National Council to Hold CMS 2025 PFS & OPPS Rule Briefing November 21
Medicare
Inside Aging November 2024 Now Available
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
Changes to Amount in Controversy Announced for Appeals in 2025
Novitas Solutions has announced that there are changes to the Amount in Controversy (AIC) for appeals filed on or after January 1, 2025. The AIC requires the claims value in dispute to meet the threshold for obtaining an Administrative Law Judge (ALJ) hearing and a judicial review in federal district court. The AIC is recalculated and published on an annual basis and is identified in a provider’s appeal notice of decision.
The AIC for appeals filed on or after January 1, 2025:
- ALJ hearing will increase to $190.
- Federal district court will increase to $1900.
The amount in controversy is calculated in the following manner:
- Amount Charged minus Medicare Payments Already Made or Awarded = Subtotal Balance
- Subtotal Balance minus Any Applicable Deductible/Coinsurance = AIC
Novitas Solutions is the Medicare Administrative Contractor (MAC) for Jurisdiction JL, which includes DC, DE, MD, NJ, and PA.
RCPA Member Achieva Family Trust Shares Upcoming Events on Changes to IDA Waivers, Medicare, and More
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.
Novitas Solutions to Conduct Medicare Compliance Matters Virtual Symposium
Novitas Solutions, the Medicare Administrative Contractor (MAC) for Pennsylvania, will be conducting a three-day Medicare Compliance Matters Virtual Symposium. The symposium is free of charge and will be conducted September 17 – September 19. It will offer 44 webinars that include essential information, updates, and key information on Medicare compliance.
Members who are Medicare-certified providers are encouraged to review the agenda and register for sessions that you would benefit from. The full agenda and registration information is available here.
DHS Announces Applicants Selected for Agreement Negotiations for Community HealthChoices Program Re-Procurement
The Department of Human Services (DHS) today announced applicants selected through a Request for Applications (RFA) process to administer Pennsylvania’s Community HealthChoices (CHC) program, the Medicaid managed care program that covers adults who are dually eligible for Medicare and Medicaid or who qualify to receive Medicaid long-term services and supports due to a need for the level of care provided in a nursing facility.
Selected applicants will now move to a readiness review period before the agreements are fully executed.
The five selected plans will be available statewide. They include the three current incumbents and two plans new to Community HealthChoices:
- Aetna Better Health of Pennsylvania
- Health Partners Plans
- PA Health and Wellness
- UPMC For You
- Vista Health Plan (AmeriHealth Caritas/Keystone First)
RCPA will be reaching out to the selected applicants to be at the upcoming PD&A meeting in September. If you have any questions, please contact Fady Sahhar or Melissa Dehoff.
CMS Medicare Updates & Education Webinar Announced for May 9
The Centers for Medicare and Medicaid Services (CMS) has announced the next Medicare Updates and Education webinar. The webinar, “Medicare & Other Programs for People With Disabilities,” is scheduled for May 9, 2024, from 1:00 pm – 2:30 pm and will include information about:
- What’s Happening in Medicare – May 2024;
- NTP Announcements and Resources;
- Women’s Health Week (May 12 — May 18);
- National Osteoporosis Prevention Month;
- World No Tobacco Day (May 31);
- Older Americans Month;
- Arthritis Awareness Month;
- Mental Health Awareness Month; and
- Coverage to Care.
To participate, please register here.
White House Announces Release of Access Final Rule
The While House issued a press release announcing that the Access Final Rule will be released later today. These regulations include:
- The Nursing Home Minimum Staffing Rule, which will require all nursing homes that receive federal funding through Medicare and Medicaid to have 3.48 hours per resident per day of total staffing, including a defined number from both registered nurses (0.55 hours per resident per day) and nurse aides (2.45 per resident per day);
- Introducing the requirements of the rule in phases to make sure nursing homes have the time they need to hire staff, with longer timeframes for rural communities;
- Ensuring adequate compensation for home care workers for HCBS operations of in-home care (both Personal Assistance Services and Community Habilitation) by “requiring that at least 80 percent of Medicaid payments for home care services go to workers’ wages. This policy would also allow states to take into account the unique experiences that small home care providers and providers in rural areas face while ensuring their employees receive their fair share of Medicaid payments and continued training as well as the delivery of quality care;”
- The state requirement to be more transparent in how much they pay for home care services and how they set those rates, increasing the accountability for home care providers; and
- The creation of a state home care rate-setting advisory group made up of beneficiaries, home care workers, and other key stakeholders to advise and consult on provider payment rates and direct compensation for direct care workers.
We will continue to monitor the details of these regulations and Pennsylvania’s plans to comply. If you have any questions, please contact Fady Sahhar.
