This week in Medicare—4/24/2024
CMS Releases Maryland Total Cost of Care Model Progress Report
On April 8, CMS published an Evaluation Report on the first four years of the Maryland Total Cost of Care (MD TCOC) Model. The MD TCOC Model builds on the Maryland All-Payer Model and introduces new components, including significant new investment in primary care, to engage a wider range of providers in care transformation throughout the state.
Between 2019 and 2022, the MD TCOC model reduced Medicare fee-for-service spending by 2.1% and hospital admissions by 16.2%. The model also reduced disparities in unplanned readmissions, preventable admissions, and timely follow-up by race and place. From 2019 to 2021, the model reduced total Medicare spending, including non-claims payments, by $689 million. CMS plans to continue to evaluate the model’s impact on spending, service use, and quality.
CMS Initiative Addresses Climate Change in the Healthcare Industry
On April 10, CMS published a Fact Sheet on the Decarbonization and Resilience Initiative, which is a voluntary element of the proposed Transforming Episode Accountability Model (TEAM). The initiative is designed to address threats posed by climate change to the nation's health and healthcare system by collecting, monitoring, assessing, and addressing hospital carbon emissions and their effects on outcomes, costs, and quality.
Participants would report metrics in four priority areas: organizational, building energy, anesthetic gas, and transportation. Participants who opt in to this initiative would receive individualized feedback and technical assistance aimed at improving decarbonization strategies over time, including a benchmark comparison of their emissions.
Updated OIG Work Plan
On April 15, the OIG updated its Work Plan with the following new items:
- Audit of Vertically Integrated Medicare Part D Sponsors
- Ensuring Dual-Eligible Enrollees’ Access to Drugs Under Part D: Mandatory Review
- Utilization of Peripheral Vascular Procedures and CMS’s Related Program Integrity Efforts
CMS Issues Fact Sheet for Potential Medicare Coverage of PrEP Using Antiviral Drugs
On April 15, CMS published a Fact Sheet on a proposed NCD for Preexposure Prophylaxis (PrEP) Using Antiretroviral Drugs to Prevent HIV. CMS initially proposed this NCD on July 12, 2023. Although there are no coverage changes at this time, CMS is providing additional information about the proposed NCD to promote an effective transition of coverage and minimize disruptions if it is finalized.
Currently, HIV PrEP drugs may be covered by Part D and are typically subject to a deductible and coinsurance or co-pay. If finalized, the proposed NCD would transition coverage of PrEP drugs to Part B, and beneficiaries would not have Part B cost-sharing obligations. CMS encourages proactive preparation by Part D sponsors, pharmacies, claims clearinghouses, Part D pharmacy claims processors, and pharmacy benefit managers.
The fact sheet also includes information about enrollment, billing, claims processing, and coding.
April Quarterly Update for 2024 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
On April 15, CMS published Medicare Claims Processing Transmittal 12584, which rescinds and replaces Transmittal 12553, dated March 21, to add BR 13574.9 and update the effective date.
Effective for claims with dates of service on or after January 1, the Common Working File will add HCPCS Level II codes A6549, A6584, A6593, and A6609 to category 56.
The original transmittal was issued to communicate the quarterly updates to the DMEPOS fee schedule.
CMS also revised MLN Matters MM13574 to reflect these changes.
Effective date: January 1, 2024, for BR 13574.9; April 1, 2024
Implementation date: April 1, 2024
Report of Hospice Election for Part D (Response File)
On April 16, CMS published One-Time Notification Transmittal 12585, which rescinds and replaces Transmittal 12518, dated February 22, to revise the implementation date, revise BR 13348.4, and remove BR 13348.6. CMS clarified that contractors are to participate in up to four calls to coordinate and discuss responsibilities regarding the file transfer process between the Virtual Data Centers, CMS, and Part D. CMS will schedule the calls once the file transfer process begins.
The original transmittal was issued to define the response file related to CR 13202 for the hospice Part D file project to identify records that did not pass RelayHealth intake edits.
Effective date: April 1, 2024
Implementation date: April 1, 2024 – (NOTE: Final implementation is delayed until May 13, 2024)
April 2024 Update to HCPCS files
On April 17, CMS updated the Download Link for the April 2024 update to the HCPCS files.
CY 2024 Home Infusion Therapy (HIT) Payment Rates and Instructions for Retrieving the January 2024 HIT Services Payment Rates Through the CMS Mainframe Telecommunications System
On April 17, CMS published Medicare Claims Processing Transmittal 12570, which rescinds and replaces Transmittal 12504, dated February 6, to update the policy section to reflect the extension of the work geographic practice cost index floor through December 31, 2024.
The original transmittal was published regarding updates to HIT service payment rates, and it was previously rescinded and replaced in December 2023 and February 2024.
Effective date: January 1, 2024
Implementation date: January 2, 2024
Additional Implementation Edits on Hospice Claims for Hospice Certifying Physician Medicare Enrollment
On April 19, CMS published Medicare Claims Processing Transmittal 12586 to implement additional edits on Hospice Claims for Hospice Certifying Physician Medicare Enrollment. Starting May 1, CMS will begin implementing checks to deny hospice claims if the physician in the Attending field is not on the file to enforce this new rule. The additional edit checks will look at the REF PHYS NPI field on the claim as well as the ATT PHYS NPI field when both fields are populated to ensure the certifying physicians, including hospice physicians and hospice attending physicians, are enrolled in or opted out of Medicare.
CMS published MLN Matters 13531 on the same date to accompany the transmittal.
Effective date: May 1, 2024
Implementation date: October 7, 2024
Manual Updates for Clarification on Services Under the Medicare Hospice Benefit for Dually Eligible Veterans
On April 19, CMS published Medicare Benefit Policy Transmittal 12589, which rescinds and replaces Transmittal 12589, dated February 22, to revise language in Chapter 9 of the Medicare Benefit Policy Manual. CMS replaced the verbiage “Veteran’s eligible beneficiaries” with “dually eligible veterans (i.e., eligible for both Medicare and Veterans benefits).”
The original transmittal was issued to clarify services under the Medicare hospice benefit for dually eligible veterans.
Effective date: March 25, 2024
Implementation date: March 25, 2024