- Public Inspection: CMS: Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program for Federal Fiscal Year 2026
- Public Inspection: CMS: Medicare Program: Fiscal Year 2026 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Program Requirements
- CMS: Request for Information; Health Technology Ecosystem
- VA: Staff Sergeant Fox Suicide Prevention Grant Program Funding Opportunity
- State: 60-Day Notice of Proposed Information Collection: J-1 Visa Waiver Recommendation Application
- Public Inspection: CMS: Request for Information: Health Technology Ecosystem
- HHS: Request for Information (RFI): Ensuring Lawful Regulation and Unleashing Innovation To Make American Healthy Again
- VA: Solicitation of Nominations for the Appointment to the Advisory Committee on Tribal and Indian Affairs
- GAO Seeks New Members for Tribal and Indigenous Advisory Council
- VA: Staff Sergeant Fox Suicide Prevention Grant Program Funding Opportunity
- Telehealth Study Recruiting Veterans Now
- USDA Delivers Immediate Relief to Farmers, Ranchers and Rural Communities Impacted by Recent Disasters
- Submit Nominations for Partnership for Quality Measurement (PQM) Committees
- Unleashing Prosperity Through Deregulation of the Medicare Program (Executive Order 14192) - Request for Information
- Dr. Mehmet Oz Shares Vision for CMS
Primary Care and Oral Health Integration
A new article, “What Primary Care Innovation Teaches Us About Oral Health Integration” emphasizes the role of primary care and oral health integration in improving population health and addressing health inequities. The article was published in the in the January 2022 issue of the American Medical Association (AMA) Journal of Ethics. The article offers five lessons from the patient-centered medical home movement to inform primary and oral health care integration.
Biden-Harris Administration Requires Insurance Companies and Group Health Plans to Cover the Cost of At-Home COVID-19 Tests, Increasing Access to Free Tests
As part of its ongoing efforts across many channels to expand Americans’ access to free testing, the Biden-Harris Administration is requiring insurance companies and group health plans to cover the cost of over-the-counter, at-home COVID-19 tests, so people with private health coverage can get them for free starting January 15. The new coverage requirement means that most consumers with private health coverage can go online or to a pharmacy or store, buy a test, and either get it paid for up front by their health plan, or get reimbursed for the cost by submitting a claim to their plan. This requirement incentivizes insurers to cover these costs up front and ensures individuals do not need an order from their health care provider to access these tests for free.
Beginning January 15, 2022, individuals with private health insurance coverage or covered by a group health plan who purchase an over-the-counter COVID-19 diagnostic test authorized, cleared, or approved by the U.S. Food and Drug Administration (FDA) will be able to have those test costs covered by their plan or insurance. Insurance companies and health plans are required to cover 8 free over-the-counter at-home tests per covered individual per month. That means a family of four, all on the same plan, would be able to get up to 32 of these tests covered by their health plan per month. There is no limit on the number of tests, including at-home tests, that are covered if ordered or administered by a health care provider following an individualized clinical assessment, including for those who may need them due to underlying medical conditions.
“Under President Biden’s leadership, we are requiring insurers and group health plans to make tests free for millions of Americans. This is all part of our overall strategy to ramp-up access to easy-to-use, at-home tests at no cost,” said HHS Secretary Xavier Becerra. “Since we took office, we have more than tripled the number of sites where people can get COVID-19 tests for free, and we’re also purchasing half a billion at-home, rapid tests to send for free to Americans who need them. By requiring private health plans to cover people’s at-home tests, we are further expanding Americans’ ability to get tests for free when they need them.”
Over-the-counter test purchases will be covered in the commercial market without the need for a health care provider’s order or individualized clinical assessment, and without any cost-sharing requirements such as deductibles, co-payments or coinsurance, prior authorization, or other medical management requirements.
As part of the requirement, the Administration is incentivizing insurers and group health plans to set up programs that allow people to get the over-the-counter tests directly through preferred pharmacies, retailers or other entities with no out-of-pocket costs. Insurers and plans would cover the costs upfront, eliminating the need for consumers to submit a claim for reimbursement. When plans and insurers make tests available for upfront coverage through preferred pharmacies or retailers, they are still required to reimburse tests purchased by consumers outside of that network, at a rate of up to $12 per individual test (or the cost of the test, if less than $12). For example, if an individual has a plan that offers direct coverage through their preferred pharmacy but that individual instead purchases tests through an online retailer, the plan is still required to reimburse them up to $12 per individual test. Consumers can find out more information from their plan about how their plan or insurer will cover over-the-counter tests.
“Testing is critically important to help reduce the spread of COVID-19, as well as to quickly diagnose COVID-19 so that it can be effectively treated. Today’s action further removes financial barriers and expands access to COVID-19 tests for millions of people,” said CMS Administrator Chiquita Brooks-LaSure.
State Medicaid and Children’s Health Insurance Program (CHIP) programs are currently required to cover FDA-authorized at-home COVID-19 tests without cost-sharing. In 2021, the Biden-Harris Administration issued guidance explaining that State Medicaid and Children’s Health Insurance Program (CHIP) programs must cover all types of FDA-authorized COVID-19 tests without cost sharing under CMS’s interpretation of the American Rescue Plan Act of 2019 (ARP). Medicare pays for COVID-19 diagnostic tests performed by a laboratory, such as PCR and antigen tests, with no beneficiary cost sharing when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional. People enrolled in a Medicare Advantage plan should check with their plan to see if their plan offers coverage and payment for at-home over-the-counter COVID-19 tests.
This effort is in addition to a number of actions the Biden Administration is taking to expand access to testing for all Americans. The U.S. Department of Health and Human Services (HHS) is providing up to 50 million free, at-home tests to community health centers and Medicare-certified health clinics for distribution at no cost to patients and community members. The program is intended to ensure COVID-19 tests are made available to populations and settings in need of testing. HHS also has established more than 10,000 free community-based pharmacy testing sites around the country. To respond to the Omicron surge, HHS and FEMA are creating surge testing sites in states across the nation.
For more information, please see these Frequently Asked Questions, https://www.cms.gov/files/document/11022-faqs-otc-testing-guidance.pdf
For additional details on the requirements, visit https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf
COVID-19: New HCPCS Code for Remdesivir Antiviral Medication
Following the recent statement from the National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel regarding therapies for the COVID-19 Omicron variant, CMS created HCPCS code J0248 for VEKLURY™ (remdesivir) antiviral medication when administered in an outpatient setting. This code is available for use by all payers and is effective for dates of service on or after December 23, 2021:
- Long descriptor: Injection, remdesivir, 1 mg
- Short descriptor: Inj, remdesivir, 1 mg
Medicare Administrative Contractors (MACs) determine Medicare coverage when there is no national coverage determination, including in cases when providers use FDA-approved drugs for indications other than what is on the approved label. The MACs consider the major drug compendia, authoritative medical literature and accepted standards of medical practice to determine medical necessity when considering coverage. Therefore, the MACs will determine Medicare coverage for HCPCS code J0248 for VEKLURY™ (remdesivir) administered in an outpatient setting.
Your MAC will share coverage and claims processing information for J0248. Contact your MAC if you have questions about coverage.
CDC Releases “Rural Considerations for Vaccine Confidence and Uptake Strategies”
The Centers for Disease Control and Prevention (CDC) has released another COVID-related rural resource that may be of interest. A “Rural Considerations” addendum was recently added to its field guide for conducting a Rapid Community Assessment (RCA).
An RCA is a process for quickly collecting community insights about a public health issue in order to inform program design. The assessment involves reviewing existing data and conducting community-based interviews, listening sessions, observations, social listening, and surveys. In addition to the rural considerations addendum, the CDC RCA webpage provides an assessment guide and tools for those who wish to better understand their community’s needs regarding COVID-19 vaccine acceptance and uptake among adults, adolescents, and children. Addendums for conducting RCAs in tribal communities and among adolescent populations were also recently posted to the webpage.
The original COVID-19 Vaccination Field Guide: 12 Strategies for Your Community presents evidence-based strategies being applied in communities across the country to increase COVID-19 vaccine confidence and uptake. To help rural communities apply these strategies, the addendum includes rural considerations and examples for the 12 strategies based on successes in the field and input from health departments and rural health organizations.
State and local health departments, community- and faith-based organizations, and local nonprofits are encouraged to try a combination of these strategies to increase vaccination rates. Please share widely! Questions may be directed to ruralhealth@cdc.gov.
CMS Takes Action to Lower Out of Pocket Medicare Part D Prescription Drug Costs
Today, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would make updates to the Medicare Advantage (MA) and Medicare Part D programs that would lower out-of-pocket prescription drug costs for beneficiaries with Medicare Part D and improve price transparency and market competition. The proposed rule would improve beneficiaries’ experiences with MA and Part D, with a strong emphasis on individuals who are dually eligible for Medicare and Medicaid. Ultimately, CMS is taking action to hold MA and Part D plans to a higher standard in offering benefits and improve health equity in the programs.
“We are dedicated to ensuring older Americans and those with disabilities who are served by the Medicare program have access to quality, affordable health care, including prescription drugs and therapies,” said CMS Administrator Chiquita Brooks-LaSure. “Today’s proposed actions follow our guiding principles by improving health equity and enhancing access to prescription medications.”
In recent years, more Part D plans and pharmacies have entered into arrangements—called price concessions—where plans pay less money to pharmacies for dispensed drugs if the pharmacies do not meet certain metrics. However, there is no public visibility on these pharmacy price concessions, and these lower prices are not passed along to the beneficiary at the point of sale. In late 2018, CMS sought comment on a policy that would require Part D plans to apply all price concessions they receive from network pharmacies at the point of sale, which would reduce beneficiary cost-sharing. Having considered the comments, CMS is now proposing this policy, which would take effect January 1, 2023, to reduce beneficiaries’ Medicare Part D out-of-pocket costs and improve price transparency and market competition in the Part D program.
The proposed rule also takes steps to improve experiences for dually eligible beneficiaries who are enrolled in Dual Eligible Special Needs Plans (D-SNPs). D-SNPs are plans offered by MA organizations that enroll individuals who are eligible for both Medicare and Medicaid. The proposed rule would require that MA organizations with a D-SNP establish, maintain, and consult with one or more enrollee advisory committees to ensure the experiences of people with both Medicare and Medicaid are considered in plan decision making. The proposed rule would also simplify materials that describe how to access Medicare and Medicaid services and streamline the grievance and appeals processes in certain D-SNPs. The rule also proposes a change to MA cost-sharing rules that would result in more equitable payments to providers who serve dually eligible individuals and may improve dually eligible individuals’ access to providers.
In addition, CMS is proposing actions that reduce health disparities by ensuring that all MA special needs plans solicit information about an individual’s barriers to accessing care, through standardized questions in required health risk assessments on housing instability, food insecurity, and transportation. Also, the proposed rule seeks to protect people with Medicare by ensuring they receive accurate and accessible information about Medicare coverage. For example, CMS is proposing to strengthen oversight of third-party marketing organizations that act, directly or indirectly, on behalf of MA organizations and Part D sponsors. These changes include requiring that MA and Part D plans provide information in all required beneficiary communications about the availability of free translation services.
This proposed rule also protects beneficiaries by holding plans to a higher standard when reviewing applications for new or expanded MA plans by requiring that plan applicants demonstrate a sufficient network of contracted providers to care for beneficiaries. CMS also proposes to limit MA plans’ ability to expand or enter into new contracts if their previous performance is poor. This rule further protects beneficiaries by clarifying requirements for plans during disasters and emergencies to ensure that beneficiaries have uninterrupted access to needed services.
CMS is also proposing to hold plans more accountable for how Medicare revenue is spent, including providing greater transparency regarding the amounts used to provide supplemental benefits (e.g., dental, vision, hearing, transportation, meals) by requiring MA and Part D plans to expand reporting of information on the percent of plan revenue spent on patient care and quality improvement activities, known as the medical loss ratio.
In order to increase our understanding of issues related to access to behavioral health care for enrollees in MA plans, the agency also seeks feedback on the challenges with building behavioral health provider networks within MA health plans and the overall impact of potential CMS policy changes on network adequacy and behavioral health access in MA plans.
For a fact sheet detailing the CY 2023 Medicare Advantage and Part D Proposed Rule (CMS-4192-P), please visit: https://www.cms.gov/newsroom/fact-sheets/cy-2023-medicare-advantage-and-part-d-proposed-rule-cms-4192-p.
To view the proposed rule, please visit: https://www.federalregister.gov/public-inspection.
New Guidance on Medicaid Payment for Mobile Crisis Services Released
The Centers for Medicare & Medicaid Services (CMS) issued guidance to state Medicaid officials on the scope of and payments for qualifying community-based mobile crisis intervention services authorized by the American Rescue Plan Act of 2021. The guidance describes the requirements for qualifying services and provider qualifications, options for provider payments, and the requirements for receiving an increased federal share of costs. States are encouraged to take into account additional travel time when developing services for rural areas. Research has found higher proportions of rural populations have mental illness and substance use disorder compared to urban as well as challenges accessing care.
Message From HRSA’s New Administrator Carole Johnson
I am Carole Johnson, and this week, I am joining HRSA as the Administrator. I am especially delighted to join HRSA in this role, having spent time earlier in my career as part of the agency’s health care workforce team. Returning to HRSA as Administrator is an honor, and I look forward to working each day with the incredibly committed staff, grantees and partners who make up the HRSA community. I want to share my appreciation for Deputy Administrator Diana Espinosa’s dedication to the communities that HRSA serves and leadership as Acting Administrator over the past year.
Like you, I am deeply committed to HRSA’s mission of improving health outcomes and achieving health equity. I have seen firsthand HRSA’s tireless efforts to provide equitable access to COVID-19 vaccination and services and to support health care providers struggling with the financial impacts of the pandemic through my work with the White House COVID-19 Response Team. As Commissioner of the New Jersey Department of Human Services, which provides health care and social services to one-in-five New Jerseyans, I saw the impact of HRSA programs on ensuring access to affordable primary care, supporting health professionals who serve in underserved communities, and reducing disparities in infant and maternal health outcomes and HIV care. I have also had the opportunity to work closely with HRSA and others inside and outside of government on implementing the Affordable Care Act and combating the opioid epidemic.
It’s an extraordinary list of services and supports that this team delivers in communities across the country, and it only happens with the help and partnership of so many community leaders. I look forward to hearing your thoughts and feedback on how we can become an even stronger agency as we work to advance health equity and improve access to care and services for those who need it most.
With best wishes for the new year,
Carole Johnson
ARC Welcomes Governor Larry Hogan as 2022 States’ Co-Chair
The Appalachian Regional Commission (ARC) is pleased to announce that Maryland Governor Larry Hogan has been selected to serve as their states’ co-chair for 2022.
Governor Hogan will be working collaboratively with all 13 Appalachian states and the ARC federal office to advance the strategic investment priorities in ARC’s 2022-2026 Strategic Plan.
During FY 2021, ARC invested more than $163 million in the Region, which is projected to leverage an additional $1.04 billion in private investments, create or retain nearly 21,000 jobs, and train over 25,000 students, workers, and leaders in new skills across Appalachia.
Oral Health Resources Available in Spanish
The National Network for Oral Health Access (NNOHA) worked with the Puerto Rico Primary Care Association and released many of their popular oral health resources in Spanish. They are in the process of translating more materials that will be published in the coming weeks.
ASTDD to Launch National Oral Health Data Portal
The Association of State and Territorial Dental Directors (ASTDD) is working to create the nation’s first comprehensive oral health data portal. The ASTDD National Oral Health Data Portal will bring oral health status, workforce, access, cost, and quality of life information from existing federal, state, and other datasets into one consolidated, publicly-accessible website. ASTDD will be hosting a webinar on January 10th at 3 pm ET to launch the portal.