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November 3, 2021

3 Final Payment Rules

CMS Physician Payment Rule Promotes Greater Access to Telehealth Services, Diabetes Prevention Programs

Final Rule Advances Health Equity, Person-Centered Care

On November 2, CMS is announcing actions that will advance its strategic commitment to drive innovation to support health equity and high quality, person-centered care. CMS' Calendar Year (CY) 2022 Physician Fee Schedule (PFS) final rule will promote greater use of telehealth and other telecommunications technologies for providing behavioral health care services, encourage growth in the diabetes prevention program, and boost payment rates for vaccine administration. The final rule also advances programs to improve the quality of care for people with Medicare by incentivizing clinicians to deliver improved outcomes.

"Promoting health equity, ensuring more people have access to comprehensive care, and providing innovative solutions to address our health system challenges are at the core of what we do at CMS," said CMS Administrator Chiquita Brooks-LaSure. "The Physician Fee Schedule final rule advances all these strategic priorities and helps build a better Medicare program for the future."

Expanding Use of Telehealth and Other Telecommunications Technologies for Behavioral Health Care

The final rule makes significant strides in expanding access to behavioral health care – especially for traditionally underserved communities – by harnessing telehealth and other telecommunications technologies. In line with legislation enacted last year, CMS is eliminating geographic barriers and allowing patients in their homes to access telehealth services for diagnosis, evaluation, and treatment of mental health disorders.

"The COVID-19 pandemic has highlighted the gaps in our current health care system and the need for new solutions to bring treatments to patients, wherever they are," said Brooks-LaSure. "This is especially true for people who need behavioral health services, and the improvements we are enacting will give people greater access to telehealth and other care delivery options."

CMS is bringing care directly into patients' homes by providing certain mental and behavioral health services via audio-only telephone calls. This means counseling and therapy services, including treatment of substance use disorders and services provided through Opioid Treatment Programs, will be more readily available to individuals, especially in areas with poor broadband infrastructure.

In addition, for the first time outside of the COVID-19 public health emergency (PHE), Medicare will pay for mental health visits furnished by Rural Health Clinics and Federally Qualified Health Centers via telecommunications technology, including audio-only telephone calls, expanding access for rural and other vulnerable populations.

Promoting Growth in Medicare Diabetes Prevention Program

Prediabetes impacts over 88 million American adults, with many at risk for developing type 2 diabetes within five years. Many traditionally underserved communities – including African Americans, Hispanic/Latino Americans, American Indians, Pacific Islanders, and some Asian Americans – face an elevated risk of developing type 2 diabetes.

As the U.S. marks Diabetes Awareness Month this November, CMS is taking steps to improve its Medicare Diabetes Prevention Program (MDPP) expanded model, which was developed to help people with Medicare with prediabetes from developing type 2 diabetes.

Under the expanded model, local suppliers provide structured, coach-led sessions in community and health care settings using a Centers for Disease Control and Prevention-approved curriculum to provide training in dietary change, increased physical activity, and weight loss strategies. CMS is waiving the Medicare enrollment fee for all organizations that apply to enroll as an MDPP supplier on or after January 1, 2022. CMS has been waiving this fee during the COVID-19 PHE for new MDPP suppliers and has witnessed increased supplier enrollment. Next, CMS is shortening the MDPP services period to one year instead of two years. This change will make delivery of MDPP services more sustainable, reduce the administrative burden and costs to suppliers, and improve patient access by making it easier for local suppliers to participate and reach their communities. Finally, CMS is restructuring payments so MDPP suppliers receive larger payments for participants who reach milestones for attendance.

CMS expects these changes will result in more MDPP suppliers, increased access to MDPP services for people with Medicare in rural areas, and a decrease in the number of individuals with diabetes in both urban and rural communities.

Increased Access to Medical Nutrition Therapy Services

The PFS final rule also streamlines access to Medical Nutrition Therapy (MNT), which includes services provided by registered dietitians or nutrition professionals to help people with Medicare better manage their diabetes or renal disease. MNT establishes goals, a care plan, and interventions, as well as plans for follow-up over multiple visits to assist with behavioral and lifestyle changes relative to help address an individual's nutrition needs and medical condition or disease(s).

CMS removed a requirement that limited who could refer people with Medicare to MNT services, allowing any physician (M.D. or D.O.) to do so. This change should particularly benefit people living in rural areas as the MNT services are provided to eligible individuals with no out of pocket costs and may be provided via telehealth.

Encouraging Proven Vaccines to Protect Against Preventable Illness

As the COVID-19 pandemic has so starkly demonstrated, access to safe and effective vaccines is vital to public health. CMS will maintain the current payment rate of $40 per dose for the administration of the COVID-19 vaccines through the end of the calendar year in which the ongoing PHE ends. Effective January 1 of the year following the year in which the PHE ends, the payment rate for COVID-19 vaccine administration will be set at a rate to align with the payment rate for the administration of other Part B preventive vaccines. CMS will also continue to facilitate vaccinations for common diseases such as influenza, pneumonia, and hepatitis B.

This year Medicare reviewed payments for vaccinations to ensure doctors and other health professionals are paid appropriately for providing vaccinations. This final rule will nearly double Medicare Part B payment rates for influenza, pneumococcal, and hepatitis B vaccine administration from roughly $17 to $30. CMS hopes this change will increase access to these potentially life-saving injections and lead to greater vaccination uptake.

Expanded Pulmonary Rehabilitation Coverage Under COVID

As part of CMS' continuing efforts to address the current PHE, the agency finalized expanded coverage of outpatient pulmonary rehabilitation services, paid under Medicare Part B, to individuals who have had confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks. This goes beyond CMS' PFS proposed rule which would have focused the expanded coverage to those hospitalized with COVID-19. CMS also finalized a temporary extension of certain cardiac and intensive cardiac rehabilitation services available via telehealth for people with Medicare until the end of December 2023.

Advancing the Quality Payment Program and MIPS Value Pathways

To further improve the quality of care for people with Medicare, the PFS final rule makes several key changes to CMS' Quality Payment Program (QPP), a value-based payment program that promotes the delivery of high-value care by clinicians through a combination of financial incentives and disincentives.

For example, CMS finalized a higher performance threshold that clinicians will be required to exceed in 2022 to be eligible for positive payment incentives. This new threshold was determined in accordance with statutory requirements for the QPP's Merit-based Incentive Payment System (MIPS).

CMS is also moving forward with the next evolution of QPP and officially introducing the first seven MIPS Value Pathways (MVPs) ̶ subsets of connected and complementary measures and activities, established through rulemaking, that clinicians can report on to meet MIPS requirements. MVPs are designed to ensure more meaningful participation for clinicians and improved outcomes for patients by more effectively measuring and comparing performance within different clinician specialties and providing clinicians more meaningful feedback. This initial set of MVP clinical areas include: rheumatology, stroke care and prevention, heart disease, chronic disease management, lower extremity joint repair (e.g., knee replacement), emergency medicine, and anesthesia.

To incentivize high-quality care for professionals that are often a key point of contact for underserved communities with acute health care needs, CMS has also revised the current eligible clinician definition to include clinical social workers and certified nurse-midwives among those participating in MIPS.

Ensuring Accurate Payments Through Clinical Labor Update

CMS recognizes the importance of making accurate payments for services provided under Medicare to ensure the integrity of the program as well as to support continued access to care. For the first time in nearly 20 years, CMS is updating the clinical labor rates that are used to calculate practice expense under the PFS. As a result, payments to primary care specialists that involve more clinical labor, such as family practice, geriatrics, and internal medicine specialties, are expected to increase. This increase will to drive greater person-centered care for these services particularly for disadvantaged groups and underserved communities. There will be a four-year transition period to implement the clinical labor pricing update, which will help maintain payment stability and mitigate any potential negative effects on health care providers by gradually phasing in the changes over time.

Increasing Access to Physician Assistants' Services

Finally, CMS is implementing a recent statutory change that authorizes Medicare to make direct Medicare payments to Physician Assistants (PAs) for professional services they furnish under Part B. For the first time, beginning January 1, 2022, PAs will be able to bill Medicare directly. As a result, more individuals with Medicare will have access to these services as PAs will have the same opportunity as certain other Medicare practitioners to bill Medicare for professional services.

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CMS OPPS/ASC Final Rule Increases Price Transparency, Patient Safety and Access to Quality Care

On November 2, in keeping with President Biden's Competition Executive Order, CMS is releasing a final rule that will further advance its commitment to increasing price transparency, holding hospitals accountable and ensuring consumers have the information they need to make fully informed decisions regarding their health care. The Calendar Year (CY) 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule with Comment Period will strengthen enforcement of price transparency requirements for hospitals, and increase Medicare beneficiary quality and safety by halting the phased elimination of the Inpatient Only (IPO) list for surgical procedures.

"CMS is committed to promoting and driving price transparency, and we take seriously concerns we have heard from consumers that hospitals are not making clear, accessible pricing information available online, as they have been required to do since January 1, 2021," said CMS Administrator Chiquita Brooks-LaSure. "We are also taking actions to enhance patient safety and quality care."

Price Transparency

Beginning January 1, 2022, CMS will increase the penalty for some hospitals that do not comply with the Hospital Price Transparency final rule. Specifically, CMS is setting a minimum civil monetary penalty of $300 per day that will apply to smaller hospitals with a bed count of 30 or fewer, and a penalty of $10 per bed per day for hospitals with a bed count greater than 30, not to exceed a maximum daily dollar amount of $5,500. Under this approach, for a full calendar year of noncompliance, the minimum total penalty amount would be $109,500 per hospital, and the maximum total penalty amount would be $2,007,500 per hospital.

Hospital price transparency helps people know what a hospital charges for the items and services they provide, an important factor given that health care costs can cause significant financial burdens for consumers. While enforcement activities are necessary to drive compliance with price transparency, CMS is also committed to working with hospitals to help them meet those requirements.

Enhancing Beneficiary Protections

CMS is also enhancing beneficiary protections by finalizing policies that will allow for a more evidence-based approach in determining whether procedures should be payable in the outpatient setting. In the CY 2021 OPPS/ASC final rule, CMS finalized a policy to eliminate the IPO list over a three-year period, removing 298 services in the first phase of the elimination. A large number of stakeholder comments opposed elimination of the list, primarily due to safety concerns with performing certain procedures in an outpatient setting.

For CY 2022, CMS is halting the elimination of the IPO list and, after clinical review of the services removed from the list in CY 2021, CMS is adding all but a small number of procedures back to the list. CMS is also reinstating the ASC Covered Procedures List (CPL) criteria that were in effect in CY 2020 and adopting a process for stakeholders to nominate procedures they believe meet the requirements to be added to the ASC CPL.

Health Equity, Access to Emergency Care in Rural Areas and Lessons from COVID-19

In the OPPS/ASC Payment System proposed rule, CMS also issued Requests for Information (RFIs) and solicited comments on a number of potential proposals and actions to further the vision of advancing health equity, driving high-quality, person-centered care, and promoting affordability and sustainability. The comments will help inform future rulemaking around these topics. Future rulemaking will include additional opportunities for public comments.

  • Health equity: CMS received input on ways to make reporting of health disparities based on social risk factors and race and ethnicity more comprehensive and actionable by including additional demographic data points (e.g., race, ethnicity, Medicare/Medicaid dual eligible status, disability status, LGBTQ+, and socioeconomic status).
  • Access to emergency care in rural areas: the proposed rule included an RFI on Rural Emergency Hospitals (REHs). CMS received robust comments in response to this RFI and looks forward to taking each of those comments into consideration during the rulemaking process for the development of the REH requirements.
  • Lessons from COVID-19: CMS solicited comments on the extent to which hospitals are using flexibilities offered during the COVID-19 public health emergency (PHE) to provide mental health services remotely and whether CMS should consider changes to account for shifting practice patterns. In addition, comments were received on the collection and reporting of COVID-19 vaccination status of hospital outpatient department and ASC staff, and making this information available to the public so consumers know how many workers are vaccinated in different health care settings.

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Biden-Harris Administration Improves Home Health Services for Older Adults and People with Disabilities

Final rule accelerates shift from volume-based incentives to quality-based incentives and advances coordination of care through Quality Reporting Programs

On November 2, CMS issued a final rule that furthers CMS' strategic commitment to drive innovation that promotes comprehensive, person-centered care for older adults and people with disabilities by accelerating the shift from paying for home health services based on volume, to a system that incentivizes value and quality. The final rule will also strengthen CMS' data collection efforts to identify and address health disparities and use of care among people who are dually eligible for Medicare and Medicaid, people with disabilities, people who identify as LGBTQ+, religious minorities, people who live in rural areas, and people otherwise adversely affected by persistent poverty or inequality.

The Calendar Year 2022 Home Health Prospective Payment System (PPS) Final Rule addresses challenges facing Medicare beneficiaries who receive health care at home. The final rule finalizes nationwide expansion of the successful Home Health Value-Based Purchasing (HHVBP) Model to incentivize quality of care improvements.

"CMS is committed to helping people get the care they need, where they need it," said CMS Administrator Chiquita Brooks-LaSure. "This final rule will improve the delivery of home health services for people with Medicare. It will also improve our data collection efforts, helping us to identify health disparities and advance health equity."

The CMS Innovation Center (Innovation Center) launched the original HHVBP Model on January 1, 2016, to determine whether CMS could improve the quality and delivery of home health care services to people with Medicare by offering financial incentives to providers that offer better quality of care with greater efficiency. The original HHVBP Model comprised all Medicare-certified home health agencies (HHAs) providing services across nine randomly selected states. The Third Annual Evaluation ReportExternal website of the participants' performance from 2016-2018 showed an average 4.6 percent improvement in HHAs' quality scores and an average annual savings of $141 million to Medicare.

The final policies promulgated in this rule expand the HHVBP Model nationally, with the first performance year beginning January 1, 2023. The HHVBP Model is one of four Innovation Center models that have met the requirements to be expanded in duration and scope since 2010. Starting in 2025, CMS will adjust fee-for-service payments to Medicare-certified HHAs based on the quality of care provided to beneficiaries during the CY 2023 performance year. Throughout 2022, CMS will provide technical assistance to HHAs to ensure they understand how performance will be assessed. Overall, these policies support the Agency's commitment to advancing value-based care by providing incentives for HHAs to improve the beneficiary experience and quality of care.

Additionally, the final rule will advance CMS' coordination of care efforts through improvements to the Home Health Quality Reporting Program, Long-Term Care Hospital Quality Reporting Program, and Inpatient Rehabilitation Facility Quality Reporting Program and finalizes the mandatory COVID-19 reporting requirements for Long Term Care facilities (nursing homes) established as a part of the May 2020 and May 2021 Interim Final Rules beyond the current COVID-19 public health emergency (PHE) until December 31, 2024. The rule removes or replaces several quality measures to reduce burden and increase focus on patient outcomes. CMS is also finalizing its proposals to begin collecting data on two measures promoting coordination of care in the Home Health Quality Reporting Program effective January 1, 2023 as well as measures under Long-Term Care Hospital Quality Reporting Program and Inpatient Rehabilitation Quality Reporting Program effective October 1, 2022. The effective dates position the agency to support the recent Executive Order 13985 of January 20, 2021, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government.

Finally, this rule implements provisions of the Consolidated Appropriations Act, 2021External website that establish survey and enforcement requirements for hospice programs serving Medicare beneficiaries. These provisions will require the use of multidisciplinary survey teams, prohibition of surveyor conflicts of interest, and expansion of surveyor training to include accrediting organizations (AOs). The provisions also establish a hospice program complaint hotline and create the authority for CMS to impose enforcement remedies for noncompliant hospice programs. These changes will strengthen oversight, enhance enforcement, and establish consistent and transparent survey requirements in hospice care.

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