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.
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.
The Centers for Medicare and Medicaid Services (CMS) recently released a final ruleto update the home health (HH) prospective payment system (PPS) for calendar year (CY) 2024. 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 Congress.
Highlights of the final rule which takes effect Jan. 1, 2024, include:
A negative 2.89% behavioral offset to achieve budget neutrality due to the transition to the Patient-driven Groupings Model (PDGM). This is half of the estimated permanent adjustment of 5.78%.
A 30-day standard payment rate of $2,038.13, for home health agencies that submit the required quality data. This is a 1.4% increase from the current rate after the 3% market basket update is reduced for the negative behavioral adjustment and budget neutrality.
Recalibration of the PDGM case-mix weights, low utilization payment adjustment thresholds, functional levels and comorbidity adjustment subgroups.
Updates to the expanded HH value-based purchasing program previously expanded to all 50 states. All HH agencies certified before Jan. 1, 2022, will have a reduction or an increase to their Medicare payments by up to 5% based on their performance on specified quality measures beginning in CY 2025.
The adoption of two new measures to the HH quality reporting program with the CMS finalizing the removal of two measures and public reporting of four measures.
Payment rates for the administration of home intravenous immune globulin items and Services.
Creation of the hospice informal dispute resolution and special focus programs.
Changes to durable medical equipment, prosthetics, orthotics and supplies outlined by the Consolidated Appropriations Act of 2023.
A decrease in the labor-related share of the HH 30-day period standard rate from 76.1% in 2023 to 74.9%.
The MHA will provide an updated impact analysis of the final rule in the near future.
Members with questions should contact Vickie Kunz at the MHA.
The Centers for Medicare and Medicaid Services (CMS) recently released a final rule for Medicare Advantage plans (MA) and the Medicare Prescription Drug Benefit Program for calendar year (CY) 2024.
The rule increases oversight of MA plans and seeks better alignment with Medicare fee-for-service (FFS), including clarifying that MA plans cannot use clinical criteria guidelines that are more restrictive than Medicare FFS to ensure that MA beneficiaries receive access to the same medically necessary care which is increasingly important as enrollment in MA continues to grow.
As recently reported, 59% of Michigan’s total Medicare beneficiaries are enrolled in an MA plan, with enrollment by county ranging from 42% to 75%. The final rule:
Prohibits MA plans from limiting or denying coverage for a Medicare-covered service based on their own internal or proprietary criteria if such restrictions do not exist under Medicare FFS.
Explicitly states that MA plans must adhere to the Two-Midnight Rule, the Inpatient Only List and case-by-case expectation criteria that apply for Medicare FFS.
Prohibits MA plans from denying coverage or redirecting post-acute care to a lower level unless the patient explicitly does not meet the Medicare coverage criteria required for the recommended level of care.
Explicitly states that MA plans must provide both coverage and payment for care provider to stabilize an emergency medical condition determined using the prudent layperson standard regardless of the final diagnosis.
Requires health plan physician or other professionals to have expertise in the field of medicine related to the service being requested in the prior authorization (PA).
Requires PAs to be valid for an entire course of approved treatment and provide a minimum 90-day transition period if an enrollee undergoing treatment switches to a new MA plan.
Establishes additional processes to oversee MA plan utilization management programs including an annual review of policies to ensure compliance with Medicare rules and consistency with current clinical guidelines.
Strengthens behavioral health network adequacy requirements in several ways:
MA plans are currently required to provide access to an adequate network of “appropriate providers”, including primary care physicians, specialists, hospitalists and others. Plans are also required to demonstrate that the network includes an adequate number of psychiatrists and inpatient psychiatric facilities. This rule adds providers that specialize in behavioral health services to this list, including clinical psychologists and licensed clinical social workers.
Codifies standards for appointment wait times for primary care and behavioral health services.
Clarifies that emergency behavioral health services are not subject to PA.
Requires MA plans to notify enrollees when the enrollee’s behavioral health or primary care provider is dropped from the network mid-year.
Amends general access to services standards to explicitly include behavioral health services.
Requires MA plans to establish care coordination programs to increase parity between behavioral and physical health services.
Restricts MA plan marketing practices to protect beneficiaries from misleading advertisements and pressure tactics designed to increase enrollment.
Expands requirements for MA plans to provide culturally and linguistically appropriate services.
Establishes a new Health Equity Index to be incorporated into the MA plan Star Ratings beginning in 2027 to improve performance for patients with certain social risk factors.
Implements statutory provisions of the Inflation Reduction Act and the Consolidated Appropriations Act of 2021 related to the prescription drug affordability and coverage for eligible low-income individuals.
The CMS indicates that it intends to release a second rule to address remaining proposals from the December 2022 proposed rule that were not addressed in this rule, with the second rule to have a later effective date, expected to be no earlier than Jan. 1, 2025.
Members with questions should contact Vickie Kunz at the MHA.
The Centers for Medicare and Medicaid Services recently released a final rule to update the Medicare fee-for-service inpatient prospective payment system for fiscal year 2023, which begins Oct. 1, 2022. Hospitals are invited to participate in a national webinar hosted by DataGen at 3 p.m. Sept. 14 to review key provisions of the rule and estimated impact analysis provided by the MHA. The webinar is free of charge, but registration is required.
The deadline to provide contact information in preparation for the state’s anticipated grant program to implement an Emergency Department Medication for Opioid Use Disorder program has been extended to Sept. 23.
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The Centers for Medicare and Medicaid Services (CMS) recently released a final rule to update the Medicare fee-for-service (FFS) hospital inpatient prospective payment system (IPPS) for fiscal year (FY) 2023. The rule will: Reduce disproportionate …
The Centers for Medicare & Medicaid Services (CMS) recently released a final rule to update the Medicare fee-for-service prospective payment system for inpatient psychiatric facilities for fiscal year (FY) 2023, which begins …
The Centers for Medicare & Medicaid Services recently released a final rule to update the Medicare fee-for-service prospective payment system for inpatient rehabilitation facilities for fiscal year (FY) 2023, which begins …
The Centers for Medicare and Medicaid Services (CMS) recently released a final rule to update the Medicare fee-for-service long-term care hospital prospective payment system (PPS) for fiscal year (FY) 2023, which begins Oct. …
In preparation for the state’s anticipated grant program to implement an Emergency Department Medication for Opioid Use Disorder (ED MOUD) program, the MHA is asking all members to fill out …
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It’s well known within the healthcare industry that issues of employee turnover, lack of applicants and salary compression were exacerbated in 2020 and 2021. Unfortunately, these trends have continued throughout …
The Keckley Report
Solving Healthcare Workforce Shortages Requires Taking Self-care More Seriously
“The Labor Department reported that the U.S. added 528,000 jobs in July including 69,600 in healthcare. The unemployment rate fell to 3.5%, June job openings were down to 10.7 million from 11.3 million in May and government officials announced that the economy has now recouped the 22 million jobs lost in the pandemic.
But the more sobering news is that inflation has negated the workforce’ 5.1% wage gain in the last year and 1 in 5 workers is looking for employment elsewhere for higher pay and better benefits. And it’s even worse in the healthcare delivery workforce—the hospitals, long-term care facilities, clinics and ancillary service providers where 12 million work. During the COVID-19 pandemic, hospital employee turnover increased to 19.5%–five times higher than the general workforce. And today, 45% of physicians report burnout—double the rate pre-pandemic.”
Members are reminded to review their preliminary wage and occupational mix data released May 23 by the Centers for Medicare and Medicaid Services and submit any requests for changes to their Medicare Administrative Contractor by Sept. 2 since no new requests for changes will be accepted after that date.
The MHA received media coverage on a variety of topics during the weeks of Aug. 1 and Aug. 8. Areas of focus included health insurance tax credits from the American Rescue Plan Act (ARPA), healthcare benefits in the Inflation Reduction Act, growing demand for healthcare careers and more.
The Centers for Medicare and Medicaid Services (CMS) recently released a final rule to update the Medicare fee-for-service (FFS) long-term care hospital (LTCH) prospective payment system (PPS) for fiscal year (FY) 2023, which begins Oct. 1, 2022. The rule will:
Increase the standard federal rate by a net 3.8% for cases that meet LTCH criteria for services provided by LTCHs in compliance with CMS quality program reporting requirements.
Continue paying cases that fail to meet the required LTCH criteria (diagnosis-related group (DRG), intensive care unit, or ventilator criteria) at the site-neutral rate under the dual-rate payment system implemented in FY 2016.
Establish a high-cost outlier (HCO) threshold of $38,518 for cases paid based on the LTCH standard rate, up 17% from the current $33,015 threshold, resulting in fewer cases qualifying for an outlier payment. The CMS adjusts this threshold annually to maintain outlier payments at the targeted 8% of aggregate LTCH payments. Cases paid at the site neutral rate are subject to the inpatient PPS HCO, finalized at $38,859 for FY 2023.
Set a permanent cap to limit annual wage index decreases at 5%.
Calculate Medicare Severity-Long Term Care-DRG relative weights using an averaging approach, with COVID-19 cases included and excluded and then averaging the two sets of relative weights.
Set a permanent cap on annual decreases at 10% for MS-LTC-DRG relative weights to mitigate negative impacts of significant weight decreases.
The MHA is continuing to review the final rule and will provide hospitals with an updated impact analysis in the near future. Members with questions should contact Vickie Kunz at the MHA.
The Keckley Report