Payment Methodology Grid for Medicare Advantage PFFS/MSA

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1 Payment Methodology Grid for Medicare Advantage PFFS/MSA This applies to SmartValue and Security Choice Private Fee-for-Service (PFFS) plans and SmartSaver and Save Well Medical Savings Account (MSA) plans. Refer to the Provider Disclosure for Terms and Conditions associated with rendering services to members of these plans. This grid indicates the methodology used to price services allowed under Medicare coverage guidelines for Medicare Advantage plans available when claims are adjudicated, including any Correct Coding Initiative (CCI) edit rules. Actual claim payment is subject to eligible member benefits in effect on the date services are rendered, and may be reduced by applicable member cost-sharing deductibles, co-pays, or coinsurance. Acute Care Hospital Inpatient Service Acute Care Hospital Outpatient Services Ambulance Independent and Provider Based Anesthesia/Physician Performed Anesthesia/Physician Medical Direction of two or more Nurse Anesthetists concurrently The Medicare Base Payment Rate, any Outlier amount, Operating Expense, Capital Expense, Disproportionate Share, Organ Acquisition costs and Transfer payments will be calculated. Rate File (ONMPRF) will be used to group/price APC claims for any Medicare approved provider. When processing an APC claim, components that comprise the total reimbursement amount (for example - accounting for outlier, drugs and devices paid as passthroughs) will be included. Other services such as labs and physician services are paid on those fee schedules. CMS fee schedules will be used, allowing for base rate and mileage. The payment will be calculated according to Medicare s methodology: Medicare anesthesia conversion factor by locality x sum of uniform base units + time units + physical status units. The payment will be calculated according to Medicare s methodology: Medicare anesthesia conversion factor by locality x sum of uniform base units + time units + physical status units.

2 Ambulatory Surgical Center Assistant at Surgery (Physicians) Blood Braces (orthotics/prosthetics) Cancer Hospitals Inpatient Services Cancer Hospitals Outpatient Services Based on fee schedules accessed via CMS or intermediary websites. If a physician is the assistant, payment is 16% of the Medicare Fee Schedule. If a physician assistant is the assistant, payment is 85% x 16% of the Medicare Fee Schedule. Reimbursed under Outpatient Prospective Payment System (OPPS) for hospital outpatient services. Allowed at 100% of the Medicare Durable Medical Equipment Prosthetic, Orthotic, and Supplies Fee Schedule. Covered when furnished incident to physicians services or on a physician s order. Paid based on the lesser of their actual costs or their TEFRA limited costs. Payment adjustments are then made depending on the difference between these two costs. Routine costs are generally reimbursed on an interim basis using a per diem amount. Ancillary costs are reimbursed using a payment to charge ratio. Cancer hospitals are also eligible for outlier payments. Facilities are required to supply a copy of their annual FI rate letter to show the interim per diems for inpatient and the cost-to-charge ratios for outpatient services. Rate File (ONMPRF) will be used to group/price APC claims for any Medicare approved provider.

3 Certified Registered Nurse Anesthetist (CRNA) Clinical Nurse Specialist Clinical Psychologist Clinical Social Workers Clinical Trial Services Community Mental Health Centers CORF (Comprehensive Rehabilitation Facility) Co-Surgeons Co-Surgeons, Team Surgery Critical Access Hospital (CAH) It will be calculated according to Medicare s methodology: Medicare anesthesia conversion factor by locality x sum of uniform base units + time units. Payment is made on an assignment basis only. The above allowance is divided equally between the anesthesiologist and the anesthetist. Allowed at 85% of Medicare Fee Schedule. Allowed at 100% of Medicare Fee Schedule. Allowed at 75% of Medicare Fee Schedule. Medicare FIs directly reimburse all qualifying approved clinical trial services provided to a Medicare Advantage enrollee according to the appropriate fee for service methodology. Rate File (ONMPRF) will be used to group/price APC claims for any Medicareapproved provider. Reimbursement is based on the Medicare physician fee schedule. Vaccines are reimbursed under the OPPS. For each co-surgeon, the allowed amount is 63.5% of the global surgery allowed amount under the Medicare fee schedule. Team surgery reimbursement is by report. Inpatient services are PPS exempt and paid at 103% of reasonable costs for services furnished during cost report periods on or after January CAHs are reimbursed based on a per diem rate provided by the CAH s fiscal intermediary (FI). CAH will provide a copy of their most recent interim letter from their FI and will be paid at

4 103% of the interim rate. An update of the FI interim rate letter is required to be submitted annually or more often if changes occur. IME and DGME for inpatients are paid by the FIs on behalf of Medicare Advantage members. Capital IME is paid by the Medicare Advantage plan. Outpatient services are Prospective Payment System (PPS) exempt and paid at 103% of reasonable costs for services furnished during cost report periods on or after January CAHs are reimbursed based on a per diem rate provided by the CAH s FI. CAH will provide a copy of their most recent interim letter from their FI and will be paid at 103% of the interim rate. An update of the FI interim rate letter is required to be submitted annually or more often if changes occur. Diabetic Shoes Drugs Durable Medical Equipment (DME) Epoetin (EPO) Medicare coverage guidelines apply, and are only covered for certain conditions with annual limit. Reasonable charge subject to payment limits. Reimbursement for Part B-covered drugs is calculated using CMS fee schedule. Medicare-covered outpatient drugs/biologicals that qualify for passthrough payments will be processed. Most drugs for PPS hospital inpatients are not billable since they are assumed to be included in the DRG amounts. For bills from the hospital outpatient department, the cost is generally included in the APC payment (except for certain new drugs which may be payable). fee schedules. EPO is paid $10 per 1,000 units when administered by an ESRD facility or physician.

5 ESRD Facility FQHC Independent and Provider based Health Professional Shortage Area (HPSA) Home Health Agencies Independent and Provider Based Home Infusion Hospital Transfer Acute to Acute Laboratory Mammography Screening Geographically adjusted composite rates from the CMS website are used to determine reimbursement. Each facility must supply their pricing information and valid Medicare billing number. Reimbursement is at 80% of the lesser of the all-inclusive rate or the national limit, plus 20% of the actual charge. There is no wrap-around payment due from CMS. Reimbursement is determined using the Medicare physician fee schedule. A 10% bonus is paid for services performed in a HPSA (based on qualifying zip code). Payments are made on a PPS basis. HIPPS groups and pricers available via the CMS website are used to determine reimbursement. Reimbursement per Medicare Durable Medical Equipment Prosthetic, Orthotic, and Supplies (DMEPOS) fee schedule for applicable services. Part B covered drugs use the Medicare Fee Schedule to determine reimbursement at 95% of Average Wholesale Price (AWP). Transferring hospitals are reimbursed a per diem rate. The per diem rate is the full DRG amount divided by the geometric mean length of stay for the DRG. Twice the per diem is paid on the first day and the per diem for every following day up to the transfer or the full DRG amount. fee schedules. Allowed at 100% of Medicare fee schedule.

6 Medicare Dependent Hospital Inpatient Services Medicare Dependent Hospital Outpatient Services Nurse Practitioner Physical Therapy, Occupational Therapy, Speech Therapy Physician (MD) Physician (DO) Physician Assistant Physician Shortage Area (PSA) Prosthetic Devices Psych Hospital Inpatient and Outpatient Services The National Medicare Provider Rate File (NMPRF) is used to group/price DRG claims for Medicare approved providers. Rate File (ONMPRF) is used to group/price APC claims for Medicare approved providers. Allowed at 85% of the Medicare fee schedule. Allowed at 100% of Medicare fee schedule. fee schedules. Physician Services are priced according to the Correct Coding Initiative (CCI) edits and payment rules are configured to follow Local Medical Review Policies. fee schedules. Physician Services are priced according to the Correct Coding Initiative (CCI) edits and payment rules are configured to follow Local Medical Review Policies. Allowed at 85% of Medicare fee schedule. An additional payment bonus of 5% is payable in areas designated by CMS as physician scarcity areas based on qualifying zip code. Allowed at 100% of the Medicare Durable Medical Equipment Prosthetic, Orthotic, and Supplies Fee Schedule. Inpatient Psychiatric Facility Prospective Payment System (IPFPPS) is used for both freestanding psychiatric hospitals and certified psychiatric units of general acute care hospitals. Reimbursement is calculated using pricer via CMS website.

7 Registered Dietitian Rehab Hospital Inpatient Services Rehab Hospital Outpatient Services Allowed at 85% of Medicare fee schedule. Reimbursement is calculated using pricer via CMS website. Rate File (ONMPRF) is used to group/price APC claims for Medicare approved providers. Religious Non-Medical Health Care Institutions Rural Health Clinic Independent and Provider Based Skilled Nursing Facilities (SNF) Independent and Provider Based Each facility must supply their pricing information and valid Medicare billing number. Rural Health Clinics (RHC) are reimbursed based on 80% of the per-visit payment limit plus 20% of the actual charges of covered services. RHCs owned by rural hospitals with less that 50 beds are paid on a cost basis and are PPS exempt and paid at 103% of reasonable costs for services furnished during cost report periods on or after January RHCs are reimbursed based on a per diem rate provided by the RHC s FI. RHC will provide a copy of their most recent interim letter from their FI and will be paid at 103% of the interim rate. An update of the FI interim rate letter is required annually or more often if changes occur. The all-inclusive methodology applies only to RHC services, not to other services performed at an RHC such as lab, the technical components of diagnostic tests, etc. SNF is paid on the Prospective Payment System (PPS). RUG and HIPPS codes are used along with the CMS Web site pricer to determine reimbursement.

8 Surgical Dressings Swing Beds X-Ray The Medicare DMEPOS fee schedule applies to all surgical dressings except those applied incident to a physician s professional services, those furnished by an HHA and those applied while a patient is being treated in an outpatient department or as an acute care inpatient. website pricer. Allowed at 100% of Medicare fee schedule.

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