This week in Medicare updates—4/12/23

FY 2024 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) Proposed Rule

On April 3, CMS released a draft copy of the FY 2024 IRF PPS Proposed Rule, which was published in the Federal Register on April 7. CMS estimates the total IRF PPS payments will increase by 3.7% for FY 2024. CMS is also proposing to allow hospitals to open a new IRF unit and begin getting paid at any point during the cost reporting period provided the hospital notifies the CMS regional office and MAC at least 30 days ahead of time. The rule includes additional changes to the IRF Quality Reporting Program.  

CMS published a Fact Sheet on the proposed rule on the same date. Comments are due by June 2.

 

FY 2024 Hospice Payment Rate Update Proposed Rule

On April 4, CMS published the FY 2024 Hospice Payment Rate Update Proposed Rule in the Federal Register. Proposals include a 2.8% increase in hospice payments for 2024 and a proposed aggregate cap amount of $33,396.55. The rule also includes a proposal attempting to address fraud, waste, and abuse by proposing that physicians who order or certify hospice services for Medicare beneficiaries must be enrolled in Medicare or have validly opted out as a prerequisite for payment for the hospice period of care in question. CMS included a warning about increasing concerns regarding fraud, waste, and abuse in the hospice industry and said it will be making an effort to address those concerns throughout the year. 

CMS published a Fact Sheet on the proposed rule. Comments on the proposed rule are due by May 30.

 

FY 2024 Inpatient Psychiatric Facility (IPF) PPS Proposed Rule

On April 4, CMS released a draft copy of the FY 2024 IPF PPS Proposed Rule, which was published in the Federal Register on April 10. CMS proposes an IPF payment rate update of 1.9% for FY 2024, which is slightly higher than the proposed 1.5% increase for FY 2023. Other proposals include an amendment to the regulations to allow hospitals to open a new IPF unit at any time during the cost reporting period as long as a 30-day advance notice is provided to the CMS regional office and the MAC. CMS included a Request for Information (RFI) regarding data CMS could collect that could be used to help inform possible revisions to payment rate calculation for FY 2025 and beyond.   

CMS published a Fact Sheet on the proposed rule on the same date. Comments are due by June 5.

 

FY 2024 Skilled Nursing Facility (SNF) PPS Proposed Rule

On April 4, CMS released a draft copy of the FY 2024 SNF PPS Proposed Rule, which was published in the Federal Register on April 10. CMS proposed a 3.7% increase to the SNF payment rate for 2024. This number incorporates the 2.3% reduction that will finish the two-year phase-in of the PDPM parity adjustment. CMS also included a proposal regarding changes to civil monetary penalties when a facility actively waives its right to a hearing in writing in order to receive a penalty reduction. CMS said that 95% of facilities facing civil monetary penalties currently follow this process. Therefore, CMS said it would create a system in which a failure to submit a timely request for a hearing would be treated as a constructive waiver and the accompanying 35% penalty reduction would remain. This proposal is intended to reduce the burden involved with tracking and managing written waiver requests. 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 to accompany the rule. Comments are due by June 5.

 

Final Rule: Contract Year (CY) 2024 Policy and Technical Changes to the Medicare Advantage Program and Medicare Prescription Drug Benefit Programs

On April 5, CMS published a draft copy of a Final Rule regarding the policy and technical changes for CY 2024 Medicare Advantage (MA) plans, Part D plans, and Programs of All-Inclusive Care for the Elderly (PACE). The rule includes multiple changes for prior authorization for MA organizations, such as:

• A requirement that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary
• A requirement that coordinated care plans provided a minimum 90-day transition period during which a new MA plan cannot require prior authorization when an enrollee currently undergoing treatment switches to the new MA plan
• A requirement for MA plans to establish a Utilization Management Committee to review policies annually and ensure consistency with FFS Medicare’s national and local coverage decisions and guidelines
• A requirement that a prior authorization request for a course of treatment must be valid for as long as medically necessary to avoid disruptions in care, in accordance with applicable coverage criteria, the patient’s medical history (for example, diagnoses, conditions, functional status), and the treating provider’s recommendation

The rule also includes policies regarding improved access to behavioral health care, restrictions on misleading marketing tactics, and more. 

CMS published a Press Release and Fact Sheet on the rule on the same date. The rule was published in the Federal Register on April 12.

The regulations are effective June 5. Provisions in the rule are applicable to coverage beginning January 1, 2024, except when noted otherwise.