Tag: Vaccine
BCBS RSV Vaccine Update
Sept. 1, 2023
RSV Vaccine Coverage Update
Applies to all non-grandfathered groups
Beginning Sept. 1, 2023, we will cover the Respiratory Syncytial Virus (RSV) vaccine without cost sharing for adults, as recommended by the Advisory Committee on Immunization Practices (ACIP).
- This year, the Food and Drug Administration (FDA) approved two new RSV vaccines, Abrysvo and Arexvy, for the prevention of lower respiratory tract disease caused by RSV in those age 60 and older.
- We will cover both RSV vaccines without cost sharing when obtained at a doctor’s office (as a medical claim) or at a participating pharmacy (as a pharmacy claim) for groups that have Prime® Therapeutics as their Pharmacy Benefits Manager (PBM).
- Groups that have carved-out pharmacy benefits should check with their PBM to confirm their coverage and implementation of this update.
- As with any preventive service, the vaccine must be obtained from an in-network provider to be covered without cost sharing.
- This coverage update is effective Sept. 1, regardless of renewal date for all non-grandfathered ACA-compliant plans.
Note: The RSV vaccine for infants (Beyfortus) is a different drug and is covered under the medical plan only.
Blue Cross and Blue Shield of Texas (BCBSTX) contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics. MyPrime.com is an online resource offered by Prime Therapeutics.
2023 Medicare Physician Fee Schedule Final Rule
On November 01, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates and policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2023.
Employee Vaccinations
TMA Ask the Expert: Employee Vaccinations
“The rule does not apply to independent physician practice settings”
ICD-10 Adds Z Codes
Starting April 1, 2022
You will have new ICD-10-CM Z codes to report if you find the patient you are treating is partially vaccinated or unvaccinated for COVID-19.
- New subcategory Z28.31 (Underimmunization for COVID-19 status), and under it, two new patient status codes:
- Z28.310 (Unvaccinated for COVID-19).
- Z28.311 (Partially vaccinated for COVID-19).
- Z29.39 (Other underimmunization status).
MGMA Washington Connection
- COVID-19 PHE ends January 16, 2022 if HHS Secretary does not renew.
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MGMA successfully advocates for sunsetting of healthcare ETSOn Dec. 27, 2021, the Occupational Safety and Health Administration (OSHA) issued a statement on the status of its COVID-19 healthcare emergency temporary standard (ETS), confirming that it is withdrawing the ETS with the exception of the recordkeeping portions.Last August, MGMA urged OSHA to not make this standard permanent, due to it disrupting ongoing efforts of medical groups to balance the needs of patients against the imperative to protect employees. Although OSHA is letting this ETS sunset, it expressed its intentions to revisit the issue of protecting healthcare workers from COVID-19 in the future by issuing another standard. MGMA will urge the Agency to solicit input from stakeholders, such as medical groups, when developing such a standard.
- Updated member resources to navigate surprise billingOn Jan. 1, 2022, the No Surprises Act requirements prohibiting certain out-of-network balance billing and new uninsured (or self-pay) good faith estimate price transparency requirements took effect. Throughout 2021, the Biden Administration released several rules implementing these newly effective requirements. The Administration will continue to release additional rules throughout 2022 outlining the remaining patient protections that have not yet been implemented.The MGMA Government Affairs team has updated member-exclusive resources to help group practices better understand the requirements in place. Check out the most up-to-date resources on the MGMA Surprise Billing landing page.
- MIPS 2021 data submission window openClinicians can now submit and review data for the 2021 performance year for the Merit-based Incentive Payment System (MIPS). The data submission window closes on March 31, 2022 at 8 p.m. (ET). The Centers for Medicare and Medicaid Services provided several flexibilities for clinicians due to the COVID-19 public health emergency, including applying an automatic reweighting of performance scores for individual clinicians.
In other MIPS updates: on Jan 1. 2022, the 2022 payment adjustment, based on clinician 2020 MIPS performance scores took effect and will be applied to Part B covered services. Additionally, looking ahead to the 2022 performance year, clinicians can now review their preliminary MIPS eligibility by signing into the Quality Payment Program website.
CoVid Vaccine Mandate, Update
ADVOCACY RESOURCE – DECEMBER 2, 2021
Claire Ernst J.D.
Government Affairs Director MGMA
Washington DC
MGMA, Update on the Court Cases Involving CoVid-19 Vaccination Mandates.
Per Claire Ernst J.D., Government Affairs Director MGMA
“I wanted to provide a quick update on the court cases involving the COVID-19 vaccination mandates. As many of you have seen, both the OSHA vaccination and testing emergency temporary standard (ETS) and the CMS facilities vaccination mandate were quickly challenged in court. Below is a quick overview of where the mandates currently stand – this is subject to change:
- OSHA vaccination and testing ETS: On Nov. 12, 2021, the U.S. Circuit Court of Appeals for the Fifth Circuit granted a motion to stay (or halt) the ETS. After that decision, OSHA suspended enforcement pending future developments in the litigation. More information about OSHA’s announcement can be found on the ETS landing page. The U.S. Court of Appeals for the Sixth Circuit now has jurisdiction over the challenges and will issue its decision. However, it is certainly possible that following the Court’s ruling, the decision could get appealed to the U.S. Supreme Court.
- CMS facilities vaccination mandate: On Nov. 30, 2021, the U.S. District Court for the Western District of Louisiana issued a preliminary injunction halting the mandate. The ruling comes one day after the U.S. District Court for the Eastern District of Missouri halted implementation of the rule for 10 states. Together, the decisions apply to all states. However, this decision is likely to get appealed as well.
MGMA will continue to monitor this evolving situation and provide updates.”
CoVID-19 Vaccine Mandate
This regulation will not apply to physician’s offices because they are not subject to CMS health and safety regulations.
Nov 4, 2021, the Biden administration released two rules pertaining to COVID-19 vaccine mandates. Both rules will require applicable employers and healthcare facilities to fully meet vaccination requirements by Jan. 4, 2022
Humana Physician News-Q4 Edition
Effective Dec. 31, 2021, the Provider Payment Integrity (PPI) contact mailbox will be disabled.
To manage overpayments, please use the Availity Portal or call Customer Care at 800-438-7885, Monday – Friday, 8 a.m. – 8 p.m., Eastern time.
Looking for new ways to reach and engage your patients?
Humana has developed the Provider Marketing Resource Center (PMRC) so you can engage, retain and grow your practice’s patient panel, regardless of their current insurance carrier.
Contact [email protected] for access to their library of customizable patient marketing materials.
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