Tag: final rule

CMS Releases FY 2026 Final Rule for Inpatient Psychiatric Facilities

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a final rule to update the Medicare fee-for-service (FFS) prospective payment system (PPS) for inpatient psychiatric facilities (IPFs) for fiscal year (FY) 2026.

Key provisions of the include:

  • Increasing the IPF PPS federal per diem base rate by a net 1.9% after all adjustments, from $876.53 to $892.87 for IPFs that comply with the CMS IPF quality reporting program (QRP) requirements. The rate for providers that failed to report quality data is $875.44.
  • Increasing the Electroconvulsive Therapy payment per treatment by a net 1.9% from $661.52 to $673.85 for IPFs that comply with IPF QRP requirements and $660.70 for IPFs that fail to report data.
  • Revising the labor-related share from the current 78.8% to 79%.
  • Increasing the cost outlier threshold by 3.3% from the current $38,110 to $39,360 to achieve the 2% target for outlier payments as compared to aggregate IPF payments, decreasing the number of cases that qualify for outlier payments.
  • Modifying the facility-level adjustment factors:
    • Rural adjustment from 1.17 to 1.18
    • Teaching adjustment from 0.5150 to 0.7957
  • Maintaining the 1.54 adjustment factor for IPFs with qualifying emergency departments.
  • Updating the IPFQR Program to:
    • Remove four measures beginning with the calendar year 2024 reporting period/FY 2026 payment determination:
      • Facility Commitment to Health Equity
      • COVID-19 Vaccination Coverage among Health Care Personnel
      • Screening for Social Drivers of Health
      • Screen Positive Rate for Social Drivers of Health
    • Modify the reporting period of the 30-day-Risk-Standardized All Cause Emergency Department Visit Following an Inpatient Psychiatric Facility Discharge measure (referred to as the IPF ED Visit measure) from a one year, calendar year to a two-year, fiscal year period.
  • Finalizing changes to the IPFQR program’s extraordinary circumstances exception (ECE) policy to include extensions as a type of relief that the agency may grant in response to an ECE request

The MHA will provide IPFs with an updated hospital-specific impact analysis and additional details on the final rule in the near future. Members with questions should contact Vickie Kunz at the MHA.

CMS Releases FY 2026 Hospital Inpatient Prospective Payment System Final Rule

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a final rule to update the Medicare fee-for-service (FFS) inpatient prospective payment system (IPPS) for fiscal year (FY) 2026.

Highlights of the final rule include:

  • Increasing the standard operating rate by a net 1.9%, after the 0.7% productivity cut and budget neutrality adjustments, from $6,624.39 to $6,752.61, for hospitals that successfully comply with the CMS quality reporting program and electronic health record requirements. Hospitals that do not meet requirements for these programs are subject to a reduced annual update.
  • Increase the federal capital rate by 2.3%, from $512.14 to $524.15.
  • Decrease the cost outlier threshold by 12.6% from $46,217 to $40,397 to maintain the target of paying 5.1% of aggregate IPPS payments as outlier.
  • Rebasing and revising the labor-related share of the standardized operating rate from 67.6% to 66% for hospitals with a wage index greater than 1.0.
  • Increasing disproportionate share hospital and uncompensated care (UCC) payments by approximately $2 billion nationally. UCC payments will be allocated using the average of three most recent years of audited Worksheet S-10 data.
  • Adding five new Medicare Severity Diagnosis Related Groups (MS-DRGs) while deleting six MS-DRGs, with most changes within Major Diagnostic Category 05, Diseases and Disorders of the Circulatory System.
  • Removing four measures from the Hospital Inpatient Quality Reporting Program effective with the 2024 reporting and FY 2026 payment period:
    • COVID-19 vaccination coverage among health care personnel.
    • Hospital commitment to health equity structural measure.
    • Screening for social drivers of health.
    • Screen positive rate for social drivers of health.
  • Modifying the Hybrid hospital-wide readmission and mortality measures and the stroke mortality and elective total hip and knee arthroplasty measures.
  • Updating and codifying the Extraordinary Circumstances Exception (ECE) policy to clarify that the CMS has discretion to grant an extension in response to an ECE request from a hospital.
  • Removing the health equity adjustment from the hospital value-based purchasing program scoring methodology beginning with the FY 2026 program.
  • Modifying the six measures in the Readmissions Reduction Program to include Medicare Advantage (MA) beneficiaries in the patient cohorts and shortening the applicable performance period from three years to two years. For example, FY 2027 HRRP penalties would be based on performance July 1, 2023, through June 30, 2025. The CMS did not finalize its proposal to include MA data in the calculations of aggregate payments for excess readmissions; as a result, aggregate penalties are expected to include 2% instead of 13% under the proposed update.
  • Making a technical update to the National Healthcare Safety Network healthcare associated infection measures baseline.

The MHA continues to review the final rule and will provide hospitals with an updated estimated impact analysis and rule brief in the next few weeks. Members with questions should contact Vickie Kunz at the MHA.

2025 Medicare Fee-for-Service Home Health Final Rule Released

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a final rule for the home health (HH) prospective payment system (PPS) for calendar year (CY) 2025. The rule includes updates to the Medicare fee-for-service (FFS) HH PPS payment rates based on changes by the CMS and those previously adopted by the U.S. Congress.

Highlights of the final rule, which takes effect Jan. 1, 2025, include:

  • A negative 2% adjustment to base payment rates to achieve budget neutrality following the transition to the Patient-driven Groupings Model (PDGM).
  • A 30-day standard payment rate of $2,057.35, up 0.9% from the current $2,038.13, for HHs that submit the required quality data.
  • Updating core-based statistical areas for wage index purposes, consistent with recent fiscal year 2025 final rules.
  • Recalibrating the PDGM case-mix weights, low utilization payment adjustment thresholds, functional levels and comorbidity adjustment subgroups.
  • Revising the fixed dollar loss ratio from 0.27 to 0.35, reducing outlier payments.
  • Requiring HH agencies to report four new patient assessment items in the HH agency Outcome and Assessment Information Set under the social determinants of health category beginning with CY 2027.
  • Adding a new standard within the Medicare Conditions of Participation requiring HH agencies to develop, implement and maintain a patient acceptance to service policy that is applied consistently to each prospective patient referred for HH care.
  • Requiring long-term care facilities to electronically report information about COVID-19, influenza and respiratory syncytial virus in a standardized format weekly through National Healthcare Safety Network beginning Jan. 1, 2025. The CMS notes that the Secretary will have the discretion to revise the reporting frequency based on changing needs for data collection.

The MHA will provide an updated impact analysis in the near future. Members with questions should contact Vickie Kunz at the MHA.

CMS Releases FY 2025 LTCH Prospective Payment System Final Rule

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a final rule to update the Medicare fee-for-service long-term care hospital (LTCH) prospective payment system (PPS) for fiscal year 2025.

Specifically, the final rule:

  • Increases the standard LTCH PPS rate by a net 2.6% from $48,117 to $49,383 for LTCHs that meet the CMS quality program reporting requirements. LTCHs that fail to meet these requirements are subject to a two percentage point reduction to the annual update.
  • Rebases the market basket to use 2022 cost report data instead of 2017.
  • Increases the high-cost outlier (HCO) threshold by 29% for standard LTCH cases from the current $59,873 to $77,048, to achieve the target of paying roughly 8% of aggregate LTCH payments as HCO payments.
  • Continues to pay cases at the site neutral rate if they fail to meet LTCH criteria.
  • Updates the cost outlier threshold for site-neutral cases to the inpatient PPS threshold finalized at $46,152, up from $42,750.
  • Revises core based statistical areas as a result of the new Office of Management and Budget labor market delineations based on the 2020 Decennial Census.
  • Updates the LTCH quality reporting program to require reporting of four new items to the LTCH Continuity Assessment Record and Evaluation Data Set, social determinant of health category. These include one item each for living situation and utilities and two items for food.
  • Modifies the Transportation assessment item to simplify response options and revise the look-back period.
  • Extends the window for admission assessments from three days to four, beginning with patients admitted on Oct. 1, 2026.

The MHA continues to review the final rule and will provide LTCHs with an updated estimated impact analysis in the next few weeks.  Members with questions should contact Vickie Kunz at the MHA.

 

CMS Releases FY 2025 Final Rule for Skilled Nursing Facilities

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a final rule to update the Medicare fee-for-service prospective payment system (PPS) for skilled nursing facilities (SNFs) for federal fiscal year (FY) 2025.

Key provisions include:

  • Increasing the per diem federal rate by a net 4.2% after the market basket update, productivity adjustment and other adjustments.
  • Updating the base year data used to determine the SNF market basket from 2018 to 2022.
  • Updating the wage index used under the SNF PPS to reflect data from the 2020 decennial census.
  • Increasing the labor-related share of the per diem rate from 71.1% to 72%.
  • Making technical updates to the code mappings used to classify patients under the Patient Driven Payment Model that assigns patients to clinical categories.
  • Revising the regulations to allow the CMS to impose additional financial penalties on facilities with health and safety deficiencies as identified.
  • Adopting four new patient assessment items related to health-related social needs, with SNFs required to collect and report specific data elements related to living situation, food and utilities beginning with the FY 2027 SNF quality reporting program (QRP).
  • Modifying the transportation item on the patient assessment item to simplify response options while also using a defined 12-month look-back period.
  • Adopting a data validation process for the SNF QRP beginning with the FY 2027 program.
  • Proposing operational updates to the SNF Value-Based Purchasing program, including policies regarding measure removal and review and corrections.
  • Updating the case mix methodology used to calculate the Total Nurse Staffing measure.

The MHA will provide SNFs with an updated facility-specific impact analysis and additional details on the final rule, effective Oct. 1, in the near future. Members with questions should contact Vickie Kunz at the MHA.

CMS Releases FY 2025 Final Rule for Inpatient Rehabilitation Facilities

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a final rule to update the Medicare fee-for-service prospective payment system (PPS) for inpatient rehabilitation facilities (IRF) for federal fiscal year (FY) 2025.

Key provisions of the rule include:

  • Increasing the IRF PPS payment rate by a net 2% after all adjustments, from $18,541 to $18,907. IRFs that fail to comply with the CMS IRF Quality Reporting Program (QRP) requirements are subject to a two-percentage point reduction.
  • Updating the wage index using the most recent Office of Management and Budget statistical area delineations based on the 2020 Decennial Census.
  • Increasing the labor-related share from the current 74.1% to 74.4%.
  • Increasing the cost outlier threshold by 15.5% from the current $10,423 to $12,043 to achieve the 3% target for outlier payments, as compared to aggregate IRF payments, decreasing the number of cases that qualify for outlier payments.
  • Updating the case mix group relative weights and average length of stay values using FY 2023 IRF claims and FY 2022 IRF cost report data.
  • Requiring IRFs to report four new items (beginning with patients admitted Oct. 1, 2026) using the IRF-Patient Assessment Instrument (IRF-PAI) as standardized patient assessment data elements under the social determinants of health (SDOH) category beginning with the FY 2028 IRF QRP including:
    • One item for living situation.
    • Two items for food.
    • One item for utilities.
  • Modifying the Transportation item collected in the IRF-PAI under the SDOH category beginning with patients admitted Oct. 1, 2026
  • Continuing to evaluate, refine and develop new measures for the IRF QRP to ensure Medicare patients and caregivers have meaningful information to make informed decisions.
  • Creating a five-star IRF QRP rating system to distinguish between quality of care offered by providers.

The MHA will provide IRFs with an updated facility-specific impact analysis and additional details on the final rule, effective Oct. 1, in the near future. Members with questions should contact Vickie Kunz at the MHA.

SAMHSA Issues Final Rule on OUD Treatment

Member News, Patient Safety and Quality

The Substance Abuse and Mental Health Services Administration (SAMHSA) issued a final rule Jan. 31 updating regulations for Opioid Treatment Programs (OTP) and standards for treatment of opioid use disorder (OUD). These rules make permanent some of the COVID-19 flexibilities and reflect updated treatment guidelines.

These updated rules apply to OTP programs, but do not apply more broadly to virtual prescribing of controlled substances.

Modifications outlined in the final rule include:

  • Buprenorphine prescriptions to be prescribed through telehealth without an initial in-person evaluation.
  • Buprenorphine prescriptions can be prescribed through audio-only telehealth.
  • Allows prescribers in OTP more flexibility in take-home doses of methadone.
    • Seven doses for people who have been in treatment for two weeks.
    • 14 doses for people who have been in treatment for 15 days or more.
    • 28 doses for people who have been in treatment for at least a month.
  • Removes the requirement that minors must have two failed withdraw attempts before receiving methadone or buprenorphine.

This rule goes into effect April 2, 2024, with a compliance date of April 2, 2026.

Members with questions may contact Michelle Norcross at the MHA Keystone Center PSO.

Outpatient Prospective Payment System Final Rule Includes Behavioral Health Additions

Member News

The Centers for Medicare & Medicaid Services (CMS) recently finalized several policies in the 2024 Medicare fee-for-service final rules for the outpatient prospective payment system (OPPS) and physician fee schedule final rule. These provisions, effective Jan. 1, 2024, will expand and improve access to behavioral health services.

Highlights include:

  • Establishing coverage for Intensive Outpatient Program services provided by hospital outpatient departments, community mental health centers and federally qualified health centers (FQHCs) and rural health clinics (RHCs) for beneficiaries who have an acute mental illness and meet certain criteria.
  • Covering services provided by marriage and family therapists and mental health counselors at RHCs and FQHCs.
  • Allowing required certifications for opioid treatment programs to be performed by non-physician practitioners.
  • Establishing three new HCPCS codes in the OPPS final rule for diagnosis, evaluation or treatment of a mental health or substance use disorder performed by hospital clinical staff for patients in their homes.
  • Delaying the in-person service requirements for mental health services provided remotely until Jan. 1, 2025.

Members can review additional information in the detailed summary.

Members with questions on the OPPS rule should contact Vickie Kunz at the MHA. Questions regarding the MHA’s behavioral health strategy should be directed to Lauren LaPine at the MHA.