This week in Medicare updates—11/24/2021
2022 Medicare Parts A & B Premiums and Deductibles
On November 12, CMS published a Fact Sheet and Press Release regarding the 2022 Medicare Parts A & B premiums, deductibles, and coinsurance amounts. These rates increased in both Part A and B from 2021 to 2022. The standard 2022 amounts are:
- Part A inpatient hospital deductible - $1,556
- Part A daily coinsurance (61st - 90th day) - $389
- Part A daily coinsurance (lifetime reserve days) - $778
- Part B monthly premium - $170.10
- Part B annual deductible - $233
- Skilled nursing facility coinsurance - $194.50
CMS noted that one of the reasons for the increase in Part B premiums/deductibles is due to factoring contingency reserves in for the Alzheimer’s drug, Aduhelm™, which Medicare does not currently cover but started an NCD analysis process for in July 2021. CMS said its projections for Part B payments do not necessarily mean that it will cover the drug, but it wanted to have a contingency plan in place due to the possibility that, should Medicare cover this drug, the high cost of it would result in significantly higher expenditures for the Medicare program.
CMS published these rate notices in the Federal Register on November 17 via separate notices for the CY 2022 Inpatient Hospital Deductible and Hospital and Extended Care Services Coinsurance Amounts, the CY 2022 Part A Premiums for the Uninsured Aged and Certain Disabled Individuals Who Have Exhausted Other Entitlements, and the CY 2022 Part B Monthly Actuarial Rates, Premium Rates, and Annual Deductible.
National Expansion of the Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model
On November 15, CMS published an MLN Fact Sheet regarding the expansion of the RSNAT Prior Authorization model. The fact sheet reviews how the model works, who is required to participate, the timeline for expansion into additional states, and how to request RSNAT prior authorization.
Medicare Fee-for-Service Estimated Improper Payments Decline by Over $20 Billion Since 2014
On November 15, CMS published a Press Release to announce the Medicare FFS estimated improper payment rate (which applies to claims processed July 1, 2019 - June 30, 2020) is 6.26%, a historic low. Inpatient rehabilitation facility claims saw a $1.81 billion decrease in estimated improper payments from 2018-2021, which CMS attributed to the success of the Targeted Probe and Educate program. DME claims saw a $388 million reduction in estimated improper payments since 2020, which CMS attributed in part to the nationwide expansion of prior authorization of certain DME items.
CMS published a Fact Sheet on improper payments on the same date.
Implementation of Changes in the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for CY 2022
On November 15, CMS published Medicare Benefit Policy Transmittal 11120, which rescinds and replaces Transmittal 11058, dated October 22, 2021, to replace code E1699 Dialysis equipment, not otherwise specified, with code E1629 Tablo hemodialysis system for the billable dialysis service under the policy section of the business requirements form. This correction also revises BRs 12499.6 and 12499.6.1. The original transmittal, which details implementation of rate and policy changes from the CY 2022 ESRD PPS final rule, is no longer sensitive and is now being posted to the internet.
CMS published MLN Matters 12499 on the same date.
Effective date: January 1, 2022
Implementation date: January 3, 2022
Adjustment of the Civil Monetary Penalties for Inflation and the Annual Civil Monetary Penalties Inflation Adjustment for 2021 Final Rule
On November 15, CMS published a Final Rule in the Federal Register in which it finalized the provisions of a September 6, 2016 interim final rule adjusting the maximum civil monetary penalty (CMP) amounts for inflation across all agencies within HHS. The rule also updates the annual inflation-related increases to CMP amounts and adds references to new penalty authorities.
Effective date: This final rule is effective November 15, 2021.
Applicability date: The adjusted CMP amounts apply to penalties assessed on or after November 15, 2021, if the violation occurred on or after November 2, 2015.
Update to the Internet Only Manual (IOM) Pub. 100-04, Chapter 3, Sections 90.1.2, 90.3, 90.3.1, and Addendum A Provider Specific File
On November 16, CMS published Medicare Claims Processing Transmittal 11113 to manualize changes to policies for stem cell acquisition, kidney acquisition costs, the low volume adjustment factor, and data elements in the PSF for LTCHs in accordance with regulatory changes, previous transmittals, and rule-making.
Effective date: December 17, 2021
Implementation date: December 17, 2021
Comparison of Average Sales Prices (ASP) and Average Manufacturer Prices (AMP): Results for the Second Quarter of 2021
On November 16, the OIG published a Report regarding drugs for which the ASP exceeds the AMP by 5% or more for two consecutive quarters or three of the previous four quarters. When this happens, CMS substitutes 103% of the AMP for the ASP-based reimbursement. In the second quarter of 2021, seven drug codes met this price substitution criteria. Six additional codes exceeded the 5% threshold but were identified as being in short supply. Another four codes had ASPs exceeding the AMPs by at least 5% in the second quarter of 2021 but didn’t meet other price substitution criteria. The OIG will provide these results to CMS for review.
Advisory Opinion 21-16
On November 16, the OIG published an Advisory Opinion regarding whether an arrangement involving a pharmaceutical manufacturer’s agreement to provide a specified number of trial units of a long-acting antipsychotic drug to certain hospitals for inpatient use would be grounds for the imposition of sanctions under civil monetary penalties related to the anti-kickback statute. These trial units would be made available to hospitals that do not accept and dispense Prescription Drug Marketing Act of 1987 (PDMA)-compliant samples in their facilities. Hospitals would have to enter into an agreement with the requestor of the opinion and agree to certain terms and conditions.
The OIG said that while the arrangement would generate prohibited remuneration under the federal anti-kickback statute, the OIG would not impose administrative sanctions on the requestor. This decision was reached because the risk of patient steering under the agreement is low, there is a low risk of overutilization, the arrangement is unlikely to increase costs to federal health care programs and could possibly save program costs over time, and it includes a number of safeguards to prevent misuse of these free trial units.
Summary of Policies in the CY 2022 MPFS Final Rule
On November 16, CMS published Medicare Claims Processing Transmittal 11115 regarding implementation of the policies finalized in the CY 2022 MPFS Final Rule. This includes the updates to the telehealth services and telehealth origination site facility fee payment amounts, billing for physician assistant services, changes to definitions and billing policies for split/shared E/M visits, and more.
CMS published MLN Matters 12519 on the same date.
Effective date: January 1, 2022
Implementation date: January 3, 2022
Instructions for Retrieving the 2022 Pricing and HCPCS Data Files Through CMS’ Mainframe Telecommunications Systems
On November 16, CMS published Medicare Claims Processing Transmittal 11114 regarding instructions for the MACs on obtaining the 2022 Pricing and HCPCS Data Files.
Effective date: January 1, 2022
Implementation date: January 3, 2022
April 2022 HCPCS Quarterly Update Reminder
On November 16, CMS published Medicare Claims Processing Transmittal 11116 regarding a reminder for the MACs that the quarterly updates to the HCPCS file will be released via the CMS mainframe in March 2022.
Effective date: April 1, 2022
Implementation date: April 4, 2022
The Supplemental Security Income (SSI)/Medicare Beneficiary Data for FY 2019 for IPPS Hospitals, Inpatient Rehabilitation Facilities (IRF), and Long-Term Care Hospitals (LTCH)
On November 16, CMS published Medicare Contractor Beneficiary and Provider Communications Transmittal 11127 regarding updated data for determining the disproportionate share hospital (DSH) adjustment for IPPS hospitals and the low-income patient (LIP) adjustment for IRFs as well as payments as applicable for LTCH discharges. The transmittal provides the links to where the files are located on the CMS website.
CMS published MLN Matters 12516 on the same date.
Effective date: December 17, 2021
Implementation date: December 17, 2021
NCA for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT)
On November 17, CMS published a Proposed Decision Memo regarding the expansion of NCD 210.14 (Lung Cancer Screening with LDCT) to expand the eligibility for this screening. The proposal simplifies requirements for counseling and shared decision-making visits, removes restrictions that it must be furnished by a physician or non-physician practitioners, reduces eligibility criteria for the reading radiologist, and removes the radiology imaging facility eligibility criteria. CMS was asked to reconsider this NCD in the spring, as the US Preventive Services Task Force had published updated recommendations on screening people at high risk for lung cancer with LDCT based on age and smoking history.
The proposed decision memo initiates a 30-day public comment period. Comments are due by December 17.
Medicare Improperly Paid Suppliers an Estimated $117 Million Over Four Years for DMEPOS Provided to Hospice Beneficiaries
On November 18, the OIG published a Review of whether Medicare properly paid suppliers for DMEPOS items provided to hospice beneficiaries. The review looked at both items billed with the GW modifier (item not related to the beneficiary’s terminal illness and related conditions) and items billed without the GW modifier. The OIG found that Medicare improperly paid DMEPOS suppliers for 121 of the 200 sampled DMEPOS items provided to hospice beneficiaries, as 63% of the sampled DMEPOS items billed with the GW modifier and 58% of the DMEPOS items billed without the GW modifier were for items related to the beneficiary’s terminal illness or related conditions. Medicare therefore should have paid the hospices for those DMEPOS items. The OIG said the improper payments occurred because the majority of suppliers were unaware they had provided DMEPOS items to hospice beneficiaries, system edit processes to protect against this were not effective or did not exist, and suppliers inappropriately used the GW modifier.
The OIG recommends CMS improve the prepayment edit process by instructing DME MACs to deny DMEPOS claims submitted by suppliers without the GW modifier for DMEPOS items provided to hospice beneficiaries, implement a postpayment edit process, instruct MACs to conduct prepayment or postpayment reviews of supplier claims with the GW modifier, and study the feasibility of including palliative items and services not related to the beneficiary’s terminal illness/related conditions within the hospice per diem. CMS concurred with the first and third recommendations but not the second and fourth recommendations.
Quarterly Listing of Program Issuances-July Through September 2021
On November 18, CMS published a Notice in the Federal Register regarding the quarterly posting of all CMS manual instructions, substantive and interpretive regulations, and other Federal Register notices published from July through September 2021.
Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule Q&As
On November 18, CMS updated a Q&A regarding the Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule to add information about requirements for assisted living facility staff, EMS workers, therapists, and pharmacies. It also discusses documentation requirements for staff vaccination.
Reduced Payment for Physical Therapy and Occupational Therapy Services Furnished In Whole or In Part By a Physical Therapist Assistant (PTA) or Occupational Therapy Assistant (OTA)
On November 18, CMS published Medicare Claims Processing Transmittal 11129, which rescinds and replaces Transmittal 10934, dated August 13, 2021, to update the background/policy section. This transmittal is no longer sensitive and may now be posted to the internet. The original transmittal was published regarding implementation of the new policies for use of the CQ/CO modifiers for PT/OT payments when services are furnished in whole or in part by a PTA/OTA. These policies were finalized in the 2022 MPFS Final Rule.
Effective date: January 1, 2022
Implementation date: January 3, 2022
Updates to Medicare Financial Management Manual, Chapter 3, Section 140.1, Bankruptcy Forms
On November 18, CMS published Medicare Financial Management Transmittal 11124 regarding changes to the bankruptcy referral checklist Tier I and II instructions to clarify the debts recalled from treasury N/A option, extend submission timeframes, clarify the fraud check in the Tier II information, and more.
Effective date: December 21, 2021
Implementation date: December 21, 2021
ESRD Treatment Choices (ETC) Model Performance Payment Adjustment (PPA) - Facility Component (Implementation CR)
On November 18, CMS published Demonstrations Transmittal 11128 regarding implementation of the PPA for ESRD facilities who are paid through the ESRD PPS. The transmittal is mainly focused on system changes to enable this payment adjustment.
Effective date: April 1, 2022 - Begin development FISS; July 1, 2022 - Continue development, testing, and implementation FISS; Full implementation of MCS; Full implementation of CWF
Implementation date: April 4, 2022 - Begin development FISS; July 5, 2022 - Continue development, testing and implementation FISS. Full implementation of MCS and CWF.
Update to Enrollment Processing Requirements for Certified Provider/Supplier Change of Ownership (CHOW) and Change of Information (COI) Applications
On November 18, CMS published Medicare Program Integrity Transmittal 11125 regarding updates to Chapter 10 of the manual to provide instructions regarding processing of CHOW and COI applications submitted by certified providers/suppliers. This is part of CMS’ move to transition certain administrative functions from the CMS Survey & Operations Group Locations to the MACs.
Effective date: December 3, 2021
Implementation date: January 3, 2022
Home Health Prospective Payment System (HH PPS) Rate Update for CY 2022
On November 19, CMS published Medicare Claims Processing Transmittal 11099 regarding updates to payment rates for the HH PPS as finalized in the CY 2022 HH PPS Final Rule. This includes the market basket update, national standardized 30-day period payment, national per-visit rates, non-routine supply payments, rural add-on provision, and outlier payments.
Effective date: January 1, 2022
Implementation date: January 3, 2022
Updated OIG Work Plan
On November 19, the OIG updated its Work Plan with the following new items:
- National Background Check Program for Long-Term Care Providers: An Interim Assessment of Idaho and Mississippi
- Identifying Denied Claims in Medicare Advantage Encounter Data
- CMS Oversight of Manufacturer-Reported Average Sales Price Data
- Medicare Payments for Inpatient Claims With Mechanical Ventilation
Advisory Opinion 21-17
On November 19, the OIG published an Advisory Opinion regarding whether an arrangement involving subsidized beneficiary cost-sharing obligations for Medicare-covered services provided as part of a clinical trial would be grounds for the imposition of sanctions under civil monetary penalties and exclusion authorities related to the anti-kickback statute and/or the prohibition on inducements to beneficiaries. The requestor manufactures an implantable device which uses vagus nerve stimulation and is a sponsor of a clinical trial looking to determine whether the device achieves superior reduction in baseline depressive symptom severity. The requestor would pay cost-sharing obligations for the Medicare beneficiaries participating in the study that the beneficiaries would otherwise owe for Medicare-reimbursable items and services. The requestor would make these payments to the person or entity the beneficiary would otherwise owe the amount.
The OIG said that while the arrangement would generate prohibited remuneration under the federal anti-kickback statute and prohibition on inducements to beneficiaries, the OIG would not impose administrative sanctions on the requestor. The OIG said the arrangement poses a low risk of overutilization or inappropriate utilization of federal healthcare items and services, allows beneficiaries to participate in the study when it otherwise would have been cost-prohibitive for them to join, and does not present any risks posed by problematic seeding arrangements.
Medicare Diabetes Prevention Program (MDPP) Service Period Change from 2 Years to 1 Year
On November 19, CMS published One-Time Notification Transmittal 11132, which rescinds and replaces Transmittal 10923, dated August 10, 2021, to add BRs 12398.2 and 12398.3. In addition, the MDPP 2022 payment rates have been added to the CR. The CR contains instructions to A/B MACs (Part B) and the Railroad Specialty MAC to update the MDPP Expanded Model payment rates for CY 2022. CMS has updated the MDPP payment rates for CY 2022 in accordance with the finalized Calendar Year 2022 Physician Fee Schedule (PFS) and included them in an attachment to this CR. Payment rates will be in effect each year from January 1st through December 31st. The transmittal is no longer sensitive and may now be posted to the internet.
Effective date: January 1, 2022
Implementation date: January 3, 2022