This week in Medicare updates—11/2/2022

Renewal of COVID-19 PHE

On October 13, ASPR published a Notice announcing that the COVID-19 PHE has been extended effective October 13, 2022. This will extend the PHE and all applicable waivers tied to it for an additional 90 days.

 

Updated EUA for Pfizer, Moderna Vaccines to Cover Boosters for Children 

On October 24, CMS updated its COVID-19 Toolkit to note that the FDA revised the Emergency Use Authorizations (EUA) for the Pfizer and Moderna COVID-19 vaccine on October 12 to authorize use for the bivalent formulations of the vaccines as a booster dose for children. The Pfizer vaccine has been approved for children ages 5 through 11 years old, and the Moderna vaccine has been approved for children ages 6 through 17. 

CMS added information about coding for the bivalent vaccines for children to its COVID-19 Vaccines and Monoclonal Antibodies page. CMS published a Press Release on this change on the same date.

 

October 2022 Update of the Ambulatory Surgical Center (ASC) Payment System

On October 25, CMS published Medicare Claims Processing Transmittal 11661, which rescinds and replaces Transmittal 11610, dated September 23, to add HCPCS J1952 to table 2, attachment A, and correct the associated number of new codes identified in the policy section B.3.a from 10 to 11. The original transmittal was issued regarding the October 2022 update of the ASC payment system. 

CMS revised MLN Matters 12915 on the same date to accompany the transmittal. 

Effective date: October 1, 2022

Implementation date: October 3, 2022

 

Payments Made to Providers Under the COVID-19 Accelerated and Advance Payments (CAAP) Program Were Generally in Compliance with the CARES Act and Other Federal Requirements

On October 25, the OIG published a Review of whether CAAP Program payments were made to providers in compliance with the CARES Act and other federal requirements. The OIG is monitoring this area because of the risks of disbursing a high amount of money (over $100 billion) over a very short period of time (March through September 2020). The OIG conducted an audit where it selected 100 providers randomly and nine additional providers because they were under bankruptcy when the CAAP Program payments were made. The OIG found that CMS’ payments to the 100 randomly selected providers were compliant, but CMS inappropriately paid three of the nine bankrupt providers because the MACs either did not correctly match the provider’s request against their bankruptcy database or did not update its bankruptcy database before the payment request was approved by CMS. In this situation, the MACs immediately identified their errors and recovered the improper payments. Because CMS generally made these payments in compliance with regulations, the OIG had no recommendations for CMS.

 

Comment Request: Hospital Wage Index Occupational Mix Survey

On October 25, CMS published a Comment Request in the Federal Register regarding the submission of the following information collection for OMB review:

• Hospital Wage Index Occupational Mix Survey

Comments are due to the OMB desk officer by November 25.

 

Revised Guidance for Staff Vaccination Requirements

On October 26, CMS published a Memorandum to state survey agency directors regarding revised guidance and survey procedures for COVID-19 vaccination requirements. The memo is replacing three previous memoranda to consolidate information into a single document for all provider types. The guidance in this memorandum applies to all states. CMS is still requiring staff at all Medicare and Medicaid certified facilities to have received the appropriate number of the primary COVID-19 vaccine series unless exempted as required by law or delayed as recommended by the CDC. Any facility staff vaccination rate below 100% constitutes noncompliance. This memorandum revises interpretive guidance for all provider types, addresses frequency of reviews of staff vaccination requirements as well as immediate jeopardy, condition-level, and actual harm determinations to ensure deficiency citations recognize good faith efforts by providers/suppliers. CMS noted that despite the enforcement remedies at its disposal, its goal is to bring health care facilities into compliance and will only use termination as a remedy as a last resort. 

Effective date: This policy should be communicated with all survey and certification staff, their managers, and the state/CMS location training coordinators immediately.

 

Use of Fire Safety Evaluation System (FESE), National Fire Protection Association 101A, Guide on Alternative Approaches to Life Safety, 2013 Edition by Health Care Occupancies and Board and Care Occupancies

On October 26, CMS revised a Memorandum, originally dated December 16, 2016, regarding enforcement of fire safety standards at healthcare facilities. The revisions incorporate changes made for nursing facilities/skilled nursing facilities to allow those facilities to use scoring values in the mandatory values chart in the National Fire Protection Association 101A, 2001 edition, effective October 1, 2022. 

Effective date: Immediately. The information provided in this memorandum should be communicated with all survey and certification staff, their managers, and the state/CMS Location Office training coordinators within 30 days of the date of this memorandum.

 

CMS Generally Ensured That Medicare Part C and Part D Sponsors Did Not Pay Ineligible Providers for Services to Medicare Beneficiaries

On October 26, the OIG published a Review of whether CMS oversight of Part C and Part D sponsors ensured compliance with federal requirements for preventing payments for Medicare services to ineligible providers. The OIG found that a relatively low number of Part C sponsors (136 out of 770) and Part D sponsors (62 out of 811) may have paid claims for health care services associated with ineligible providers. The OIG attributed these issues to potential lack of oversight or effective compliance programs by sponsors and CMS, improperly working system edits, and a lack of a CMS requirement for rejecting pharmacy claims without an active and valid provider identification number. 

The OIG made five recommendations for CMS–two of which directed Part C and D sponsors to recoup payments, two of which advised CMS to directly act in either an increased oversight role or penalize sponsors when applicable, and one of which directed Part C and D sponsors to review their lists of contracted providers and take action to ensure only eligible providers receive payments for Medicare services. CMS concurred with the recommendation for Part C and D sponsors to review lists but did not concur with the other recommendations, as it noted that these payments represented less than 0.01% of Medicare Advantage and 0.0005% of Part D payments as a whole. CMS stated that it is not clear additional oversight would improve those outcomes and that in order to conserve program resources, it tries to direct resources instead to the areas with the highest rate of return.

 

CMS Can Use OIG Audit Reports to Improve Its Oversight of Hospital Compliance

On October 27, the OIG published a Review of whether its own audits would be helpful for CMS to use to improve program oversight. The OIG specifically looked at 12 of its own audits from 2016-2018 to see results after considering the status of appeals for those audits, then examined whether CMS took action to ensure that the OIG’s recommendations were implemented. The OIG unsurprisingly found that CMS could use the OIG’s hospital compliance audits to improve CMS oversight of Medicare, but it was unable to determine how successful CMS was when following OIG recommendations for repayments because CMS did not submit sufficient information to the OIG for this review.   

The OIG made five recommendations. CMS requested the OIG remove recommendations on following up on overpayment recovery recommendations for the 12 specific audits in the report and on using the results of this audit and future hospital compliance audits in its risk assessment process, as CMS said the first recommendation is duplicative and that it already factors OIG reviews into its internal control activities. CMS agreed with recommendations on improving tracking and responding on the status of claims identified in OIG reports as those claims go through the appeals process, directing MACs to follow up with the 8 of 12 hospitals who did not respond to recommendations in the earlier audits, and revising CMS standard operating procedures to require MACs to follow up with providers at the conclusion of the appeals process and require MACs to provide additional details to CMS regarding specific follow-up actions.

 

Modification to Value-Based Insurance Design (VBID) Model Change Requests

On October 27, CMS published Demonstrations Transmittal 11674 regarding changes to implementation change requests for incorporating the Medicare hospice benefit into Medicare Advantage through the Value-Based Insurance Design (VBID) Model. The transmittal affects some of the business requirements from the previous transmittals to ensure that systems conduct a 12-month lookback in certain circumstances to identify claims that should not have paid as fee-for-service claims. 

Effective date: April 1, 2023

Implementation date: April 3, 2023

 

Instructions for Retrieving the 2023 Pricing and HCPCS Data Files Through CMS’ Mainframe Telecommunications Systems

On October 27, CMS published Medicare Claims Processing Transmittal 11663 regarding when the MACs can download the various 2023 pricing files from CMS. 

Effective date: January 1, 2023

Implementation date: January 3, 2023

 

File Conversions Related to the Spanish Translation of the HCPCS Descriptions

On October 27, CMS published Medicare Claims Processing Transmittal 11670 regarding the quarterly updates to Spanish translations of HCPCS codes provided by First Coast Service Options.

Effective date: January 1, 2023

Implementation date: January 3, 2023

 

Updates to Federally Qualified Health Center Cost Report

On October 28, CMS published Provider Reimbursement Manual Transmittal 5 regarding updates to the Federally Qualified Health Center Cost Report. Changes include revising rounding standards for ratios, updating worksheets to accommodate up to 198 consolidated FQHCs, and more.

Effective date: Cost reporting periods ending on or after October 31, 2022.

 

Update to Table with Medicare Payment Rates for Swing-Beds

On October 28, CMS published Provider Reimbursement Manual Transmittal 492 regarding changes to Table 34 in Section 2231 of the manual to update the Medicare payment rates for routine SNF-type services by swing-bed hospitals during CY 2023.

Effective date: For services furnished on or after January 1, 2023.

 

Comment Request: Data Collection to Support CMS Burden Reduction and Health Informatics Efforts

On October 28, CMS published a Comment Request in the Federal Register regarding the following information collection:

• Data Collection to Support CMS Burden Reduction and Health Informatics Efforts

Comments are due by December 27.

 

Comment Request: Generic Clearance for CMS and Medicare Administrative Contractor (MAC) Generic Customer Experience; more

On October 28, CMS published a Comment Request in the Federal Register regarding the following information collections:

• Generic Clearance for CMS and Medicare Administrative Contractor (MAC) Generic Customer Experience
• List of Screening Instruments for Housing Stability, Food Security, and Transportation Questions on Health Risk Assessments
• Data Collection to Support Eligibility Determinations for Small Businesses in the Small Business Health Options Program

Comments are due by December 27.

 

Final Rule: Implementing Certain Provisions of the Consolidated Appropriations Act of 2021 and Other Revisions to Medicare Enrollment and Eligibility Rules

On October 28, CMS published a draft copy of a Final Rule to implement sections of the Consolidated Appropriations Act of 2021 that aim to simplify Medicare enrollment rules and extend coverage of immunosuppressive drugs for certain beneficiaries. Changes include making Medicare coverage effective the month after enrollment for individuals enrolling in the last three months of their initial enrollment period or general enrollment period. It also establishes special enrollment periods for individuals who missed an enrollment period but meet certain conditions (impacted by emergency, disaster, health plan error, employer error, incarceration, termination of Medicaid coverage, and more) to allow them to enroll without having to wait for the general enrollment period and without being subject to a late enrollment penalty. 

The rule also establishes a Part B Immunosuppressive Drug benefit in which an individual with ESRD who receives a kidney transplant and does not have/does not expect to have health insurance coverage other than Medicare would be eligible to enroll in a new benefit period beyond the 26-month post-transplant period. Enrollment starts in October 2022 and coverage will start as early as January 1, 2023. Both of these policies were mandated by the Consolidated Appropriations Act. 

CMS published a Fact Sheet and Press Release on the rule on the same date. The rule is scheduled to be published in the Federal Register on November 3. It is effective January 1, 2023, except for a section on state retroactive liability and good cause exceptions, which is effective January 1, 2024.