Weekly Health Care Policy Update – November 7, 2022

In this update: 

• Legislative Update
  • Senate Finance Committee Chair Releases Report on Deceptive Marketing in MA
• Federal Agencies
  • CMS Finalizes CY 2023 Physician Fee Schedule
  • CMS Finalizes CY 2023 Hospital Outpatient and ASC Payment Rules
  • CMS Finalizes CY 2023 Home Health PPS
  • CMS Finalizes CY 2023 ESRD PPS Rule
  • CMMI Publishes One-Year Update on Strategic Vision
  • CDC Releases 2022 Clinical Practice Guidelines for Prescribing Opioids
  • FDA Advisory Panel Urges Tighter Regulation of Pulse Oximeters
• Other Updates
  • Project Clarity Announces Price Transparency Framework
  • KHN Study Shows Lowest Hospital Readmission Penalties Since September 2014
• New York State Updates
  • Governor Hochul Issues Order to Establish the New York State Master Plan for Aging
  • DOH Sends 60-Day Notice to MAP Plans for Behavioral Health Carve-In
  • DOH Updates Health Care Worker Bonus FAQs and Extends Submission Deadline
  • CMS Approves New York’s “Reasonable Opportunity Period” Extension Waiver
  • OPWDD Releases 2023-2027 Strategic Plan
  • OASAS Releases RFI on Restructuring of Addiction Services Financing System
• Funding Opportunities
  • OMH Releases HealthySteps RFA Round 2
  • OMH Reissues Intensive Crisis Stabilization Center RFP for Three Locations
  • ACS Releases RFP for Workforce Development Services

Legislative Update

Senate Finance Committee Chair Releases Report on Deceptive Marketing in MA
On November 3^rd, Senate Finance Committee Chair Ron Wyden (D-OR) released a majority staff report entitled “Deceptive Marketing Practices Flourish in Medicare Advantage” (MA). The report highlights practices such as “deceptive mail advertisements, misleading claims about increasing Social Security benefits, aggressive in-person marketing tactics, and enrolling beneficiaries, particularly those dually eligible for Medicare and Medicaid, in a new plan without their consent.”
 
The report recommends that CMS should reinstate marketing requirements that were reduced under the previous administration, implement robust rules for MA marketing materials, and perform other enforcement and oversight activities.
 
The report is available here.

Federal Agencies

CMS Finalizes CY 2023 Physician Fee Schedule
On November 1^st, the Centers for Medicare & Medicaid Services (CMS) finalized a rule establishing the Medicare Physician Fee Schedule (PFS) for calendar year (CY) 2023. The PFS includes payment rates for about 8,000 services, defined by their Healthcare Common Procedure Coding System (HCPCS) codes. PFS rates are based on three components called Relative Value Units (RVUs) that reflect practitioner work, practice expense (PEs), and liability insurance. Each of the RVU components is adjusted by a geographic index specific to that component. The components are summed and then multiplied by a conversion factor to produce a dollar amount.
 
The final rule establishes a conversion factor of $33.06, essentially unchanged from the proposed rule factor of $33.08. This decrease is accounted for by several factors:  

• The statutory update, under current law, of 0% for CY 2023;
• The expiration of the temporary 3% increase to the conversion factor for CY 2022, which was passed at the end of 2021; and
• Required budget neutrality adjustments to account for RVU changes.

The rule contains many other policy revisions. Some notable items are detailed further in the below subsections:  

• Implementation of the extension of telehealth flexibilities through at least 2023;
• New billable codes and clinical flexibilities to expand access to behavioral health (BH) and other types of care;
• A proposed new calculation for the Medicare Economic Index (MEI), which is used to estimate input price costs of providing physician services and would change the relative distribution of RVUs;
• Changes to the parameters of the Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) model.

Telehealth Extension through 2023
The PFS enacts the policies passed in 2021 year-end legislation that establish a “phase-down” of Medicare telehealth flexibilities after the expiration of the Covid-19 public health emergency (PHE). These include: 

• Extending the availability of several services temporarily available through telehealth under the PHE until the end of CY 2023 on a Category III basis (or later if the PHE does not end in 2023).
• Extending telehealth flexibilities that are in place during the PHE until 151 days after the PHE ends. CMS reemphasizes that this includes payment parity with in-person rates, at the non-facility-based rate, through the end of CY 2023 (or later if the PHE does not end in 2023).
• Establishing the use of CPT modifier “93” or “FQ” for providers (including health centers) to bill for audio-only visits.
• Delaying the in-person visit requirements for mental health visits furnished by rural health clinics and federally qualified health clinics via telecommunications technology until 152 days after the end of the PHE.

New Billable Codes and Clinical Flexibilities
CMS finalized the following actions to increase access to behavioral health services:  

• Allowing LPCs and LMFTs to practice under general supervision: CMS is creating an exception to supervision requirements to allow BH services to be provided under general supervision, rather than direct supervision, of a physician, when provided by auxiliary personnel on an “incident to” basis. Specifically, this includes licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs), who may not otherwise be paid under the PFS; and
• New code for BH care management services: CMS is creating a new code (G0323) to allow clinical psychologists or clinical social workers to bill Medicare for care management services for BH conditions.

CMS also finalized:  

• New codes for chronic pain management services: CMS is creating new codes and valuations for chronic pain management services, which would establish a monthly bundled code to facilitate overall care for chronic pain, with a 30-minute minimum (code G3002) and 15-minute increments (code G3003). 
  • CMS has slightly revised the definitions of the codes, including allowing G3003 to be billed an unlimited number of times per month if medically necessary (rather than a maximum of three times).
• Updates to colorectal cancer screening policies: CMS is finalizing proposed changes to match recent recommendations by reducing the minimum age limit to 45 years and including follow-up colonoscopies after a positive non-invasive test as a colorectal screening test which may be covered without cost-sharing.
• Ability for audiologists to bill without a referral: CMS is finalizing a policy allowing audiologists to bill for direct provision of certain services without a physician referral. 
  • In response to feedback, CMS will not implement this through a new, separate code. Instead, audiologists may bill CPT codes within a list of 36 allowed services with a new modifier “AB.”
• Coverage of dental services when linked to other services: Medicare will now explicitly cover dental services when they are “inextricably linked to, and substantially related and integral to the success of” otherwise covered medical services. CMS lists several specific examples, such as reconstruction of a dental ridge due to removal of a tumor or treatment of an oral infection to facilitate an organ transplant. It will also accept public suggestions on other clinical scenarios in which coverage would be appropriate, which may be submitted every year by February 10^thto be considered for the next year’s rule.

Update to the Calculation of the MEI
Although the MEI is no longer used to set the conversion factor, CMS still uses it as a component of setting geographic price adjustments and of maintaining relativity between work and PE RVUs. The current MEI therefore determines that in total, work RVUs represent about 51% of costs, PE RVUs represent 45%, and malpractice RVUs represent 4%. The existing MEI has not been rebased and revised since 2014 (which was based on 2006 data), and CMS proposes to do so starting in 2024 (based on 2017 data). CMS is finalizing certain modifications to its proposed method to rebase the MEI, including accounting for a greater share of net income. 

CMS noted that the majority of commenters advised CMS to wait to update the RVU pools until the American Medical Association completes efforts to collect practice cost data from physician practices. CMS had proposed not to implement this provision in CY 2023 and is finalizing that proposal. Instead, CMS will return to this topic in future rulemaking.
 
Changes to the Parameters of the MSSP Program
CMS seeks to encourage more participation in MSSP, and especially to encourage enrollment of providers who serve higher-cost populations. It is finalizing the following policies for the MSSP program as proposed: 

• ACO Investment Program: CMS will provide incentives and upfront capital for new ACOs serving underserved populations. Specifically, CMS will offer advance incentive payments (AIPs) to low-revenue ACOs that are new to the MSSP and do not have existing experience with performance-based risk Medicare payments. 
  • These payments will be a one-time fixed payment of $250,000 and eight per-member (up to 10,000 members) quarterly payments of up to $45.
  • The quarterly payment amount will be based on a risk score ranging between 1 and 100. All dual eligibles will have a risk score of 100 (conferring the full $45 per member per quarter). Other beneficiaries will have a score based on geography (specifically, the percentile rank of the Area Deprivation Index of their census block group of residence).
  • AIPs will be recouped once the ACO begins to achieve shared savings during their agreement period.
• Upside-only runway extension: CMS will, as proposed, extend the upside-only runway for new MSSP entrants by allowing them to sign up for one 5-year Level A agreement. They would then be eligible to enter the current glide path (which allows an additional 2 years at Level B before transitioning to downside risk).
• No mandatory transition to ENHANCED: CMS will allow ACOs to continue in Level E of the BASIC track indefinitely, rather than requiring them to transition to the ENHANCED track.

CMS also seeks to strengthen incentives for successful ACOs to remain in the program, which is affected by benchmarking rebasing and by the so-called “rural glitch”. CMS envisions moving to an “administratively set benchmark” in the long term. In this rule, CMS finalized the following revisions to the benchmarking methodology, starting in 2024, as proposed: 

• Blended benchmark incorporating pre-set trend: CMS will introduce a “three-way blend” of the existing national and regional growth factors as well as a new prospective administrative growth factor. The administrative component will be set in advance of an ACO’s 5-year agreement period, and will therefore provide a degree of certainty to the ACO and reduce the impact of national and regional changes.
• Re-adding prior savings into the benchmark: CMS will reinstitute the “prior savings adjustment” that will add savings achieved by an ACO across the past three years back into the ACO’s benchmark in future years.
• Reducing the maximum negative regional adjustment: This will now be a maximum reduction of 1.5%. This level will be reduced further based on the proportion of underserved and high-risk-score enrollees.

CMS also proposes several other changes, including: 

• Health equity adjustment to quality scores: CMS will institute a “health equity adjustment” to quality scores for ACOs that report all-payer electronic Clinical Quality Measures (eCQMs) or Merit-Based Incentive Payment System (MIPS) CQMs. The adjustment will be calculated based on their quality performance on each of the six measures in the APM Performance Pathway (APP) set, multiplied by an “underserved multiplier” and then capped at 10 bonus points.
• Sliding scale for shared savings and losses: CMS will reinstate the “sliding scale” approach to shared savings and losses for ACOs, based on their health equity adjusted quality score. ACOs that meet existing quality benchmarks will receive the full shared savings for their risk level (e.g., 40% for Level A/B). ACOs that do not meet the quality benchmarks but which do reach at least 10^th percentile for one of the four APM Performance Pathway measures will be eligible for shared savings on the sliding scale, scaled by their health equity adjusted quality score.
• Shared savings for low-revenue ACOs not meeting the minimum savings rate: Starting in 2024, low-revenue BASIC track ACOs that produce savings below the minimum required to earn shared savings will now be eligible for partial shared savings. These ACOs will be eligible to earn half of the shared savings they would be eligible for (i.e., 20% for Level A/B).
• Applying risk adjustment growth cap on aggregate basis after demographic changes: Starting in 2024, the cap on growth of risk scores will incorporate the ACO’s growth in demographic risk scores between the baseline year and the performance year. Furthermore, instead of being applied separately to each eligibility category (e.g., ESRD, disabled, aged dual, and aged non-dual), the cap will be applied “only if the ACO’s aggregate growth in prospective HCC risk scores […] across all of the populations” exceeds the limit.

Other
CMS also finalized proposals to:  

• Adopt most of the changes in coding and document for Other Evaluation and Management (E/M) visits approved by the AMA CPT Editorial Panel effective January 1, 2023;
• Delay the split (or shared) visits policy finalized in CY 2022, which limits the definition of the “substantive portion” of a visit to being more than half the total time, for one year until CY 2024.
• Establish definitions related to a requirement for manufacturers of certain single-dose container or single-use package drugs to provide refunds for discarded amounts, as required by the Infrastructure Investment and Jobs Act. However, CMS has modified its proposal to issue a preliminary report by the end of 2023 before establishing a timeline for the adoption of the requirement manufacturers to submit reports and refunds on discarded drugs;
• Revise the methodology for pricing the drug component of the methadone weekly bundle and the add-on code for take-home supplies of methadone to help stabilize the price for methadone, and other proposed policy changes to opioid treatment program (OTP) payments;
• Refine the payment amount for preventive vaccine administration under Medicare Part B;
• Revise the Clinical Laboratory Fee Schedule (CLFS); and
• Make a series of changes to the Medicare Ground Ambulance Data Collection System.

CMS did not finalize proposed changes to policies and definitions on skin substitute products.
 
Finally, CMS finalized changes to the Quality Payment Program focused on continuing to develop new Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs). As such, CMS will make limited changes in traditional MIPS to provide clinicians continuity and consistency while they gain familiarity with MVPs.

The final rule is available here and will be published in the Federal Register on November 18^th. CMS has also released a fact sheet on the proposed rule here.
 
CMS Finalizes CY 2023 Hospital Outpatient and ASC Payment Rules
On November 1^st, CMS issued the CY 2023 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Payment System Final Rules. Overall, CMS is updating OPPS and ASC payment rates for hospitals by 3.8%. This update reflects a projected hospital market basket percentage increase of 4.1%, reduced by 0.3% for the productivity adjustment. This adjustment is higher than the 2.7% increase initially proposed.
 
Additional key policies in the final rule include: 

• Rural Emergency Hospitals: CMS will provide a 5% payment for each covered outpatient department service furnished by a Rural Emergency Hospital in addition to the standard OPPS payment rate.
• 340B: CMS is finalizing a general payment rate of ASP plus 6% for drugs and biologicals acquired through the 340B Program. CMS is implementing a –3.09% reduction to the payment rates for non-drug services to achieve budget neutrality for the 340B drug payment rate change for CY 2023. Claims for 340B-acquired drugs paid after the district court’s September 28, 2022 ruling are paid at the default rate (generally ASP plus 6%).
• Non-opioid pain management: CMS will continue its current policy of providing for separate payment for those non-opioid pain management drugs and biologicals that function as supplies in the ASC setting that CMS determines are FDA approved, have an FDA-approved indication for pain management or as an analgesic, and have a per-day cost above the OPPS drug packaging threshold.
• Behavioral health services: CMS will consider behavioral health services furnished remotely by clinical staff of hospital outpatient departments, including staff of critical access hospitals (CAHs), through the use of telecommunications technology to beneficiaries in their homes, covered outpatient services for which payment is made under the OPPS. CMS will also require that a beneficiary receive an in-person service within six months prior to the first time hospital clinical staff provides the behavioral health services remotely, and that there must be an in-person service without the use of communications technology within 12 months of each behavioral health service furnished remotely by hospital clinical staff. Exceptions to the in-person visit requirement maybe made when the hospital clinical staff member and beneficiary agree that the risks and burdens of an in-person service outweigh the benefits of it, among other requirements. In addition, in instances where there is an ongoing clinical relationship at the time the PHE ends, the in-person requirement will apply. Audio-only interactive telecommunications systems may be used to furnish these services in instances where the beneficiary is unable to use, does not wish to use, or does not have access to two-way, audio/video technology. 
• Domestic NIOSH-approval N95s: CMS will provide biweekly payment adjustments under the IPPS and OPPS to offset the additional marginal resource costs that hospitals face in procuring domestically made NIOSH-approved surgical N95 respirators.
• Organ procurement and research: CMS will use a new method of accounting for research organs that will improve payment accuracy and maintain organ availability for the research community. CMS will also address potential financial barriers to organ donation after cardiac death.
• Software as a Service: CMS will create SaaS add-on codes to allow for separate payment for these services. CMS will also continue to consider for future rulemaking how payment policies should adapt to better recognize these evolving services.
• Partial hospitalization: CMS will maintain the existing rate structure for partial hospitalization program (PHP), with a single PHP Ambulatory Payment Classification (APC) for each provider type, for days with three or more services per day. For CY 2023 only, CMS will maintain the CY 2022 Community Mental Health Center (CMHC) APC payment rate of $142.70 for the CY 2023 CMHC APC final payment rate.
• Quality Reporting Program: CMS will maintain voluntary reporting of the Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (OP-31). CMS is requiring REHs to have an account with the Hospital Quality Reporting (HQR) System secure portal and a designated Security Official (SO).
• Star Ratings: CMS will use publicly-available measure results on Hospital Compare or its successor websites from a quarter from within the previous twelve months (instead of the previous year).

The full rule is available here.
 
CMS Finalizes CY 2023 Home Health PPS
On October 31^st, CMS issued the CY 2023 Home Health Prospective Payment System (HH PPS) Rate Update final rule. Overall, the rule increases payments to home health agencies in CY 2023 by 0.7%, or a total of $125 million, compared to CY 2022. This estimate is a significant change from the proposed rule, which estimated an aggregate $810 million decrease in payments. The 0.7% increase is the result of a 4% home health payment increase, a roughly 3.5% decrease due to the PPS behavioral assumption adjustment, and a 0.2% increase based on an adjustment to the fixed-dollar loss ratio used by CMS to identify outlier payments. In addition, the rule updates the home infusion therapy payment rate to 8.7%.
 
Additional policies in the final rule include: 

• Wage Index: CMS finalized a permanent 5% cap on decreases in the HH PPS wage index for CY 2023 and subsequent years.
• Telecommunications technology: CMS will begin to collect data regarding the use of telecommunications technology during a home health period of care, voluntarily submitted by HHAs, beginning January 1, 2023. Mandatory reporting will begin July 1, 2023.
• Home Health Value-Based Purchasing Model: In the Home Health Value-Based Purchasing Model, CMS is changing the HHA baseline year from CY 2019 to CY 2022 for existing HHAs with a Medicare certification date prior to January 1, 2019 and from CY 2021 to CY 2022 for HHAs with a Medicare certification date prior to January 1, 2022, starting in the CY 2023 performance year. Beginning in CY 2023, CMS will change the baseline year from CY 2019 to CY 2022.
• OASIS Data Collection: CMS is ending the temporary suspension of OASIS data collection, and will require submission of all-payer OASIS data for purposes of the HH Quality Reporting Program (QRP) beginning with the CY 2027 program year. Two quarters of data will be required for CY 2027. Failure to submit data will not result in a penalty from January 1, 2025 through June 30, 2025. 

The final rule is available here.
 
CMS Finalizes CY 2023 ESRD PPS Rule
On October 31^st, CMS issued the CY 2023 final rule updating Medicare payment rates and policies under the end-stage renal disease (ESRD) PPS for renal dialysis services. Overall, CMS expects to spend $7.9 billion furnishing renal dialysis services in CY 2023, using a base rate of $265.57, an increase of $7.67 from the current base rate of $257.90. The base rate reflects a productivity-adjusted market basket increase of 3.0% and application of the wage index budget-neutrality adjustment factor (0.999730).
 
CMS also made a number of changes to the ESRD Quality Incentive Program (QIP). Key changes include: 

• CMS is pausing the Standardized Hospitalization Ratio (SHR) clinical measure, the Standardized Readmission Ratio (SRR) clinical measure, the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) clinical measure, the Long-Term Catheter Rate clinical measure, the Percentage of Prevalent Patients Waitlisted (PPPW) clinical measure, the Kt/V Dialysis Adequacy Comprehensive clinical measure, and the Standardized Fistule Rate clinical measure.
• ​​CMS will use CY 2019 data to calculate performance year (PY) 2023 performance standards in place of the CY 2020 data CMS had previously finalized.
• CMS will begin expressing the Standardized Hospitalization Ratio (SHR) clinical measure and Standardized Readmission Ratio (SRR) clinical measure results as rates beginning with PY 2024.
• CMS will adopt the Covid-19 Vaccination Coverage among Healthcare Personnel (HCP) measure in the PY 2025 ESRD QIP measure set as a reporting measure.

Additional policies in the final rule include: 

• ​​ESRD-B: CMS finalized a proposal to rebase and revise the ESRD Bundled (ESRD-B) market basket to a 2020 base year. CMS is also updating the labor-related share to 55.2% based on the 2020-based ESRD-B market basket weights.
• Wage Index: CMS is increasing the wage index floor from 0.5 to 0.6 and establishing a policy to apply a permanent 5% cap on decreases in the ESRD PPS wage index for CY 2023. A facility’s wage index will not be less than 95% of its wage index calculated in the prior CY.
• Outlier Payments: On outlier payments, the fixed dollar loss (FDL) amount for pediatric beneficiaries will decrease from $26.02 to $23.29, and the Medicare allowable payment (MAP) amount will decrease from $27.15 to $25.59. For adult beneficiaries, based on the latest data and finalized methodology, the FDL amount will decrease from $75.39 to $73.19, and the MAP amount will decrease from $42.75 to $39.62.
• Acute Kidney Injury: CMS is updating the Acute Kidney Injury (AKI) dialysis payment rate for CY 2023 to $265.57.
• Treatment Choices Model: CMS is making two payment adjustments to the ESRD Treatment Choices Model: an upward adjustment on home dialysis and home dialysis-related claims with claim service dates between January 1, 2021 and December 31, 2023; and an upward or downward performance-based adjustment on dialysis and dialysis-related claims with claim service dates between July 1, 2022 and June 30, 2027.

The final rule is available here.
 
CMMI Publishes One-Year Update on Strategic Vision
Today (November 7^th), the CMS Innovation Center (CMMI) published a one-year update on the implementation of its refreshed strategic vision. The update includes significant new detail on intermediate targets and metrics for how CMMI will measure progress towards achieving its five strategic objectives. For instance, one of CMMI’s main goals was for every Medicare fee-for-service beneficiary to be in an accountable care relationship. The report sets goals, to increase the proportion of beneficiaries in such a relationship, starting from the 2021 baseline of 44%, to 60% by 2024, to 65% by 2025, and to 100% by 2030.
 
Similarly, the report notes that CMMI’s goal to “support innovation” will be measured by five metrics, four of which relate to features of CMMI models. CMMI seeks to incorporate these features into between 70% and 100% of models by 2030: 

• Using at least two patient-reported measures;
• Providing CMS-developed participant data dashboards;
• Offering interoperable, standards-based data exchange to participants; and
• Offering technical assistance and learning supports, where applicable.

The report is available here, and a technical supplement is available here.
 
CMMI staff also published an accompanying blog post, which focuses on CMMI’s approach to encouraging value-based specialty care. It describes four “key learnings” so far and identifies four corresponding elements of its strategy going forward, which are: 

• Enhancing transparency in clinician performance;
• Continuing to deploy episode payment models aligning with ACOs and primary care, including mandatory models;
• Supporting specialists to further embed in primary care-focused models; and
• Creating incentives within population-based models to encourage specialty care integration.

The blog post is available here.
 
CDC Releases 2022 Clinical Practice Guidelines for Prescribing Opioids
On November 3^rd, the Centers for Disease Control and Prevention (CDC) released new clinical practice guidelines for opioid prescribing. The guidelines are directed at clinicians providing pain care for outpatients over the age of 18, and include recommendations for managing acute, subacute, and chronic pain. They do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care.
 
This version represents a softening of the CDC’s approach to opioid prescribing since the last time guidelines were released in 2016. Key changes include: 

• The CDC no longer recommends limiting opioid treatment for acute pain to three days.
• The CDC no longer recommends that doctors avoid increasing dosage to a level equivalent to 90 milligrams of morphine per day.
• The CDC recommends that doctors taper, not abruptly stop, opioid treatment for patients on higher doses unless there are indications of life-threatening danger.

The full guidelines are available here.
 
FDA Advisory Panel Urges Tighter Regulation of Pulse Oximeters
On November 1^st, the Anesthesiology Devices Advisory Committee at the Food and Drug Administration’s (FDA) Center for Devices and Radiological Health met to discuss factors that can affect the accuracy of pulse oximeters. Pulse oximeters are used by health care providers and consumers to obtain an indirect measure of arterial blood oxygen saturation.
 
A December 2020 report suggested that pulse oximeters may be less accurate in patients with darker skin pigmentation, leading the FDA to further review published literature, device data, and clinical evidence. As a result, the FDA issued a Safety Communication to inform patients and health care providers that although pulse oximeters are useful for estimating blood oxygen levels, these devices have limitations and a risk of inaccuracy under certain conditions, including increased risk for missed diagnosis of hypoxemia in subjects with darker skin pigmentation.
 
Though no formal votes were taken, the advisory panel called for clearer labeling and more rigorous testing of such devices, and suggested that FDA potentially tighten regulations that currently allow readings to be inaccurate up to 3%. The panel suggested that 2% or 1.5% should be the standard. Panel members also noted that future studies should contain more patients with dark skin and that data for such patients should be analyzed separately.

Other Updates

Project Clarity Announces Price Transparency Framework
On November 3^rd, Project Clarity, a workgroup of health care organizations, announced a draft set of ten “episode definitions” to help consumers compare price and quality information across providers. The open provisional service packages are an attempt to bridge the gap between the data that hospitals and payers are now required to publish on rates, and actual usability of this information. The packages include: knee arthroscopy ACL repair, breast biopsy, colonoscopy, surgical removal of prostate, removal of tonsils and adenoid glands in patients under 12, hysteroscopy with biopsy, prostate biopsy, biopsy of the esophagus, stomach, and/or upper bowel, diagnostic examination of large bowel using endoscope, and surgical procedure to decompress herniated vertebra. Project Clarity will add additional packages in coming months.
 
Project Clarity’s organizers include: 

• Seema Verma, former CMS Administrator
• Niyum Gandhi, Chief Financial Officer and Treasurer at Mass General Brigham
• Aneesh Chopra, former CTO under President Obama and President of CareJourney
• Ryan Howells, Principal at Leavitt Partners and Executive Director of the CARIN Alliance

More information is available here.
 
KHN Study Shows Lowest Hospital Readmission Penalties Since September 2014
On November 1^st, Kaiser Health News released a report on penalties received by hospitals under the Hospital Readmissions Reduction Program. The program, created by the Affordable Care Act, evaluates the rate at which Medicare patients return to hospitals within 30 days and subsequently lowers payments to hospitals that have higher than expected readmission rates. Hospitals are at risk for up to 3% of their Medicare payments for each year under the program. Due to the pandemic, CMS excluded the first six months of 2020 from consideration, as well as patients who were readmitted with pneumonia over the entire three-year period.
 
CMS’s most recent round of penalties were applied to 2,273 hospitals, with an average reduction of 0.43%, representing an aggregate of $320 million in penalties. This is the most limited impact of such penalties—both in terms of overall dollars and the number of hospitals affected—since September 2014. Even so, 75% of covered hospitals were penalized. This represents 43% of the nation’s hospitals, since 2,193 hospitals nationally are exempted from the program. 
 
The full report is available here.

New York State Updates

Governor Hochul Issues Order to Establish the New York State Master Plan for Aging
On November 4^th, Governor Hochul issued Executive Order 23, creating the State’s first “Master Plan for Aging.” The Order directs the Commissioner of the State Department of Health (DOH) and the Director of the State Office for the Aging to head a Master Plan for Aging Council, which will be charged with gathering input from relevant stakeholders to draft guidance for building healthy, livable communities that offer opportunities for older adults.
 
DOH, in partnership with the Council, will convene a Stakeholder Advisory Committee to advise the Governor and the Master Plan for Aging Council on the development of the Master Plan. The recommended Master Plan for Aging will be presented to the Governor within two years of the first Stakeholder Advisory Committee meeting. The Master Plan development process will include ongoing opportunities for public engagement, including public comment periods and town hall forums for input.
 
The Governor’s press release is available here. The Executive Order is available here.
 
DOH Sends 60-Day Notice to MAP Plans for Behavioral Health Carve-In
On October 31^st, DOH sent a 60-day notice to Medicaid Advantage Plus (MAP) plans regarding the forthcoming carve-in of behavioral health services into the MAP benefit package. Effective January 1, 2023, MAP plans will be responsible for providing and coordinating behavioral health services to all enrolled members that meet criteria for such services. Accordingly, MAP plans will be required to enhance networks and update policies, procedures, and plan benefit materials. Readiness activities for the behavioral health transition must be completed before January 1, 2023. Plans with a pending MAP application will be required to complete readiness activities prior to the approval of MAP contracting.
 
The notice is available here. Questions may be submitted to BHO@omh.ny.gov and/or OASAS.SM.BehavioralHealthMMC@oasas.ny.gov.
 
DOH Updates Health Care Worker Bonus FAQs and Extends Submission Deadline
On October 31^st, DOH announced that it will keep the Health Care Worker Bonus (HWB) Portal open to claims submissions until November 30^th, providing employers with additional time to submit claims for Vesting Periods 1 and 2. However, claims submitted after October 31, 2022 will technically be late for filing purposes. DOH is aware of several technical issues during the initial submission periods for Vesting Periods 1 and 2 that impeded the ability of certain Qualified Employers to submit claims. DOH notes that all employers should document and retain information regarding the reason for any late submission for audits and investigation purposes relating to the submission of claims for the HWB Program.
 
DOH has also updated the Frequently Asked Questions (FAQ) page, which is available here. Updated questions are highlighted. Questions may be submitted to NYSWorkersBonus@health.ny.gov.
 
CMS Approves New York’s “Reasonable Opportunity Period” Extension Waiver
On October 28^th, CMS approved New York’s application for a Reasonable Opportunity Period (ROP) Extension under 1115 demonstration waiver authority. As outlined in the federal Families First Coronavirus Response Act (FFCRA), in order to receive the 6.2 percentage point Federal Medical Assistance Percentage (FMAP) increase available under the FFCRA, states must provide Medicaid benefits to an eligible individual during a 90-day ROP if the state cannot promptly verify that individual’s declared U.S. citizenship or immigration status.
 
This 1115 authority will allow New York to maintain coverage for individuals declaring to be U.S. citizens if the agency needs more time to verify the individual’s status through available electronic data sources, if the agency determines that the individual is making a good faith effort to obtain any necessary documentation, or to assist the individual in obtaining documents needed to verify their status.
 
CMS has announced that states may request 1115 waiver amendments in order to extend the ROP or institute other Medicaid enrollment flexibilities during the PHE unwinding period. New York’s ROP extension allows for up to 15 months, beginning with the first day of the first month of New York’s unwinding period (which could begin in December 2022, January 2023, or February 2023, if the PHE ends in January 2023) to allow the State to provide coverage beyond the 90-day ROP for Medicaid-eligible individuals who have declared U.S. citizenship but for whom that status has not been verified.
 
This expenditure authority allows for coverage of individuals who have been in an ROP beginning on March 18, 2020 or at any time thereafter during the PHE, and who have had their coverage maintained in order to comply with the continuous enrollment condition under FFCRA. At the end of the verification process, if the individual’s U.S. citizenship is either unable to be verified or the individual is determined to not be a U.S. citizen, New York must take action to terminate eligibility within 30 days.
 
The CMS approval is available here.  
 
OPWDD Releases 2023-2027 Strategic Plan
On November 1^st, the New York State Office for People with Developmental Disabilities (OPWDD) released the final 2023-2027 Strategic Plan following a public comment period. Based on stakeholder feedback and a review of state data and policy, the Plan outlines the following three strategic goals for 2023-2027:  

• Strengthen the workforce, technology, and collaboration;
• Transform the system through innovation and change; and
• Enhance person-centered supports and services.

Top priorities identified during the stakeholder feedback process included: 

• Addressing the workforce crisis;
• Improving self-direction;
• Better supporting people with complex needs;
• Strengthening housing services;
• Recognizing the need for long-term planning as families and caregivers age;
• Improving access to services for underserved communities; and
• Recognizing the need to use data to measure the agency’s success on meeting strategy goals and objectives, and being more transparent with data and information.

The Strategic Plan is available here. SPG will distribute a more detailed summary of the Strategic Plan this week.
 
OASAS Releases RFI on Restructuring of Addiction Services Financing System
On November 4^th, OASAS released a Request for Information (RFI) regarding vendors that can review the current system of net deficit financing of addiction services to: 

• Make recommendations for changes designed to ensure the equitable reimbursement of substance use disorder (SUD) and gambling services; and
• Assist in the implementation of the selected methodology.

OASAS intends to select a vendor for a contract lasting up to five years, starting on May 1, 2023. The vendor will be required to work both on-site and remotely.
 
The RFI is available here. Responses are due on November 28^th. Questions should be submitted to Procurement@oasas.ny.gov by November 14^th.

Funding Opportunities

OMH Releases HealthySteps RFA Round 2
On November 1^st, the New York State Office of Mental Health (OMH) released a Request for Applications (RFA) for a second round of funding to support the implementation of HealthySteps at new sites statewide. HealthySteps is an evidence-based program that serves young children (ages 0-3) and their families in a pediatric health care setting. Through this RFA, OMH will award a total of over $15 million across 33 awardees during the five-year program. Sites will be required to hire and maintain a HealthySteps Specialist for the duration of funding, who will be responsible for supporting the health care team and promoting the child’s developmental, social-emotional, and behavioral health.

Eligible applicants are pediatric or family medical practices located in New York State (including Federally Qualified Health Centers) that serve children ages 0-3 and have the potential to deliver well-child visits. The application is open to public, private, and not-for-profit practices with a payer mix of at least 50% Medicaid and/or Child Health Plus.

Applicants must have a minimum panel size of 300 children ages 0-3 and be applying to become a new HealthySteps site. HealthySteps sites previously funded by OMH are not eligible to apply for additional sites at the same location. However, up to three applications from the same organization may be submitted to establish new sites at a different location. No more than three applications will be awarded per organization within a designated region.

The full RFA is available here. Applications are due on January 10, 2023. Questions may be submitted to carol.swiderski@omh.ny.gov through November 22^nd.

OMH Reissues Intensive Crisis Stabilization Center RFP for Three Locations
On November 4^th, OMH and the Office of Addiction Services and Supports (OASAS) reissued the Intensive Crisis Stabilization Center Request for Proposals (RFP) for two centers in New York City and one center in the Capital Region. The original RFP, released in January 2022, included awards for three centers in NYC and one center in each of the remaining nine Economic Development Regions. There were nine awardees announced in July 2022, a list of which is available here.

Crisis Stabilization Centers are a new licensure category authorized by the New York State Fiscal Year 2021-22 Enacted Budget. There are two types of Crisis Stabilization Centers, Supportive and Intensive, which will be jointly licensed by OMH and the OASAS under Article 36 of the Mental Hygiene Law. This RFP is specific to the development of Intensive Crisis Stabilization Centers (ICSCs), which provide urgent treatment to individuals experiencing an acute mental health and/or substance use crisis. ICSCs will bill Medicaid for the provision of services and will be eligible through this RFP for start-up funding, capital funding, and limited state-aid. 

Eligible applicants are not-for-profit 501(c)(3) agencies with experience providing mental health and substance use services to individuals with serious mental illness and/or substance use disorders. Applicants must demonstrate that the provider is currently licensed, certified, or otherwise authorized by OMH, OASAS, or DOH. ICSCs may be operated by or affiliated with hospitals and/or hospital-affiliated programs.

The RFP is available here. SPG’s summary of the initial opportunity is available here. Applications for the reissue are due on January 17, 2023. Questions may be submitted to carol.swiderski@omh.ny.gov through November 22^nd.

ACS Releases RFP for Workforce Development Services
On October 28^th, the New York City Administration for Children’s Services (ACS) released an RFP for Workforce Development Services. These services offer high-quality education, career readiness, and/or training programs to youth to promote opportunities for successful career development. Applicants should have current or previous experience providing community-based youth development/coaching and workforce/career development services for youth ages 14-21.

Through this program, ACS will award $9 million in total funding across two awardees during the three-year program period. One award will be made for the Bronx, Manhattan, and Westchester County, and the other award will cover Brooklyn, Queens, and Staten Island. Each awardee will receive $1.5 million in annual funding. Contracts will last for three years, starting on July 1, 2023, with the option to renew for two additional three-year terms.

The RFP is available in the PASSPort system here by searching “Workforce Development Services.” Applications are due on December 2^nd. Questions may be submitted to Workforce-RFP@acs.nyc.gov through November 25^th.

HHS Releases Funding Opportunity for Evidence-Based Falls Prevention Programs
On November 3^rd, the HHS Administration for Community Living (ACL) released a funding opportunity that aims to support organizations in reducing falls and/or falls risk among older adults and adults with disabilities through the implementation of evidence-based falls prevention programs. ACL will award $3.5 million in total funding across 4-6 awardees during the four-year program period.

Eligible applicants include private institutions of higher education and not-for-profit 501(c)(3) organizations. Interventions should focus on older adults in underserved areas/populations as defined by the federal Executive Order on Advancing Racial Equity and Support for Underserved Communities.

Applications are due on January 11, 2023. Additional details are available here.