This week in Medicare updates—6/21/2023
New Tools to Lower Prescription Drug Costs for Low-Income Seniors and People with Disabilities
On June 12, HHS published a Fact Sheet regarding new tools to help lower prescription drug costs for low-income Medicare beneficiaries via the Extra Help program, which provides eligible seniors and disabled people with help paying for Part D premiums and cost-sharing. As part of this program, CMS is releasing new national data about beneficiaries who benefit from this program. It is also releasing an outreach toolkit for beneficiary advocates and community-based organizations to raise awareness about the program benefits and help provide education on enrollment.
July 2023 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On June 13, CMS published Medicare Claims Processing Transmittal 12077, which rescinds and replaces Transmittal 12053, dated May 18, to update some language in the transmittal from April to July. The revisions also affect language related to the COVID-19 vaccine policy in section 1.B, the removal of HCPCS code J9321 from table 15, revisions to the descriptor for J9323 in table 15, and additional language about these changes to the policy section about newly established HCPCS codes for drugs, biologicals, and radiopharmaceuticals effective July 1. The original transmittal was published regarding the July update to the OPPS.
CMS revised MLN Matters 13210 on the same date to accompany the transmittal.
Effective date: July 1, 2023
Implementation date: July 3, 2023
CMS Office of the Actuary Releases 2022-2031 National Health Expenditure Projections
On June 14, CMS published a Press Release regarding a report from the CMS Office of the Actuary on projections of national health expenditures (NHE) and health insurance enrollment for 2022-2031. CMS is projecting a drop in the insured percentage of the population from a high of 92.3% in 2022 down to a potential of 90.5% in 2031. CMS attributes the possible decrease to the expiration of Medicaid enrollment conditions that had been put in place during the PHE and the potential expiration of current law provisions from the Affordable Care Act, which may expire at the end of 2025.
CMS projects an average annual expenditure growth of 7.5% for Medicare over 2022-2031. Hospital spending growth is expected to average 5.8% annually, while growth in physician and clinical services spending is projected to grow at an average rate of 5.3% from 2022-2031.
Significant Updates to Medicare Secondary Payer Manual, Chapter 6
On June 14, CMS published Medicare Secondary Payer Transmittal 12078, which rescinds and replaces Transmittal 11996, dated April 27, to update the transmittal page adding deleted sections 30.1.3 CWF/MSP Transaction Request for Contractor Assistance and 50.3 MSP “W” Records and Accompanying Processes, to remove these sections from the online manual. The original transmittal was published regarding updates to chapter 6 of the manual to add in current terminology and acronyms and to remove outdated policies and procedures.
Effective date: May 29, 2023
Implementation date: May 29, 2023
New Waived Tests
On June 15, CMS published Medicare Claims Processing Transmittal 12089 regarding the new CLIA-waived lab tests. There are six newly added waived complexity tests in this update.
CMS published MLN Matters 13253 on the same date to accompany the transmittal.
Effective date: October 1, 2023
Implementation date: October 2, 2023
Updates to Medicare Claims Processing Manual, Chapter 11 (Processing Hospice Claims), Sections 20.1.1-20.1.5, 30.2.1, 30.3, 130.1, and 130.2
On June 15, CMS published Medicare Claims Processing Transmittal 12083 regarding updates to manual language pertaining to processing hospice claims. These changes don’t reflect new policy; they clarify existing policy related to insurer unique identifiers, quality data submission, and more.
Effective date: May 15, 2023
Implementation date: July 17, 2023
FY 2024 and After Payments to Hospice Agencies That Do Not Submit Required Quality Data - This CR Rescinds and Fully Replaces CY 9460
On June 15, CMS published Provider Documentation Manual Transmittal 12090 regarding updates to language for the hospice payment reduction process to update the percent reduction from 2% to 4% beginning with FY 2024.
Effective date: January 1, 2023
Implementation date: July 17, 2023
Prior Authorization (PA) Changes to Implement the Inpatient Rehabilitation Facility (IRF) Review Choice Demonstration (RCD)
On June 15, CMS published One-Time Notification Transmittal 12080 regarding updates in the FISS and CWF to make the system changes necessary to use the prior authorization process to implement the IRF RCD. These updates will allow the FISS and CWF to assign and validate program codes for IRF claims using criteria specific to IRF claims.
Effective date: October 1, 2023
Implementation date: October 2, 2023
Allowing Audiologists to Furnish Certain Diagnostic Tests Without a Physician Order
On June 15, CMS published One-Time Notification Transmittal 12091, which rescinds and replaces Transmittal 11935, dated March 30, to update business requirement 13055.5.2 to replace MSN 90.94 with MSN 20.94. The transmittal is no longer sensitive and may now be posted to the internet. The original transmittal was published to establish edits to implement the new policy which will allow audiologists to perform certain diagnostic tests without a physician order.
Effective date: July 1, 2023
Implementation date: July 3, 2023
Updated OIG Work Plan
On June 15, the OIG updated its Work Plan with the following new items:
- Comparisons of Average Sales Prices to Widely Available Market Prices for the Second Quarter of 2023
- Medicare Payments for Clinical Diagnostic Laboratory Tests in 2022
- Nationwide Audits of Medicare Part C High-Risk Diagnosis Codes
- Audit of Selected, High-Risk Medicare Hospice General Inpatient Services