This week in Medicare—9/25/2024
COVID-19 Vaccine Prices for 2024-2025 Season
On September 9, CMS updated its Vaccine Pricing Web Page with the COVID-19 vaccine pricing information for the 2024-2025 season. The agency provided this information after the new Novavax, Pfizer-BioNTech, and Moderna COVID-19 vaccine formulas received emergency use authorization from the FDA. The web page now displays the 2024-2025 national payment allowances for CPT codes 90480, 91304, and 91318-91322, as well as HCPCS code M0201.
Medicare Disproportionate Share Hospital
On September 9, CMS updated an MLN Fact Sheet on Medicare disproportionate share hospitals (DSH) to add information from the FY 2024 IPPS final rule. Additions include changes to the disproportionate patient percentage formula, methods for determining eligible DSHs’ Factor 3 uncompensated care amounts, and more.
Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 31.0, Effective January 1, 2025
On September 11, CMS published Medicare Claims Processing Transmittal 12842 regarding the regular quarterly updates to the NCCI PTP edits. The final file should be available on or around November 15.
Effective date: January 1, 2025
Implementation date: January 6, 2025
Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure Consequent to COPD
On September 11, CMS published a Tracking Sheet to initiate a National Coverage Analysis (NCA) into coverage for NIPPV. This NCA will be limited to coverage for NIPPV in the home for the treatment of chronic respiratory failure consequent to COPD.
By publishing the tracking sheet, CMS started a 30-day public comment period. Comments are due by October 11.
October 2024 Update to the HCPCS files
On September 11, CMS updated the Download Link for the October 2024 update to the HCPCS files.
October Quarterly Update for 2024 DMEPOS Fee Schedule
On September 12, CMS published Medicare Claims Processing Transmittal 12835 regarding the October quarterly updates to the DMEPOS fee schedule. Although there are no deleted codes in the October 2024 update, there are 22 new codes and 13 new fee schedule amounts.
CMS published MLN Matters MM13774 on the same date to accompany the transmittal.
Effective date: October 1, 2024
Implementation date: October 7, 2024
OIG Advisory Opinion No. 24-08
On September 13, the OIG published an Advisory Opinion on a proposed arrangement involving a Medicare Advantage plan sharing a percentage of its savings with certain groups to which it provides coverage through Employer Group Waiver Plans. Under the proposed arrangement, the requestor would include conditions in its contracts that would govern when a group could receive a gainshare payment. This payment would be based on a target “medical loss ratio” (MLR) negotiated by both parties and calculated by the requestor. If the final calculated MLR is below the negotiated target MLR, the requestor would pay the group a separately negotiated percentage of the savings.
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.
The OIG determined that the proposed arrangement presents a risk of steering, and this risk would not be offset by any guaranteed benefits to employees. It concluded that the proposed arrangement would generate prohibited renumeration under the federal anti-kickback statute if the requisite intent were present, which would constitute grounds for the imposition of sanctions.
2025 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments
On September 13, CMS published Medicare Claims Processing Transmittal 12837 regarding instructions for obtaining the files for the automated payments of HPSA bonuses for 2025.
Effective date: January 1, 2025
Implementation date: January 6, 2025
CMS Announces Resources and Flexibilities to Assist with the Public Health Emergency in the State of Louisiana
On September 13, CMS published a News Alert to announce additional resources and flexibilities available in response to Hurricane Francine in Louisiana. CMS detailed the waivers, special enrollment opportunities, dialysis care, DMEPOS replacements, and other resources available for those impacted by the hurricane.
CMS also has a variety of resources posted on its Current Emergencies website.
OIG Work Plan
On September 16, the OIG updated its Work Plan with the following new item:
Medicare Part B Drug Payments: Impact of Price Substitutions Based on 2022 Average Sales Prices (ASP)
On September 17, the OIG published a Review on the impact of Medicare’s price substitution policy on the cost of Part B drugs. Under the price substitution policy, CMS substitutes the ASP-based payment amount for Part B drugs with a lower calculated rate if the ASP for a drug exceeds the average manufacturer’s price (AMP) by 5% in the two previous quarters or in three of the previous four quarters.
CMS found that in 2022, the price substitution policy saved Medicare and its enrollees $966,307 over the course of the year. The OIG has long said that CMS could find more savings if it would expand its price substitution criteria to include more drugs, and it noted that CMS should continue to work with manufacturers to review and respond to potential errors in drug data to better bolster the effectiveness of the price substitution policy.
CMS Releases First Annual Evaluation Report on the Kidney Care Choices Model
On September 17, CMS published the First Annual Evaluation Report on the Kidney Care Choices (KCC) Model. This voluntary model is designed to delay the onset of dialysis, increase the use of home dialysis, and increase kidney transplantation rates while reducing Medicare expenditures and preserving or enhancing quality of care.
The report showed that in the first year of the model, there was an increase in home dialysis, home dialysis training, and optimal starts to dialysis. There was no significant change, however, in transplant rates or Medicare Part A or B spending. CMS said it is too early to form conclusions on how this model will do long-term. CMS published a two-page summary of the findings on the same day as the report.
Influenza Vaccine Payment Allowances – Annual Update for 2024-2025 Season
On September 18, CMS published Medicare Claims Processing Transmittal 12848, which rescinds and replaces Transmittal 12788, dated August 15, to update the CR with two additional business requirements (13718.4 and 13718.5) that detail how contractors should reprocess any previously paid claims. The original transmittal was issued regarding the annual update to payment allowances for the influenza vaccine.
Effective date: August 1, 2024
Implementation date: September 30, 2024
OPPS Addendum A and B
On September 18, CMS published updated versions of the OPPS Addendum A and B files.
Quarterly Update for the DMEPOS Competitive Bidding Program (CBP) – January 2025
On September 19, CMS published Medicare Claims Processing Transmittal 12849 regarding instructions for downloading the quarterly update to the DMEPOS CBP.
Effective date: January 1, 2025
Implementation date: January 6, 2025
CMS Recovered Payments to Providers Under the COVID-19 Accelerated and Advance Payments Program in Compliance with Federal Requirements
On September 19, the OIG published a Report regarding CMS’ efforts to recover payments from providers made through the COVID-19 Accelerated and Advance Payments (CAAP) Program. During the COVID-19 pandemic, CMS disbursed more than $103 billion to more than 46,000 through the CAAP program. Providers had 29 months to return those payments.
The OIG found that CMS largely recovered CAAP program repayments in compliance with the terms of the Continuing Appropriations Act, 2021. Of the 100 sampled providers included in the audit, MACs completed recovery from 97 providers and continued to recover payments from the other three providers. Because of the overall success of the program, the OIG has no recommendations stemming from this report.