteis 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 1993-2013. The graph shows what will happen to 2013 Medicare reimbursement if the rate required by law goes into effect. The 2012 graph shows what would have happened to Medicare reimbursement if the amount required by law to go into effect as of 1/1/12 had not been halted by a temporary 2-month extension signed into law 12/23/2011, and a 1 year extension signed in 2012, known as “the doc fix.”
- 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.”
- Q & A for Providers re: claims reprocessing related to the Affordable Care Act and corrections to the 2010 Medicare Physician Fee Schedule. Source: WPS Medicare Part B Legacy eNews for Tuesday, May 24, 2011. The file is here, retrieved online 5/31/11 from http://www.wpsmedicare.com/part_b/departments/claims/_files/claim-repr-qnas.pdf
- “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.