This week in Medicare—10/2/2024
Medicare and Medicaid Enrollees in Many High-Need Areas May Lack Access to Medications for Opioid Use Disorder
On September 23, the OIG published a Report regarding access to medications for opioid use disorder (MOUD) in high-need areas. While Medicare and Medicaid play important roles in providing access to these medications, recent OIG work showed that many enrollees with opioid use disorder did not receive MOUD through these programs. This report looked into the access to MOUD in light of recent steps from CMS to increase access to this vital medication.
The OIG found that in 2022, hundreds of counties in high need of MOUD services lacked office-based providers for buprenorphine and opioid treatment programs. In counties where there were providers able to practice, the OIG found they frequently did not treat any Medicare of Medicaid enrollees due to Medicare Advantage prior authorization requirements, low Medicaid reimbursement rates, and inadequate public information available about MOUD provider locations.
The OIG recommends CMS geographically target efforts to increase the number of MOUD providers that treat Medicare or Medicaid enrollees in high-need counties, work with states to assess Medicaid reimbursement rates to ensure they are sufficient for MOUD providers and treatment, and work with SAMHSA to develop and maintain a list of active office-based buprenorphine providers. CMS said it supports the spirit of the recommendations but did not indicate whether it would take action on them.
Additional Oversight of Remote Patient Monitoring in Medicare is Needed
On September 24, the OIG published a Review of how remote patient monitoring (RPM) is being used as well as potential vulnerabilities for this service that may affect oversight. The OIG found that the use of RPM in Medicare increased from 55,000 enrollees in 2019 to more than 570,000 enrollees receiving the service in 2022. Approximately 43% of enrollees who received RPM did not receive all three components of it (enrollee education and device set-up, device supply, and treatment management). This raises questions as to whether RPM is being used as intended. In addition, Medicare lacks key information needed for oversight, such as who ordered the monitoring for the enrollee.
The OIG recommends CMS:
- Implement additional safeguards to ensure that RPM is used and billed appropriately in Medicare
- Require that RPM be ordered and require that claims and encounter data for RPM include information about the ordering provider
- Develop methods to identify what health data is being monitored
- Conduct provider education about billing of RPM
- Identify and monitor companies who bill for RPM
CMS concurred with or stated that it would consider all recommendations.
Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement
On September 25, CMS published Medicare Claims Processing Transmittal 12851, which rescinds and replaces Transmittal 12794, dated August 15, to revise the background section and the HH CB Code list attachment by removing the lymphedema codes that were added in error.
The original transmittal was published regarding the January 2025 update to the list of HCPCS codes used to enforce consolidated billing of home health services.
Effective date: January 1, 2025
Implementation date: January 6, 2025
Cardiology CPT Code 75580: Issue with Claims Returned to Provider
On September 26, CMS published a Note in MLN Connects regarding a revenue code issue which caused certain claims for CPT code 75580 (diagnostic radiology procedures of the heart) with 2024 dates of service to incorrectly return to provider. CMS said it corrected this issue, and any providers who had claims incorrectly returned should resubmit those claims.
Compliance with Resident’ Rights Requirement Related to Nursing Home Residents’ Right to Vote
On September 26, CMS published a Memorandum to state survey agency directors to remind facilities of the regulatory expectations ensuring nursing home residents have the ability to vote. The memo details ways nursing homes can make voting more accessible for residents and highlights the regulatory text ensuring this right.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state/regional office training coordinators immediately.
Evaluation and Management (E/M) Services Guide
On September 26, CMS updated an MLN Booklet on E/M services to add updates from the 2024 Medicare Physician Fee Schedule final rule on billing telehealth services, add information about add-on code G2211, and to update the definition of substantive portion of split (or shared) E/M visits.
Fifteenth General Update to Provider Enrollment Instructions in Chapter 10 of Medicare Program Integrity Manual
On September 27, CMS published Medicare Program Integrity Transmittal 12852 regarding updates to the manual to address several provider enrollment topics. This includes added information in sections about stays of enrollment and change of information.
Effective date: November 7, 2024
Implementation date: November 7, 2024
Final Rule: Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in Calendar Year (CY) 2023
On September 27, CMS published a Final Rule in the Federal Register regarding steps the agency is taking to address significant, anomalous, and highly suspect (SAHS) billing within accountable care organizations (ACO). This rule addresses changes to the Medicare Shared Savings Program for financial calculations from performance year 2023.
CMS determined there was SAHS billing activity involving HCPCS codes A4352 (Intermittent urinary catheter; Coude [curved] tip, with or without coating [Teflon, silicone, silicone elastomeric, or hydrophilic, etc.], each), and A4353 (Intermittent urinary catheter, with insertion supplies). CMS therefore will be changing policies for assessing 2023 financial performance of Shared Savings Program ACOs, establishing benchmarks for ACOs starting agreement periods in 2024-2026, and calculating factors used in the application cycle for ACOs applying to enter a new agreement period beginning on January 1, 2025 and continuing their participation in the program for PY 2025.
CMS published a Fact Sheet on the rule on the same date. The regulations are effective October 15, 2024.
Medicare Advantage Value-Based Insurance Design (VBID) Model CY 2025 Model Participation
On September 27, CMS published a Fact Sheet regarding participation in the Medicare Advantage VBID Model for 2025. Participation has decreased from 69 participating Medicare Advantage Organizations (MAO) in 2024 to 62 participating MAOs in 2025. The VBID Model began in January 2017 and will continue through December 2030.
2024 Premiums, Benefits, and Plan Information for Medicare Advantage and Part D Prescription Drug Plans
On September 27, CMS published a Press Release to announce the premiums, benefits, and plan information for 2025 Medicare Advantage and Part D Prescription Drug Plans ahead of the start of open enrollment, which will begin on October 15. The average monthly plan premium for Medicare Advantage is expected to be $17 per month in 2025, a decrease from the average premium of $18.23 in 2024. CMS expects that approximately 51% of all Medicare beneficiaries will be enrolled in a Medicare Advantage plan in 2025.
CMS published a Fact Sheet on this information on the same date. More information on premiums and costs for 2025 Medicare Advantage and Part D plans is available on the CMS website.
CMS Announces Resources and Flexibilities to Assist with the Public Health Emergency in Florida, Georgia, and North Carolina
On September 27, CMS published a News Alert to announce additional resources and flexibilities available in response to Hurricane Helene in Florida, Georgia, and North Carolina. CMS detailed the waivers, special enrollment opportunities, dialysis care, DMEPOS replacements, and other resources available for those impacted by the hurricane.
On September 30, CMS added information to its Current Emergencies website regarding the same resources and flexibilities in response to Hurricane Helene, but it is extending those now to South Carolina and Tennessee as well.
Adjustment to the Amount in Controversy Threshold Amounts for CY 2025
On September 27, CMS published a Notice in the Federal Register to announce the annual adjustment in the amount in controversy threshold amounts. The CY 2025 amount in controversy thresholds are $190 for ALJ hearings and $1,900 for judicial review.
The annual adjustment takes effect on January 1, 2025.
HHS Announces Cost Savings for 54 Prescription Drugs Through the Medicare Inflation Rebate Program
On September 30, CMS published a Press Release to announce a coinsurance reduction for 54 prescription drugs available through Part B from October 1, 2024 – December 31, 2024. These 54 drugs had their coinsurance rates adjusted because the drug companies raised prices at a rate faster than the rate of inflation. CMS published a list of the affected drugs on its website.
Report on the Study of the Acute Hospital Care at Home Initiative
On September 30, CMS published a Report regarding the agency’s study of the Acute Hospital Care at Home (AHCAH) initiative. The program, which was initially established during the COVID-19 PHE, was extended through December 31, 2024, under provisions from the Consolidated Appropriations Act, 2023 (CAA). The report released by CMS fulfills a requirement from the CAA of 2023 to evaluate several aspects of the initiative, such as demographic information on beneficiaries treated under the initiative, clinical conditions treated, DRGs associated with discharges from the inpatient setting versus the AHCAH program, Medicare spending and utilization for patients receiving care in the inpatient setting versus AHCAH, and more.
The study is available to download via the AHCAH webpage on the CMS website.
Correction Notice: Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Program for Contract Year 2024—Remaining Provisions and Contract Year 2025 Policy and Technical Changes Final Rule
On September 30, CMS published a Correction Notice in the Federal Register regarding corrections to typos and technical errors from the Medicare Advantage final rule, which was published in the Federal Register on April 23. The corrections are all fairly minor and involve missing letters or words.
This correcting amendment is effective September 30, 2024.
Final Decision Memo: Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent HIV Infection
On September 30, CMS published a Final Decision Memo regarding an NCD for coverage of PrEP using antiretrovirals for people at increased risk of HIV acquisition. CMS will cover PrEP to prevent HIV in individuals at increased risk for HIV infection rather than the high risk from the proposed decision memo, and the determination as to the risk factor will be made by the physician/health care practitioner.
CMS is also covering up to eight individual counseling visits every 12 months to include HIV risk assessment, HIV risk reduction, and medication adherence. CMS will cover HIV screening up to eight times annually and a single screening for hepatitis B. The cadence of eight visits and eight tests is an increase from the proposed decision memo, where CMS proposed covering seven of each.