CMS Issues Final Rules for PFS, OPPS/ASCs

The regulatory changes will create a variety of changes for providers.

Amid a flurry of regulatory activity, federal officials late last week issued twin final rules governing changes to the Medicare Physician Fee Schedule (PFS) and the Outpatient Prospective Payment System (OPPS), with the latter also featuring adjustments relevant to Ambulatory Surgical Centers (ASCs).

Officials said the PFS Final Rule specifically finalizes policies to support primary care, advance health equity, assist family caregivers, and expand access to behavioral and certain oral health care, along with providing payment for principal illness navigation services for treatment of cancer and other serious illnesses.

“The policies announced today aim to strengthen Medicare and advance health equity by expanding access to care and services for people who are part of underserved communities,” U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra said in a statement. “In addition, we are bolstering our commitment to Biden-Harris Administration priorities, including behavioral healthcare, supporting family caregivers, promoting value-based care, and advancing the President’s Cancer Moonshot.”

The PFS Final Rule also includes statutorily mandated updates to PFS payments for clinicians; in accordance with update factors specified by law, officials said these payments will be reduced by 1.25 percent overall, compared to 2023. CMS is also finalizing increases in payments for visits for many services, such as primary and longitudinal care.

“CMS remains steadfast in our commitment to supporting physicians and ensuring that people with Medicare have access to the care they need to stay healthy, as well as navigate health conditions they are facing,” CMS Administrator Chiquita Brooks-LaSure said. “CMS is taking important steps toward those goals in this rule by improving payment for primary care and access to mental healthcare, paying for new navigation services to help people with cancer and other serious illnesses navigate their treatment, supporting family caregivers, paying for services involving community health workers to address health-related social needs that impact care, and enhancing access to dental care for people with certain cancers.”

“The impact of these changes means that people with Medicare will be able to access marriage and family therapists and mental health counselors for behavioral health treatment; access culturally sensitive care from community health workers, care navigators, and peer support workers; access primary care where the provider is invested in a long-term, trusting relationship; and … (ensure that) caregivers for persons with Medicare will have access to appropriate training,” added Meena Seshamani, MD, CMS Deputy Administrator and Director of the Center for Medicare. “Taken holistically, these are some of the largest changes ever towards a Medicare that recognizes people with Medicare as whole persons, with their own families and unique life stories. After all, people are more than the sum of their ailments and diagnoses.”  

To that end, officials said a primary aim of the PFS Final Rule was “addressing unmet health-related social needs that can potentially interfere with the diagnosis and treatment of medical problems.” Remedies include:

• CMS now pays for certain caregiver training services in specified circumstances;
• CMS finalizing separate coding and payment for community health integration services, which include person-centered planning, health system coordination, promoting patient self-advocacy, and facilitating access to community-based resources to address unmet social needs (a PFS first); and
• CMS finalizing coding and payment for principal illness navigation services, which describe similar care navigation services for individuals with high-risk conditions, including cancer.

“A new diagnosis like cancer can be simultaneously challenging, confusing, and emotionally distressing – this action takes a large and important step in fulfilling the Cancer Moonshot goal of making navigation services available for every American with cancer,” CMS’s press release read. “In addition, CMS is finalizing a subset of principal illness navigation services to support individuals with behavioral health conditions through the use of auxiliary personnel such as peer support specialists.”

This includes what CMS described as some of the most important changes to improve access to behavioral healthcare in the Medicare program’s history – including addiction counseling, crisis care, substance use disorder treatment, and psychotherapy.

Yet the basics aren’t being cast aside.

“Primary care is instrumental in the delivery of high-quality, whole-person care. CMS is recognizing the value and inherent complexity in primary and longitudinal care by implementing payment and coding to more accurately and appropriately pay for these services, which aligns with the goals articulated in the HHS Initiative to Strengthen Primary Care,” officials said. “Based on interested party feedback, CMS also recognized that the redistributive impact could be lower than previously estimated for the originally finalized policy given that many office visits involve care that is discrete or time-limited, not the kind for which additional payment would be made.”

CMS said it received over 20,000 comments on the proposed rule, taking many into account in developing the finalized version.

As for the OPPS Final Rule, it too focused on expanding access to behavioral health services for people with Medicare through coverage of intensive outpatient services – and ensuring that they reap the benefits of hospital price transparency requirements.

Unlike the slight decrease in payments under the PFS, this Final Rule updated payment rates with a 3.1 percent increase for hospital outpatient and ASC services.

“HHS is committed to expanding access to behavioral healthcare for people with Medicare. This rule will fill longstanding gaps in behavioral health treatment for Medicare beneficiaries and advance health equity for Tribal communities, rural communities, and others who are underserved,” Becerra said. “We believe the public should always know what a provider charges for their services. This rule shines a brighter light on hospital prices and gives CMS new tools to enforce these actions on behalf of patients.”

“CMS is committed to expanding access to behavioral healthcare and is finalizing coverage of intensive outpatient services for both mental health conditions and substance use disorders,” Brooks-LaSure added. “Additionally, the Final Rule strengthens hospital price transparency by improving the standardization of hospital standard charges and enhancing CMS’s enforcement capabilities, thereby better enabling the American people to understand and meaningfully use hospital standard charges for items and services.”

Officials explained that this Final Rule implements the Consolidated Appropriations Act of 2023 provisions that created a new benefit category for intensive outpatient program services for individuals with acute behavioral health needs, involving care across various settings, including hospital outpatient departments, Community Mental Health Centers, Federally Qualified Health Centers, and Rural Health Clinics. Across all of these settings, intensive outpatient program services will now be available for both individuals with mental health conditions and individuals with substance use disorders. CMS is also further extending coverage for intensive outpatient services in opioid treatment programs.

“The Final Rule reflects CMS’s commitment to ensuring Medicare is comprehensive in its ability to address patient needs by filling critical gaps in behavioral health,” Dr. Seshamani said. “With this Final Rule, we will ensure people get timely access to quality care in their communities, leading to improved outcomes and better health.”

As for price transparency, CMS said it is also streamlining hospital enforcement capabilities, including implementing the following improvements:

• Certification by hospital officials as to the accuracy and completeness of the machine-readable file data;
• Requiring hospital acknowledgment of warning notices;
• Reserving the right for CMS to communicate directly with health system leadership when a hospital with a compliance issue is found to be part of a health system; and
• Publishing other enforcement activities, in addition to civil monetary penalties, on a CMS website.

To view a fact sheet on the 2024 PFS Final Rule, go online to: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule   

To view a fact sheet on the 2024 OPPS/ASC Payment System Final Rule, go to: https://www.cms.gov/newsroom/fact-sheets/cy-2024-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center-0

For a fact sheet on hospital price transparency, please visit:  https://www.cms.gov/newsroom/fact-sheets/hospital-price-transparency-fact-sheet

Mark Spivey is a national correspondent for RACmonitor and ICD10monitor who has been writing and editing material about the federal oversight of American healthcare for nearly 15 years. He can be reached at mcspivey33@gmail.com.