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Tags Posts tagged with "Final Rule"

Final Rule

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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.

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The Pennsylvania Department of Drug and Alcohol Programs (DDAP) issued Licensing Alert 07-2024 today to grant statewide exceptions to narcotic treatment programs (NTP) to expand access to medication for the treatment of opioid use disorder in alignment with the federal government’s Final Rule on 42 CFR Part 8.

The statewide exceptions to DDAP regulations that are being granted will enable:

  • People with less than one year of physical dependence on opioids to be treated at an NTP;
  • Verbal consent to treatment;
  • A wider range of dosages based on physician discretion;
  • Eight drug screens per year instead of 12;
  • An increase in take-home medication; and
  • Clinicians to determine counseling requirements unique to each person’s needs instead of mandatory minimums.

DDAP granted the statewide exceptions using 28 Pa. Code § 701.11, which gives it the authority to do so. Through Licensing Alert 07-2024, DDAP is granting these exceptions if the NTPs comply with the rules in 42 CFR Part 8. There is no need for NTPs to submit exception requests or to inform DDAP they are using these exceptions.

DDAP plans to include the changes to the federal rules when it updates its own state rules.

You can email DDAP with questions about this licensing alert.

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WellSky will be offering a one-hour webinar entitled “60 Minutes With the IRF Final Rule” that will focus on the fiscal year (FY) 2025 Inpatient Rehabilitation Facility (IRF) Final Rule, which was finalized on July 31, 2024. It will go into effect October 1, 2024. As with past final rules, it will have a financial impact on reimbursement for IRFs as well as operational changes from both this final rule and past final rules going into effect. Join long-term care expert Jane Snecinski, FACHE, MRMC, MBA, for a live webinar and learn about:

  • The algorithm for IRF reimbursement (and key factors you should know);
  • The financial impact the rule will have on your IRF reimbursement;
  • Changes to the quality reporting factors; and
  • Changes included in previous years’ IRF final rules that may go into effect October 1, 2024.

The webinar is scheduled for September 18, 2024, from 12:00 pm – 1:00 pm ET. To participate in the webinar, register here.

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Image by Markus Winkler from Pixabay

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.

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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.

  • A1250. Transportation currently collected in the IRF-PAI asks: “Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?” The response options are: (A) Yes, it has kept me from medical appointments or from getting my medications; (B) Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need; (C) No; (X) Patient unable to respond; and (Y) Patient declines to respond.
  • The finalized Transportation item asks, “In the past 12 months, has a lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?” The final response options are: (0) Yes; (1) No; (7) Patient declines to respond; and (8) Patient unable to respond.

Finalized Proposal to Remove the Admission Class Item From the IRF-PAI Beginning October 1, 2026, with Minor Modification

  • CMS asserts that the Admission Class Item is currently not used in the calculation of quality measures already adopted in the IRF QRP. It further notes that it is not used for previously established purposes unrelated to the IRF QRP, such as payment, survey, or care planning. This removal will be effective beginning with the FY 2028 IRF QRP (beginning with patients admitted on October 1, 2026); however, IRFs will not be required to collect this item beginning with patients admitted on October 1, 2024.

For additional information, CMS published a fact sheet that provides an overview of the provisions contained in the final rule.

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The Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has issued a Final Rule to advance equity and bolster protections for people with disabilities. The final rule, Discrimination on the Basis of Disability in Health and Human Service Programs or Activities, updates, modernizes, clarifies, and strengthens the implementing regulation for Section 504 of the Rehabilitation Act of 1973. Section 504 prohibits discrimination on the basis of disability in programs and activities that receive Federal financial assistance.

The historic rule provides robust civil rights protections for people with disabilities in federally funded health and human services programs, such as hospitals, health care providers participating in CHIP and Medicaid programs, state and local human or social service agencies, and nursing homes. Reflecting on over 50 years of advocacy by the disability community, it advances the promise of the Rehabilitation Act and helps to ensure that people with disabilities are not subjected to discrimination in any program or activity receiving funding from HHS. This final rule is consistent with Section 504 statutory text, congressional intent, legal precedent, and the Biden-Harris Administration’s commitment to advancing equity and civil rights.

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The Legal Action Center (LAC) will host a stakeholder meeting to discuss the recent amendments to 42 CFR Part 2, the federal privacy and confidentiality rule for substance use disorder (SUD) treatment records, from 2:00 pm – 3:00 pm on Thursday, February 29, 2024. Stakeholders, including directly impacted individuals and their loved ones, addiction treatment providers, healthcare professionals serving people with SUD, and legal and policy advocates, are encouraged to participate. The meeting will focus on the implications of the final rule, with insight from LAC attorneys. Registration is required. For more information on the final rule, visit LAC’s website.

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The Centers for Medicare and Medicaid Services (CMS) has released the fiscal year (FY) 2023 inpatient rehabilitation facility prospective payment system (IRF PPS) final rule that was published in today’s Federal Register. Some of the key provisions contained in the final rule are provided below:

Final FY 2023 Payment Updates
CMS estimates overall payments to IRFs will increase by 3.2 percent compared to FY 2022 levels (higher than the 2 percent estimated in the proposed rule). This update is the result of a 4.2 percent update to the IRF market basket reduced by a 0.3 percent productivity adjustment, which is required by law. As a result of this market basket increase and a few small budget neutrality adjustments, the standard payment conversion factor will increase from $17,240 to $17,878. ‎CMS is also adjusting the outlier threshold, which it says will reduce overall payments by 0.6 percent. CMS says the 3.2 percent overall increase will result in $275 million in increased payments to IRFs compared to 2022.

Proposed Expansion of IRF Transfer Policy to Include Home Health Services
CMS issued a Request for Information (RFI) in the proposed rule regarding the potential expansion of the current IRF transfer payment policy to include home health services. For background, IRFs receive a reduced case mix group (CMG) payment rate under the IRF transfer policy when the patient’s discharge occurs earlier than the average length of stay (for that respective CMG and tier) and the patient is discharged to a certain setting (an IRF, acute-care hospital, LTCH, nursing home that takes Medicare and Medicaid payment). The policy currently does not apply to home health.

The RFI in this year’s rule followed a December 2021 Office of Inspector General (OIG) report finding that Medicare could have saved over $993 million had the IRF transfer policy been expanded to include home health services (based on 2017 and 2018 data). The OIG therefore recommends that CMS explore ways to capture early discharges to home health care in the current policy, which CMS referenced in the proposed rule. Following a review of concern cited in stakeholder comments, CMS is not moving forward with any changes to the transfer policy at this time.

IRF Quality Reporting Program Changes & Requests for Information All-Payer IRF-PAI Reporting Proposal
CMS proposed to require collection of the IRF-PAI for all IRF patients, including those without Medicare, beginning with the FY 2025 IRF QRP (with data collection to begin on October 1, 2023). Currently the IRF-PAI is only required to be collected for Medicare Part A (fee-for-service) and Part C (Medicare Advantage) beneficiaries. In response to comments, CMS opted to finalize the proposal but with a revised implementation date. IRFs will now be required to collect IRF-PAIs on all patients, regardless of payer, for the FY 2026 IRF QRP (data collection to begin on October 1, 2024).

RFI on Future QRP Measure Expansions
CMS had issued a Request for Information (RFI) related to measures/concepts for use in the QRP in future years in the proposed rule. The agency specifically requested information on a cross-setting function measure that would include self-care and mobility items, and development of a patient-level COVID-19 vaccination measure. CMS referenced several of AMRPA’s comments, including concerns that IRF stays are typically not long enough to adequately capture COVID-19 vaccination for patients. CMS did not provide a response to comments but affirmed the agency would use the stakeholder feedback to inform future rulemaking.

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The Office of Long-Term Living (OLTL) has issued Bulletin 59-21-03, which pertains to the Home and Community-Based Settings (HCBS) Heightened Scrutiny process. Also included are the following bulletin attachments:

  • Attachment A: Final Rule Heightened Scrutiny checklist for Day Settings
  • Attachment B: Final Rule Heightened Scrutiny checklist for Employment Skills Development Settings
  • Attachment C: Final Rule Heightened scrutiny checklist for Residential Settings

OLTL is currently working to develop a training for providers on this topic and will host training sessions sometime in early 2022. Questions about the bulletin and/or the attachments should be sent via email. The bulletin is effective December 29, 2021.

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