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Medicare Updates

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  • 2025 Final Rule Medicare Physician Fee Schedule

    1 Nov 2024 5:09 PM | Zachary Edgar (Administrator)

    CY 2025 PFS Rate Setting and Conversion Factor

    By factors specified in law, average payment rates under the PFS will be reduced by 2.93% in CY 2025, compared to the average amount these services were paid for most of CY 2024. The change to the PFS conversion factor incorporates the 0% overall update required by statute, the expiration of the temporary 2.93% increase in payment for CY 2024 required by statute, and a relatively small estimated 0.02% adjustment necessary to account for changes in work relative value units (RVUs) for some services. This amounts to an estimated CY 2025 PFS conversion factor of $32.35, a decrease of $0.94 (or 2.83%) from the current CY 2024 conversion factor of $33.29.

    Supervision Policy for Physical Therapists (PTs) and Occupational Therapists (OTs) in Private Practice

    For CY 2025, CMS is finalizing a regulatory change to allow for general supervision of physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) by PTs in private practice (PTPPs) and OTs in private practice (OTPPs) for all applicable physical and occupational therapy services. This finalized change will give PTPPs and OTPPs more flexibility in meeting the needs of beneficiaries and safeguard patient access to medically necessary therapy services, including those experiencing challenges accessing these services in rural and underserved areas, and it will align with general supervision of PTAs and OTAs by PTs and OTs who work in institutional providers.

    Certification of Therapy Plans of Treatment with a Physician or NPP Order

    For CY 2025, CMS is finalizing amendments to the certification regulations to lessen the administrative burden for therapists (PTs, OTs, and speech-language pathologists (SLPs)) and physician/NPPs. These changes will provide an exception to the physician/NPP signature requirement on the therapist-established treatment plan for purposes of the initial certification, in cases where a written order or referral from the patient’s physician/NPP is on file and the therapist has documented evidence that the treatment plan was transmitted to the physician/NPP within 30 days of the initial evaluation. CMS also solicited comment, as suggested by interested parties, as to the need for a regulation to address the amount of time during which the physician/NPP who signed the written order for therapy services could make changes to the therapist-established treatment plan by contacting the therapist directly, but CMS did not adopt such a timeline restriction. Instead, CMS clarified that, for the cases meeting the exception to the signature requirement policy, payment should be made available for any therapy services furnished prior to a physician/NPP-modified treatment plan if all payment requirements are met. The comment solicitation as to whether there should be a 90-day (or other) limit to the physician/NPP order extending from the order date to the first date of treatment/evaluation by the therapist did not result in a policy being adopted by CMS.

    Reference

    CMS Newsroom

    Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule


  • 2025 Proposed Medicare Physician Fee Schedule

    11 Jul 2024 10:51 AM | Zachary Edgar (Administrator)

    Payment Rate Cut

    Average payment rates under the PFS are proposed to be reduced by 2.93% in 2025 compared to the average amount these services are being paid for most of 2024. The change to the PFS conversion factor incorporates the 0.00 percent overall update required by statute, the expiration of the 2.93% increase in payment for 2024 required by statute, and a relatively small estimated 0.05% adjustment necessary to account for changes in work relative value units (RVUs) for some services. This amounts to a proposed estimated 2025 PFS conversion factor of $32.36, a decrease of $0.93 (or 2.80%) from the current 2024 conversion factor of $33.29.

    Supervision Policy for Physical Therapists (PTs) and Occupational Therapists (OTs) in Private Practice

    CMS is proposing a regulatory change to allow for general supervision of physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) by PTs in private practice (PTPPs) and OTs in private practice (OTPPs) for all applicable physical and occupational therapy services.

    General supervision means that supervising PTs and OTs can be off-site while PTAs and OTAs treat patients, therapists must be available by phone.

    This proposed change will give PTPPs and OTPPs more flexibility in meeting the needs of beneficiaries and safeguard patient access to medically necessary therapy services, including those experiencing challenges accessing these services in rural and underserved areas; and it will align with general supervision of PTAs and OTAs by PTs and OTs who work in institutional providers.   

     

    Certification of Therapy Plans of Treatment with a Physician or NPP Order

    CMS is proposing amendments to the certification and recertification regulations to lessen the administrative burden for therapists and physician/NPPs. These changes, if finalized, would provide an exception to the physician/NPP signature requirement on the therapist-established treatment plan for purposes of the initial certification in cases where a written order or referral from the patient’s physician/NPP is on file and the therapist has documented evidence that the treatment plan was transmitted to the physician/NPP within 30 days of the initial evaluation.

    CMS is also soliciting comments, as suggested by interested parties, as to the need for a regulation addressing the amount of time during which the physician/NPP who has written an order for therapy services could make changes to the therapist-established treatment plan by contacting the therapist directly, and whether there should be a 90-day (or other) limit to the physician/NPP order extending from the order date to the first date of treatment/evaluation by the therapist.


  • Lymphedema Compression Treatment Items

    1 May 2024 8:07 AM | Zachary Edgar (Administrator)

    Coverage

    Coverage of lymphedema compression treatment items is available as of January 1, 2024 for treating beneficiaries with any diagnosis of lymphedema. The lymphedema compression treatment items must be prescribed by a physician (or a physician assistant, nurse practitioner, or a clinical nurse specialist. Coverage of lymphedema compression treatment items for any non-lymphedema diagnosis is not allowed. The items must be furnished by an enrolled DMEPOS supplier. All suppliers, including physical therapists and other practitioners furnishing bandaging systems must be enrolled as a DMEPOS supplier to be paid under Medicare Part B for furnishing lymphedema compression treatment items.

    The following categories of lymphedema compression treatment items are covered when determined to be reasonable and necessary for the treatment of lymphedema:

    • Standard daytime gradient compression garments
    • Custom daytime gradient compression garments
    • Nighttime gradient compression garments
    • Gradient compression wraps with adjustable straps 
    • Accessories (e.g., zippers, linings, padding or fillers, etc.) necessary for the effective use of a gradient compression garment or wrap
    • Compression bandaging supplies
    • Other items determined by CMS to be lymphedema compression treatment items under the benefit category determination process. These procedures consider public consultation via public meetings and in writing for new lymphedema compression treatment items.

    With respect to lymphedema compression treatment items:

    • Custom fitted gradient compression garment means a garment that is uniquely sized and shaped to fit the exact dimensions of the affected extremity or part of the body, of an individual to provide accurate gradient compression to treat lymphedema.
    • Gradient compression means the ability to apply a higher level of compression or pressure to the distal (farther) end of the limb or body part affected by lymphedema with lower, decreasing compression or pressure at the proximal (closer) end of the limb or body part affected by lymphedema.

    Replacements and Frequency Limitations

    Payment for replacement of lymphedema compression treatment items can be made for garments or wraps that are lost, stolen, or irreparably damaged. 

    If a patient’s medical condition has changed enough to warrant the need for a new size or type of garment or wrap, payment can be made for the new garment or wrap. 

    Except for replacements of lymphedema compression treatment items addressed above, no payment may be made for gradient compression garments or wraps with adjustable straps furnished other than at the following frequencies:

    • Three (3) units of daytime gradient compression garments or wraps with adjustable straps per affected extremity or part of the body once every six (6) months.
    •  Two (2) garments for nighttime use per affected extremity or part of the body once every two (2) years.

    There are no set frequency limitations for compression bandaging supplies. The DME MACs have discretion to determine the replacement and frequency of compression bandaging supplies that are reasonable and necessary.

    Reference

    Medicare Benefit Manual.  Chapter 15 – Covered Medical and Other Health Services § 145

  • Congress Reduces Medicare Rate Cut

    9 Mar 2024 11:22 AM | Zachary Edgar (Administrator)

    The Consolidated Appropriations Act, 2024 (H.R. 4366) will reduce Medicare Part B cuts from 3.4% to 1.7% for the remainder of 2024.

    When signed into law this will effectively increase current payments rates by 1.7% compared to rates so far in 2024.  

    Expect rate increases in either April or May. 

  • Physician Fee Schedule 2024 Final Rule - Therapy Servicws

    3 Nov 2023 9:35 AM | Zachary Edgar (Administrator)

    CY 2024 PFS Ratesetting and Conversion Factor

    Overall payment reduction of 1.25% in 2024.

    By factors specified in law, overall payment rates under the PFS will be reduced by 1.25% in CY 2024 compared to CY 2023. CMS is also finalizing significant increases in payment for primary care and other kinds of direct patient care.

    The final CY 2024 PFS conversion factor is $32.74, a decrease of $1.15 (or 3.4%) from the current CY 2023 conversion factor of $33.89. 

    Supervision Policy for Physical and Occupational Therapists Assistants in Remote Monitoring

    Therapy assistants do not need on-site supervision for remote monitoring services.

    Since 2005, CMS has required PTs and OTs in private practices (PTPPs and OTPPs, respectively) to provide direct supervision of their therapy assistants. CMS is finalizing a regulatory change to allow for general supervision of therapy assistants by PTPPs and OTPPs for remote therapeutic monitoring (RTM) services.

    Supervision Policy for Physical and Occupational Therapy Assistants in Private Practice

    No Change.

    In the proposed rule, CMS solicited comments on whether to revise the current direct supervision policy for therapy assistants working with PTPPs and OTPPs to require general supervision for all therapy services, not just for RTM services. In particular, CMS sought feedback and any available supporting data on the potential effects of implementing such a policy, including but not limited to patient quality of care, patient safety, and changes in utilization. CMS received feedback in response to all of the questions and will take it into consideration for future rulemaking. 

    Payment for Outpatient Therapy Services when Furnished by Institutional Staff to Beneficiaries in Their Homes Through Communication Technology

    Institutional providers are able to continue to bill for physical therapy, occupational therapy, speech-language pathology, DSMT and MNT services on the telehealth list furnished remotely the same way that they could during the PHE through the end of CY 2023. CMS is finalizing the proposed policy that — with the addition of a requirement to use the 95 modifier on all claims, except Method II critical access hospitals (CAHs), and — to note specifically for outpatient hospitals that patients’ homes no longer need to be designated as provider-based entities — CMS continues to allow institutional providers to bill for outpatient therapy, DSMT, and MNT services furnished remotely at least through the end of CY 2024. 

    Reference

    Centers for Medicare & Medicaid Services

    Calendar Year (CY) 2024 Medicare Physician Fee Schedule Final Rule


  • Home Health Final Rule - Lymphedema Compression Garments

    2 Nov 2023 9:34 AM | Zachary Edgar (Administrator)

    Lymphedema Compression Treatment Items

    Section 4133 of the CAA, 2023 establishes a Medicare Part B benefit for standard and custom-fitted gradient compression garments and other compression treatment items for the treatment of lymphedema that are prescribed by an authorized practitioner.

    Compression garments for treatment of lymphedema have not been previously covered by Medicare because, prior to the enactment of the CAA, 2023, there was no statutory benefit category for such items. This rule addresses the scope of the new benefit by defining what constitutes a standard- or custom-fitted gradient compression garment and identifying other compression items used for the treatment of lymphedema that fall under the new benefit category, beginning January 1, 2024.

    The rule sets forth Medicare payment for gradient compression garments for both daytime and nighttime use as well as ready-to-wear, non-elastic, gradient compression wraps with adjustable straps and compression bandaging systems applied in a clinical setting as part of phase one decongestive therapy as well as during phase two maintenance therapy. The rule establishes that Medicare will pay for an increase in daytime garments over the amount previously proposed.

    Medicare will pay for three daytime garments every six months and two nighttime garments every two years for each affected extremity or part of the body. This rule establishes the initial Healthcare Common Procedure Coding System (HCPCS) codes and the payment methodology for these items and outlines how future coding, benefit category, and payment determinations for these items will be made.

    The payment basis that we are finalizing for lymphedema compression treatment items approximates the payment methodology by the Department of Veterans Affairs, which is the average Medicaid State agency payment amounts plus 20 percent. In the event that Medicaid State agency payment rates are not available, payment rates will be based on the average of payment amounts established by TRICARE and internet retail prices.

    If neither Medicaid nor TRICARE payment amounts are available, Medicare payment rates will be based on the average internet retail prices for a lymphedema compression treatment item.


  • Medicare 2024 Proposed Physician Fee Schedule Changes to Assistant Supervision

    14 Jul 2023 11:10 AM | Zachary Edgar (Administrator)

    Supervision Policy for Physical and Occupational Therapists in Private Practice

    Since 2005, CMS has required PTs and OTs in private practices (PTPPs and OTPPs, respectively) direct supervision of their therapy assistants. CMS is proposing a regulatory change to allow for general supervision of their therapy assistants by PTPPs and OTPPs for remote therapeutic monitoring (RTM) services. This will align with the RTM general supervision policy that CMS finalized in CY 2023 rulemaking.

    CMS is also soliciting comments on whether to revise the current direct supervision regulatory policy for PTPPs and OTPPs of their therapy assistants to the general supervision policy for all services, not just for RTM services. CMS is particularly interested in receiving comments, including any available supporting data, on the potential effects of implementing such a policy, including but not limited to patient quality of care, patient safety, and changes in utilization.  


  • Calendar Year (CY) 2024 Home Health Prospective Payment System Proposed Rule

    30 Jun 2023 10:15 AM | Zachary Edgar (Administrator)

    On June 30, 2023, the Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2024 Home Health Prospective Payment System (HH PPS) Rate Update proposed rule, which would update Medicare payment policies and rates for Home Health Agencies (HHAs). This rule proposes a permanent, prospective adjustment to the CY 2024 home health payment rate to account for the impact of the implementation of the Patient-Driven Groupings Model (PDGM). This adjustment accounts for differences between assumed behavior changes and actual behavior changes on estimated aggregate expenditures due to the implementation of the PDGM and 30-day unit of payment as required by the Bipartisan Budget Act of 2018, which amended section 1895(b) of the Social Security Act (the Act). CMS previously finalized, for CY 2023, a permanent adjustment that was half of the estimated required permanent adjustment.

    In addition, CMS is also proposing to rebase and revise the home health market basket; revise the labor-related share; recalibrate the PDGM case-mix weights; update the low utilization payment adjustment (LUPA) thresholds, functional impairment levels, and comorbidity adjustment subgroups for CY 2024; codify statutory requirements for disposable negative pressure wound therapy (dNPWT), and establish regulations to implement payment for items and services under two new benefits: lymphedema compression treatment items and home intravenous immune globulin (IVIG). The actions CMS is taking in this proposed rule would help improve patient care and also protect the Medicare program’s sustainability for future generations. In addition, the proposed rule includes several hospice-related enrollment provisions. We believe these provisions would help protect hospice beneficiaries by more closely scrutinizing hospice owners and ensuring that they do not pose program integrity risks.

    CY 2024 Proposed Payment Updates and Policy Changes Updates for Home Health Agencies  

    This rule proposes routine, statutorily required updates to the home health payment rates for CY 2024. The proposed home health payment update percentage is a proposed 2.7 percent increase (approximately $460 million). Accounting for an estimated 5.1 percent decrease[1] , as required by statute, that reflects the effects of the proposed prospective, permanent behavior assumption adjustment ($870 million decrease), and an estimated 0.2 percent increase that reflects the effects of a proposed update to the fixed-dollar loss ratio (FDL) used in determining outlier payments ($35 million increase,), CMS estimates that Medicare payments to HHAs in CY 2024 would decrease in the aggregate by 2.2 percent, or $375 million compared to CY 2023, based on the proposed policies.  

    PDGM and Behavior Assumptions 

    On January 1, 2020, CMS implemented the home health PDGM and a 30-day unit of payment, as required by section 1895(b) of the Social Security Act, as amended by the Bipartisan Budget Act of 2018. The PDGM better aligns payments with patient care needs, especially for clinically complex beneficiaries. The law required CMS to make assumptions about behavior changes that could occur because of the implementation of the 30-day unit of payment and the PDGM. In the CY 2019 HH PPS final rule with comment period, CMS finalized three behavior assumptions (clinical group coding, comorbidity coding, and LUPA threshold). The law also requires CMS to annually determine the impact of differences between assumed behavior changes and actual behavior changes on estimated aggregate expenditures, beginning with 2020 and ending with 2026, and to make temporary and permanent increases or decreases, as needed, to the 30-day payment amount to offset such increases or decreases. Additionally, in the CY 2019 HH PPS final rule (83 FR 56455), CMS stated that we interpret actual behavior change to encompass both behavior changes that were previously outlined, as assumed by CMS when determining the budget-neutral 30-day payment amount for CY 2020, and other behavior changes not identified at the time the 30-day payment amount for CY 2020 was determined. In the CY 2023 HH PPS final rule, using CY 2020 and 2021 claims, CMS finalized a methodology for analyzing the differences between assumed versus actual behavior changes on estimated aggregate expenditures and calculated levels of actual and estimated aggregate expenditures. Based on analyses of CYs 2020 and 2021 claims data, CMS determined a permanent adjustment was needed. In CY 2023, CMS finalized implementing half (-3.925 percent) of the permanent adjustment estimated at the time (-7.85 percent).  

    For the CY 2024 HH PPS proposed rule, using updated CY 2022 claims and the methodology finalized in the CY 2023 HH PPS final rule, CMS determined that Medicare paid more under the new system than it would have under the old system. CMS is proposing an additional permanent adjustment percentage of -5.653 percent in CY 2024 to address the differences in the aggregate expenditures. The proposed permanent adjustment of -5.653 percent includes the remaining -3.925 percent (to account for CYs 2020 and 2021) not applied to the CY 2023 payment rate and accounts for actual behavior changes in CY 2022. The law provides CMS the discretion to make any future permanent or temporary adjustments in a time and manner determined appropriate through analysis of estimated aggregate expenditures through CY 2026. As such, we are not proposing to implement a temporary adjustment in CY 2024.

    Rebasing and Revising the Home Health Market Basket

    Since the HH PPS was implemented, the market basket used to update HH PPS payments has been rebased and revised to reflect more recent data on home health cost structures. CMS last rebased and revised the home health market basket in the CY 2019 HH PPS final rule with comment period, where a 2016-based home health market basket was adopted. For CY 2024, CMS is proposing to adopt a 2021-based home health market basket, which includes proposed changes to the market basket cost weights and price proxies.  Additionally, we are proposing that the market basket update for the final rule be based on the most recent data available at the time of rulemaking.

    Updating the Labor-Related Share

    As a result of the proposed rebasing and revising of the home health market basket, the proposed CY 2024 labor-related share (LRS) is 74.9 percent, which is based on the proposed 2021-based home health market basket compensation cost weight (the current labor-related share is 76.1 percent). Additionally, we are proposing to implement the revised labor-related share in a budget-neutral manner.

    Proposal for Disposable Negative Pressure Wound Therapy 

    In accordance with Division FF, section 4136 of the Consolidated Appropriations Act (CAA), 2023, CMS is proposing to codify statutory requirements for negative pressure wound therapy (NPWT) using a disposable device for patients under a home health plan of care. The CAA, 2023 requires that beginning January 1, 2024, there is a separate payment for the device only. Payment for the services to apply the device is to be included under the home health prospective payment system. There are also changes to now report the disposable device on the type of home health claim most familiar to Home Health Agencies. 

    Recalibration of PDGM Case-Mix Weights 

    Each of the 432 payment groups under the PDGM has an associated case-mix weight and LUPA threshold. CMS’ policy is to annually recalibrate the case-mix weights and LUPA thresholds using the most complete utilization data available at the time of rulemaking. In this proposed rule, CMS is proposing to recalibrate the case-mix weights (including the functional levels and comorbidity adjustment subgroups) and LUPA thresholds using CY 2022 data to more accurately pay for the types of patients HHAs are serving. 

    Request for Information on Access to Home Health Aide Services

     

    CMS is soliciting comments from the public, including home health providers, as well as patients and advocates, regarding information related to ensuring the appropriate access to and provision of home health aide services for all beneficiaries receiving care under the home health benefit. This proposed rule also includes additional questions regarding any notable barriers and obstacles to recruiting and retaining home health aides, as well as ways to ensure that home health aides are consistently paid wages that are equivalent to other care settings and commensurate with the impact they have on patient care.

    Home Health (HH) Quality Reporting Program (QRP)

    CMS is proposing the adoption of the following measures:

    1. COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date (Patient/Resident COVID-19 Vaccine) measure to the HH QRP beginning with the CY 2025 HH QRP.
    2. CMS also proposes to adopt the Functional Discharge Score (DC Function) measure to the HH QRP beginning with the CY 2025 HH QRP.

    The COVID-19 Vaccine measure continues CMS’s commitment to promoting the uptake of the COVID-19 vaccine and ensures alignment with current CDC guidance. 

    CMS is proposing the removal of the following measures:

    1. With the addition of the Discharge Function measure, we propose to remove the Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (Application of Functional Assessment/Care Plan) measure from the HH QRP beginning with the CY 2025 HH QRP.
    2. Additionally, CMS is proposing removal of two OASIS items no longer necessary for collection, the M0110 – Episode Timing and M2220- Therapy Needs items. 

    CMS is proposing the public reporting of four measures:

    1. Discharge Function;
    2. Transfer of Health (TOH) Information to the Provider—Post-Acute Care (PAC) Measure (TOH-Provider);
    3. Transfer of Health (TOH) Information to the Patient—Post-Acute Care (PAC); and
    4. COVID-19 Vaccine:  Percent of Patients/Residents Who Are Up to Date.

    We are also proposing technical changes to § 484.245(b) to codify our requirement that HHAs must meet or exceed a data submission threshold set at 90 percent of all required OASIS and submit the data through the CMS-designated data submission systems.  We are also seeking input on future HH QRP measure concepts and providing updates on HH QRP health equity initiatives.

    Expanded Home Health Value-Based Purchasing (HHVBP) Model

    Applicable Measure Set used in the expanded Home Health Value-Based Purchasing (HHVBP) Model

    For the expanded HHVBP Model, CMS is proposing to:

    • Codify in the Code of Federal Regulations the measure removal factors finalized in the CY 2022 HH PPS final rule;
    • Replace the two Total Normalized Composite Measures (for Self-Care and Mobility) with the Discharge Function Score measure effective January 1, 2025;
    • Replace the OASIS-based Discharge to Community (DTC) measure with the claims-based Discharge to Community-Post Acute Care (PAC) Measure for Home Health Agencies effective, January 1, 2025;
    • Replace the claims-based Acute Care Hospitalization During the First 60 Days of Home Health Use and the Emergency Department Use without Hospitalization During the First 60 Days of Home Health measures with the claims-based the Potentially Preventable Hospitalization measure effective January 1, 2025; 
    • Change the weights of individual measures due to the change in the total number of measures; and,
    • Beginning with performance year CY 2025, we propose to update the Model baseline year to CY 2023 for all applicable measures in the proposed measure set, including those measures included in the current measure set with the exception of the 2-year DTC-PAC measure, which would be CY 2022 and CY 2023.

    Appeals Process

    CMS is proposing to add an additional opportunity to request a reconsideration of the annual Total Performance Score (TPS) and payment adjustment.

    Public Reporting Update

    CMS is including an update to remind HHAs and other stakeholders that public reporting of HHVBP performance data and payment adjustments will begin in December 2024. 

    Health Equity Update

    CMS is including an update on health equity to let stakeholders know that we are committed to developing approaches to meaningfully incorporate the advancement of health equity into the expanded HHVBP Model.  As we move this important work forward, we will continue to take input from home health stakeholders and monitor the application of proposed health equity policies across CMS initiatives, such as proposed payment adjustments in the Hospital and SNF Value-Based Purchasing Programs.  At this time, however, we would like to give HHAs time to learn the requirements of the expanded Model, gather at least two years of performance data, and study effects of the expanded Model on health equity outcomes before incorporating any potential changes to the expanded Model regarding health equity.

    Home Intravenous Immune Globulin (IVIG) Items and Services

    As required under Division FF, section 4134 of the CAA, 2023, CMS is proposing regulations to implement coverage and payment of items and services related to administration of IVIG in a patient’s home for a patient with a diagnosed primary immune deficiency disease (PIDD). Currently, Medicare pays for the IVIG product using the average sales price (ASP) methodology, and the items and services needed for in-home administration of IVIG for the treatment of PIDD are paid under a Medicare demonstration program. This demonstration program will end on December 31, 2023, and the CAA, 2023 establishes permanent coverage and payment of the items and services needed for in-home administration beginning on January 1, 2024.

     Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Policy Issues

    Lymphedema Compression Treatment Items

    Section 4133 of the CAA, 2023 establishes a Medicare Part B benefit for standard and custom-fitted gradient compression garments and other compression treatment items, for the treatment of lymphedema that are prescribed by an authorized practitioner.  Compression garments for treatment of lymphedema have generally not been covered by Medicare because, prior to the enactment of the CAA, 2023, there was no statutory benefit category for such items. This rule would address the scope of the new benefit by defining what constitutes a standard- or custom-fitted gradient compression garment and identifying other compression items used for the treatment of lymphedema that would fall under the new benefit category, beginning January 1, 2024. The rule proposes that Medicare would cover gradient compression garments for both daytime and nighttime use as well as ready-to-wear, non-elastic, gradient compression wraps with adjustable straps, and compression bandaging systems applied in a clinical setting as part of phase one decongestive therapy. This rule would establish the initial Healthcare Common Procedure Coding System (HCPCS) codes and the payment methodology for these items and propose how future coding, benefit category, and payment determinations for these items would be made. The proposed payment basis for lymphedema compression treatment items is the average Medicaid State agency payment amounts plus 20 percent. In the event that Medicaid State agency payment rates are not available, this rule proposes to base payment rates on the average of TRICARE and internet retail prices. If neither Medicaid nor TRICARE payment amounts are available, this rule proposes to base Medicare payment rates on the average internet retail prices for a lymphedema compression treatment item.

    Medicare Definition of Brace

    This proposed rule would also codify the longstanding Medicare definition of brace to provide clarification on the scope of the Medicare Part B benefit for leg, arm, back, and neck braces and as a result, would classify certain exoskeleton-type devices as braces for Medicare payment purposes.

    Safeguarding Taxpayer Dollars

    DMEPOS Refill Policy

    In response to concerns related to auto-shipments and delivery of DMEPOS supplies that may no longer be needed or not needed at the same level of frequency/volume, CMS instituted policies to require suppliers to contact the beneficiary prior to dispensing DMEPOS refills. CMS is proposing to codify its long-standing refill policy, with some changes.  We are proposing to require documentation indicating that the beneficiary confirmed the need for the refill within the 30-day period prior to the end of the current supply. Additionally, we are proposing to codify our requirement that delivery of DMEPOS items (that is, date of service) be no sooner than 10 calendar days before the expected end of the current supply. CMS is also seeking comments for consideration in future rulemaking on ways to balance beneficiary burden with the potential risks/burdens of not verifying the beneficiary’s actual need for recurring supplies for certain individuals with permanent health conditions.

    Hospice Enrollment Provisions

    CMS is also proposing several provider enrollment regulatory changes to prevent and address hospice fraud, waste, and abuse in the future. CMS believes that these provider enrollment provisions related to hospice ownership and management will strengthen protections against hospice fraud schemes and improve transparency. The proposed hospice enrollment-related regulatory changes in this proposed rule include:

    • Subjecting hospices to the highest level of provider enrollment application screening, which includes fingerprinting all 5 percent or greater owners of hospices;
    • Expanding the HHA change in majority ownership provisions in 42 CFR § 424.550(b) to include hospice changes in majority ownership; and
    • Clarifying that the definition of “Managing Employee” in 42 CFR § 424.502 includes the administrator and medical director of a hospice.

    Other Provider Enrollment Provisions

    Finally, to further protect the Trust Funds and Medicare beneficiaries, we are proposing additional provider enrollment provisions, which include, but are not limited to, the following:

    • Reducing the period of Medicare non-billing for which a provider or supplier can be deactivated under § 424.540(a)(1) from 12 months to 6 months.
    • Strengthening the program integrity safeguards associated with a provisional period of enhanced oversight under section 1866(j)(3) of the Social Security Act.

    Reference

    Centers For Medicare and Medicaid.  News Room.  Calendar Year (CY) 2024 Home Health Prospective Payment System Proposed Rule (CMS-1780-P)


  • Fiscal Year 2024 Inpatient Rehabilitation Facility Prospective Payment System Proposed Rule

    3 Apr 2023 2:30 PM | Zachary Edgar (Administrator)

    On April 3, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update Medicare payment policies and rates under the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) and the IRF Quality Reporting Program (QRP) for fiscal year (FY) 2024. CMS is publishing this proposed rule in accordance with the legal requirements to update Medicare payment policies for IRFs on an annual basis.

    For FY 2024, CMS is proposing to update the IRF PPS payment rates based on the proposed IRF market basket update, less a proposed productivity adjustment. The proposed rule includes annual updates to the prospective payment rates, the outlier threshold, the case-mix-group relative weights and average length of stay values, the wage index, and associated impact analysis. In addition, the rule includes a proposal to revise and rebase the IRF market basket, as well as a proposal to modify its regulations to allow hospitals to open and begin billing Medicare for an excluded IRF unit anytime within the cost reporting year.  

    CMS is also proposing two new and one modified measure proposals for the IRF Quality Reporting Program (QRP). In addition, CMS is proposing three measure removals and is proposing one public reporting policy.

    This fact sheet discusses the provisions of the proposed rule. The FY 2024 Inpatient Rehabilitation Facility Prospective Payment System proposed rule (CMS-1781-P) can be downloaded from the Federal Register at  https://www.federalregister.gov/public-inspection/2023-06968/medicare-program-inpatient-rehabilitation-facility-prospective-payment-system-for-federal-fiscal .

    Proposed Updates to the FY 2024 IRF PPS Payment Policies

    For FY 2024, CMS is proposing to update the IRF PPS payment rates by 3.0 percent based on the proposed IRF market basket update of 3.2 percent less a proposed 0.2 percentage point productivity adjustment. CMS is proposing that if more recent data become available (for example, a more recent estimate of the market basket update or productivity adjustment), CMS would use these data, if appropriate, to determine the FY 2024 market basket update and the productivity adjustment in the final rule. In addition, the proposed rule contains an adjustment to the outlier threshold to maintain outlier payments at 3.0 percent of total payments. This adjustment would result in a 0.7 percentage point increase in outlier payments. CMS estimates that overall IRF payments for FY 2024 would increase by 3.7 percent (or $335 million) relative to payments in FY 2023.

    Proposed Modification to the Excluded Unit Regulation

    CMS proposes to allow hospitals to open a new IRF unit and begin being paid under the IRF PPS at any time during the cost reporting period, provided the hospital notifies the CMS Regional Office and the Medicare Administrative Contractor in writing at least 30 days before the date of the change and maintains the information needed to accurately determine the costs attributable to the IRF unit.  Such a change would also remain in effect for the rest of the cost reporting period. CMS believes this will alleviate unnecessary burden and administrative complexity placed upon hospitals and increase access to care.

    Rebase and Revise the IRF Market Basket

    Approximately every four years, CMS rebases and revises the IRF market basket used to update IRF PPS payments to reflect more recent data on IRF cost structures. CMS last rebased and revised the IRF market basket in the FY 2020 IRF PPS rule, where CMS adopted a 2016-based IRF market basket. The proposal for FY 2024 would be to adopt a 2021-based IRF market basket and includes proposed changes to the market basket cost weights, price proxies, market basket update, and labor-related share.

    Proposed Updates to the IRF QRP

    The IRF QRP is a pay-for-reporting program. IRFs that do not meet reporting requirements are subject to a two-percentage point reduction in their Annual Increase Factor.

    In the FY 2024 IRF PPS proposed rule, CMS is proposing to:

    Adopt the Discharge Function Score measure beginning with the FY 2025 QRP

    This measure assesses functional status by assessing the percentage of IRF patients who meet or exceed an expected discharge function score, and uses mobility and self-care items already collected on the IRF Patient Assessment Instrument (IRF-PAI). The adoption of this measure would replace the Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan (Application of Functional Assessment/Care Plan) measure.

    Adopt the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date (Patient/Resident COVID-19 Vaccine) measure beginning with the FY 2026 IRF QRP

    The measure reports the percentage of stays in which patients in an IRF are up-to-date with recommended COVID-19 vaccinations in accordance with the Centers for Disease Control and Prevention’s (CDC’s)most recent guidance.  Data would be collected using a new standardized item on the IRF-PAI.

    Modify the COVID-19 Vaccination Coverage among Healthcare Personnel (HCP COVID-19 Vaccine) measure beginning with the FY 2025 IRF QRP

    This measure tracks the percentage of healthcare personnel (HCP) in IRFs who are considered up to date with recommended COVID-19 vaccination in accordance with the CDC’s most recent guidance.  The prior version of this measure reported only on whether HCP had received the primary vaccination series for COVID-19, while the proposed modification of this measure would require IRFs to report the cumulative number of HCP who are up-to-date with recommended COVID-19 vaccinations in accordance with the CDC’s most recent guidance.

    Remove three measures from the IRF QRP beginning with the FY 2025 IRF QRP

    The measures CMS is proposing to remove are: (1) the Application of Functional Assessment/Care Plan measure; (2) the IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (Change in Self-Care Score) measure; and (3) the IRF Functional Outcome Measure:  Change in Mobility Score for Medical Rehabilitation Patients (Change in Mobility Score) measure.  We propose removal of the Application of Functional Assessment/Care Plan measure because it meets conditions for measure removal factors one (that is, measure performance among IRFs is so high and unvarying that meaningful distinctions in improvements in performance can no longer be made) and six (that is, the proposed DC Function measure is more strongly associated with desired patient functional outcomes).  We propose removal of the Change in Self-Care Score and Change in Mobility Score measures because they meet the condition for measure removal factor eight (that is, the costs associated with a measure outweigh the benefits of its use in the IRF QRP).  Additionally, the Change in Self-Care Score and Change in Mobility Score measures are similar or duplicative of other measures within the IRF QRP.

    Begin the public reporting of the Transfer of Health Information to the Provider—PAC Measure and the Transfer of Health Information to the Patient—PAC Measure beginning with the September 2024 Care Compare refresh or as soon as possible

    These measures report the percentage of patient stays with a discharge assessment indicating that a current reconciled medication list was provided to the subsequent provider or to patients or their families or caregivers at discharge or transfer.

    Reference

    Centers for Medicare and Medicaid

    Newsroom – April 3, 2023

    Fiscal Year 2024 Inpatient Rehabilitation Facility Prospective Payment System Proposed Rule (CMS-1781-P)


  • Dually Eligible Beneficiaries

    25 May 2022 2:09 PM | Zachary Edgar (Administrator)

    Dually eligible beneficiaries are low-income beneficiaries enrolled in both Medicare and Medicaid. This includes beneficiaries enrolled in Medicare Part A, Part B, or both, and getting full Medicaid benefits or only help with Medicare premiums or cost-sharing.

    Billing Dual Eligible/QMBs

    Medicare providers cannot bill QMB beneficiaries for Medicare cost-sharing. This includes

    Medicare deductibles, coinsurance, and copayments. In some cases, a beneficiary may owe

    a small Medicaid copayment. Medicare and Medicaid payments are considered payment in full.

    This prohibition applies even if the provider or supplier doesn’t participate in Medicaid.

    Providers are subject to sanctions if they bill a QMB above the total Medicare and Medicaid payments, even when Medicaid pays nothing.

    If a provider bills a QMB for Medicare cost-sharing, or turn a bill over to collections, the provider must recall it. If a provider collecst any QMB cost-sharing money, it must be refunded.

    Verifying Dual Eligible/QMB

    Providers should use the Medicare 270/271 HIPAA Eligibility Transaction System (HETS) and

    the Medicare Remittance Advice to identify if a beneficiary is a QMB and owes no Medicare

    cost-sharing.

    Advanced Beneficiary Notification of Non-Coverage (ABNs)

    Providers cannot bill the dually eligible beneficiary up front when an ABN is provided.

    Once Medicare and Medicaid adjudicates the claim, the provider may only charge the beneficiary in these circumstances:

    • ·       If the beneficiary has QMB coverage without full Medicaid coverage and Medicare denies the claim, the ABN could allow the provider to shift financial responsibility to the beneficiary under Medicare policy.
    • ·       If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or won’t pay because you don’t participate in Medicaid), the ABN could allow the provider to shift financial responsibility to the beneficiary under Medicare policy, subject to state laws that limit beneficiary responsibility.

    Types of Dually Eligible Beneficiaries

    1. Full Medicaid (only)

    Benefits

    Full Medicaid coverage refers to the package of services beyond Medicare premiums coverage and cost-sharing certain beneficiaries get when they qualify for certain eligibility groups under a state’s Medicaid Program. States must cover some of these groups (like Supplemental Security Income [SSI] recipients). States have the option to cover others, like the special income level institutionalized beneficiary group, home- and community-based waiver participants, and medically needy individuals.

    Dually eligible beneficiaries who get Medicaid only are enrolled in Part A and or Part B and qualify for full Medicaid benefits but not for MSP groups. States may pay their Part B premium.

    Qualifications

    States decide income and resource criteria.

    States can require Part A or B enrollment if they pay the beneficiary’s premiums for these parts.

    Beneficiaries must show they need a certain level of care or meet state-specific medical criteria to qualify for certain categories.

    2. Qualified Medicare Beneficiary (QMB) Only Without Other Medicaid

    Benefits

    Medicaid pays Part A (if any) and Part B premiums.

    Medicaid is liable for Medicare deductibles, coinsurance, and copayments

    for Medicare-covered items and services. Even if Medicaid doesn’t fully

    cover these charges, the QMB isn’t liable for them.

    Qualifications

    Income can be up to 100% of the Federal Poverty Level (FPL).

    Resources can’t be more than 3 times the SSI resource limit, increased

    annually by the Consumer Price Index (CPI).

    QMB qualifications include enrollment in Part A (or if uninsured for Part

    A, have filed for premium Part A on a conditional basis).

    3. Qualified Medicare Beneficiary Plus (QMB+)

    Benefits

    Medicaid pays Part A (if any) and Part B premiums.

    Medicaid is liable for Medicare deductibles, coinsurance, and copayments

    for Medicare-covered items and services. Even if Medicaid doesn’t fully

    cover these charges, the QMB+ isn’t liable for them.

    Get full Medicaid coverage plus Medicare premiums and cost-sharing coverage.

    Qualifications

    Meet QMB-related eligibility requirements described in Table 2 and full Medicaid eligibility requirements in Table 1.

    4. Specified Low-Income Medicare Beneficiary (SLMB) Only Without Other Medicaid

    Benefits

    Medicaid pays Part B premium.

    Qualifications

    Income between 100%–120% of FPL.

    Resources can’t be more than 3 times the SSI resource limit, increased annually by the CPI.

    Enrolled in Part A.

    5. Specified Low-Income Medicare Beneficiary Plus (SLMB+)

    Benefits

    Medicaid pays Part B premium.

    Get full Medicaid coverage plus Medicare Part B premium coverage (see Table 1 for a definition of full Medicaid coverage).

    Qualifications

    Meet SLMB-related eligibility requirements described in Table 4 and full Medicaid eligibility requirements in Table 1.

    6. Qualifying Individual (QI)

    Benefits

    Medicaid pays Part B premium.

    Benefits limited to first-come, first-served.

    Qualifications

    Income between 120%–135% of FPL.

    Resources can’t be more than 3 times the SSI resource limit, increased annually by the CPI.

    Enrolled in Part A.

    QI beneficiaries aren’t eligible for any other Medicaid coverage.

    7. Qualified Disabled Working Individual (QDWI)

    Benefits

    Medicaid pays Part A premium.

    Qualifications

    Income up to 200% of FPL.

    Resources up to 2 times the SSI resource limit.

    Individuals under 65 with a qualifying disability who lost premium-free Part A coverage after returning to work and now must pay a premium to enroll in Part A.

    QDWI beneficiaries aren’t eligible for any other Medicaid coverage.


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Zachary Edgar JD, LLM is the managing partner for Therapy Comply.  Zachary is a healthcare attorney that specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

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