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Tags Posts tagged with "Medicare"

Medicare

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Image by David Mark from Pixabay

RCPA continues its efforts to update members on the White House funding freeze while partnering with the National Council for Mental Wellbeing and ANCOR in examining the implications stemming from the White House Office of Management and Budget’s (OMB) January 27 memorandum temporarily freezing federal disbursements to many federal programs.

The National Council has provided the following update:

Federal agencies have been directed to fill out a spreadsheet as part of an analysis by Feb. 7 to ensure compliance with the president’s most recent executive orders. This is a breakdown of which health programs are included in this latest action.

Notably, we recognize conflicting guidance has been issued. While the above report identifies Medicaid programs, a Q&A document from the administration notes that Medicaid will continue without pause. As of Tuesday morning, all 50 states reported outages of their Medicaid online portals, and the Trump administration has stated they are aware of the outages and expect the portals to be back online shortly.

Also, several groups have taken action to block this funding freeze. As of this writing, several Democratic state attorneys general said they would ask a court to block the freeze from taking effect. Several groups representing nonprofits, public health professionals and small businesses have already filed suit in D.C. asking the court to prevent the freeze from continuing. On Tuesday evening, U.S. District Court Judge Loren L. AliKhan issued a temporary stay on the funding freeze until Feb. 3 at 5:00 pm ET.

The funding freeze may lead to project delays or cancellations, resulting in layoffs of workers involved in these programs, and may ultimately increase the unemployment rate, making it vital lawmakers understand the impact of this freeze on communities across the country.

Most notable are the concerns with the intersects of Medicaid funding though the information that has been released. The Q&A document states:

Q: Is this a freeze on benefits to Americans like SNAP or student loans?

A: No, any program that provides direct benefits to Americans is explicitly excluded from the pause and exempted from this review process. In addition to Social Security and Medicare, already explicitly excluded in the guidance, mandatory programs like Medicaid and SNAP will continue without pause.

RCPA will continue to communicate new developments with members as they emerge. If you have any questions, please contact your RCPA Policy Director.

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The Centers for Medicare & Medicaid Services (CMS) has made updates to the training schedule for Home and Community-Based Services (HCBS) provisions of the Medicaid Access Rule. The new training session dates and tentative topics for each session can be found below. These dates and topics are subject to change.

  • May 14, 2025, 3:00 pm ET: Timely Access, Waiting Lists, Person-Centered Planning Reporting Requirements & Minimum Performance Levels, and Website Requirements
  • June 11, 2025, 3:00 pm ET: Institutional Rule Provisions*

*Nursing Facility and Intermediate Care Facilities for Individuals with Intellectual Disabilities Rate Transparency provisions finalized in CMS-3442-F: Medicare and Medicaid

You can learn more about the training series and register for upcoming sessions on the HCBS Provisions of the Medicaid Access Rule Training Series registration web page.

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Capitol hill building in the morning with colorful cloud , Washington DC.

On December 21, President Biden signed into law the 2025 American Relief Act, a stopgap funding bill passed by Congress on December 20 that funds the federal government through March 14, 2025, and includes over $110 billion for disaster relief.

The bill extends certain Medicare telehealth flexibilities through March 31, 2025, under Section 3207, including the six-month in-person requirement for mental health services, the expanded originating sites, and coverage of audio-only services.

The bill also extends funding for several expiring health care programs through March 31, 2025, including the National Health Service Corps at $85 million and the Teaching Health Center Graduate Medical Education Program at $43 million, both under Section 3101.

In addition, the stopgap bill delays scheduled reductions to the Medicaid Disproportionate Share Hospitals allotments, which are currently set to result in a total reduction of $32 billion between 2025 and 2027. Under Section 3401, the bill delays these cuts through April 1, 2025.

You can read the bill text and a summary of the health care provisions.

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In early December, the Centers for Medicare and Medicaid Services (CMS) released the Comprehensive Care for Joint Replacement (CJR) Model Evaluation Report. This report provides the results for the first year of the CJR model extension (performance year six) after significant changes to the CJR model were implemented. According to CMS, the revisions to the CJR model generated net savings of $54.2 million for Medicare in performance year six while maintaining the quality of care for patients.

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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:

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Photo by Tingey Injury Law Firm on Unsplash

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.

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