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On August 3, President Trump issued an Executive Order on Improving Rural Health and Telehealth Access that focuses on ways to finance rural health care and proposes a permanent extension for some telehealth policies. As part of the order, within 30 days, HHS will launch a new payment model to ensure that rural healthcare providers are able to provide the necessary level and quality of care.
Also this week, CMS issued a proposed Medicare Physician Fee Schedule rule that would, if finalized, have far-ranging impacts for patients and families with advanced and serious illness, as well as the providers that care for them. Perhaps most consequentially, the rule seeks to cement some of the regulatory flexibilities around telehealth delivery and payment that have been enacted during the public health emergency.
Additionally, there were a handful of regulatory changes proposed that focus on advance care planning within Medicare value-based care programs, a key issue for C-TAC members and a top C-TAC policy priority.
Key provisions in the rule are as follows:
Advance Care Planning
- CMS is proposing to add an ACP quality measure (NQF # 326) to the measure set that clinical social workers can choose from when they report back to CMS as is required of their participation in the Merit-Based Incentive Payment System (MIPS), which is one of CMS’ two foundational value-based care transformation initiatives (the other being alternative payment models – APMs). Providers’ (including clinical social workers) payment adjustments under MIPS are impacted by their reporting on the measures in their designated specialty sets. The proposed addition of the ACP measure would be applicable to the MIPS 2023 performance year and beyond.
- This proposed change is significant because CMS acknowledges that “this clinical concept [ACP] is applicable to their [clinical social worker] scope of practice since these clinicians are integral to ensuring patients have up to date advance care plans and/or surrogate decision makers documented within the medical record.” Adding this ACP measure to the allowable reporting set for clinical social workers in MIPS links this service to payment under Medicare in a direct way. C-TAC has been leading advocacy with CMS and members of Congress to allow clinical social workers to bill for the Medicare ACP codes (CPT codes 99597 & 99498). We are heartened at this proposed change, as it is more validation from CMS that clinical social workers can play a major part in expanding access to, and the quality of, ACP services.
- CMS is proposing to modify the definition of “primary care services” for purposes of beneficiary assignment in the Medicare Shared Savings Program (i.e. the ACO program) regulations to exclude advance care planning CPT codes 99497 and 99498 when they are billed in an inpatient care setting. This proposed change would be used to determine beneficiary assignment to an ACO for the performance year starting on January 1, 2021, and all subsequent performance years.
- CMS states in the rule that it has heard from some ACOs that including ACP CPT codes that have been billed in an inpatient setting in the beneficiary assignment methodology may result in beneficiaries being assigned to the ACO based on inpatient care, rather than based on primary care by their regular health care providers (which is the goal of ACO assignment).
- CMS is proposing to permanently add certain services to the Medicare telehealth list that it initially included as part of its response to the COVID-19 Public Health Emergency (PHE). Some of these proposed services are relevant and frequently utilized in the care of seriously-ill beneficiaries, including Assessment and Care Planning for Patients with Cognitive Impairment (CPT code 99483), Domiciliary or Rest Home Evaluation & Management (CPT codes 99334-99335), and Home-Based Evaluation & Management (CPT codes 99347-99348). CMS is seeking comment on additional codes/services it added to the telehealth list during the pandemic that are not being proposed for permanent inclusion in this rule. In our comments on this rule, C-TAC will ask that the Medicare ACP codes (CPT codes 99497-9948) be added to the list permanently.
- CMS proposes expanding the list of both Category 1 telehealth services (permanent telehealth services) and Category 3 telehealth services (services that are in effect for the duration of the public health emergency). CMS is seeking input on the list as well as additional services for consideration.
- CMS reiterates and clarifies that telehealth rules do not apply when a physician and beneficiary are in the same location even if audio/visual technology is used in furnishing the service.
- CMS is not proposing to continue to recognize the audio-only E/M services (CPT Codes 98966-98968 & 99441-99443) but is seeking input on whether it should develop payment/coding for a service similar to virtual check-ins but for a longer unit of time.
1. CMS Releases Final 2021 Payment Rules for Hospices, Skilled Nursing Facilities, & Inpatient Psychiatric Facilities
The following three final rules were released:
Medicare Program; FY 2021 Hospice Wage Index and Payment Rate Update:
Key provisions include:
- CMS will apply a 2.4 percent increase to the hospice payment rates for FY 2021, as proposed.
- CMS declined to delay the effective date of the modified hospice election statement and addendum requirements due to reasons related to COVID-19.
- CMS is finalizing the adoption of the revised geographic delineations provided by the Office of Management and Budget, which are used to identify a beneficiary’s location to calculate the wage index. This will reclassify some areas to “rural” or “urban”. The modifications and addendum statement requirements will be effective for hospice elections beginning on and after October 1,2020. The purpose of the modified election statement and new addendum requirements is for hospices to clearly delineate which services are “related” and “unrelated” to a patient’s terminal diagnosis and therefore fall within or outside of the scope of hospice coverage.
These rules will take effect on October 1, 2020.
2. Newly Introduced Legislation Would Strengthen Respite Under the Medicare Hospice Benefit
The COVID-19 Hospice Respite Care Relief Act of 2020 was introduced in the US Senate on August 4th by Senators Sherrod Brown (D-OH) and Shelly Moore Capito (R-WV). This bipartisan legislation would expand Medicare’s hospice respite care benefit during a public health crisis. Specifically, the legislation would give the Secretary of Health and Human Services (HHS) the authority to allow hospice patients to receive respite care at home and for longer periods of time during any public health emergency, including the current coronavirus (COVID-19) pandemic.
3. HHS Releases Report on the Flexibility of Telehealth Services:
The Department of Health and Human Services (HHS) released a report outlining trends in Medicare fee-for-service primary care visits and the use of telehealth services during the pandemic. The report examined Medicare claims data from January through June to analyze if the flexibilities in Medicare telehealth flexibilities have benefited access to the primary health care. Key findings include:
- Medicare FFS in-person visits for primary care declined significantly in mid-March and began to rise again through May
- Nearly half of Medicare primary care visits were provided via telehealth in April, compared with less than one percent before the PHE in February
- As in-person visits started to resume in mid-April, the use of telehealth in primary care declined slightly but remained steady at the beginning of June.
- Providers in rural counties had smaller increases in Medicare primary care telehealth visits compared with providers in urban areas
See the full report here for more information.
4. COVID-19: Administrative & Regulatory Action:
CMS and the CDC announced that they will reimburse providers for giving counseling services to patients about the importance of self-isolation after they are tested for COVID-19 and prior to the onset of symptoms. Eligible providers will receive these reimbursements through CMS’ existing evaluation and management (E/M) payment codes no matter where a test is administered, including doctor’s offices, urgent care clinics, hospitals and community drive-thru or pharmacy testing sites. See press release here.