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7 Things to Know about Medicare for 2019

7 Things to Know about Medicare for 2019

As we wrap up 2018, the Centers for Medicare and Medicaid Services (CMS) has released a variety of information healthcare providers need to know about billing Medicare in 2019. We’ve created a short list of the top seven things you should know.

Medicare Fee Schedule

In November, CMS released the 2019 Medicare Physician Fee Schedule. For a detailed look at some of the provisions that were part of that final rule, check out our blog post, “2019 Medicare Physician Fee Schedule: What You Need to Know.” If you just want a data source of the updated fees for Indiana and Michigan, here are WPS GHA’s downloadable fee schedules. A zipped file of updated fees for all states is available on the CMS Physician Fee Schedule webpage.

Medicare Part B Premiums

The standard monthly premium for 2019 Medicare Part B will increase slightly from the 2018 rate of $134 to $135.50. The small increase is the result of a 2.8 percent cost-of-living adjustment (COLA) announced by the Social Security Administration, which implements a “hold harmless” provision for Medicare Part B premium increases. In other words, beneficiaries whose COLA to their social security benefit is not enough to cover the increase in the Medicare premium will pay less than the $135.50.

A small percentage of Medicare beneficiaries pay increased premiums based on a sliding scale of incomes greater than $85,000 per year. Depending on their modified adjusted gross income from two years ago, these beneficiaries might pay as much as $460.50 in monthly premiums in 2019.

These premiums do not apply to Medicare Advantage or prescription drug plans, whose premiums are determined separately.

Part B Deductible

CMS also announced that the annual deductible for all Medicare Part B beneficiaries will be $185 in 2019 (compared to $183 in 2018). This deductible does not apply to Medicare Advantage or prescription drug plans, whose deductibles are determined separately.


As the Merit-Based Incentive Payment System (MIPS) enters its third year, eligible providers should begin planning to participate in 2019. Not participating in the program in 2019 or failure to meet certain program standards could result in a -7 percent payment adjustment of covered professional services paid under or based on the Medicare Physician Fee Schedule in 2021.

For 2019, several new provider types were included among the “eligible providers,” including

  • Physical therapists
  • Occupational therapists
  • Qualified speech-language pathologists
  • Qualified audiologists
  • Clinical psychologists
  • Registered dietitians or nutrition professionals

As well, CMS will use a third criterion for determining MIPS eligibility. For 2018, clinicians or groups were excluded from MIPS if they had ≤ $90K in Part B allowed charges for covered professional services or if they provided care to ≤ 200 beneficiaries. In addition to those two criteria, for 2019, clinicians or groups may be excluded if they provide ≤ 200 covered professional services under the Medicare Physician Fee Schedule.

However, CMS has created a new “opt-in feature” for excluded clinicians and groups. For 2019, clinicians or groups would be able to opt-in to MIPS if they meet or exceed one or two, but not all, of the low volume threshold criteria.

To determine if you or a provider you work with is eligible for MIPS in 2019, visit CMS’s Quality Payment Program Participation Status page.

New Medicare Card: MAC Look-Up Tool Updated

Each Medicare Administrative Contractor’s (MAC’s) secure portal Medicare Beneficiary Identifier (MBI) look-up tool now returns the MBI even if the new Medicare card has not been mailed. Providers who do not already have access should sign up for their MAC’s portal to use the tool.

CMS began mailing the new Medicare cards in April 2018 and will meet the statutory deadline for replacing all Medicare cards by April 2019. Patients who have not received their new Medicare card can call 1-800-MEDICARE to get one. Also, remember that you can use either the Health Insurance Claim Number or the MBI for all Medicare transactions through December 31, 2019.

New Medicare Advantage Open Enrollment Period

In 2019, a new Medicare Advantage Open Enrollment Period will run from January 1 – March 31 every year. Beneficiaries enrolled in a Medicare Advantage plan will have a one-time opportunity to:

  • Switch to a different Medicare Advantage plan
  • Drop their Medicare Advantage plan and return to Original Medicare, Part A and Part B
  • Sign up for a stand-alone Medicare Part D Prescription Drug Plan (if they return to Original Medicare).

Closing the Donut Hole

Over the next two years, Medicare beneficiaries who have prescription drug coverage (Part D) will see the coverage gap, known as the donut hole, shrink until it’s closed in 2020.

Beginning in 2018, beneficiaries began receiving extra discounts for brand-name drugs that fell within the coverage gap. In 2018, those discounts brought the price down to 35 percent of the total, and in 2019, beneficiaries will have to pay only 30 percent of the total. By 2020 beneficiaries will pay no more than the 25 percent copay for covered brand-name drugs—the same percentage they pay from the time they meet the deductible until they reach the out-of-pocket spending limit.

The gap will close for generic drugs by 2020, too, when beneficiaries will also pay no more than the 25 percent copay, though the amount beneficiaries pay until then is a larger percentage of the total price than for brand-name drugs. In 2018, beneficiaries had to pay 44 percent of the cost, and in 2019, they’ll pay 37 percent.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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