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CMS

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ODP Announcement 23-013 informs all interested parties of the submission of Pennsylvania’s Heightened Scrutiny locations to the Centers for Medicare and Medicaid Services (CMS). The information submitted is available on the Department of Human Services’ (Department) website.

On February 1, 2023, the department submitted all locations identified as requiring a Heightened Scrutiny review by CMS. The information submitted may be viewed at the bottom of this web page. CMS will make final heightened scrutiny review determinations available online. Questions about Heightened Scrutiny or this communication should be sent electronically.

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The Centers for Medicare and Medicaid Services (CMS) has updated the calendar year (CY) 2023 per beneficiary threshold amounts for therapy services. These threshold amounts, also known as therapy caps, are reflected on claims with the KX modifier to confirm that services are medically necessary as justified by appropriate documentation in the medical record. There is one amount for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined and a separate amount for Occupational Therapy (OT) services. Claims from providers for therapy services above the threshold amounts without the KX modifier are denied.

For CY 2023, the KX modifier threshold amounts are: (a) $2,230 for PT and SLP services combined, and (b) $2,230 for OT services.

For additional information, refer to CMS Transmittal 11626 and the 2023 Therapy Code List and Dispositions.

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Date: February 8, 2023
Time: 1:30 pm – 3:00 pm ET
Registration Required
Closed captioning will be available.

In this webinar, the Department of Long-Term Services and Supports (DLTSS) will be discussing state requirements and opportunities for resuming Medicaid Home and Community-Based Services (HCBS) operations when we approach the end of the Public Health Emergency (PHE). This includes:

  • CMS resources to support states in unwinding PHE flexibilities, including considerations for HCBS;
  • An overview of HCBS-related PHE flexibilities to unwind, with a focus on the 1915(c) HCBS in 1915(c) waivers and the Centers for Medicare and Medicaid (CMS) approval process;
  • An overview of HCBS-related PHE flexibilities that can be made permanent in 1915(c) waivers and the CMS approval process; and
  • Other considerations for HCBS programs when unwinding from the PHE.

Following the presentation, webinar participants will have the opportunity to ask questions.

Register Today!

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The Centers for Medicare and Medicaid Services (CMS) issued a press release announcing an increase in three accountable care initiatives that will grow and provide higher quality care to more than 13.1 million people with Medicare in 2023. The initiatives include:

The Shared Savings Program is the largest accountable care initiative in the country and is a permanent program in Medicare that was established by the Affordable Care Act (ACA). The Shared Savings Program has 456 ACOs and 10.9 million assigned beneficiaries in 2023. While the Shared Savings Program experienced a decrease in the number of ACOs and assigned beneficiaries for 2023, the policies finalized in the calendar year (CY) 2023 Medicare Physician Fee Schedule final rule are expected to grow participation in the program for 2024 and beyond, when many of the new policies are set to go into effect. These policies are expected to drive growth in participation, particularly in rural and underserved areas, promote equity, and advance alignment across the accountable care initiatives, and increase the number of beneficiaries assigned to ACOs participating in the program by up to four million over the next several years.

The ACO REACH Model aims to improve the quality of care for people with Traditional Medicare through better care coordination and by increasing access to accountable care in underserved communities. Innovative features the Model will test include benchmark adjustments to shift payments to better support care for the underserved and enhanced Medicare benefits, including care in the home. In 2023, ACO REACH will increase access to accountable care in underserved populations. The ACO REACH Model will have 824 Federally Qualified Health Centers, Rural Health Centers, and Critical Access Hospitals participating in 2023 — more than twice the number in 2022. Increasing the number and reach of ACOs in underserved communities will help close racial and ethnic disparities that have been identified among people with Traditional Medicare in accountable care relationships.

The KCC Model focuses on coordinating care for Medicare beneficiaries with chronic kidney disease stages 4 and 5 and end-stage renal disease (ESRD). In addition to care coordination, the KCC Model focuses on key areas of concern for this population, including delaying the onset of dialysis and increasing access to kidney transplantation so more patients can live fuller and longer lives.

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ODP Announcement 23-008 announces that the amendment to the Adult Autism Waiver (AAW), effective January 1, 2023, was approved by the Centers for Medicare & Medicaid Services (CMS) on January 13, 2023. The amendment to the AAW includes the following substantive changes:

  • Adding reserved waiver capacity for individuals who are discharged from a state center or are released from incarceration after a period of at least six consecutive months.
  • Aligning of provider qualifications in the AAW with the Consolidated, Community Living, and Person/Family Directed Support (P/FDS) waivers, whenever possible.
  • Allowing relatives to deliver the Life Sharing component of the Residential Habilitation service.
  • Requiring that agencies that provide Residential Habilitation/Life Sharing be qualified and enrolled to provide Residential Habilitation/Life Sharing in the Consolidated or Community Living waivers.
  • Increasing the annual fiscal limit in the Transportation service to $5,000 per participant’s Individual Support Plan (ISP) year.
  • Allowing one of the four required individual monitorings conducted by the Supports Coordinator each year to be conducted remotely. NOTE: For all individuals receiving Residential Habilitation (Community Homes or Life Sharing), remote monitorings are not permitted. See ODP Announcement 22-085 for additional information.
  • Allowing delivery of direct services using remote technology (teleservices). The requirements in the AAW will become effective when Appendix K flexibilities expire, six months after the expiration of the federal COVID-19 public health emergency.
  • Aligning the Assistive Technology service, where possible, with the Consolidated, Community Living, and P/FDS waivers. This includes adding generators for the participant’s primary residence.
  • Adding a new service, Remote Supports. A separate communication will be published in the coming weeks, providing instructions about how to add new Remote Supports procedure codes to ISPs. Remote Supports should not be added to ISPs until this communication is published.

The waiver application approved by CMS and the record of change document are available here.

ODP will be holding a webinar to discuss major changes made in the approved AAW amendment. Webinars specific to Remote Supports will be scheduled and communicated in the coming weeks. The date, time, and registration link for the general AAW amendment webinar are as follows:

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The Office of Management and Budget (OMB) has released the Unified Regulatory Agenda and Regulatory Plan, which outlines regulatory actions federal agencies are considering in the coming months. Regulations can be searched by specific agency, such as Department of Health and Human Services (HHS), which includes the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Substance Abuse and Mental Health Services Administration (SAMHSA).

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ODP Announcement 23-002 reports that the renewals for the Consolidated, Community Living, and Person/Family Directed Support (P/FDS) Waivers have been approved by the Centers for Medicare & Medicaid Services (CMS) with an effective date of January 1, 2023. CMS approves waivers for a five-year period. The current Consolidated, Community Living, and P/FDS Waivers expired June 30, 2022, but were extended twice as discussions continued between the Office of Developmental Programs (ODP) and CMS.

Major changes in the renewals include:

  • Remote Supports has been added as a separate, discrete service in all three waivers.
  • Clarification about the activities that can be performed under the Communication Specialist service has been added, the amount of Communication Specialist services that participants can receive each year has increased from 40 hours to 60 hours, and effective January 1, 2024, the communication specialist will be required to successfully complete training provided by ODP.
  • The amount of Benefits Counseling services that participants can receive each year has increased from 10 hours to 15 hours.
  • The amount of tuition that can be covered through Education Support services has increased from $35,000 to $40,000.
  • Companion services have expanded to support additional participants at their place of employment.
  • Supported Employment services can now support participants during work-related trips.
  • Participant Directed Goods and Services have been added to the Consolidated Waiver.
  • The purpose of the Supports Broker service has been clarified, and recertification requirements for Supports Brokers have been added.
  • The Specialized Supplies service will continue to cover personal protective equipment once Appendix K flexibilities end.
  • Music, Art, and Equine-Assisted Therapy are available to individuals who receive residential services.
  • Staff working for, or contracting with, Residential Habilitation, Life Sharing, or Supported Living providers must complete Department-approved training on the common health conditions that may be associated with preventable deaths.
  • Clarification about requirements for using technology in the provision of waiver services has been added with a focus on protecting individual privacy when using technology.
  • Clarification about experience and education requirements for Supports Coordinators and Supports Coordinator Supervisors has been added, and Supports Coordinators will continue to be allowed to use teleservices to perform some of the required face-to-face monitoring per year.

A list of all major changes made in the renewals is available in the record of change document and each full waiver application approved by CMS, which are available at:

ODP will be holding a webinar to discuss major changes made in these approved waiver renewals on February 9, 2023, from 1:00 pm – 2:00 pm. You can register for the webinar here.

Questions about this communication should be directed to the appropriate Office of Developmental Programs Regional Office.

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In an effort to provide additional information on a new provider type recently announced by the Centers for Medicare and Medicaid Services (CMS), a Medicare Learning Network (MLN) fact sheet was released. This new provider type, Rural Emergency Hospitals (REH), is a new Medicare Part A provider type. Starting January 1, 2023, Medicare will pay for Medicare-enrolled REHs to deliver emergency hospital, observation, and other services to Medicare patients on an outpatient basis. Additional information, including how to become an REH, billing, payment, reporting quality data, etc. is available in the fact sheet.

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