Weekly Health Care Policy Update – November 8, 2024

November 15, 2024

In this update: 

  • Federal Agencies
    • CMS Releases CY 2025 OPPS/ASC Payment System Final Rule
    • CMS Releases CY 2025 Physician Fee Schedule Final Rule
    • CMS Releases CY 2025 Home Health Final Rule
    • HRSA Provides Opportunities for Feedback on OPTN Policy and Data Collection
    • CMS to Hold National Leadership Call on November 20th
  • Other Updates
    • MACPAC Holds October Meeting
  • New York State Updates
    • DOH Seeks Comments on Proposal to Expand 1115 Waiver Workforce Program and Medicaid Buy-In for Disabled Population
    • DOH Adopts Final Regulations to Clarify Provider Enrollment and Access to Medicaid Data in the SHIN-NY
    • DOH Expands Coverage of LCSW/LMSW Mental Health Services to All Populations in Article 28 Settings
    • OPWDD Issues Proposed Regulations to Require Emergency Management and Preparedness Plans
    • DOH Expands Reimbursement for Adverse Childhood Experiences (ACEs) Screening to Adult Populations

Federal Agencies

CMS Releases CY 2025 OPPS/ASC Payment System Final Rule
On November 1st, the Centers for Medicare and Medicaid Services (CMS) issued the Calendar Year (CY) 2025 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 3.1%. This update reflects a projected hospital market basket percentage increase of 3.4%, reduced by 0.5 percentage points for the productivity adjustment.

Additional key policies in the final rule include: 

  • Intensive Outpatient Program (IOP): CMS is maintaining the existing rate structure for two IOP APCs for each provider type: one for days with three services per day and another for four or more services per day.
  • Partial Hospitalization Program: CMS updated per diem rates for an allotment of services (furnished in hospital outpatient departments and CMHCs) and weekly hours for CY 2025.
  • Access to Non-Opioid Treatments for Pain Relief: CMS is finalizing provisions to provide temporary additional payments for certain non-opioid treatments for pain relief in the hospital outpatient department (HOPD) and ASC settings through the end of 2027.
  • Request for Information (RFI) on Domestic Personal Protection Equipment (PPE): CMS is seeking comment on policies to improve PPE supply through additional hospital payments.
  • Obstetrical (OB) Services: CMS is finalizing new national health and safety standards in the Conditions of Participation (CoPs) for hospitals and Critical Access Hospitals (CAHs) that offer OB services. Specifically, CMS is finalizing provisions related to organization and staffing, staff training, the Quality Assessment and Performance Improvement (QAPI) Program, emergency services readiness, and transfer protocols.
  • Hospital Inpatient Quality Reporting (IQR) Program: CMS is finalizing its proposal to continue voluntary reporting of the core clinical data elements (CCDEs) and linking variables for both the Hybrid Hospital-Wide Readmission and Hybrid Hospital-Wide Standardized Mortality measures.
  • Hospital Outpatient Quality Reporting (OQR) Program: CMS is finalizing proposals to adopt or make adjustments to the Hospital Commitment to Health Equity, Screening for Social Drivers of Health, Screen Positive Rate for Social Drivers of Health, and the Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery Patient Reported Outcome-Based Performance measures.
  • Ambulatory Surgical Center Quality Reporting (ASCQR) Program: CMS is finalizing proposals to adopt the same measures as the OQR program, except for the Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery Patient Reported Outcome-Based Performance measure.
  • Overall Hospital Quality Star Rating: CMS is continuing to seek additional information on the Safety of Care measure group.
  • Medicaid and CHIP: CMS is codifying the 12 months of continuous eligibility requirement for children under the age of 19 enrolled in Medicaid and CHIP.

The fact sheet is available here.

CMS Releases CY 2025 Physician Fee Schedule Final Rule
On November 2nd, CMS issued the CY 2025 Medicare Physician Fee Schedule (PFS) Final Rule. The rule finalizes policy changes for Medicare payments under the Physician Fee Schedule (PFS) and other Medicare Part B issues for calendar year (CY) 2025. Overall, payment rates under the PFS will be reduced by 2.93% in CY 2025 compared to CY 2024, as required by law unless Congress acts in a year-end omnibus funding bill to mitigate this cut. CMS is finalizing the CY 2025 PFS conversion factor at $32.35, a corresponding decrease of $0.94 from the CY 2024 PFS conversion factor of $33.29.

Key policies in the final rule include: 

  • Caregiver Training Services (CTS): CMS is finalizing new coding and payment for caregiver training for direct care services and supports.
  • Services Addressing HRSN: CMS is continuing to review submissions from an RFI regarding Community Health Integration (CHI) services, Principal Illness Navigation (PIN) services, and Social Determinants of Health (SDOH) Risk Assessment. Findings can be found in the final rule.
  • Office/Outpatient (O/O) Evaluation and Management (E/M) Visits: CMS is finalizing payment of the O/O E/M visit complexity add-on code.
  • Telehealth: Regulatory flexibilities on telehealth services are set to expire at the beginning of 2025. CMS made the following changes:
    • New Services: CMS is adding several services to the Medicare Telehealth Services List on a permanent basis, including caregiver training services on a provisional basis and PrEP counseling and safety planning interventions;
    • Frequency Limitations: CMS finalized the continued suspension of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations;
    • Telecommunications System: CMS is finalizing parameters for a two-way, real-time audio-only communication technology for certain services;
    • Provider Location: CMS will continue to permit distant site practitioner flexibility; and
    • Scope of Practice and Supervision: CMS is making some adjustments to supervision requirements and options for virtual presence.
  • Advanced Primary Care Management Services (APCM): CMS is establishing coding and payment for a new set of APCM services, focusing on care management. These codes are stratified based on patient medical and social complexity.
  • Cardiovascular Risk Assessment and Management: CMS is establishing coding and payment for an Atherosclerotic Cardiovascular Disease (ASCVD) risk assessment service and risk management services.
  • Behavioral Health Services: CMS is establishing coding and payment for crisis intervention safety planning. CMS is also finalizing payment for more Food and Drug Administration (FDA)-approved digital mental health treatment devices, with accompanying codes for monitoring.
  • Opioid Treatment Programs (OTPs): CMS is finalizing a number of telecommunication technology flexibilities for services furnished in OTPs.
  • Hospital Add-On for Infectious Diseases: CMS is finalizing a new Healthcare Common Procedure Coding System (HCPCS) code to capture the risks associated with infectious disease in hospitals.
  • Strategies for Improving Global Surgery Payment Accuracy: CMS is finalizing a policy to improve payment accuracy for some 90-day global package services.

The fact sheet is available here.

CMS Releases CY 2025 Home Health Final Rule 
On November 1st, CMS issued the CY 2025 Home Health Prospective Payment System (HH PPS) Rate Update Final Rule. Overall, the rule increases payments to home health agencies in CY 2025 by 0.5%, or a total of $85 million, compared to CY 2024. The 0.5% increase is the result of a 2.7% home health payment increase, a roughly 1.8% decrease due to the PPS behavioral assumption adjustment, and a 0.4% decrease based on an adjustment to the fixed-dollar loss ratio used by CMS to identify outlier payments.

Additional policies in the final rule include: 

  • Patient-Driven Groupings Model (PDGM): In the process of reconciling old and new methodologies, CMS is finalizing a partial adjustment to the CY 2025 payment rate.
  • Outcome and Assessment Information Set (OASIS): CMS is finalizing processes to crosswalk mapping for different versions of OASIS (D and E).
  • Home Health Conditions of Participation (CoPs) Updates: CMS is finalizing new standards for Home Health Agencies (HHAs) patient acceptance-to-service policies and CoP changes to reduce avoidable care delays.
  • Home Health (HH) Quality Reporting Program (QRP) Updates: CMS is finalizing four new items for patient assessment pertaining to SDOH.
  • Expanded Home Health Value-Based Purchasing (HHVBP) Model: The final rule summarizes comments related to the model’s Implementation and Monitoring technical expert panel (TEP).
  • Long-Term Care (LTC) Facility Acute Respiratory Illness Data Reporting: CMS is finalizing new data reporting standards for acute care respiratory illnesses.
  • Medicare Provider Enrollment: CMS is implementing a new pathway for providers and suppliers that are reactivating their Medicare billing privileges.

The fact sheet is available here.

HRSA Provides Opportunities for Feedback on OPTN Policy and Data Collection
On November 5th, the Health Resources Services Administration (HRSA) announced opportunities for interested stakeholders to provide comments on ongoing Organ Procurement and Transplantation Network (OPTN) reform. The Securing the U.S. Organ Procurement and Transplantation Network Act, Congress’s directive to modernize this infrastructure, focuses on the importance of data collection. In turn, HRSA currently has two notices for public comment related to collecting data from candidates. Additionally, HRSA is seeking comment on changes to OPTN governance.

The notices are available here, here, and here.

CMS to Hold National Leadership Call on November 20th
On November 20th at 2pm, CMS Administrator Chiquita Brooks-LaSure and her leadership team will hold their fourth and final CMS Leadership National Call Update for 2024. The call will offer an update on CMS’s accomplishments in the last quarter, including recent policy announcements and key initiatives. 

Registration is available here.

Other Updates

MACPAC Holds October Meeting 
On October 31st and November 1st, the Medicaid and CHIP Payment and Access Commission (MACPAC) convened for its monthly public meeting. The Commissioners discussed the impact of Medicaid expansion on increasing access to opioid use disorder (OUD) medications. The meeting covered a number of topics related to children including continuous eligibility, youth residential treatment services, and transitions of care for youth with special health care needs. Additionally, the Commissioners discussed managed care External Quality Review (EQR) policy options, principally in regard to data sharing and transparency, and the use of directed payments.
 
The slides are available here.

New York State Updates

DOH Seeks Comments on Proposal to Expand 1115 Waiver Workforce Program and Medicaid Buy-In for Disabled Population
On November 6th, the New York State (NYS) Department of Health (DOH) published a proposed amendment to the Medicaid Redesign Team (MRT) 1115 Waiver for public comment. The amendment would expand the Medicaid Buy-In Program for Working People with Disabilities (MBI-WPD) and increase flexibilities within the Career Pathways Training (CPT) Program, part of the New York Health Equity Reform (NYHER) waiver.

Medicaid Buy-in Program for Working People with Disabilities (MBI-WPD)
The Fiscal Year (FY) 2023-24 Enacted Budget included legislation to expand the MBI-WPD program and seek waivers necessary to do so. MBI-WPD offers working individuals with disabilities the opportunity to maintain financial independence through employment while retaining their Medicaid coverage, despite earnings that may otherwise make them ineligible.  As approved in the FY 2023-24 Budget, DOH seeks to expand the current MBI-WPD by removing the age limit and increasing the income and resource limits. Specifically, the amendment would: 

  • Eliminate the age limit of 65 years (the minimum age of 16 remains);
  • Increase the maximum income from 250% of the Federal Poverty Level (FPL) to 2,250% of FPL;
  • Increase the maximum resources from the current Medicaid resource limit for non-Modified Adjusted Gross Income (MAGI) populations (currently $31,175 for a one-person household) to a flat level of $300,000;
  • Remove the consideration of income and resources of legally responsible relatives when determining MBI-WPD eligibility;
  • Implement a new income-based premium structure, with no monthly premium for individuals under 250% FPL and a premium cap not to exceed 8.5% of the individual’s income; and
  • Establish a program enrollment cap of 30,000 individuals.

Career Pathways Training (CPT) Program
The CPT program is a $646 million component of the NYHER waiver, approved in January 2024, which allows the Medicaid program to pay for workforce training programs as well as to reimburse employers for backfill costs for CPT program participants who are absent from work while fulfilling training requirements, in return for participants making a commitment to serve a high-need Medicaid/uninsured population. As part of this amendment request, NYS seeks to increase the number of allowable days of backfill payments from two days per week to up to five days per week, as the two-day limit “is not sufficient to cover absences required by more intensive programs associated with certain titles under the program.”

DOH will host two virtual public hearings during which the public may provide oral comments on the draft amendment: 

  • November 25th 1pm-3pm (pre-registration here)
    • Individuals who wish to provide comment will need to register with an “SP” in front of their name (ex: SP Jane Doe) and must email 1115waivers@health.ny.gov no later than November 22nd at 4pm to confirm registration.
  • December 4th 1pm-3pm (pre-registration here)
    • Individuals who wish to provide comment will need to register as above no later than December 3rd at 4pm.

The draft amendment request is available here. Written comments may be submitted to 1115waivers@health.ny.gov with “Medicaid Buy-In Program for Working People with Disabilities (MBI-WPD) Demonstration Program and Career Pathways Training (CPT) Program Amendment” in the subject line through December 6th.

DOH Adopts Final Regulations to Clarify Provider Enrollment and Access to Medicaid Data in the SHIN-NY 
On November 6th, DOH adopted final regulations to amend section 504.9 of Title 18 of the New York Codes, Rules, and Regulations (NYCRR) to clarify provider access to Medicaid Confidential Data (MCD) in the Statewide Healthcare Information Network for New York (SHIN-NY). The regulations: 

  • Clarify that patient consent is obtained at the provider level, removing any question as to whether Qualified Entities (QEs) must obtain a separate consent at the entity level in order for their participants to access data pertaining to Medicaid beneficiaries;
  • Clarify that QEs are not required to enroll as Medicaid providers in order to facilitate the exchange of clinical and other data pursuant to patient consent;
  • Clarify that the QEs may permissibly disclose MCD where the patient has provided consent and the disclosure is made for a purpose connected to the administration of the Medicaid program.

In response to public comment on the proposed regulations, and to account for recent amendments to Part 300 allowing SHIN-NY participants to connect to and exchange data using the statewide network without contracting with a Qualified Entity, references to “Qualified Entity” and “Qualified Entities” have been updated to read “Qualified Entity or the entity that facilitates a SHIN-NY Participant’s connection to the Statewide Data Infrastructure.”

The final regulations are available here. Comments received on the proposed regulations and DOH responses to comments are available in the State Register here.

DOH Expands Coverage of LCSW/LMSW Mental Health Services to All Populations in Article 28 Settings
As authorized by the FY 2023-24 Enacted Budget, the NYS Medicaid program will now cover mental health counseling provided by Licensed Clinical Social Workers (LCSWs) and Licensed Master Social Workers (LMSWs) in Article 28 outpatient settings for all ages and patient populations. Previously, LCSWs and LMSWs were limited to serving individuals under 21 and pregnant women up to 12 months postpartum. No such restrictions existed for Licensed Marriage and Family Therapists (LMFTs) and Licensed Mental Health Counselors (LMHCs). This expansion is effective immediately for both Medicaid fee-for-service and Medicaid managed care plans.

Additional details are available in the September Medicaid update here.

OPWDD Issues Proposed Regulations to Require Emergency Management and Preparedness Plans 
On November 6th, the NYS Office for People with Developmental Disabilities (OPWDD) issued proposed regulations that would add a new section to Part 633 of Title 14 NYCRR to require OPWDD providers (except for Family Care Providers) to develop and review annually: 

  • An agencywide Emergency Management Plan; and
  • An Emergency Preparedness Plan for each facility certified or operated by OPWDD.

Each provider would be required to engage in a documented risk assessment to develop the plans that considers public health emergencies, natural hazards/disasters, and human-made hazards. All staff and volunteers would receive training on the plans on an annual basis, with new staff/volunteers receiving training within three months of employment.

OPWDD is proposing these regulations in direct response to an Office of the State Comptroller (OSC) audit of OPWDD’s Covid-19 pandemic response (here), which recommended that OPWDD review and update its emergency management protocol and ensure that facility-level emergency plans are adequate.

The proposed regulations are available in the State Register here. Public comment may be submitted to rau.unit@opwdd.ny.gov through January 5, 2025.

DOH Expands Reimbursement for Adverse Childhood Experiences (ACEs) Screening to Adult Populations
As authorized by the FY 2024-25 Enacted Budget, the NYS Medicaid program will reimburse for Adverse Childhood Experiences (ACEs) screenings conducted in primary care settings for adults ages 21-65 years. This change is effective October 1, 2024 for Medicaid fee-for-service populations and January 1, 2025 for Medicaid managed care populations. The ACEs screening for adults is limited to once per lifetime. Annual ACEs screening will continue to be covered for children and adolescents as medically necessary.

Eligible providers may be licensed or unlicensed individuals under the supervision of a licensed provider. Screeners must have training and experience using the screening tools and delivering trauma-informed care.

Additional details, including suggested screening tools and billing information, are available in the September Medicaid update here.