This week in Medicare—7/3/2024
Correction Notice: Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting
On June 24, CMS published a Correction Notice in the Federal Register to correct typographical and technical errors in a final rule published in the Federal Register on May 10, 2024, that established minimum staffing standards for long-term care facilities. Corrections include revising an implementation date, moving the definition of state directed payments to another section, and more.
Dates: This correcting document is effective June 21, 2024.
Medicare Part D Vaccines
On June 24, CMS updated an MLN Fact Sheet on Medicare Part D vaccines. CMS clarifies that Part D plans may not immediately add newly approved vaccines to their formularies. If a new vaccine isn’t on the Part D plan’s formulary, coverage can be requested through the formulary exception process.
CMS also clarified that providers are to bill Part D vaccines, including their associated administration costs, on one claim when the same provider is both dispensing and administering the vaccine. This update applies to both in-network and out-of-network providers.
Period of Enhanced Oversight for New Hospices in Arizona, California, Nevada, and Texas
On June 24, CMS updated an MLN Fact Sheet on the period of enhanced oversight for new hospices in Arizona, California, Nevada, and Texas. CMS clarified that hospices reactivating after being in a deactivated status are considered to be new hospices for the period of enhanced oversight.
CMS Posts New FAQs on the National Coverage Determination for PrEP
On June 25, CMS published an FAQ on the NCD for Pre-exposure Prophylaxis (PrEP) Using Antiretroviral Drugs to Prevent HIV Infection. CMS created the FAQ in response to public feedback asking that more technical information for submitting future Medicare Part B claims for PrEP for HIV be released in advance of the final NCD. The FAQ covers enrollment, billing, and more.
July 2024 Update of the Ambulatory Surgical Center [ASC] Payment System
On June 25, CMS published Medicare Claims Processing Transmittal 12697, which rescinds and replaces Transmittal 12673, dated June 13, to remove HCPCS codes J3393, J3394, J9172, J9322, and J9324 from Table 2 in Attachment A and revise the original policy to reflect these deletions.
The original transmittal was issued to provide the July 2024 update to the ASC payment system.
CMS published a revised version of MLN Matters 13656 on the same date to accompany the transmittal.
Effective date: July 1, 2024
Implementation date: July 1, 2024
Manual Updates for Clarification on Services Under the Medicare Hospice Benefit for Dually Eligible Veterans
On June 25, CMS published Medicare Benefit Policy Transmittal 12696, which rescinds and replaces Transmittal 12589, dated April 19, to revise language pertaining
Effective date: March 25, 2024
Implementation date: March 25, 2024
CMS Publishes List of Part B Drug With Lower Coinsurance for July 1 – September 30
On June 26, CMS published a Press Release to announce the List of 64 prescription drugs for which Part B beneficiary coinsurance may be lower between July 1 – September 30, 2024. The lower coinsurance is due to the policy from the Inflation Reduction Act where people with Medicare may pay a lower coinsurance for Part B drugs if the drug’s price increases faster than the rate of inflation. The drugs on these lists may change quarterly.
CY 2025 Home Health Prospective Payment System (HH PPS) Proposed Rule
On June 26, CMS published a draft copy of the CY 2025 HH PPS Proposed Rule, which is scheduled to be published in the Federal Register on July 3. To account for the impact of implementing the Patient-Driven Groupings Model (PDGM), CMS is proposing a permanent prospective adjustment of -4.067% to the 2025 home health payment rate.
CMS is proposing a home health payment update of 2.5% for 2025, which would be offset by an estimated 3.6% decrease related to the PDGM and 0.6% decrease for the proposed fixed dollar loss. The agency estimates that Medicare payments to home health agencies in CY 2025 would decrease by 1.7%, or $280 million.
CMS published a Fact Sheet on the proposed rule on the same date. Comments are due on August 26.
Utilization of KX Modifier Medicare Physician Fee Schedule Payment for Dental Services Inextricably Linked to Covered Medical Services
On June 27, CMS published One-Time Notification Transmittal 12702 regarding the usage of modifier KX for dental services inextricably linked to covered medical services under the Medicare Physician Fee Schedule. The transmittal provides guidance to MACs on using modifier KX, determining inextricable linkage, and developing educational materials.
Beginning July 1, MACs may establish adjudication guidelines related to claims submitted with dental services inextricably linked to covered medical services related to the inclusion or absence of the KX modifier. For claims received on and after January 1, 2025, MACs may deny dental claims not containing the KX modifier as statutorily noncovered.
Effective date: July 1, 2024
Implementation date: July 1, 2024
Quarterly Update for the DMEPOS Competitive Bidding Program (CBP) – October 2024
On June 27, CMS published Medicare Claims Processing Transmittal 12699 regarding the quarterly update to the DMEPOS CBP files. This transmittal provides instructions on how to update the files in the system.
Effective date: October 1, 2024
Implementation date: October 7, 2024
CY 2025 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Proposed Rule
On June 27, CMS published a draft copy of the CY 2025 ESRD PPS Proposed Rule, which is scheduled to be published in the Federal Register on July 5. CMS is proposing to increase the ESRD PPS base rate to $273.20, which would increase total payments to all ESRD facilities by approximately 2.2%. The agency expects to pay $7.2 billion to roughly 7,700 ESRD facilities for furnishing renal dialysis services in 2025.
Of note, CMS is proposing to allow payment for acute kidney injury (AKI) renal dialysis services furnished to individuals in their homes. The agency is proposing to update the AKI dialysis payment rate for 2025 to $273.20, which is equal to the proposed ESRD PPS base rate. The rule also includes information on how CMS intends to operationalize the inclusion of oral-only drugs and biological products into the ESRD PPS.
CMS published a Fact Sheet on the proposed rule on the same date.
New State Codes for Arizona, California, Nevada, and Texas
On June 27, CMS published One-Time Notification Transmittal 12701 to announce that new hospice state codes have been assigned for Arizona, California, Nevada, and Texas. The new codes are as follows:
- Arizona: D9
- California: D6, D7, D8
- Nevada: E1
- Texas: E2, E3
Effective Date: July 1, 2024
Implementation date: July 1, 2024