The following is the latest health policy news from the federal government for November 1-7.  Some of the language used below is taken directly from government documents.

Medicare Payment Regulations

Late last week CMS published four regulations describing how Medicare will pay certain providers in 2025.  The following is a brief overview of those regulations.

Medicare Outpatient Prospective Payment System
  • Rate increase of 2.9 percent for outpatient and ambulatory surgical center services.
  • New Conditions of Participation for obstetrical services.
  • Additional payments for selected non-opioid treatments for pain relief.
  • Minor modifications of the inpatient-only list.
  • A change in the review time frame for prior authorization requests for outpatient department services from 10 business days to seven calendar days.
  • Changes in Medicaid and CHIP continuous eligibility.
  • For further information, see the final rule, this CMS news release, and this CMS fact sheet.
Medicare Physician Fee Schedule
  • Rates cut 2.93 percent.
  • Changes in telehealth services, including delivery of audio-only services, permitting physicians to use office addresses when providing telehealth services from home, and changes in reimbursement for virtual supervision of practitioners and residents.
  • New codes for advanced primary care management services.
  • Changes to enhance access to behavioral health services and opioid treatment programs.
  • Addition of a complexity code for office/outpatient evaluation and management visits under selected circumstances.
  • For further information, see the final rule, this CMS news release, this CMS fact sheet, and a separate CMS fact sheet addressing the Shared Savings Program.
Home Health Prospective Payment System
  • 0.5 percent increase in overall spending in 2025.
  • Recalibrates patient-driven groupings model (PDGM) case-mix weights.
  • Updates low-income utilization thresholds, functional impairment levels, and comorbidity adjustment subgroups.
  • Revises home health wage index.
  • Updates 2025 fixed-dollar loss ratio for outlier payments.
  • Updates agency Conditions of Participation.
  • Introduces four new social determinants of health data elements in the standardized patient assessment.
  • For further information, see the final regulation and this CMS fact sheet.
End-Stage Renal Disease Prospective Payment System
  • Raises base rate from current $265.57 to $273.82.
  • Finalizes a new wage index.
  • Expands list of ESRD outlier services.
  • Modifies low-volume payment adjustment policy.
  • Changes payments for services provided to patients with acute kidney injury.
  • Changes payments for selected services furnished to beneficiaries in their homes.
  • For further information, see the final regulation and this CMS fact sheet.
No Surprises Act

A federal court has overturned a lower court ruling about the rates that can be used when determining the qualifying payment amount, or QPA, that is an essential part of the process of deciding payment disputes between health care payers and providers.  The ruling permits the administration to use what are called “ghost rates” – rates that providers have not actually offered, and that providers maintain reduce payments – in QPA calculations.  The ruling is viewed as advantageous for health care payers and as a partial win for the federal government.  Learn more about the court’s findings from this decision by the U.S. Court of Appeals for the Fifth District.

Centers for Medicare & Medicaid Services
  • Following up on publication of the final hospital outpatient prospective payment system regulation for 2025, CMS has published a separate summary of 2025 policy changes for the quality payment program.  Find that summary here and a separate fact sheet here.
  • CMS posted an updated list of billing and payment codes used only for single-dose containers of discarded drugs and biologicals paid separately under Part B that may require the JW and JZ modifiers, depending on the setting.  Find that updated list here.
  • The deadline to submit a calendar year 2023 hardship exception application for the Medicare Promoting Interoperability Program for critical access hospitals is November 30, 2024.  Learn more about the criteria for applying for the exception and how to do so from this CMS notice.
  • The submission deadline for the inpatient rehabilitation facility, long-term-care hospital, and skilled nursing facility quality reporting programs is November 18.  Learn more about the required data and how to submit it from this CMS notice.
Department of Health and Human Services
  • HHS’s Health Resources and Services Administration (HRSA) has updated its lists of health professional shortage areas (HPSAs).  Go here for links to the lists based on provider types and geography.
  • In a new issue brief, HHS’s Office of the Assistant Secretary for Planning and Evaluation (ASPE) documents coverage gains among young adults under the Affordable Care Act, the American Rescue Plan, and the Inflation Reduction Act.  The uninsured rate among this group declined by more than half, from 31.5 percent in 2009 to 13.1 percent in 2023, as employer-sponsored dependent coverage increased by more than 20 percent.  Medicaid coverage increased in both expansion and non-expansion states, with a greater increase in expansion states, while direct purchase (non-group) coverage, which includes Marketplace coverage, had a greater increase in non-expansion states.  Learn more from the ASPE report “Health Insurance Coverage and Access to Care Among Young Adults, Ages 19 to 25.”
  • Another new ASPE research report describes patterns in insurance coverage and uninsurance rates in rural and urban areas, reviews non-financial challenges in gaining access to care faced by many rural residents, and describes disparities in health outcomes between urban and rural areas. The brief discusses policies, programs, and resources designed to address barriers to care in rural America and the role that federal and state health care coverage programs like Medicaid, CHIP, Medicare, and Marketplace play in providing health insurance coverage for rural residents.  Learn more from the ASPE report “Access to Health Care in Rural America:  Current Trends and Key Challenges.”
  • In a new blog post, HHS’s Office of the Assistant Secretary of Technology Policy/Office of the National Coordinator for Health IT describes advances in the use of health information technology and documents the increasing use of the data that technology generates.  Find that post here.
HHS Newsletters
HHS Videos

CMS has posted a short tutorial on how hospitals can view their eCQM data results.

National Institutes of Health

Adopting pediatric readiness standards in emergency departments could save more than 2000 lives a year according to a new NIH-funded study.  Learn more about the study and its findings from this NIH news release.

Medicaid and CHIP Payment and Access Commission (MACPAC)

Last week MACPAC held two days of public meetings.  The subjects discussed during those meetings were:

  • medications for opioid use disorder and related policies
  • timely access to home- and community-based services
  • multi-year continuous eligibility for children
  • youth use of residential treatment services
  • managed care external quality review policy options
  • transitions of care for children and youth with special health care needs
  • directed payments in Medicaid managed care

Go here for MACPAC’s own summary of the meetings and for links to the presentations used during the discussion of each of these subjects.

Stakeholder Events

CMS – Healthcare Common Procedure Coding System (HCPCS) Public Meeting – November 6-8

CMS will hold a virtual Healthcare Common Procedure Coding System (HCPCS) public meeting to discuss its preliminary coding, Medicare benefit category, and payment determinations, if applicable, for new revisions to the HCPCS Level II code set for non-drug and non-biological items and services.  The meetings will be held on Wednesday, Thursday, and Friday, November 6-8, from 9:00 to 5:00 (eastern) each day.  Learn more about the purpose of the meeting, its agenda, how to submit questions and written comments, deadlines for submitting questions and materials or to request an opportunity to speak, and how to register to participate from this CMS notice.

MedPAC – Commissioners Meeting – November 7-8

MedPAC commissioners will hold their next public meeting on Thursday, November 7 and Friday, November 8.  Information about the agenda and how to participate are not yet available but when they are they will be posted here.

CMS – Hospital Open Door Forum – November 12

CMS will hold an open-door forum for hospital leaders on Tuesday, November 12 at 2:00 (eastern).  Go here to register to participate.

CMS – Overview of QPP Policies in the CY 2025 Medicare PFS Final Rule – November 14

CMS will host a webinar on November 14 at 1:00 (eastern) to provide an overview of the final Medicare quality payment program policies for the 2025 performance year.  Go here to learn more about the webinar and to register to participate.

CDC – 2024–2025 Recommendations for Influenza Prevention and Treatment in Children – November 14

As part of its clinician outreach and communication activity, the CDC will hold a “2024–2025 Recommendations for Influenza Prevention and Treatment in Children:  An Update for Pediatric Providers” webinar on Thursday, November 14 at 2:00 (eastern).  During this webinar, presenters will provide an overview of influenza prevention and treatment recommendations for the 2024-2025 season from the American Academy of Pediatrics and the CDC.  Continuing education credits are offered for participating.  Go here to learn more about the webinar and how to participate.

HHS – Office of the Assistant Secretary for Health – Greenhouse Gas Reduction Fund Opportunities for the Health Sector Webinar – November 20

HHS’s Office of the Assistant Secretary for Health, its Office of Climate Change and Health Equity, and two recipients of Environmental Protection Agency Greenhouse Gas Reduction Fund grants will present information on current plans to finance clean energy projects across the country and how the health sector can pursue such funding.  The webinar will be held on Wednesday, November 20 at noon (eastern).  Go here to register to participate.

CMS – Rural Health Open Door Forum – November 21

CMS will hold an open-door forum for rural health leaders on Thursday, November 21 at 2:00 (eastern).  Go here to register to participate.

HHS – Office of the Assistant Secretary for Technology Policy – Annual Meeting – December 4-5

HHS’s Office of the Assistant Secretary for Technology Policy will hold its annual meeting in Washington, D.C. on Thursday, December 4 and Friday, December 5.  Participants will hear about key issues at the intersection of health care, public health, policymaking, and technology through a variety of keynote speakers and main stage, breakout, and education sessions.  Go here for additional information and to register to attend.

CMS – 2024 CMS Optimizing Health Care Delivery to Improve Patient Lives Conference – December 12

CMS will hold a virtual conference that will convene change-makers from the health care community and federal government to share innovative ideas, lessons learned, and best practices that strengthen patient health care delivery and access to high-quality care by reducing the administrative burdens that affect patients and the health care workforce.  The conference will be held on Thursday, December 12 at 11:00 (eastern).  Go here for further information and to register to participate.