This week in Medicare—10/9/2024
HHS Announces Cost Savings for 54 Prescription Drugs Through the Medicare Inflation Rebate Program
On September 30, CMS published a Press Release to announce a coinsurance reduction for 54 prescription drugs available through Part B from October 1, 2024 – December 31, 2024. These 54 drugs had their coinsurance rates adjusted because the drug companies raised prices at a rate faster than the rate of inflation. CMS published a list of the affected drugs on its website.
Report on the Study of the Acute Hospital Care at Home Initiative
On September 30, CMS published a Report regarding the agency’s study of the Acute Hospital Care at Home (AHCAH) initiative. The program, which was initially established during the COVID-19 PHE, was extended through December 31, 2024, under provisions from the Consolidated Appropriations Act, 2023 (CAA). The report released by CMS fulfills a requirement from the CAA of 2023 to evaluate several aspects of the initiative, such as demographic information on beneficiaries treated under the initiative, clinical conditions treated, DRGs associated with discharges from the inpatient setting versus the AHCAH program, Medicare spending and utilization for patients receiving care in the inpatient setting versus AHCAH, and more.
The study is available to download via the AHCAH webpage on the CMS website.
Correction Notice: Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Program for Contract Year 2024—Remaining Provisions and Contract Year 2025 Policy and Technical Changes Final Rule
On September 30, CMS published a Correction Notice in the Federal Register regarding corrections to typos and technical errors from the Medicare Advantage final rule, which was published in the Federal Register on April 23. The corrections are all fairly minor and involve missing letters or words.
This correcting amendment is effective September 30, 2024.
Final Decision Memo: Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent HIV Infection
On September 30, CMS published a Final Decision Memo regarding an NCD for coverage of PrEP using antiretrovirals for people at increased risk of HIV acquisition. CMS will cover PrEP to prevent HIV in individuals at increased risk for HIV infection rather than the high risk from the proposed decision memo, and the determination as to the risk factor will be made by the physician/health care practitioner.
CMS is also covering up to eight individual counseling visits every 12 months to include HIV risk assessment, HIV risk reduction, and medication adherence. CMS will cover HIV screening up to eight times annually and a single screening for hepatitis B. The cadence of eight visits and eight tests is an increase from the proposed decision memo, where CMS proposed covering seven of each.
CMS to Provide Hurricane Helene Public Health Emergency Accelerated and Advance Payments to Medicare Fee-for-Services Providers and Suppliers
On October 2, CMS published a News Alert to announce the availability of accelerated payments to certain Medicare Part A providers and advance payments to certain Medicare Part B suppliers affected by Hurricane Helene beginning October 2, 2024. These payments may be granted in amounts equal to a percentage of the preceding 90 days of claims payments, and they will be repaid through automatic recoupment for a period of 90 days after the issuance.
OPPS Addendum A and B
On October 2, CMS published Updated Versions of the OPPS Addendum A and B files.
HHS Releases Final Guidance for Second Cycle of Historic Medicare Drug Price Negotiation Program
On October 2, CMS published Final Guidance on the implementation of the Medicare Drug Negotiation Program for initial price applicability year 2027. The guidance outlines the process for the second cycle of negotiations, which will occur during 2025 and may result in negotiated maximum fair prices (MFP) effective for 2027. CMS issued this guidance in response to comments received on previous draft guidance and lessons learned from the first cycle of negotiations.
For the second cycle of negotiations, the first optional negotiation meeting between CMS and a participating drug company will occur after the initial offer is issued and before the due date for potential written counter offers. CMS plans to announce the selection of up to 15 additional drugs covered by Part D for the second cycle of negotiations by February 1, 2025.
CMS published a Press Release and a Fact Sheet on the guidance on the same date.
New Strategic Plan: Safeguarding the Integrity of HHS Grants and Contracts
On October 3, the OIG published a new Strategic Plan for safeguarding the integrity of HHS grants and contracts. The plan is designed to strengthen compliance with requirements throughout the grants and contracts life cycle, promote award practices that achieve program outcomes, and mitigate fraud, waste, abuse, and mismanagement.
DMEPOS: Adding New Product Categories to CMS-855S Enrollment Form on October 26
On October 3, CMS published a Note in MLN Connects regarding the new product categories that will be included on the electronic CMS-855S DMEPOS Enrollment Form beginning October 26. The new categories are as follows:
- Cognitive behavioral therapy devices
- Rehabilitative therapy devices
- Urinary suction pumps
- External electrical stimulation devices (not otherwise classified)
October 2024 Update of the Ambulatory Surgical Center [ASC] Payment System
On October 3, CMS published Medicare Claims Processing Transmittal 12864, which rescinds and replaces Transmittal 12824, dated September 5, to add HCPCS code Q5131, remove HCPCS code C9172, and update the descriptors for HCPSC code J9172 in Table 3. Three new HCPCS codes are added to Table 6, and a new Table 7 has been created to add descriptor changes for HCPCS code A2024.
Effective date: October 1, 2024
Implementation date: October 7, 2024
Overview of the Hospice Special Focus Program (SFP)
On October 4, CMS published a Memorandum to state survey agency directors on hospice SFP criteria and the roles and responsibilities of CMS, state survey agencies, and accrediting organizations. The hospice SFP is designed to address issues that could place beneficiaries at risk of receiving poor-quality care.
The memorandum includes information on SFP identification, selection, surveys, and enforcement. Hospice programs that fail to meet the SFP completion criteria may be considered for termination from the Medicare program.
Effective date: Immediately. Please communicate to all appropriate staff within 30 days.