The Centers for Medicare & Medicaid Services’ (CMS) CY2025 Physician Fee Schedule (PFS) Proposed Rule, released in preview form on July 10, 2024, contains various provisions that will impact federally qualified health centers’ (FQHC) service offering and payment under Medicare. The rule contains provisions that will, if finalized, allow for various service expansions and enhancement in payments for FQHCs in Medicare, as well as building on the trend of greater recognition of technology-based services in Medicare. In particular, the proposals, if finalized, would allow CMS to carry out the following in CY2025:

1.  Broaden the capacity for FQHCs and other providers to use audio-only telehealth, rather than the audio-visual modality, where necessary to support patient care;

2.  Allow FQHCs to furnish and be paid for Medicare advanced primary care management (APCM) services—a more comprehensive approach to primary care targeted to individuals with greater clinical needs—and to receive additional payments for use of the APCM model;

3.  Require, for the first time, that FQHCs and rural health clinics (RHCs) bill Medicare for care management and care coordination using detailed codes; this change will allow FQHCs to be paid more for more resource-intensive care management services, and also to be paid add-on fees for add-on fees if time is spent on care management in a month in excess of the threshold requirement;

4.  Provide, for the first time, for separate initial payment to FQHCs for the administration of Medicare Part B-covered preventive vaccines including hepatitis B, pneumococcal, influenza, and COVID-19 vaccines (with payment for all of the latter three being later reconciled to the FQHCs’ documented costs on its cost report);

5.  Refine the payment methodology for FQHCs for intensive outpatient services (IOP), a behavioral health service added to the Medicare FQHC benefit effective Jan. 1, 2024, so that FQHCs could be paid at a higher rate for days of IOP services where more than four services are provided in a single day;

6.  Rebase the FQHC market basket inflationary index (CMS has done this only one time prior since the inflationary index was first introduced in 2017); and

7.  Postpone further (until Jan. 1, 2026) the implementation of a requirement that patients receiving telecommunications-based mental health visits in an FQHC have had an in-person mental health visit during the six months prior to the initiation of the telecommunications-based care.

Comments are due by Sept. 9. Click here to learn more and access the proposed rule.

The Pennsylvania Primary Care Career Center is seeking a Talent Acquisition Specialist to join their team and help Community Health Centers recruit primary care providers and other staff. If you know anyone who would be a great candidate for this position, please share the link to the job post and encourage them to apply online or send their resume and cover letter to Caitlin Wilkinson, Co-Director of the Pennsylvania Primary Care Career Center.

Legislation reining in prescription drug middlemen was signed by the Governor this week. House Bill 1993 deals with contracts between pharmacies and the 72 pharmacy benefit managers (PBM) operating in the state, transparency and accountability measures and pharmacies administering immunizations among other things. Through our aggressive advocacy, PACHC was able to have language added to help protect covered entities, including FQHCs, from pickpocketing by PBMs. The language in the bill in Chapter 6 states that, A PBM licensed by the department to conduct business in this Commonwealth may not, as part of a contract agreement issued or renewed following the effective date of this section with a pharmacist or pharmacy under this part reimburse a qualified health center or covered entity an amount lesser than similar entities not participating in the program under section 340(b) of the Public Health Service Act (58 Stat. 682, 42 U.S.C. § ). This language does not address the issue with contract pharmacies.

Rep. Mike Kelly R-PA from the House Ways and Means Health Subcommittee is sponsoring the Health Care Sharing Ministry Tax Parity Act (HCSM). The bill would allow members of faith-based organizations and ministries to deduct healthcare related expenses from their taxes to achieve tax fairness for ministries that share health care costs. The rules make it clear that these organizations would not be able to offer health insurance to ensure there would be no loopholes with the current tax rules. Millions of Americans participate in HCSM programs sharing the cost of more than $1 billion in medical expenses.

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights and the Centers for Medicare & Medicaid Services (CMS) recently issued a final rule under Section 1557 of the Affordable Care Act (ACA) to strengthen nondiscrimination protections and advance civil rights in health care. This rule reinstates non-discrimination standards for all Health and Human Services health programs and activities, protects LGBTQI+ patients from discrimination, requires that all entities including insurers and providers let people know language assistance and services are available, requires staff training on sections of the 1557 policies and respects federal guarantees regarding religious freedoms and conscience as set for by 45 CFR 92.3 and 92.302. See the Fact Sheet.

The Maternal and Child Health Stillbirth Prevention Act of 2024, HR 4581, passed through both the House and the Senate, and now awaits President Biden’s signature before it becomes law. The bipartisan bill amends the Maternal and Child Health Services Block Grant program to allow states to use those dollars for stillbirth prevention and research activities but does not include additional funding.

On Tuesday, June 25, by a margin of 133-69, lawmakers in the Pennsylvania House passed House Bill 1140, which would require health insurance policies – as well as government health insurance programs like Medical Assistance and the Children’s Health Insurance Program (CHIP) – to cover FDA-approved contraceptive drugs, devices and products for covered individuals. The bill’s prime sponsor, Democratic state Rep. Leanne Krueger, said in a statement after the House vote that the bill would establish state-level protections for contraceptive access. “Pennsylvania currently has no protections in state law for contraceptive access, so attacks at the federal level jeopardize our access,” Krueger said. The bill currently awaits action from the state Senate.