Medicare & Insurance

The AOA provides information and resources to assist members in staying abreast of the numerous Medicare rules and regulations. The AOA also advocates directly with the Centers for Medicare & Medicaid Services (CMS) regarding issues of concern to the optometric profession.

Medicare enrollment

Medicare provider/supplier enrollment applications: The Medicare enrollment application (CMS-855 or Internet-based Provider Enrollment, Chain and Ownership System (PECOS)) is an Office of Management and Budget approved form and is available in PDF fillable format. This format allows a user to complete an application using Adobe Acrobat and save this information on their personal computer or download the application.

Required re-enrollment or "revalidation"

Section 6401 (a) of the Affordable Care Act established a requirement for all enrolled providers/suppliers to revalidate their Medicare enrollment information under new enrollment screening criteria.

The most efficient way to submit your revalidation information is by using the Internet-based PECOS location on the CMS website. PECOS allows you to review information currently on file, update and submit your revalidation via the Internet. You must either electronically sign the revalidation application or print, sign, date and mail the paper certification statement to your MAC.

Important: Each provider/supplier is required to revalidate their entire Medicare enrollment record to include all active practice locations and/or current reassignments.

Established due dates - The CMS has established due dates by which you must revalidate. The revalidation due dates will always be on the last day of the month (i.e., June 30, 2016; July 31, 2016; August 30, 2016). You are expected to submit your revalidation application by this date. Generally, this due date will remain with you throughout subsequent revalidation cycles.

Posted due dates on data.cms.gov - Beginning March 1, 2016, a listing of all currently enrolled providers/suppliers will be available at CMS' website. DME supplier information will currently display as blank and will not include due dates at this time. Those due for revalidation will display a revalidation due date, all other providers/suppliers not up for revalidation will display a "TBD" (To Be Determined) in the due date field. The revalidation due date will be posted up to 6 months in advance of the revalidation due date to provide sufficient notice and time for the provider/supplier to comply. The file will be updated periodically.

Medicare and insurance

2019 Merit-based Incentive Payment System/Quality Payment Program

The Centers for Medicare and Medicaid Services (CMS) created the Quality Payment Program (QPP) based on MACRA legislation. The QPP provides penalties and incentive payments based on your Merit-based Incentive Payment System (MIPS) scores. MIPS requires doctors to more robustly report their quality measures, electronic health record (EHR) use and practice improvement activities to get paid at the highest levels. Better performance in each category will result in higher MIPS scores with a greater chance of earning incentives and avoiding payment penalties.

CATEGORY PERFORMANCE CATEGORIES SCORE
Quality Think PQRS. 45% of overall
Improvement Activities Think about your role in overall public health. 15% of overall
Promoting Interoperability Formerly known as Advancing Care information. Think meaningful use. 25% of overall
Cost How much does it cost CMS for you to provide care? 15% of overall


Avoiding 2021 penalties based on 2019 performance

You can be excluded from the QPP and avoid future penalties if at least one of the following applies to you (see CMS' MIPS Participation/Exclusion Lookup Tool to check your eligibility):

  • 2019 is your first year submitting claims to Medicare.
  • Your Medicare billing charges are less than or equal to $90,000.
  • You provide care for 200 or fewer Part B-enrolled Medicare beneficiaries.
  • You provide 200 or fewer Medicare covered services.
  • You are a Qualifying APM Participants (QP) and Partial Qualifying APM Participant (Partial QP).

If none of the above conditions apply, you can avoid up to a 7% penalty (reduction) in your 2021 Medicare payments by earning at least 30 points in your overall 2019 MIPS score. You can do this by a combination of the following:

  • Report six measures in the Quality category.
  • Report two medium-weighted or one high-weighted activity in the Improvement Activities category.
  • Report the required measures in the Promoting Interoperability category.

Earning 2021 incentives based on 2019 performance

Up to a 7% incentive (increase) in 2021 Medicare payments can be earned based on the level of 2019 participation and MIPS score. For more information on scoring, penalties and incentives, see "AOA's 2019 MIPS Guidebook: A Road Map to Success for Doctors of Optometry."

Additional AOA resources 

Additional CMS resources: 

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