CMS Roundup

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The Centers for Medicare & Medicaid Services (CMS) provides an at-a-glance summary of news from around the agency.

CMS Releases Final Evaluation Report on Comprehensive Primary Care Plus Model

December 15: CMS released the final report on the evaluation of the Comprehensive Primary Care Plus (CPC+) Model. CPC+ was a primary care practice transformation model, supporting practices at varying levels of readiness in two tracks. The report found that during the five performance years of the model, participating practices transformed the way they provided many aspects of care. This transformation led to reduced outpatient emergency department visits, acute inpatient hospitalizations, and acute inpatient expenditures. However, these reductions were insufficient in either track to reduce total Medicare expenditures or achieve net savings, after accounting for increased expenditures in other areas and enhanced CPC+ payments. In both tracks, CPC+ practices that also participated in the Medicare Shared Savings Program at baseline successfully reduced acute inpatient expenditures and total expenditures.

CMS Takes Major Actions on Federal Independent Dispute Resolution (IDR) Process  

December 15: The Departments of Health and Human Services, Treasury, and Labor, including CMS representing HHS, (The Departments) reopened the Federal IDR portal for all dispute types, including previously initiated batched disputes, new batched disputes, and new single disputes involving air ambulance services. The Federal IDR process protects consumers against out-of-network balance billing by providing a process whereby providers (including air ambulance providers), facilities, and health plans can resolve payment disputes for certain out-of-network charges. Since August 2023, parts of the portal to submit Federal IDR disputes were closed due to recent court orders and opinions. The portal is now fully operational.

December 18: The Departments, including CMS representing HHS, issued a final rule on Federal IDR Process Administrative Fee and Certified IDR Entity Fee Ranges. This final rule amends existing regulations to provide that the administrative fees charged by the Departments to participate in the Federal IDR process, and the ranges for certified IDR entity fees for single and batched determinations, will be established by the Departments in notice and comment rulemaking, rather than in guidance. This rule also finalizes an administrative fee of $115 per party for disputes initiated on or after the effective date of this rule. It also finalizes a certified IDR entity fee range of $200-$840 for single determinations and $268-$1,173 for batched determinations for disputes initiated on or after the rule’s effective date. This rule and its associated fees are also effective for disputes initiated on or after January 22, 2024. Information is available on this fact sheet.

December 22: The Departments, including CMS representing HHS, posted a notification on the No Surprises Act website that the Departments intend to reopen the comment period for submitting comments on the proposed rule Federal Independent Dispute Resolution Operations. The Departments intend to publish a notice in the Federal Register with further details on reopening the comment period.

CMS Posts Reports on the Medicare-Medicaid Financial Alignment Initiative

December 20: CMS posted four reports on the Medicare-Medicaid Financial Alignment Initiative (FAI). This initiative is designed to integrate financing and service delivery for Medicare-Medicaid enrollees. CMS is partnering with states to test models intended to achieve those goals. CMS released the third evaluation report for the Rhode Island and South Carolina demonstrations and the third preliminary evaluation report for the Texas demonstration. CMS also released the third brief report for the New York Integrated Appeals and Grievances demonstration. Rhode Island and South Carolina show some improvements in utilization and quality results. Texas shows mixed utilization and quality results. The Rhode Island and South Carolina reports show increases in Medicare spending, while Texas shows no change. The New York Integrated Appeals and Grievances demonstration is described by plans, advocates, and the state as a key benefit for people with both Medicare and Medicaid.

CMS Issues Proposed Rule Establishing Appeal Processes for Certain People with Medicare

December 21: CMS issued a proposed rule that would establish appeal processes for certain people with Traditional Medicare who are admitted to a hospital as an inpatient but subsequently reclassified by the hospital as an outpatient receiving observation services. Additional information can be found on this fact sheet.

New Laboratory Regulation Adjusts Fees, Revises Requirements & Permitted Sanctions 

December 22: CMS, in collaboration with the CDC, released a final rule titled Clinical Laboratory Improvement Amendments of 1988 (CLIA) Fees; Histocompatibility, Personnel, and Alternative Sanctions for Certificate of Waiver Laboratories. The final rule adjusts laboratory fees to provide sustainable funding for the user-fee-funded CLIA program; revises certain requirements for clinical laboratories certified under CLIA; and provides additional discretion to CMS to impose alternative sanctions against non-compliant laboratories.

ICYMI: Comments Due Soon on Notice of Marketplace Benefit and Payment Parameters for 2025 Proposed Rule 

Comments are due January 8, 2024, on the Notice of Benefit and Payment Parameters for 2025 Proposed Rule. The rule proposes standards for issuers and Marketplaces and requirements for agents, brokers, web brokers, direct enrollment entities, and assisters that help Marketplace consumers. This proposed rule also includes several proposals impacting the Medicaid program, Children’s Health Insurance Program (CHIP), and the Basic Health Program (BHP). Information on the proposed rule can be found here

Other Recent Releases: 

December 15: HHS to Improve Maternal Health Outcomes with New CMS Care Model that Expands Access to Services, Other Proven Maternal Health Approaches

December 18: Biden-Harris Administration Releases New Medicaid and CHIP Renewal Data Showing the Role State Policy Choices Play in Keeping Kids Covered 

December 20: HealthCare.gov Enrollment Exceeds 15 Million, Surpassing Previous Years’ Milestones

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