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CMS
CMS Releases Physician Fee Schedule CY 2025 Final Rule
The Center for Medicare and Medicaid Services (CMS) has released the Physician Fee Schedule CY 2025 Final Rule. You can view CMS’ press release, fact sheet, and final rule page in the Federal Register for more information. There were critical areas addressed in this year’s Physician Fee Schedule (PFS), including:
- The extension of some telehealth flexibilities permitted under CMS’ authority absent Congressional action;
- Updated payment for social determinants of health risk assessments as a part of Opioid Use Disorder intake activities furnished at Opioid Treatment Programs (OTP);
- The establishment of a new add-on code to account for coordinated care, referral services, and peer supports at OTPs;
- Payment for safety planning intervention and post-discharge follow-up;
- The establishment of six G codes that mirror current interprofessional consultation Common Procedural Terminology codes used by practitioners who are eligible to bill E/M visits; and
- Recognition of responses to CMS’ request for information on Certified Community Behavioral Health Clinics.
For the OPPS Final Rule, please see links to CMS’ press release, fact sheet, and final rule page in the Federal Register. Some highlights from this final rule include:
- The maintenance of the Partial Hospitalization Program and Intensive Outpatient Program rate structures;
- Narrowing the definition of “custody” in Medicare’s payment exclusion rule to mitigate barriers to Medicare access by individuals who have recently been released from incarceration or are on parole, probation, or home detention; and
- Changes to Medicaid regulation, allowing states implementing the Medicaid clinic services benefit to cover clinic services outside the “four walls” of behavioral health clinics.
If you have any further questions regarding these final rulings or the application of the “four walls” impacts on Pennsylvania, please contact RCPA COO and Mental Health Director Jim Sharp.
OMHSAS Provides Updated Telehealth Guidance on “Four Walls”
On Friday, November 1, the Centers for Medicare & Medicaid Services (CMS) released an anticipated Final Rule titled “CY 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS 1809-FC),” which includes three new exceptions for the federal “four walls” rule. At present, the “four walls” rule prohibits Medicaid payment for clinic services when both the practitioner and individual receiving service are outside of the “four walls” of the clinic unless the services are being provided to unhoused individuals (such as through street medicine). The new exception for Indian Health Services and Tribal Facilities is required nationally. The exceptions for Behavioral Health Clinics and Rural clinics are optional. States who determine that their Behavioral Health Clinic and/or Rural Health Clinic populations served meet the four criteria established by CMS (see page 1323 of the final rule) must submit a Medicaid State Plan Amendment (SPA) and receive approval from CMS for these exceptions to be in place for their state.
The Office of Mental Health and Substance Abuse Services (OMHSAS) had been working toward a short-term state level solution to the four walls issue for both Outpatient Psychiatric Clinics and Drug and Alcohol Clinics. However, now that a long-term federal option has been made available, the team in OMHSAS will be pivoting to pursue this newly available federal exception for Behavioral Health Clinics. While OMHSAS is still in the process of developing a timeline for the new State Plan Amendment, their team will be working on this as a top priority, with the goal of having a SPA in place in early 2025.
It has been confirmed that OMHSAS will not be shifting their current enforcement policy around the four walls while they work through getting this waiver in place. RCPA will continue its collaboration with OMHSAS on the process as this move forwards. If you have any questions, please contact RCPA COO and Mental Health Policy Director Jim Sharp.
For additional information, please see the following:
- Full Final Rule
- CMS FAQ on the Final Rule
- Email for Questions Regarding OMHSAS Telehealth Policy
OLTL Removes Background Checks From 2025 Waiver Amendment
Part of the CHC waiver discussions that began with the Office of Long-Term Living (OLTL) this spring related to mandatory background checks for employees. Since this discussion, OLTL has decided not to move forward with this change in the renewal and amendment submitted to CMS. This change in position was a result of the subsequent public comments and feedback on the collateral impacts.
Also contributing to this reversal were coordinated advocacy efforts by RCPA’s Coalition for Choice partners, resulting in the elimination of the requirement for federal background checks, including FBI fingerprinting, for over 125,000 caregivers and direct care workers for services in the Community HealthChoices and OBRA waivers. The costs for these mandatory background checks would have been in excess of $50 per employee.
The resulting decision will be included in the review and presentation of changes during the LTSS meeting next Wednesday, November 6. At this time, the background check requirements remain under consideration by OLTL for future amendments and renewals.
If you have any questions or need assistance, please reach out to Fady Sahhar.
Webinar on ID/A Waiver Amendments Effective January 1, 2025, to Be Held October 30
Intellectual Disability/Autism (ID/A) Waiver Amendments Effective January 1, 2025
Audience: All Stakeholders
Date: October 30, 2024, 11:00 am – 12:00 pm
Register Here
The Centers for Medicare and Medicaid Services (CMS) approved amendments to the Consolidated, Community Living, and Person/Family Directed Support Waivers (ID/A Waivers) effective January 1, 2025. This webinar will provide a general overview of the changes made in the ID/A waivers. There will be time during the session for presenters to answer questions submitted by participants during the webinar.
BIAA Event to Focus on Brain Injury as a Chronic Health Condition
The Brain Injury Association of America (BIAA) will be conducting an event via Zoom that will focus on the recent announcement from the Centers for Medicare and Medicaid Services (CMS) that formally designated brain injury as a chronic health condition. The session, “CMS Chronic Condition Designation — What it Means for You,” will be held on September 24, 2024, at 12:00 pm.
Panelists for this event include:
- Denver Supinger, BIAA’s Director of Advocacy and Government Relations;
- Karen Kimsey, former Director of the Department of Medical Assistance Services;
- Paul Bosworth, brain injury survivor and member of BIAA’s Brain Injury Survivors Council; and
- Darcy Keith, brain injury survivor and member of BIAA’s Brain Injury Survivors Council.
To participate in the event, please register here.
Legislation for Telehealth Flexibilities Introduced
Legislation for Telehealth Flexibilities Introduced:
HB 2560 To Address Psychiatry Time Requirements and “4 Walls”
RCPA is pleased to announce that yesterday, September 10, State Representative Tina Pickett (R-District 10) introduced House Bill 2560, which was referred to the House Health and Human Services Committee. The legislation is focused on addressing two critical telehealth considerations, including an update of the outpatient psychiatric outpatient time requirements and the Federal Medicaid payment standard known as the “4 Walls.” The latter would abrogate DHS 55 Pa. Code § 1153.52 Payment Conditions for Various Services and 55 Pa. Code § 5200.52 Treatment Planning. By addressing the “4 Walls” requirement, telehealth services by a practitioner can be delivered outside the physical outpatient clinics and will be categorized under licensed mobile mental health services.
On a parallel track, the Center for Medicare and Medicaid Services (CMS) has proposed a final rule exception that would eliminate the “4 Walls” requirements among several other actions. On September 9, 2024, RCPA submitted comments regarding the Medicaid Clinic Services 4 Walls Exceptions on behalf of our membership in support of the proposed exception to eliminate this Medicaid standard.
Additionally, the bill requires that providers who want to deliver telehealth services 100% must maintain a written agreement with a geographically proximate outpatient psychiatric clinic that operates a physical facility and provides in-person services at the outpatient psychiatric clinic within 40 miles or 60 minutes travel from the residence of the individual receiving services AND that the written agreement must include a provision that a referred individual must be seen by the geographically proximate outpatient psychiatric clinic within 10 days of the referral.
Finally, the bill addresses the required 50% psychiatric in-clinic time requirements of 55 Pa. Code Chapter 5200 for Psychiatric Outpatient Clinics. The proposed legislation outlines that required psychiatric time may be provided in person or by the use of telebehavioral health technology by psychiatrists, as specified by department regulations. Advanced practice professionals may also provide a portion of the psychiatric time, as specified by department regulations, either in person or by the use of telebehavioral health. Onsite supervision requirements can be performed by either a psychiatrist or an advanced practice professional. Lastly, the legislation permits DHS to issue waivers to fully remote providers so they can serve patients covered by private insurance.
The introduction of the bill represents a unified effort with OMHSAS, our partners in the Pennsylvania General Assembly, and stakeholders across the Commonwealth to enhance our system’s capacity to deliver services to those most in need. We ask that you join us in working with your legislators to pass this critical legislation.
RCPA will continue to update members as the legislation advances. If you have any questions, please contact RCPA COO and Mental Health Director Jim Sharp.
CMS Hospital/Quality Initiative Open Door Forum Scheduled for Tomorrow, Sept. 10
The Centers for Medicare and Medicaid Services (CMS) will host the next hospital/quality initiative (QI) open door forum call tomorrow, September 10, at 2:00 pm. Agenda topics for this call will include:
- FY 2025 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Final Rule CMS-1808-F
- FY 2025 Inpatient Psychiatric Facilities PPS Final Rule
- Open Question and Answer
The call will be held via Zoom webinar. Attendees must register in advance for this webinar. Register here. After registering, you will receive a confirmation email containing information about joining the webinar.
Access Rule Trainings Now Open for Registration
The Centers for Medicare and Medicaid Services (CMS) has announced an upcoming training series on the Access Rule:
- September 16, 2024, at 1:30 pm – 2:30 pm ET: Incident Management Systems and Critical Incident Reporting
- October 9, 2024, at 3:00 pm – 4:00 pm ET: HCBS Measure Set
- December 11, 2024, at 3:00 pm – 4:00 pm ET: Grievance Systems
- February 12, 2025, at 3:00 pm – 4:00 pm ET: Timely Access, Waiting Lists, Person Centered Planning Reporting Requirements & Minimum Performance Levels
- March 12, 2025, at 3:00 pm – 4:00 pm ET: Website Requirements
- April 9, 2025, at 3:00 pm – 4:00 pm ET: HCBS Rate Transparency
- May 14, 2025, at 3:00 pm – 4:00 pm ET: Medicaid Advisory Committee (MAC) and Beneficiary Advisory Council (BAC)
- June 11, 2025, at 3:00 pm – 4:00 pm ET: Institutional Rule Provisions* (This refers to the ICF payment transparency provision of the nursing home staffing regulations.)
Registration is available here. When you register, select all the trainings you would like to attend from the checklist. You can register for one or multiple training dates.
CMS Issues RFI on Potential Consolidation of Medicare Administrative Contractors
The Centers for Medicare and Medicaid Services (CMS) has issued a Request for Information (RFI) to obtain feedback from both the industry and the public about the potential consolidation of four Medicare Administrative Contractors (MAC) jurisdictions into two jurisdictions, as well as to obtain feedback on extending MAC contracts to ten years.
MACs are private health care insurers that have been awarded a geographic jurisdiction to process Medicare Part A and Part B medical claims or Durable Medical Equipment (DME) claims for people with Traditional fee-for-service (FFS) Medicare. Information on the role of MACs can be found here.
