This week in Medicare updates—4/20/2022
FY 2023 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Proposed Rule
On April 11, CMS published a draft copy of the FY 2023 SNF PPS Proposed Rule, which was published in the Federal Register on April 15. CMS proposed a decrease in Part A payments of approximately $320 million for FY 2023. This is based on a 3.9% update to payment rates generated by a 2.8% SNF market basket update plus a 1.5% market basket forecast error adjustment combined with a negative 0.4% productivity adjustment and a negative 4.6% decrease in SNF PPS rates as a result of a proposed recalibrated parity adjustment. When CMS implemented the PDPM in 2019, it called for implementation to happen in a budget-neutral manner. However, CMS data analysis shows an unintended increase in payments since PDPM implementation, leading to the need for a parity adjustment. CMS used comments from stakeholders received during the 2022 rulemaking cycle to determine how to account for the effects the COVID-19 PHE may have had on data, and it used a methodology based on those comments to determine the 4.6% negative adjustment.
As in other PPS proposed rules for FY 2023, CMS proposed a permanent 5% cap on annual wage index decreases. Other proposals in the rule include changes to PDPM ICD-10 code mappings, several quality reporting changes, and SNF value-based purchasing program changes.
CMS published a Fact Sheet and Press Release on the proposed rule on the same date. Comments are due by June 10.
Advisory Opinion No. 22-06
On April 11, the OIG published an Advisory Opinion regarding whether the provision of free genetic testing and counseling services to individuals meeting specified clinical criteria would be grounds for the imposition of sanctions under civil monetary penalties or exclusion authorities related to the anti-kickback statute and prohibition on beneficiary inducements. Under this arrangement, the Requestor–a biopharmaceutical company that manufactures two forms of a drug used to treat a rare cardiac disorder–would offer a free genetic test to screen for the gene mutations associated with the disorder and free genetic counseling services to certain individuals. The disorder can be either hereditary or occur spontaneously, and having the genetic mutation associated with the genetic version of the disorder is not sufficient to diagnose an individual with the disorder and therefore would have no bearing on whether a physician would prescribe the Requestor’s medication. The requestor, however, has a contract with a testing vendor who produces the customized specimen collection kits used to conduct the genetic tests involved in the arrangement.
The OIG said that while this arrangement would implicate the anti-kickback statute and prohibition on beneficiary inducements, it would not impose sanctions in this case. The OIG said it reached this decision based on the fact that several features of the arrangement make it unlikely to lead to overutilization or inappropriate utilization, the arrangement is unlikely to skew clinical decision making or raise concerns regarding patient safety or quality of care, and there are various safeguards in place to prevent use of the arrangement as a marketing or sales tool to induce physicians to order additional items and services.
Renewal of COVID-19 PHE
On April 12, ASPR published a Notice announcing that the COVID-19 PHE has been extended effective April 16, 2022. This will extend the PHE and all applicable waivers tied to it for an additional 90 days. ASPR previously published an announcement stating they would provide 60 days notice prior to the termination of the PHE.
Notice of New Interest Rate for Medicare Overpayments and Underpayments - 3nd Qtr Notification for FY 2022
On April 12, CMS published Medicare Financial Management Transmittal 11349 regarding the third quarter update to the interest rate on Medicare overpayments and underpayments. The Department of Treasury has changed the private consumer rate to 9.375%.
Effective date: April 18, 2022
Implementation date: April 18, 2022
Final Rule: Maximum Out-of-Pocket (MOOP) Limits and Service Category Cost Sharing Standards
On April 14, CMS published a Final Rule with Comment Period in the Federal Register regarding two proposals from the “CY 2021 and 2022 Policy and Technical Changes to the Medicare Advantage Program,” which was published in the Federal Register on February 18, 2020. CMS is now finalizing two proposals from that rule: the MOOP limits for Parts A and B services and the cost-sharing limits for Parts A and B services, including service category cost-sharing limits and per member per month actuarial equivalence cost-sharing. CMS is also requesting comments on new or different ways to update and change cost-sharing limits in future years for service categories subject to the regulations, including mental health services.
Comments are due by July 13.
Effective date: June 13, 2022
Applicability date: The provisions in this rule will apply to coverage beginning January 1, 2023
Update to Chapter 18 of the Claims Processing Manual and Chapter 15 of the Benefit Policy Manual to Add Data Regarding COVID-19 and its Administration to Current Claims Processing Requirements and Other General Updates
On April 14, CMS published Medicare Claims Processing Transmittal 11355 and Medicare Benefit Policy Transmittal 11355 regarding changes to the manuals to add payment processing instructions for COVID-19 vaccines and their administration in the same way as influenza and pneumococcal vaccines. The updates also include manual language to streamline the approval process for Medicare centralized billers for flu, pneumococcal, and COVID-19. The majority of the changes apply to the Claims Processing Manual.
CMS published MLN Matters 12634 on the same date to accompany the transmittals.
Effective date: May 16, 2022
Implementation date: May 16, 2022
New State Codes for California
On April 14, CMS published One-Time Notification Transmittal 11356 regarding the assignment of new state codes for California, as California has exhausted its supply of CMS Certification Numbers (CCN) for multiple provider types. The new state codes are California B3, B4, and B5.
Effective date: October 1, 2022
Implementation date: October 3, 2022
Updated Code Descriptors for Prior Authorization for Certain Hospital Outpatient Department (HOPD) Services
On April 14, CMS published an Update on its Prior Authorization for Certain HOPD Services webpage to note that the code descriptions for some of the services included in the prior authorization program have been updated to align with the AMA changes. The codes themselves have not changed. CMS updated the descriptors in Appendix A and B of the Operational Guide for the program.
CLIA Laboratories Surveyor Guidance for New and Modified CLIA Requirements Related to SARS-CoV-2 Test Result Reporting
On April 15, CMS revised a Memorandum to state survey agency directors regarding updates to CLIA laboratory requirements to meet the SARS-CoV-2 test result reporting provisions. Revisions were made after the CDC updated reporting guidance for COVID-19 testing on March 8. CMS updated the CLIA Surveyor Guidance and the FAQ in this memorandum in accordance with the latest guidance from the CDC.
Effective date: Immediately. This policy should be communicated with all survey and certification staff, their managers, and the state agency/CMS branch location training coordinators within 30 days of this memorandum.