This week in Medicare updates—4/11/18
Final Rule: Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-For-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program
On April 2, CMS published a Final Rule that updates policies for a variety of Medicare programs, including Medicare Advantage and the prescription drug benefit program (Part D), to support innovative approaches to improving quality, accessibility, and affordability; improve the CMS customer experience; expand the Patients over Paperwork initiative; and implement other changes among all parts of Medicare. The Final Rule also includes a number of provisions to help address the opioid epidemic and confront the increasing drug prices for Part D beneficiaries.
CMS published a Fact Sheet on the same date to accompany the Final Rule. The Fact Sheet addresses topics including additional transparency for star ratings, implementation of the Comprehensive Addiction and Recovery Act of 2016, expedited substitutions of certain generic drugs and other midyear formulary changes, and more.
CMS also issued a Press Release on the same date regarding both the Final Rule and the 2019 Medicare Advantage and Part D Rate Announcement and Call Letter.
Applicability dates: The applicability date of the provisions of this rule is January 1, 2018 except for provisions in §§ 422.100(f)(4) and (5), § 422.101(d), and §422.100(f)(6), which are applicable for contract year 2020. E-Prescribing and the Part D Prescription Drug Program; Updating Part D E-Prescribing Standards discussed in section D8 is applicable January 1, 2020 conditioned on The Office of the National Coordinator for Health Information Technology (ONC) adopting the same standard for use in its Electronic Health Record Certification Program by that date.
Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter
On April 2, CMS published the 2019 Rate Announcement and Call Letter regarding final policy and payment updates to the Medicare Advantage and Part D programs for 2019. These policy and rate changes include an update to the CMS-HCC Risk Adjustment model, a number of new policies aimed at combating the opioid epidemic, a change to the value of encounter data when calculating risk scores, and more.
CMS published a Fact Sheet on the same date to accompany the rate announcement and call letter. CMS also issued a Press Release on the same date regarding both the rate announcement and call letter as well as a Final Rule on a variety of Medicare updates for all parts of the program.
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD)
On April 3, CMS published Medicare Claims Processing Transmittal 4016, which rescinds and replaces Transmittal 3992, and Medicare National Coverage Determinations Transmittal 206, which rescinds and replaces Transmittal 205, both dated March 2, 2018, to remove the April 2018 implementation date and to remove the Place of Service indicators 19 and 22 in business requirements 10295.04.1.1 and 10295.04.1.1.1. All policy manuals have also been updated to reflect these changes. The original transmittal was issued to inform contractors that an NCD covering SET for treatment of PAD was effective May 25, 2017.
On April 5, CMS released a revised version of MLN Matters 10295 to accompany the transmittals.
Effective date: May 25, 2017
Implementation date: July 2, 2018 - for MAC local edits and for Shared System edits
Claims Processing Actions to Implement Certain Provisions of the Bipartisan Budget Act of 2018
On April 4, CMS published One-Time Notification Transmittal 2051, which rescinds and replaces Transmittal 2047, dated March 20, 2018, to include page 2 of Attachment B Rural Add-On Rate tables. The original transmittal was issued to provide directions for reprocessing claims related to several provisions of the Bipartisan Budget Act of 2018.
On April 5, CMS published a revised version of MLN Matters 10531 to accompany the transmittal.
Effective date: January 1, 2018
Implementation date: April 2, 2018 - date to begin reprocessing claims
2018 MIPS Quality Performance Fact Sheet
On April 5, CMS published a Fact Sheet regarding the quality performance category of the Merit-based Incentive Payment System (MIPS) for 2018. The fact sheet provides background information on the MIPS program as whole before outlining how providers can participate in the quality performance category in 2018. The performance category will be worth 50% of providers’ final MIPS score in 2018, and providers may be eligible for up to 10 bonus percentage points based on how they have improved within the category from the 2017 reporting period to the 2018 reporting period.
Clarifying Instructions Related to Proof of Delivery and Dates of Service
On April 6, CMS published Medicare Program Integrity Transmittal 785 to clarify existing instructions regarding the use of shipping and/or delivery dates as the claim date of service for delivery of durable medical equipment.
Effective date: May 7, 2018
Implementation date: May 7, 2018
New Waived Tests
On April 6, CMS published Medicare Claims Processing Transmittal 4018 to inform contractors of new waived Clinical Laboratory Improvement Amendments (CLIA) tests approved by the FDA. The six newly added waived test codes, effective dates, and descriptions include:
- 80305QW, December 7, 2017, Jant Pharmacal Corporation Accutest Value+Multi-Drug Urine Test Cup
- 87502QW, December 19, 2017, Cepheid Gene Xpert Xpress System (Xpert Flu Xpress)
- 87880QW, December 21, 2017, Quidel Sofia 2 (Sofia StrepA+FIA){from throat swab only}
- 82044QW, 82570QW, January 11, 2018, Medline Industries, Inc., Medline 120 Mini Analyzer Test System (Medline Industries, Inc. Medline Urinalysis Reagent Strips)
- 80061QW, 82465QW, 83718QW, 84478QW, January 19, 2018, ACON Laboratories Inc., Mission Cholesterol Pro Monitoring System (Mission Cholesterol Pro Test Cartridges)
- G0433QW, January 30, 2018, bioLytical Laboratories, INSTI HIV-1/HIV-2 Antibody Test {Fingerstick whole blood}
Effective date: July 1, 2018
Implementation date: July 2, 2018
Increased Ambulance Payment Reduction for Non-Emergency Basic Life Support (BLS) Transports to and from Renal Dialysis Facilities
On April 6, CMS published Medicare Claims Processing Transmittal 4017 to provide instructions on implementing a section of the Bipartisan Budget Act of 2018 that increases a fee schedule payment reduction for non-emergency BLS transports of beneficiaries with end-stage renal disease to and from renal dialysis treatments to 23%. This section applies to transports occurring on or after October 1, 2018.
Effective date: October 1, 2018
Implementation date: October 1, 2018