This week in Medicare updates—6/14/2023
Medicare Part D Vaccines
On June 5, CMS revised an MLN Fact Sheet regarding Part D vaccines. The fact sheet explains the difference between Part B and Part D covered vaccines and discusses various in-network and out-of-network Part D vaccine options. CMS made minor updates related to coverage of the administration of the vaccines.
Final Rule: Policy and Regulatory Changes to the Omnibus COVID-19 Health Care Staff Vaccination Requirements
On June 5, CMS published a correction to a Final Rule in the Federal Register regarding the removal of expiring language related to COVID testing and adding requirements related to COVID vaccine education and offering vaccines to staff, patients, residents, and clients. Quality Measures Under Consideration (MUC) are discussed and include the percentage of patients offered and up-to-date on COVID vaccines and percent of staff considered up-to-date. The measures are applicable to multiple quality systems, including MIPS and provider value-based purchasing programs. A draft copy of the rule was published on May 31 but was missing the effective dates for the policies included in the rule.
The regulations in the final rule are effective August 4, 2023.
July 2023 Update of the Ambulatory Surgical Center (ASC) Payment System
On June 5, CMS published Medicare Claims Processing Transmittal 12069, which rescinds and replaces Transmittal 12060, dated May 25, to add HCPCS C1747 and CPT 50080 and 50081 code pairs in the policy section in Attachment A, and to add an associated business requirement (13216.14). The original transmittal was published regarding the July 2023 updates to the ASC payment system.
On June 13, CMS published Medicare Claims Processing Transmittal 12076, which rescinds and replaces Transmittal 12069, dated June 5, to correct the descriptor for J9323 and remove J9321 from Attachment A, Table 3. The original transmittal was published regarding the July 2023 updates to the ASC payment system.
CMS revised MLN Matters 13216 on the same date to accompany the transmittal.
Effective date: July 1, 2023
Implementation date: July 3, 2023
Requirements for Hospital Discharges to Post-Acute Care Providers
On June 6, CMS published a Memorandum to state survey agency directors regarding regulatory requirements for hospital discharges and transfers to post-acute care. The memo highlights areas of concern related to missing or inaccurate patient information when patients are discharged from a hospital, discusses discharge planning requirements, and notes resources providers may find helpful when developing policies/procedures to meet those requirements.
Effective date: Immediately.
Update to Medicare Claims Processing Manual, Chapter 9 and Chapter 18 to Clarify Vaccine Payment Instructions for Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC)
On June 7, CMS published Medicare Claims Processing Transmittal 12070 regarding updates to the manual to clarify when an encounter that includes vaccine administration would qualify as a visit.
Effective date: July 10, 2023
Implementation date: July 10, 2023
Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndromes
On June 7, CMS published a Tracking Sheet, which initiates the start of an NCA to reconsider the NCD covering allogeneic HSCT for MDS (NCD 110.23). This NCD currently provides coverage of this treatment for beneficiaries participating in a Coverage with Evidence Development (CED) clinical trial. The NCA will examine whether Medicare should cover this treatment without the CED requirement in the future.
There is a 30-day comment period for the initial request. Comments are due by July 7.
CMS Announces Multi-State Initiative to Strengthen Primary Care
On June 8, CMS published a Press Release to announce it is launching a new Innovation Center model– the Making Care Primary (MCP) Model–in eight states starting July 1, 2024. The model will run for 10.5 years and will have three tracks: (1) building infrastructure, (2) implementing advanced primary care, and (3) optimizing care and partnerships. As with other innovation models, the MCP Model will include prospective payments for primary care, but those prospective payments shift as participants move through the three tracks. The first track focuses on building the foundation for implementing a prospective payment system, and therefore it will remain a fee-for-service-based system but will allow participants to earn financial rewards for improving patient health outcomes. The second track shifts to a 50/50 blend of prospective and fee-for-service payments, while the third track transitions into fully prospective, population-based payment.
CMS published information on eligibility criteria, model purpose, and more on the MCP Model webpage. CMS will begin accepting applications for the model later this summer.
Gender-Specific Services: Billing Correctly and Usage of the Condition Code/Modifier
On June 8, CMS published a Note in MLN Connects regarding billing for gender-specific services. CMS is reminding providers that effective July 1, the NUBC revised Condition Code 45 to Gender Incongruence, which they define as a “marked and persistent incongruence between an individual’s experienced gender and sex at birth.” The note includes directions on billing for these types of services. Institutional providers will continue to report Condition Code 45 for claims related to transgender, intersex, and gender-expansive systems issues. Clinicians billing for Part B professional claims will report the KX modifier in these situations.
CMS Publishes List of Part B Drugs With Lower Coinsurance for July 1 - September 30
On June 9, CMS published a Press Release to announce the List of 43 prescription drugs for which Part B beneficiary coinsurance may be lower between July 1 - September 30, 2023. The lower coinsurance is due to the policy from the Inflation Reduction Act where people with Medicare may pay a lower coinsurance for Part B drugs if the drug’s price increases faster than the rate of inflation. The drugs on these lists may change quarterly.
CMS included a Fact Sheet from March 2023 to accompany the Press Release as a reminder of how this policy works.
Final Action: Treatment of Medicare Part C Days in the Calculation of a Hospital’s Medicare Disproportionate Patient Percentage
On June 9, CMS published a Final Action in the Federal Register regarding a policy in which the calculation of a hospital’s disproportionate patient percentage would include patients enrolled in Medicare Part C for cost reporting periods starting before FY 2014. CMS will count patients enrolled in a Medicare Advantage plan in the Medicare fraction of the DPP and not in the numerator of the Medicaid fraction for fiscal years prior to FY 2014.
This policy was the subject of multiple lawsuits, including two which went up to the Supreme Court. In the most recent case, Becerra v. Empire Health Foundation from 2022 regarding how to calculate the Medicare and Medicaid fractions of the DSH adjustment, the justices stated numerous times in transcripts from arguments in the case that the language Medicare used to govern this left them confused, exhausted, and as Justice Stephen Breyer stated, “the chances I understand it correctly are near zero.” The Court ruled in that case that HHS’s interpretation of the statute that counts these patients in the Medicare equation is correct.
The policy in the final action is effective August 8, 2023.
One-Time Change to CAH Annual Average 96-Hour Patient Length of Stay Calculations
On June 9, CMS published a Memorandum to state survey agency directors regarding a one-time change to the CAH 96-hour patient length of stay calculation to account for the period of time when the limit for this annual average length of stay was waived due to the COVID-19 PHE. The requirement to limit this average length of stay at 96 hours will go back into effect for CAHs for the first full cost reporting period after May 11, 2023, and it should not include any of the months covered under the COVID-19 PHE blanket waiver.
Effective date: Immediately. Please communicate to all appropriate staff within 30 days.