This week in Medicare updates—7/13/2022

Part D Plans Generally Include Drugs Commonly Used by Dual Eligibles: 2022

On July 1, the OIG published a Data Snapshot regarding whether Part D formularies cover prescription drugs commonly used by dually eligible beneficiaries. This review is mandated by Congress. The OIG found that a majority of Part D plans (95 of 132) cover almost all of the drugs (97%) most commonly used by dual eligibles. This is consistent with OIG findings on this info from previous years.

 

The Reduced Outlier Threshold Applied to Transfer Claims Did Not Significantly Increase Medicare Payments to Hospitals

On July 6, the OIG published a Review of the financial impact of Medicare’s transfer policy and reduced outlier threshold on Medicare total payments for transfer claims as compared to what hospitals would have been paid if the beneficiary had been discharged instead of transferred. The OIG found that the reduced outlier threshold for transfer claims did not have a significant impact on total Medicare payments. Under the transfer policy, Medicare decreased DRG rate payments by $10.8 million. However, the reduced outlier threshold led to an increase in outlier payments by $13.7 million, resulting in a net increase of $2.9 million in total Medicare payments for transfer claims compared to what hospitals would have been paid if the beneficiaries had been discharged. This total was not significant enough to indicate a need for policy changes, and the OIG therefore had no recommendations.

 

FDA Updates EUA for Paxlovid

On July 6, the FDA revised the EUA for Paxlovid to allow pharmacists to prescribe and dispense Paxlovid to eligible patients without having to see a doctor or other clinician. The FDA also updated the Fact Sheet for Health Care Providers to accompany this change in who may prescribe Paxlovid.

 

Proposed Decision Memo: Cochlear Implantation

On July 6, CMS published a Proposed Decision Memo regarding a revision to NCD 50.3, Cochlear Implantation, to expand coverage by changing the definition of limited benefit from amplification to define it as test scores of less than or equal to 60% correct on recorded tests of open-set sentence cognition when the patient meets specific coverage criteria. CMS also proposes coverage of cochlear implants for beneficiaries who might not meet the coverage criteria but are participating in an FDA-approved investigational device exemption clinical trial or when provided as a routine cost in clinical trials under section 310.1 of the NCD manual. 

Comments on the proposed coverage are due by August 5.

 

ESRD Treatment Choices (ETC) Model Performance Payment Adjustment (PPA) - Facility Component (Implementation CR) 

On July 6, CMS published Demonstrations Transmittal 11489, which rescinds and replaces Transmittal 11330, dated March 30, to add a new attachment (ETC Facility PPA Valid Ranges), which includes the different payment adjustments of the ETC model that apply to this instruction and to update the Participant File Mock Template. This correction also updates business requirement 12492.8.5. The original transmittal was published regarding implementation of the PPA for ESRD facilities who are paid through the ESRD PPS.

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.

 

Infection Prevention and Control and Antibiotic Stewardship Program Interpretive Guidance Update

On July 6, CMS published a Memorandum to state survey agency directors regarding an update to interpretive guidance for hospital requirements that was finalized in September 2019 via the Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction Final Rule. The rule revised hospital Conditions of Participation (CoP) for 42 CFR §482.42 pertaining to infection prevention and antibiotic stewardship programs. The memo contains the text of the changes to the interpretive guidelines for the CoPs.

Effective date: Immediately. Please communicate to all appropriate staff within 30 days.

 

Updated List of Lab Tests Subject to Exceptions to the Lab Date of Service (DOS) Policy

On July 6, CMS published a Download Link to an updated list of lab tests subject to exceptions to the lab DOS policy.

 

New Edit for Prospective Payment System (PPS) Outpatient and Inpatient Bill Types Receiving an Outlier Payment When a Device Credit is Reported

On July 7, CMS published One-Time Notification Transmittal 11488 regarding the implementation of an edit for OPPS and IPPS bill types to validate Medicare outlier overpayment when the claim contains device credit amounts. 

Effective date: January 1, 2023

Implementation date: January 3, 2023

 

Comment Request: Solicitation for Applications for Medicare Prescription Drug Plan 2024 Contracts

On July 7, CMS published a Comment Request in the Federal Register regarding the following information collection:

• Solicitation for Applications for Medicare Prescription Drug Plan 2024 Contracts

Comments are due by September 6.

 

CY 2023 Medicare Physician Fee Schedule Proposed Rule

On July 7, CMS published a draft copy of the CY 2023 Medicare Physician Fee Schedule Proposed Rule, which is scheduled to be published in the Federal Register on July 29. The rule proposes decreasing the conversion factor down from $34.61 in 2022 to $33.08 in 2023. Other proposals in the rule include but are not limited to:

• Adopting coding/documentation changes for E/M visits (including hospital inpatient, observation, emergency department, and more) that align with changes made by the AMA CPT Editorial Panel for January 1, 2023. This includes eliminated use of history and exam to determine code level, revised interpretive guidelines for levels of medical decision-making, and the choice of medical decision-making or time in determining code level.
• Delaying by one year the split-shared visits policy that was finalized in CY 2022 for the definition of substantive portion as more than half the total time.
• Extending the time that telehealth services are temporarily included on the telehealth services list during the PHE but are not included on a Category I, II, or III basis for 151 days following the end of the PHE
• Creating a new general behavioral health integration (BHI) service that is personally performed by clinical psychologists or clinical social workers to account for monthly care integration where the mental health services furnished by these provider types are the focal point of care integration.
• Making an exception to direct supervision requirements under “incident to” regulations at 42 CFR 410.26 allowing behavioral health services provided under general supervision of a physician or non-physician practitioner (NPP) when the services or supplies are provided by auxiliary personnel incident to the services of a physician or NPP.

CMS is seeking comments on a variety of topics from the rule, such as how to improve global surgical package valuation and pay more accurately for global surgical packages under the PFS, the potential use of the proposed and updated Medicare Economic Index (MEI) cost share weights in calibrating payment rates, changes in coding and policies regarding skin substitutes, and more. Comments are due 60 days after the rule’s publication in the Federal Register. 

CMS published a Press Release, Fact Sheet on the PFS rule as whole, Fact Sheet on the Quality Payment Program changes, Fact Sheet on Medicare Shared Savings Program Proposals, and a Blog Post on behavioral health changes on the same date.

 

Final Decision Memo: Home Use of Oxygen

On July 8, CMS published a Final Decision Memo regarding NCD 240.2 (Home Use of Oxygen). CMS is amending the period of initial coverage for patients from 120 days to 90 days in order to align with the 90-day statutory time period established in §1834(a)(5)(E) of the Social Security Act. Effective July 8, CMS is also giving MACs the authority to determine reasonable and necessary coverage of oxygen and equipment in the home for patients who don’t fall under the scope of the NCD. Initial coverage for patients with other conditions will be limited to the shorter of 90 days or the number of days included in the practitioner prescription at the MAC’s discretion, and coverage may be renewed if deemed medically necessary by the MACs. CMS did not receive any public comments when it proposed this revision.