The Centers for Medicare and Medicaid Services (CMS) has released an informational bulletin, as well as a slide presentation, that are related to continuity of coverage for individuals receiving home and community-based services (HCBS). The purpose of the bulletin is to highlight the federal renewal requirements and available flexibilities to promote continuity of coverage.
The Centers for Medicare and Medicaid Services (CMS) released and published the fiscal year (FY) 2025 inpatient rehabilitation facility prospective payment system (IRF PPS) final rule in the August 6, 2024, Federal Register. Some of the key provisions contained in the provider rule are noted below.
Payment Updates
CMS estimates aggregate payments to IRFs will increase by 2.8 percent in FY 2025, compared to the 4.0 percent payment update that CMS finalized for FY 2024. This update is the result of an annual market basket update, reduced by a productivity adjustment, budget neutrality adjustments for changes to CMG weights and labor/wage changes, and adjustments to the outlier case threshold.
As in previous years, CMS will adopt new delineations for the Core-Based Statistical Areas (CBSA) as identified by the Office of Management and Budget (OMB). [Additional and more detailed information on these new CBSAs can be found in OMB Bulletin No. 23-01] These changes will result in certain counties being reclassified from urban to rural and vice-versa, as well as some counties shifting to different CBSAs. As a result, CMS projects that approximately 10 percent of providers will have a higher wage index, but 16 percent will face a decrease in wage index values (primarily for those reclassified as urban, thus losing the rural adjustment). Thus, CMS finalized a transitional “phase-out” policy for those negatively impacted, such that IRFs set to lose their rural adjustment will retain two-thirds of the adjustment in FY 2025, one-third of the adjustment in FY 2026, and fully “lose” the rural adjustment in FY 2027. CMS estimates that 8 IRFs would be reclassified as urban and thus lose the 14.9 percent rural adjustment.
CMS increased the outlier threshold amount from $10,423 for FY 2024 to $12,043 for FY 2025 (slightly lower than the proposed rule’s projection). This change will account for an estimated 0.2 percent decrease to aggregate payments across the IRF PPS in FY 2025.
Quality Reporting Program (QRP) Updates
CMS finalized its proposal to adopt four new items as Standardized Patient Assessment Data Elements (SPADE) under the social determinants of health (SDOH) category beginning with the FY 2028 IRF QRP: one Living Situation item; two Food items; and one Utilities item. CMS notes that these new SPADES are intended to assist IRFs in “better addressing those identified needs with the patient, their caregivers, and community partners during the discharge planning process, if indicated.”
Transportation Item Modification Finalized Beginning with the FY 2028 IRF QRP (October 1, 2026 Implementation)
Consistent with the AHC HRSN Screening Tool, CMS finalized a proposal to modify the A1250. Transportation item currently collected in the IRF–PAI in two ways: (1) revise the look-back period for when the patient experienced lack of reliable transportation; and (2) simplify the response options.
Finalized Proposal to Remove the Admission Class Item From the IRF-PAI Beginning October 1, 2026, with Minor Modification
For additional information, CMS published a fact sheet that provides an overview of the provisions contained in the final rule.
The Centers for Medicare and Medicaid Services (CMS) has recognized traumatic brain injury (TBI) as a chronic health condition. TBI has been added to CMS’ list of chronic conditions for chronic special needs plans (C-SNPs) through its Medicare Advantage program, effective for the January 2025 plan year.
The addition of TBI to the list of chronic conditions was included in a final rule published by CMS in the June 2024 Federal Register, which will become effective on January 1, 2025. Obtaining official recognition of TBI as a chronic condition from CMS is a significant step forward and provides validation that brain injury should be more broadly recognized as a chronic condition.
In March 2024, the Brain Injury Association of America (BIAA) published a position paper requesting CMS, along with the Centers for Disease Control and Prevention (CDC), to designate brain injury as a chronic condition. Formal recognition, the paper states, has the potential to provide several advantages for people with brain injury, including the allocation of additional public health resources to focus on the lifelong effects of brain injury as well as health insurance plans, primarily Medicare and Medicaid, providing additional benefits and other supports as they do for other chronic health conditions. The greatest benefit, however, would be an increase in public awareness of the long-term effects of brain injury that affect the estimated 5 million Americans with a brain injury-related disability.
BIAA will be hosting a live Question and Answer (Q&A) session in the near future to discuss these changes and future tools and resources to assist survivors and their loved ones advocate for further expanding coverage.
The Office of Developmental Programs (ODP) shared ODPANN 24-072. This communication is to inform all interested parties of the submission of a proposed amendment to the Adult Autism Waiver (AAW) to the Centers for Medicare & Medicaid Services (CMS). The amendment includes all proposed changes as well as clarifications to the proposed new American Sign Language-English Interpreter service. The clarifications were added as a result of public comment.
Please view the announcement for details.
ODP Announcement 24-071 informs stakeholders of the submission of the Performance-Based Contracting (PBC) 1915(b)4 Waiver and 1915(c) Waiver amendments to the Centers for Medicare and Medicaid Services (CMS). The Office of Developmental Programs (ODP) has included with this announcement multiple documents and resources that are essential for understanding and implementing PBC. The documents are:
Submitted amendments for Consolidated and Community Living 1915(c) and 1915(b)(4) Selective Contracting Waiver for Residential Services are available online. All significant changes resulting from public comments can be found in the PBC Implementation Guide under Appendix A, titled, “Significant Changes to Performance-Based Contracting Proposal as a Result of Public Comment April 20-June 4, 2024.”
As a reminder, all residential providers must sign and return the Residential Provider Agreement to ODP by July 31, 2024. Please direct any questions about this information to ODP electronically.
ODP Bulletin 00-24-01 Performance-Based Standards for Residential Services has been published, providing detailed information regarding the standards that will be utilized to evaluate performance of residential providers in PA. An expected timeline for implementation of residential performance standards and tier assignment and the evaluation standards that will be used to assign tiers to providers have also been published.
ODP submitted waiver amendments for the 1915(c) waiver and the new 1915 (b)(4) waiver to the Centers for Medicare & Medicaid Services (CMS) on July 26, 2024. RCPA anticipates the fee schedule rates will be published in the PA Bulletin on August 31, 2024. Implementation of the new rates will happen October 1, 2024, with an effective date of July 1, 2024.
All non-residential services, including participant directed services, will receive an 8% increase. All residential services will receive a 6% increase. Implementation of PBC will include rate add-ons of:
Pay for Performance will also be available.
ODP will hold a webinar on Monday, July 29, to provide an overview of these changes. You can register for the meeting here. Please direct any questions about this information to ODP electronically.
Deputy Secretary Ahrens of the Office of Developmental Programs (ODP) shared a PowerPoint today, July 25, 2024, at the MAAC meeting. Highlights included ODP’s plan to publish several documents. ODP will be submitting waiver amendments for the 1915(c) waiver and the new 1915 (b)(4) waiver to the Centers for Medicare & Medicaid Services (CMS) on July 26, 2024. In addition, ODP Bulletin 00-24-01: Performance-Based Standards for Residential Services and an ODP announcement regarding the waiver submission, including an implementation guide and provider self-assessment, will be released tomorrow, July 26.
RCPA will share these documents with members as soon as they are available.
ODP Announcement 24-069 provides an update to all stakeholders about the status of the Performance-Based Contracting (PBC) 1915(b)4 Waiver and 1915(c) Waiver amendment submissions to the Centers for Medicare and Medicaid Services (CMS). The Office of Developmental Programs (ODP) has changed the date for submission of proposed waiver changes to CMS to Friday, July 26, 2024.
Due to the delay in submitting the waivers, ODP has also rescheduled the July 22 webinar for residential providers to Monday, July 29, from 9:00 am – 10:00 am. In this session, ODP will review revisions to the proposed waiver submissions and implementation plan, supporting documents, and instructions for tier determination and provider data submission. Anyone previously registered does not need to re-register and can expect an email notification of the change. If you are unable to attend on July 29, ODP requests that you unregister. This session will be recorded and posted on MyODP at the Performance-Based Contracting – MyODP page.
Register for the webinar here. Please direct any questions about this information electronically.
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