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Insights and Trends

Headlines from the Hill: December Edition

Healthcare Headlines from the Hill

Stay ahead of the latest regulatory shifts and healthcare breaking news with Headlines from the Hill.

In this month’s edition you will find:

Medicare Physician Fee Schedule Final Rule: What to expect in 2024.

CMS recently issued its physician fee schedule (PFS) final rule for calendar year (CY) 2024. The rule also includes policies related to the Medicare Shared Savings Program (MSSP) and the Quality Payment Program (QPP), both of which were created by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Policies will generally take effect January 1, 2024.

Some of CMS’ key policies include: 

      • Withdrawing all regulations related to the Appropriate Use Criteria (AUC) program.

      • Revising its definition of the substantive portion of a split (or shared) visit to be more than half of the total time spent by the physician and non-physician practitioners performing the split (or shared) visit or a substantive part of the medical decision making.

      • Delaying implementation of CMS’ rebased and revised Medicare Economic Index (MEI) until future rulemaking.

      • Operationalizing the extension of several telehealth waivers, which were authorized by the Consolidated Appropriations Act (CCA) of 2023.

      • Implementing several provisions to increase access to behavioral health services.

      • Adding five new Merit-Based Incentive Payment System (MIPS) Value Pathways for CY 2023.

      • Offering Advanced Alternative Payment Model (APM) track bonus payments in 2025 to those that qualify.

      • Permitting the reporting of Medicare-only clinical quality measures in the MSSP.

      • Aligning MSSP’s certified EHR use requirements with the MIPS Promoting Interoperability requirements beginning with CY 2025 reporting.

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IRF Discharge Planning Requirements: CMS considering additional guidance.

CMS is contemplating additional guidance related to the post-acute care (PAC) discharge planning regulations. As background, CMS most recently revised the discharge planning rules in 2019 (as required by the IMPACT Act), requiring that acute care hospitals provide certain patients with information on their PAC options as part of the discharge process, among other requirements.

Of particular significance, IRFs are required to be included on the mandated list of Medicare – participating PAC providers that serve the geographic area of the patient for whom PAC services are indicated. The final rule directed acute care hospitals to maintain their own lists of available PAC providers, and provided that acute care hospitals have “the flexibility to implement the requirements to present its list [of PAC providers] in a manner that is most efficient and least burdensome in its particular setting.” 

The final rule indicated that the specific information that hospitals must provide about the post-acute care providers/options would be clarified through sub regulatory guidance; to date, however, CMS has not yet provided any additional guidance or clarification from this section of the regulation.

This past summer, CMS issued guidance that provides further clarity on how hospitals must provide “all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences” to the patients’ post-acute care providers and caregivers upon discharge. 

In response to this guidance, several organizations have urged CMS to provide more specificity about the types of information that must be provided to the patient about their post-acute care options. In response, CMS indicated that it was contemplating additional guidance on these issues.

In recent years, organizations have reported the following concerns: 

      • Lack of information on the differences across the PAC settings included on the discharge planning list.

      • References to outdated IRF names/addresses.

      • Failure to classify post-acute care providers by setting, creating confusion for patients looking to understand their SNF vs. IRF options when numerous entities have “rehabilitation” in their name.

      • Lack of information on bed availability.

      • Inconsistent and/or outdated quality information for the listed PAC providers.

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Medicare Advantage: New rule to begin in Q1 2024.

The American Hospital Association (AHA) released the AHA Medicare Advantage (MA) Implementation Guide for the calendar year 2024 rule. Beginning January 1, 2024, a number of key MA provisions will begin, including:

      • Prohibiting MA plans from limiting or denying coverage for a Medicare-covered service based on their own internal or proprietary criteria in a way that differs from requirements under Traditional Medicare.

      • Requiring MA plans to adhere to the two-midnight rule for coverage of inpatient admissions.

      • Prohibiting MA plans from denying payment for a service based on medical necessity if the service was prior authorized.

      • Requiring prior authorizations to be valid for an entire course of approved treatment and to be valid through a 90-day transition period if an enrollee undergoing treatment switches to a new MA plan.

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Medicaid Enrollment: Decline by 8.6%.

An annual survey of state Medicaid directors finds that states expect national Medicaid enrollment will decline by 8.6% in state fiscal year (FY) 2024 as state Medicaid agencies continue to unwind pandemic-related continuous enrollment protections.

Driven by anticipated changes in enrollment, total Medicaid spending growth (federal and state spending combined) is expected to slow in FY 2024 to 3.4%; however, the state (non-federal) share of Medicaid spending is expected to increase by 17.2% in FY 2024 primarily due to the phasing out of enhanced federal Medicaid matching funds (set to expire December 31, 2023).

While the unwinding of the continuous enrollment provision and enhanced federal match rate were dominant policy issues at the end of FY 2023 and headed into FY 2024, states were also focused on an array of other policy responses.

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