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The Centers for Medicare and Medicaid Services (CMS) issued a final rule with comment period that will implement key provisions in the Affordable Care Act of 2010 that expand preventive services for Medicare beneficiaries, improve payments for primary care services, and promote access to health care services in rural areas.  The new policies will apply to payments under the Medicare Physician Fee Schedule (MPFS) for services furnished on or after January 1, 2011.

 “The rule we are issuing today is a major step toward improving the health status of Medicare beneficiaries by providing coverage for an annual wellness visit that will allow a physician and patient to develop a closer partnership to improve the patient’s long term health,” said CMS administrator Donald Berwick, M.D.  “The rule will also eliminate out-of-pocket costs for most preventive services beginning January 1, 2011, reducing barriers to access for many beneficiaries.”

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On Friday, October 8, 2010, Governor Schwarzenegger signed legislation to enact the 2010 State Budget. The Department of Health Care Services notified the Fiscal Intermediary to release all payable held claims and process all provider claims over the weekend.

All payable claims that were received by 12:00 Noon on Friday, October 8 were processed over the weekend. The State Controller's Office will be mailing the warrants on Thursday, October 14, with an Electronic Fund Transfer date of Monday, October 18.

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Beginning January 1, 2011, your clients will get an Annual Wellness visit, covered by Medicare every 12 months, starting a year (12 months) after they get their initial “Welcome to Medicare” physical exam. And if your client never had a Welcome to Medicare exam, that’s ok; now they can get their free Annual Wellness visit each year. This is the first time Medicare will cover an annual exam, and there is no cost-sharing (coinsurance or deductible) for this service.

During the visit, your client and health care provider will develop a personalized prevention plan, building off of the initial exam. Note, there are slight distinctions between the first wellness visit and subsequent such visits.

The initial Annual Wellness visit includes:

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Effective July 1, 2010, the state of California did not have an approved budget for current fiscal year 2010-11. The fiscal intermediary, HP Enterprise Services, continues to adjudicate claims, and providers continue to be reimbursed pursuant to state law, as outlined in the online update July 9, 2010 entitled Fiscal Year 2010-11 State Budget Reimbursement Contingency.

During this period of no state budget, the following non-institutional provider types will continue to receive payment regardless of the status of the state budget for Medi-Cal services rendered to beneficiaries:

AIDS Waiver Services

Occupational Therapists

Audiologists

Optometric Group

Care Coordinator

Optometrists

Certified Acupuncturist

Orthotists

Certified Nurse Midwife

Out-of-State

Certified Pediatric & Family Nurse Practitioners

Outpatient Heroin Detoxification Center

Chiropractors

Pharmacies/Pharmacists

Christian Science Practitioner

Physical Therapists

Clinical Nurse Specialist Crossover Provider Only

Physicians

Dispensing Opticians

Physicians Group

EPSDT Supplemental Services Providers

Podiatrists

Group Certified Pediatric & Family Nurse Practitioners

Portable X-Ray

Group Respiratory Care Practitioners

Prosthetics

Health Access Program

Psychologists

Hearing Aid Dispensers

Respiratory Care Practitioner

Independent Diagnostic Testing Facility Crossover

RVNs Individual Nurse

Nurse Anesthetists

Speech Therapists

During this period of no state budget, the following institutional provider types will continue to receive payment regardless of the status of the state budget for services rendered to Medi-Cal beneficiaries:

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The Centers for Medicare & Medicaid Services (CMS) issued an interim final regulation on May 5, 2010 implementing provisions of the Affordable Care Act that permit only a Medicare-enrolled physician or eligible professional to certify or order home health services, durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), and certain items and services under Medicare Part B. The new law applies to orders, referrals and certifications made on or after July 1. However, according to a June 30, 2010 press release from CMS, CMS will not implement automatic rejections of claims submitted by providers that have attempted to enroll in the Provider Enrollment, Chain and Ownership System (PECOS).

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