On August 7 the Centers for Medicare & Medicaid Services (CMS) published the Calendar Year (CY) 2024 Medicare Physician Fee Schedule (PFS) proposed rule in the Federal Register.  The purpose of this annual update is to set Medicare Part B reimbursement rates for physician services and outpatient therapy, among other services, and to update or amend other Part B payment and coverage policies.  These rates apply to Part B services furnished in a variety of settings, such as physician offices, hospitals, skilled nursing facilities and other post-acute care settings, hospices, and patients’ homes. The proposed rule will be open for public comment through September 11, and a Fact Sheet is available here.  This article provides an overview of selected proposals that will be of interest to aging services providers.

Payment Rates

Overall proposed payment amounts under the CY 2024 PFS would be cut by 1.25% compared to CY 2023.  One of the key elements in the payment rate calculation formula, known as the conversion factor (a dollar amount that is applied to a CMS-determined measure of the time, resources, and expertise required to deliver a given service to a patient) is proposed to drop by 3.3% compared to 2023.  This year’s proposal follows other payment cuts that have been implemented by CMS in recent years.

Driving the overall decrease is a requirement that any changes to the PFS must be made in a budget neutral way.  If new billing codes are added to the Part B fee schedule, or if CMS proposes increases in payment for existing services (e.g., CMS may revalue a given service to reflect its estimate of the total resources required to deliver that service), dollars are redistributed from existing codes to maintain budget neutrality.  For example, CMS is proposing to implement a separate add-on payment (HCPCS code G2211) for outpatient office visits beginning January 1, 2024, which CMS believes will better recognize the inherent resource costs clinicians may incur when longitudinally treating a patient’s single, serious, or complex chronic condition. If finalized, establishing payment for this add-on code would have redistributive impacts for other CY 2024 payments under the Medicare PFS.

As has been the case many times in recent years, we can expect significant advocacy from physicians, therapy providers, and other affected practitioners for Congress to provide additional funding to reduce or override the proposed cuts altogether, and we will follow this evolving story.

Extension of Telehealth Policies and Flexibilities

The Medicare telehealth flexibilities adopted by CMS during the COVID-19 Public Health Emergency (PHE) were twice extended by Congress: the 2022 Consolidated Appropriations Act (CAA) extended certain policies for 151 days after the end of the PHE, and the 2023 CAA further extended the policies through the end of CY 2024.  CMS in its proposed rule confirms that it intends to implement the telehealth-related provisions of the 2023 CAA through December 31, 2024, including these:

• The temporary expansion of the scope of telehealth originating sites for services furnished via telehealth to include any site in the United States where the beneficiary is located at the time of the telehealth service, including an individual’s home.
• The expansion of the definition of telehealth practitioners to include qualified occupational therapists, qualified physical therapists, qualified speech-language pathologists, and qualified audiologists.

Of note, on June 6 Representatives Mikie Sherrill (D-NJ) and Diana Harshbarger (R-TN), along with 16 other original cosponsors, reintroduced the Expanding Telehealth Access Act. The bill would permanently allow audiologists, occupational therapists, physical therapists, speech language pathologist, and facilities that provide these services, to bill these services via telehealth permanently. A companion bill was introduced in the Senate by Senators Daines (R-MT), Smith (D-MN), Rosen (D-NV) and Moran (R-KS).

• Delaying the requirement for an in-person visit with the physician or practitioner within six months prior to initiating mental health telehealth services, and again at subsequent intervals as CMS determines appropriate.
• Continued coverage and payment of telehealth services included on the Medicare Telehealth Services List (as of March 15, 2020) until December 31, 2024.

In addition to implementing provisions of the 2023 CAA, CMS is also proposing that the following flexibilities would run through the end of Calendar Year 2024:

• Beginning in CY 2024, telehealth services furnished to people in their homes would be paid at the non-facility PFS rate to protect access to mental health and other telehealth services by aligning with telehealth-related flexibilities that were extended via the 2023 CAA. The “non-facility rate” is the geographically adjusted fee schedule amount paid to a physician or other practitioner for services furnished in their office or other non-facility outpatient setting, which is typically higher than the facility rate.
• During the PHE, CMS removed certain restrictions on how frequently a service may be furnished via Medicare telehealth: a limit of once every 3 days for subsequent inpatient visits, once every 14 days for subsequent nursing facility visits, and a limit of once per day for critical care consultation services. The frequency limitations took effect again on May 12, 2023, upon expiration of the PHE; however, CMS elected to exercise enforcement discretion and is not considering these frequency limitations through December 31, 2023.  CMS is now further proposing to remove these telehealth frequency limitations for CY 2024.
• Certain Medicare services must be furnished under the direct supervision of a physician or other practitioner, meaning that the supervisor must be physically present in the same location as the person being supervised and be immediately available to assist. This applies, for example, to supervision of physical therapy assistants and occupational therapy assistants providing private practice outpatient services.  During the PHE, however, CMS temporarily allowed the supervising person to be remote.  CMS is now proposing to continue to define “direct supervision” to permit the presence and immediate availability of a supervising practitioner through virtual presence (real-time audio and video interactive telecommunications, not audio-only) rather than in-person, physical availability, through December 31, 2024.  Extending this definition through 2024 would align the timeframe of this policy with the PHE-related telehealth policies that were extended under provisions of the 2023 CAA.  CMS is soliciting comment on whether it should consider extending the definition of direct supervision to permit virtual presence beyond December 31, 2024.
• During the PHE and continuing through the end of 2023, outpatient therapy services delivered by institutional providers – including skilled nursing facilities, and home health agencies (to individuals who are not homebound) – could be furnished via telehealth, including to beneficiaries in their homes. CMS is proposing to continue to allow these providers to bill for these services when furnished remotely in the same manner they have during the PHE for COVID–19 through the end of CY 2024.
• CMS is proposing to increase the Medicare telehealth originating site fee for 2024 to $29.92, compared to the current fee of $28.64.

Additions to the Medicare Telehealth Services List

CMS is proposing to add health and well-being coaching services to the Medicare Telehealth Services List on a temporary basis for CY 2024, and to add Social Determinants of Health Risk Assessments (described below) on a permanent basis.  The agency is also proposing a revised process to analyze requests received for addition of services to the Medicare Telehealth Services List, including a determination on whether the requested services should be added permanently or provisionally, beginning next year.

Payment for Caregiver Training Services

In recognition of the important role caregivers can play in supporting a patient’s overall care, CMS is proposing to make payment when practitioners train and involve caregivers to support patients with certain diseases or illnesses (e.g., dementia) in carrying out a treatment plan.

Medicare would pay for these caregiver training services (CTS) when furnished face-to-face by a physician or a non-physician practitioner (nurse practitioners, clinical nurse specialists, certified nurse-midwives, physician assistants, and clinical psychologists) under an individualized treatment plan or by a physical therapist, occupational therapist, or speech language pathologist under an individualized therapy plan of care.  Notably, this service could be billed even when the patient is not present, so long as the patient consents.  The initial proposal would authorize payment once per year per beneficiary, for a single session of CTS, but CMS is seeking comment on whether the service should be billable more frequently.

For purposes of the proposal, a caregiver means a layperson, such as a family member, guardian, friend, or neighbor, who provides unpaid assistance to a person with a chronic illness or disabling condition.  Caregivers would be trained by the treating practitioner in strategies and specific activities that improve symptoms, functioning, and adherence to treatment related to the patient’s diagnoses.

For example, a caregiver of a patient with dementia or other cognitive disabilities could be taught how to structure the patient’s environment to support and reinforce desired patient behaviors, to reduce the negative impacts of the patient’s diagnosis on the patient’s daily life, and to develop technical skills to manage the patient’s challenging behavior.  Or a caregiver of a patient recovering from a stroke or having mobility issues would be taught how to facilitate the patient’s activities of daily living, transfers, mobility, communication, and problem-solving to reduce the negative impacts of the patient’s diagnosis on the patient’s daily life and assist the patient in carrying out a treatment plan.

Services Addressing Health-Related Social Needs

In recent years CMS has been exploring ways to better support practitioners’ work when they incur additional time and resources helping patients with serious illnesses navigate the healthcare system or removing health-related social barriers that interfere with the practitioner’s ability to execute a plan of care.

Auxiliary personnel often obtain information about and help address social determinants of health – such as food, transportation or housing insecurity – that support a practitioner’s ability to diagnose or treat a patient; or they may help patients with similarly serious, high-risk illnesses, such as newly diagnosed cancer patients, navigate and implement their plan of care.

CMS notes that medical practice has evolved to increasingly recognize the importance of these activities in enhancing access to care and improving outcomes for Medicare beneficiaries and that practitioners are performing them more often.  Payment for these activities is currently included in payment for other services such as evaluation and management (E/M) visits and some care management services; however, CMS believes the services are being underutilized.

Accordingly, CMS is proposing new payment changes for CY 2024, to expressly identify these services for payment and distinguish them from current care management services, and to better account for resources involved in furnishing patient-centered care involving a multidisciplinary team of clinical and other staff.  Specifically, the agency is proposing new coding to describe three types of services that may be provided by auxiliary personnel – community health workers, care navigators, and peer support specialists – incident to a billing physician or practitioner’s professional services.

Social Determinants of Health Risk Assessment

While medical practice currently includes assessment of Social Determinants of Health (SDOH) in taking patient histories and informing care, CMS believes the resources involved in these activities are not appropriately reflected in current coding and payment policies.  Accordingly, CMS is proposing a new stand-alone code for administration of an optional SDOH Health Risk Assessment that may be billed every six months as part of a comprehensive social history in relation to an E/M visit.  This risk assessment involves a review of the individual’s SDOH or identified social risk factors that influence the diagnosis and treatment of medical conditions.  When conducted through a standardized, evidence-based tool, this practice can effectively identify unmet needs and enable analytical comparisons across populations.

 Community Health Integration Services and Principal Illness Navigation Services

CMS is proposing separate coding and payment for Community Health Integration (CHI) Services, which include person-centered planning, health system coordination, promoting patient self-advocacy, and facilitating access to community-based resources to address unmet social needs that interfere with the practitioner’s diagnosis and treatment of the patient.

CMS is also proposing separate coding and payment for Principal Illness Navigation (PIN), which is designed to help people with Medicare who are diagnosed with a serious, high-risk disease identify and connect with appropriate clinical and support resources, through the support of a single-dedicated individual such as a patient navigator or peer specialist.  Examples of diseases for which patient navigation services could be reasonable and necessary could include cancer, chronic obstructive pulmonary disease, congestive heart failure, dementia, HIV/AIDS, severe mental illness, and substance use disorder.

The specific activities conducted in providing either CHI or PIN are similar, including:

• A person-centered assessment, to understand the intersection between the SDOH needs and the problems addressed in the initiating E/M visit, or in the case of PIN the individualized context of the serious, high-risk condition.
• Health education and support with health care access and health system navigation.
• Coordinating receipt of needed services from healthcare practitioners, providers, and facilities; and from home- and community-based service providers, social service providers, and caregivers.
• Communication with practitioners, home- and community-based service providers, hospitals, and skilled nursing facilities (or other health care facilities) regarding the patient’s psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors.
• Coordination of care transitions between and among health care practitioners and settings, including transitions involving referral to other clinicians; follow-up after an emergency department visit; or follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities.

Both CHI and PIN services could be billed once per month following an initiating E/M visit by a billing practitioner who will also be furnishing the CHI or PIN services in subsequent months.  CMS believes that certain types of E/M visits, such as inpatient/observation visits, ED visits, and SNF visits would not typically serve as CHI initiating visits because the practitioners furnishing the E/M services in those settings would not typically be the ones to provide continuing care to the patient, including furnishing necessary CHI services in the subsequent month(s).

Specifically in relation to Community Health Integration, CMS proposes that these services provided to an individual could not be billed while the patient is under a home health plan of care under Medicare Part B, since it believes there would be significant overlap between CHI and services furnished under a home health plan of care, particularly in relation to medical social services and comprehensive care coordination.

In the case of both CHI and PIN services, CMS is proposing that a billing practitioner may arrange to have the services provided by auxiliary personnel who are external to, and under contract with, the practitioner or their practice, such as through a community-based organization (CBO) that employs CHWs.  There must be sufficient clinical integration between the third party and the billing practitioner in order for the services to be provided in this way.

When CMS refers to community-based organizations, it means public or private not-for-profit entities that provide specific services to the community or targeted populations in the community to address the health and social needs of those populations. They may include community-action agencies, housing agencies, area agencies on aging, centers for independent living, aging and disability resource centers or other non-profits that apply for grants or contract with healthcare entities to perform social services.

CMS notes its understanding that many CBOs provide social services and do other work that is beyond the scope of CHI or PIN services, but believes they are well-positioned to develop relationships with practitioners for providing these services.

Composition of Hospice Interdisciplinary Group

The 2023 Consolidated Appropriations Act added a provision that allowed marriage and family therapists (MFTs) and mental health counselors (MHC) to serve on the hospice interdisciplinary group in the social work role. The legislative language is written as an “or” – that the interdisciplinary group role can be filled by a social worker, or MFT, or MHC. LeadingAge’s understanding is that this was an effort to expand options for hospice providers in this time of workforce crisis. The CMS proposed rule is implementing this statutory provision, but CMS’s explanation includes some language that is unclear regarding the optionality of including these new professionals on the interdisciplinary group. The proposed rule uses “or” language, but CMS also indicates that the hospice patient’s needs, preferences and goals should guide the determination. We will ask CMS to clarify and confirm that the use of MFTS and MHCs is optional for hospices.

Medicare Part B Payment for Preventive Vaccine Administration Services

Base Rate: Since 2022 CMS has paid a single, uniform payment rate to providers and suppliers that administer a pneumococcal, influenza, hepatitis B vaccine ($30, indexed for inflation) but has paid a higher rate ($40, indexed for inflation) for administration of a COVID-19 vaccine.  Under the CMS proposed rule, effective January 1, 2024, the payment amount for administration of all four vaccines would be identical; that is, the Medicare Part B payment for administration of a COVID-19 vaccine will shift back into a single, uniform rate applied to all four of these preventative vaccines.

Add-On for In-Home Administration. In June 2021, CMS announced an additional Medicare Part B payment for in-home COVID-19 vaccine administration, which was established on a preliminary basis during the PHE.  Among other conditions, the add-on applied only when the sole purpose of the visit was to administer the vaccine (not if the provider furnished another Medicare-covered service in the same home on the same date).  Based on data that show that this payment has helped improve healthcare access to vaccines for underserved Medicare populations, including the aged, CMS is proposing to maintain this additional payment (approximately $36 currently) for the administration of a COVID-19 vaccine in the home.  Notably, CMS is also proposing to extend this in-home additional payment to the administration of the other three preventive vaccines included in the Part B preventive vaccine benefit — the pneumococcal, influenza, and hepatitis B vaccines — when provided in the home.

This additional payment amount will be annually updated using the percentage increase in the Medicare Economic Index and adjusted to reflect geographic cost variations. CMS is proposing to limit the additional payment to one payment per home visit, even if multiple vaccines are administered during the same home visit.  However, every vaccine dose that is furnished during a home visit will still receive its own unique vaccine administration base payment.

Conclusion

If finalized, the new rates and related rules would go into effect January 1, 2024. LeadingAge will continue our analysis of these CMS proposals and their potential impacts for our members, and provide additional information in the weeks ahead.