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CMS Updates Medicare Payment Policies for IPFs, SNFs, and Hospices

On July 31, CMS finalized three Medicare payment rules that further advance our efforts to strengthen the Medicare program by better aligning payments for Inpatient Psychiatric Facilities (IPFs), Skilled Nursing Facilities (SNFs), and hospices.

Inpatient Psychiatric Facilities:

The final rule updates Medicare payment policies and rates for the IPF Prospective Payment System (PPS) for FY 2021. In this final rule, CMS is finalizing a 2.2 percent payment rate update and finalizing its proposal to adopt revised Office of Management and Budget (OMB) statistical area delineations resulting in wage index values being more representative of the actual costs of labor in a given area. CMS is finalizing updates to allow advanced practice providers, including physician assistants, nurse practitioners, psychologists, and clinical nurse specialists to operate within the scope of practice allowed by state law by documenting progress notes in the medical record of patients for whom they are responsible, receiving services in psychiatric hospitals.

Skilled Nursing Facilities:

The final rule updates the Medicare payment rates and the quality programs for SNFs. These updates include routine technical rate-setting updates to the SNF PPS payment rates, as well as finalizes adoption of the most recent OMB statistical area delineations and applies a 5 percent cap on wage index decreases from FY 2020 to FY 2021. CMS is also finalizing changes to the ICD-10 code mappings that would be effective beginning in FY 2021 in response to stakeholder feedback. CMS projects aggregate payments to SNFs will increase by $750 million, or 2.2 percent, for FY 2021, compared to FY 2020.

Hospices:

For FY 2021, hospice payment rates are updated by the market basket percentage increase of 2.4 percent ($540 million). Hospices that fail to meet quality reporting requirements receive a 2 percentage point reduction to the annual market basket percentage increase for the year. The hospice payment system includes a statutory aggregate cap. The aggregate cap limits the overall payments made to a hospice annually. The final hospice cap amount for the FY 2021 cap year is $30,683.93, which is equal to the FY 2020 cap amount ($29,964.78) updated by the final FY 2021 hospice payment update percentage of 2.4 percent.

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National Rural Health Advocacy to Win Fight to Protect 340B Drugs for Rural Providers

NRHA Continues to Win Fight to Protect 340B Drugs for Rural Providers

The Centers for Medicare & Medicaid Services (CMS) proposed to cut Medicare Part B payments to hospitals for 340B-purchased drugs next year and in subsequent years by 6.2 percent below the current rate. However, as in the past, Critical Access Hospitals and rural Sole Community Hospitals were exempted from the cuts and will continue to be paid the default ASP plus 6 percent rate in the proposal. CMS made the announcement in its Hospital Outpatient Prospective Payment System (OPPS) proposed rule for calendar year 2021. Comments are due no later than 5:00 p.m. Eastern on Oct. 5.

Similar proposals for reductions that included cuts to rural providers have been proposed by CMS and Congress in the past. After extensive advocacy, NRHA was able to fight off proposed reductions to CAHs and SCHs. “Our challenge remains to protect this important program for all rural providers. 340B is vital in rural America and can mean the difference in providing services, employing staff, and keeping the doors open,” said Maggie Elehwany, Vice President of Government Affairs on NRHA.

Reimbursement for 340B drugs for disproportionate share hospitals (DSH), rural referral centers (RRC), and non-rural sole community hospitals (SCH) under OPPS would be set at average sales price (ASP) minus 34.7 percent, plus an add-on of 6 percent of ASP, for a net payment rate of ASP minus 28.7 percent. CMS has been paying these hospitals ASP minus 22.5 percent since 2018.

CMS derived the new, lower reimbursement rate from its survey in April and May of hospitals’ net average acquisition costs for drugs bought through the 340B program, including sub-ceiling price discounts. In the new proposed rule, CMS said, “Those survey data confirm that the ASP minus 22.5 percent rate is generous to 340B hospitals, and the survey data supports an even lower payment rate.”

A federal appeals court ruled 2-1 Friday that CMS had statutory authority to impose a nearly 30 percent cut to Medicare Part B drug reimbursement rates for 340B hospitals in 2018 and 2019. The reduction also is in place this year.

NRHA vows to be vigilant. CMS said it, “May revisit [its] policy to exempt rural SCHs, as well as other hospital designations for exemption from the 340B drug payment reduction, in future rulemaking.” Advocacy efforts and soliciting powerful stories from rural providers on their utilization of drug savings will be imperative during the next few months.

“We must continue to fight to protect 340B for CAHs, SCHs and expand it to all rural providers. We need all our members to join this fight,” said Elehwany.

CMS Updates Medicare Payment Policies for IRFs

On August 4, CMS finalized a Medicare payment rule that further advances our efforts to strengthen the Medicare program by better aligning payments for Inpatient Rehabilitation Facilities (IRFs). The final rule updates Medicare payment policies and rates for facilities under the IRF Prospective Payment System (PPS) for FY 2021. This final rule also includes making permanent the regulatory change to eliminate the requirement for physicians to conduct a post admission visit since much of the information is included in the pre-admission visit. This flexibility was offered during the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE), and the rule would make this flexibility permanent beyond the expiration of the PHE. In recognition of the interdisciplinary role that non-physician practitioners are currently performing with patients in the IRF, CMS is also finalizing that a non-physician practitioner may perform one of the three required visits in lieu of the physician in the second and later weeks of a patient’s care when consistent with the non-physician practitioner’s state scope of practice. Additionally, for FY 2021, CMS is updating the IRF PPS payment rates by 2.4 percent.

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Trump Administration Proposes Policies to Provide Seniors with More Choices and Lower Costs for Surgeries

Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) proposed rule advances CMS’ commitment to increasing competition

As directed by President Trump’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors, CMS is proposing several policies that would give Medicare beneficiaries more choices in where they seek care and lower their out-of-pocket costs for surgeries. The proposed rule takes steps that would allow hospitals and ambulatory surgical centers to operate with better flexibility and patients to have what they need to make informed decisions on where they receive care.

“President Trump’s mandate is to put patients and doctors back in charge of health care,” said CMS Administrator Seema Verma. “Following through on that mandate entails loosening the stranglehold of government control that has accumulated over decades. Surgeries can be expensive. Patients should have as many options as possible for lowering their costs while getting quality care. These proposed changes, if finalized, would do exactly that, help put patients and doctors back in the driver’s seat and in a position to make decisions about their own care.”

For patients having surgery, hospital outpatient departments are subject to the same quality and safety standards as inpatient settings under Medicare rules. With this in mind, for 2021, CMS proposes to expand the number of procedures that Medicare would pay for in the hospital outpatient setting by eliminating the “Inpatient Only list,” which includes procedures for which Medicare will only make payment when performed in the hospital inpatient setting. This proposed change would remove regulatory barriers to give beneficiaries the choice to receive these services in a lower cost setting and convenience to go home as early as the same day after a procedure, when their clinician decides such a setting is appropriate. CMS would phase-in this proposal over three years and would gradually allow over 1,700 additional services to be paid when furnished in the hospital outpatient setting. In 2021, approximately 300 musculoskeletal services (such as certain joint replacement procedures) would be newly payable in the hospital outpatient setting. The proposed change would be the largest one-time reduction to the Inpatient Only list by far; from 2017 through 2020, approximately 30 services total were removed from the Inpatient Only list.

Medicare pays for most services furnished in ASCs at a lower rate than hospital outpatient departments. As a result, when receiving care in an ASC rather than a hospital outpatient department, patients can potentially lower their out-of-pocket costs for certain services. For example, for one of the most common cataract surgeries, currently, on average, a Medicare beneficiary pays $101 if the procedure is done in a hospital outpatient department compared to $51 if done in a surgery center.

CMS proposes to expand the number of procedures that Medicare would pay for when performed in an ASC, which would give patients more choices in where they receive care and ensure CMS does not favor one type of care setting over another. For CY 2021, we propose to add eleven procedures that Medicare would pay for when provided in an ASC, including total hip arthroplasty. Since 2018, CMS has added 28 procedures to the list of surgical services that can be paid under Medicare when performed in ASCs.

Additionally, we propose two alternatives that would further expand our goals of increasing access to care at a lower cost. Under the first alternative, CMS would establish a process where the public could nominate additional services that could be performed in ASCs based on certain quality and safety parameters. Under the other proposed alternative, we would revise the criteria used to determine the procedures that Medicare would pay for in an ASC, potentially adding approximately 270 procedures that are already payable when performed in the hospital outpatient setting to the ASC list. Under this alternative, we solicit comment on whether the ASC conditions for coverage (the baseline health and safety requirements for Medicare-participating ASCs) should be revised given the potential for a significant expansion in the nature of services that would be added under this alternative proposal.

As part of the Trump Administration’s commitment to lowering drug prices, CMS is proposing a change that would lower beneficiaries’ out-of-pocket drug costs for certain hospital outpatient drugs. In 2018 and 2019, CMS implemented a payment policy to help beneficiaries save on coinsurance for drugs that were administered at hospital outpatient departments and acquired through the 340B program, which allows certain hospitals to buy outpatient drugs at lower costs. Due to CMS’ policy change, which was recently upheld by the United States Court of Appeals for the D.C Circuit, Medicare beneficiaries now benefit from the steep discounts that 340B-enrolled hospitals receive when they purchase drugs through the 340B program.

For 2021, CMS would provide even larger discounts for beneficiaries by proposing to further reduce the payment rate for drugs purchased through the 340B Program based on hospital survey data on drug acquisition costs. CMS is proposing to pay for 340B acquired drugs at average sales price minus 28.7 percent. With this proposed change, CMS estimates that, in 2021, Medicare beneficiaries would save an additional $85 million on out-of-pocket payments for these drugs and that OPPS payments for 340B drugs would be reduced by approximately $427 million. The savings from this change would be reallocated on an equal percentage basis to all hospitals paid under the OPPS. We propose that children’s hospitals, certain cancer hospitals, and rural sole community hospitals would continue be excepted from these drug payment reductions. In the alternative, and in light of the court’s recent decision, we propose to continue our current policy of paying ASP minus 22.5% for 340B drugs.

In continuing the agency’s Patients Over Paperwork Initiative to reduce burden for health care providers, CMS is proposing to establish, update, and simplify the methodology to calculate the Overall Hospital Quality Star Rating (Overall Star Rating) beginning with CY 2021. The Overall Star Rating summarizes a variety of quality measures published on the Medicare.gov Hospital Compare tool for common conditions that hospitals treat, such as heart attacks or pneumonia. Along with publicly reported data on Hospital Compare, the Overall Star Rating helps patients make better informed health care decisions.

Responding to stakeholder feedback about the current methodology used to calculate the Overall Star Rating, CMS is proposing revisions on how to calculate the ratings and grouping hospitals in the Readmission measure group by the hospital’s percentage of patients who are dually enrolled in Medicare and Medicaid, which would help provide better insight on health disparities. These and other proposed changes are intended to reduce provider burden, improve the predictability of the star ratings, and make it easier to compare ratings between similar hospitals.

As part of the agency’s Rethinking Rural Health Initiative, in the FY 2020 Inpatient Prospective Payment System (IPPS) final rule, CMS increased the wage index for certain low wage index hospitals for at least four years, beginning in FY 2020. In the CY 2020 OPPS/ASC Payment System final rule, CMS adopted changes to the wage index for outpatient hospitals as were finalized in the FY 2020 IPPS final rule, including the increase in wage index for certain low wage index hospitals. The OPPS wage index adjusts hospital outpatient payment rates to account for local differences in wages that hospitals face in their respective labor markets. For 2021, under the OPPS, CMS proposes to continue to adopt the IPPS post-reclassified wage index, including the wage index increase for certain low wage index hospitals. The increase would address a common concern that the current wage index system contributes to disparities between high and low wage index hospitals. Overall, CMS estimates that payment for outpatient services in rural hospitals across the country would increase by 3 percent, which is 0.5 percent higher than the national average increase of 2.5 percent.

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2020 Assister Certification Training on the Marketplace Learning Management System (MLMS) “Go-Dark”

As we prepare to release the 2021 Assister Certification Training, the 2020 Assister Certification Training that is hosted on the Marketplace Learning Management System (MLMS), will be taken offline at 6:00 p.m. (ET) on August 28, 2020.  During this “go-dark” period, assisters will not be able to access the certification training.  We anticipate that the 2021 Assister Certification Training will be available later this summer.

Assisters who need to take the current training before the 2021 training is available should complete the 2020 Assister Certification training prior to its removal on August 28.

Please note: this is training for assisters in the Federally-facilitated Marketplace, and assisters in State-based Marketplace  or State-based Marketplace using the Federal platform should follow their state’s training and certification requirements.

 

HHS Report on Telehealth Utilization amid COVID-19

The U.S. Department of Health and Human Services (HHS), through the Assistant Secretary for Planning and Evaluation (ASPE), issued a new report showing the dramatic utilization trends of telehealth services for primary care delivery in fee-for-service (FFS) Medicare in the early days of the COVID-19 pandemic. The report analyzes claims data from January through early June and underscores how telehealth flexibilities helped to spur and maintain Medicare beneficiaries’ access to their primary care providers. At the start of the COVID-19 public health emergency (PHE), with stay-at-home orders in place and warnings on the risk for severe illness from COVID-19 increasing with age, the report found Medicare FFS in-person visits for primary care fell precipitously in mid-March. It then found that in April, nearly half (43.5%) of Medicare primary care visits were provided through telehealth compared with less than one percent (0.1%) in February before the PHE. Read the press release.

Quest Predicts New FDA-Approved Lab Method Will Slash COVID-19 Test Turnaround Times

Commercial labs like Quest Diagnostics have faced challenges in keeping pace with outbreaks, leading to extended times to turn around coronavirus tests.  The delay–in some cases of up to several weeks– have made testing of significantly less value. With the announcement by Quest on Wednesday that the Food and Drug Administration has granted the company emergency authorization to use a new technique, the company said it expects “to achieve average turnaround times of 1 day for ‘Priority 1’ patients and 2-3 days for all other patients in coming weeks.” The new technique, which “speeds the process of extracting viral RNA from specimens,” will also boost Quest’s overall testing capacity. Read more.

HHS Announces Revised Reporting Schedule for Provider Relief Fund

On July 21, the Department of Health and Human Services (HHS) released information updating the timeline and schedule for mandatory reports on the use of Provider Relief Funds (PRF). (Please note: this information supersedes the announcement from May 2020 that reports would be due within 10 days of the end of each calendar quarter; that guidance has been rescinded.) The first report will now be due no later than Feb. 15, 2021 and will cover all funds used during CY 2020. Health centers that have not spent all their PRF monies in CY 2020 must submit a second report on their use of PRF funds in 2021; this report is due no later than July 31, 2021. HHS indicates that no reports will be accepted after July 10, 2021, suggesting that June 30, 2021 is the final date for using PRF funds; however, HHS has yet to say anything explicit about such an end date. HHS has also not released anything on what information must be included in these reports. HHS states that this information will be available no later than August 17, and that the reporting system will open on October 1. Please see the official HHS announcement for further details. Also, the NACHC “mega-spreadsheet” of info on Federal COVID funding sources will be updated ASAP to reflect this new info, including the chart list of major deadlines in Tab 2.

Value-Based Care: A Primer for Outreach and Enabling Services Staff

Health Outreach Partners, a HRSA-funded National Training and Technical Assistance Partners (NTTAP), created this free, downloadable publication, Value-Based Care: A Primer for Outreach and Enabling Services Staff, to introduce value-based care and incentive payments to outreach and enabling services staff at community health centers. It describes the role of value-based care in outreach and provides specific examples of value-based care models and the relevance to health center outreach and enabling services staff.

New Pennsylvania Reinsurance Program

The Pennsylvania Insurance Department, in partnership with the Pennsylvania Health Insurance Exchange Authority, received authorization to operate a Reinsurance Program under section 1332 of the Affordable Care Act, also known as a State Relief and Empowerment waiver, from 2021 through 2025. The reinsurance program will reduce premiums for consumers on the marketplace by approximately 5-10 percent for plan year 2021 and increase affordability and access to quality coverage. Reinsurance programs provide a direct benefit to consumers by paying a portion of provider claims that would normally be paid by consumers through higher premiums.