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Medicare & MassHealth

Medicare & MassHealth



Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). You can learn more about Medicare here

  • How do I become a Medicare provider?

Merit-based Incentive Payment System (MIPS)

In 2016 the Physician Quality Reporting System (PQRS) transitioned to the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program. 

  • How do I know if I am included in MIPS?

    You’re a part of the Quality Payment Program in 2017 if you bill Medicare more than $30,000 in Part B allowed charges a year and provide care for more than 100 Medicare patients a year. You must both meet the minimum billing and the number of patients to be in the program. If you are below either, you are not in the program. We do not need to do anything if our volume falls below the threshold. If you decide to participate in MIPS, you will earn a performance-based payment adjustment. If you do NOT meet the low volume threshold of $30,000 + 100 patients, and do not participate in 2019, you will be penalized (the penalty was 5% for other specialties in 2018). To check if you are included in MIPS, visit:
  • Will the Centers for Medicare & Medicaid Services (CMS) inform clinical social workers if they meet the requirements to use a low volume threshold for reporting?

    Providers should confirm their low threshold exemption on a yearly basis with Medicare. Providers may receive a letter from CMS confirming whether they met the low threshold criteria. If a provider does not receive a letter during the fall of 2018, there is a MIPS eligibility look-up tool provided at, where clinicians can search by their NPI number. Providers can also contact the QPP help desk at or call 866-288-8292 to verify the exemption.
  • Will clinical social workers be penalized if they do not report measures in 2019?

    YES. Failure to participate in MIPS in 2019 will result in a penalty for those who do not meet the low threshold exemption (if it is sustained). The projected penalty for failure to report or incorrect or incomplete reporting has not been announced for 2019. For 2018, it is a minus 5 percent penalty. In addition to these frequently asked questions, clinical social workers may refer to the CMS QPP website, at, or may contact the QPP help desk at or 866-288-8292.

Qualified Medicare Beneficiary (QMB) Program

People with Medicare who are in the QMB program are also enrolled in Medicaid and get help with their Medicare premiums and cost-sharing.

  • How do I access online QMB explanation of benefits (EOBs) through MassHealth?


MassHealth is Massachusetts' combined program for Medicaid and Children's Health Insurance Program (CHIP). You can learn more about MassHealth here.

  • How do I become a MassHealth provider? 

  • How do I enroll to become a MassHealth Ordering, Referring, and Prescribing (ORP) provider?

    Effective for the 2018 licensing renewal period (deadline September 30, 2018), all Licensed Independent Clinical Social Workers (LICSWs) are required to apply to be a billing or non-billing ORP provider through MassHealth. You can read more about this requirement on MassHealth's website here, or visit NASW-MA's webpage with FAQs and application instructions
  • I heard that MassHealth moved to an Accountable Care Organization (ACO)-based model of care. How will this affect me and my clinical social work practice? 

  • I want to help my client enroll in MassHealth. How can I help them navigate open enrollment? 

    NASW-MA has a new resource available in English, Spanish, and Portuguese. One side is intended for clients and patients, helping them know where to go to enroll in health insurance during the open enrollment period (November 1, 2017 - January 23, 2018). The other side is intended for clinicians and providers, answering health insurance enrollment-related questions that may come up when discussing open enrollment with clients and patients. Download PDF: English Spanish | Portuguese 

Thank you to Erica Kirsners, LICSW, for helping to organize and present this information in an informative and meaningful way. 


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