This week in Medicare—12/4/2024
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Update to Medicare Deductible, Coinsurance and Premium Rates for Calendar Year (CY) 2025
On November 25, CMS published Medicare General Information, Eligibility, and Entitlement Transmittal 12980, which rescinds and replaces Transmittal 12963, dated November 15, to correct a link.
The original transmittal was issued to instruct contractors on how to update claims processing systems with the new CY 2025 Medicare rates.
CMS revised MLN Matters 13796 on the same date.
Effective date: January 1, 2025
Implementation date: January 6, 2025
Rural Emergency Hospitals
On November 25, CMS updated an MLN Fact Sheet on Medicare payment for rural emergency hospital (REH) services. The agency added information on Indian Health Service hospitals and listed the CY 2025 REH facility monthly payment amount.
OIG Advisory Opinion No. 24-09
On November 25, the OIG published an Advisory Opinion on a proposed arrangement to begin billing patients’ insurance plans and waiving their cost-sharing amounts for treatment-in-place (TIP) emergency medical services without an associated ambulance transport. Under the proposed arrangement, the requestor—an emergency ambulance supplier and the primary 911 response agency in its county—would implement a charge for TIP services furnished in connection with 911 responses. The charge would be based on the level of care furnished to the patient and would not exceed amounts currently submitted for payment for the same level of care furnished in connection with an ambulance transport. The requestor would impose this charge regardless of the patient’s health insurance.
The requestor asked for an opinion as to whether this arrangement would be grounds for the imposition of sanctions under the federal anti-kickback statute and/or beneficiary inducements civil monetary penalty (CMP).
The OIG determined that the proposed arrangement would generate prohibited renumeration under the federal anti-kickback statute and beneficiary inducements CMP if the requisite intent were present, but it would not impose sanctions.
Proposed Rule: CY 2026 Policy and Technical Changes to the Medicare Advantage (MA) Program and Medicare Prescription Drug Benefit Programs
On November 26, CMS published a draft copy of a Proposed Rule regarding policy and technical changes to MA plans, Part D plans, and Programs of All-Inclusive Care for the Elderly (PACE).
CMS is proposing to permit Part D coverage of anti-obesity medications for the treatment of obesity when such drugs are indicated to reduce excess body weight and maintain weight reduction long-term for individuals with obesity. However, the agency indicated it would continue to exclude these medications from Part D coverage for individuals who are overweight but without obesity or another condition that is a medically accepted indication.
To improve access to behavioral health services, CMS is proposing the following standards for MA plans:
- 20% coinsurance or actuarially equivalent copayment limit for mental health specialty services, psychiatric services, partial hospitalization/intensive outpatient services, and outpatient substance abuse services
- Zero cost-sharing for opioid treatment program services
- 100% of estimated Medicare fee-for-service cost-sharing for inpatient hospital psychiatric services
CMS is also proposing to build on existing prior authorization and utilization management safeguards, adjust MA and Part D medical loss ratio reporting, and more.
CMS released a Press Release and Fact Sheet on the proposed rule on the same date. The rule is scheduled to be published in the Federal Register on December 10, and comments are due by January 27, 2025.
Alternative Payment Model Updates and the Increasing Organ Transplant Access Model
On November 26, CMS published a draft copy of a Final Rule to establish the Increasing Organ Transplant Access (IOTA) model, a new, six-year mandatory model aimed at increasing access to kidney transplants while improving care quality and reducing disparities.
After receiving comments on provisions in the related May 2024 proposed rule, CMS made several changes to the IOTA model’s requirements, including the following:
- Delaying the model start date to July 1, 2025
- Increasing the maximum amount a transplant hospital may receive from CMS based on its performance score (upside risk payment) from $8,000 to $15,000 per Medicare kidney transplant
- Removing the requirement for providers to review organ offers declined on behalf of the attributed patient
- Removing the health equity payment adjustment and allowing the health equity plans to be voluntary
CMS published a Press Release on the rule on the same date.
Quarterly Update to Home Health (HH) Grouper
On November 27, CMS published Medicare Claims Processing Transmittal 12982 regarding the April 2025 update to the HH Grouper software.
Effective date: April 1, 2025
Implementation date: April 1, 2025
Making Care Primary (MCP) Informational Unsolicited Responses (IURs)
On November 27, CMS published Demonstrations Transmittal 12983 to instruct contractors on certain scenarios for reprocessing claims in line with the MCP model logic. Contractors are to flag claims that have already been processed as fee-for-services if the MCP beneficiary file is updated late as an IUR and correct the pricing.
Effective date: July 1, 2024
Implementation date: April 7, 2025