Fiscal Watch – October 17, 2024

To help patients choose a Medicare coverage option that best suits their needs, WSHA developed a new Medicare Facts brochure for hospitals and providers to share with Medicare eligible patients. The Medicare open enrollment period for calendar year 2025 runs from October 15 through December 7, 2024. During this period Medicare eligible patients can elect to remain in regular Medicare or select one of the various Medicare Advantage plans.

The brochure, available in both English and Spanish outlines the differences between the types of Medicare plans and provides a list of things for patients think about before making a switch. The document can be printed on 11×17 paper and folded to create a brochure and can be modified as needed. (Andrew Busz, andrewb@wsha.org)

The Centers for Medicare and Medicaid Services (CMS) recently updated its complaint submission form and process to receive complaints regarding Medicare Advantage (MA) plans regarding noncompliance with the 2024 Medicare Advantage rule. The rule, which went into effect January 1, 2024, generally limits MA plans to the utilization review and prior authorization requirements under original Medicare and places conditions on use of internal coverage criteria. It also required MA plans to follow the two-midnight rule regarding determination of inpatient versus observation services.

A CMS FAQ document regarding what is required of MA plans under the rule is here. The FAQs detail when and how insurers are permitted to use internal coverage criteria instead of federal standards, as well as requirements for public disclosure of those criteria. (Andrew Busz, andrewb@wsha.org) 

The Washington Health Care Authority recently sent a Provider Alert to clarify a billing change for administration of vaccines obtained through the Vaccines for Children (VFC) program. The change was effective for services on or after July 1, 2024. Providers should bill for the vaccine administration and the vaccine itself as separate charges. Administration of the vaccine should be billed using the appropriate CPT code and the vaccine with the appropriate vaccine procedure code and modifier SL. A copy of the alert with a billing example is here. 

This change was made to ensure uniformity and consistency across billing practices for VFC and non-VFC vaccines. This change is generally budget neutral to providers, compared to the previous billing policy. HCA has revised the EPSDT Well-Child Program Billing Guide, the Enhanced Pediatric, Physician-Related/Professional Services, and Professional Administered Drug Fee Schedules to reflect the changes.  (Andrew Busz, andrewb@wsha.org) 

Senate Bill 5986, enacted during the 2024 legislative session, adds ground ambulance services to the services subject to the balance billing prohibitions and dispute resolution process under the state’s Balance Billing Protection Act (BBPA) effective January 1, 2025. The new provisions apply to coverage subject to the BBPA and do not apply under the federal No Surprises Act.

The Office of the Insurance Commissioner (OIC) has updated the BBPA’s standard notice of consumer rights to reflect the changes. Effective January 1, 2025, medical providers, facilities, ground ambulance service organizations, and behavioral health emergency service providers should post the updated form on their website and use it for required notices under WAC 284-43B-050. The bill also established minimum allowed amounts to be paid by carriers for out-of-network ground ambulance services. 

OIC is also hosting a webinar for consumers and providers on October 22, 2024, from 11:00 am to 12:00 pm. The webinar provides background and Q&A on the BBPA for ground ambulance transports.  Please register in advance to attend the webinar, which will also be recorded and posted to the OIC website.   More information about the changes is here. (Andrew Busz, andrewb@wsha.org).