- Commemorating the 2nd Anniversary of the Lower Cost Prescription Drug Law
- MolDx Local Coverage Determination Statement
- Hospital Price Transparency: Get Resources to Help You Comply
- New Residency Programs Request for Information: Submit Comments by October 15
- Open Payments: Program Year 2023 Data
- Seasonal Flu Vaccine Pricing for 2024–2025 Season
- Inpatient Rehabilitation Facility Prospective Payment System: FY 2025 Pricer Update
- Home Health Prospective Payment System Grouper: October Update
- A Prescriber’s Guide to Medicare Prescription Drug (Part D) Opioid Policies — Revised
- Chronic Care Management Services — Revised
News
Commemorating the 2nd Anniversary of the Lower Cost Prescription Drug Law
Two years ago, President Biden signed into law historic legislation to lower health care costs for millions of Americans. The Inflation Reduction Act, also known as the lower cost prescription drug law, created the first ever annual cap on out-of-pocket drug costs for people with Medicare, capped the cost of each covered insulin at $35 per month, granted Medicare the power to directly negotiate drug prices, and made Affordable Care Act marketplace plans more affordable, leading to the lowest uninsured rate in history.
See the full press release.
MolDx Local Coverage Determination Statement
The Medicare Administrative Contractors (MACs) have carefully considered all the feedback received from interested parties regarding the MolDx: Molecular Testing for Solid Organ Allograft Rejection proposed local coverage determination (LCD). In response to public comments and upon further review of the evidence, the MACs are not finalizing the proposed LCD issued on August 10, 2023. Due to the importance of identifying solid organ allograft rejection early and to ensure the public has additional opportunities to comment on the policy, the MACs intend to issue a new LCD in the coming months. When posted, the new proposed LCD will be available for review in the Medicare Coverage Database.
See the full press release.
Hospital Price Transparency: Get Resources to Help You Comply
Starting July 1, 2024, hospitals must conform to a CMS template layout and data specifications for making public their standard charge information in a comprehensive machine-readable file (MRF). Starting January 1, 2025, you’re also required to encode additional data elements.
We have resources to help you meet these new requirements:
- Data Dictionary GitHub Repository:
- Required CMS template layouts
- Data dictionary
- Examples of how to encode standard charges in the MRF
- Q&A discussion board
- Tools webpage:
- Online validator
- Command-line interface validator
- TXT file generator
- MRF naming convention tool
- Resources webpage:
- Final rules
- FAQs
- Guides
- Webinar materials
Hospital Price Transparency regulations require each hospital operating in the U.S. to publish a comprehensive MRF with the standard charges for all items and services they provide.
More Information:
- Register for the October 21 webinar on meeting the upcoming January 2025 requirements
- Email questions to PriceTransparencyHospitalCharges@cms.hhs.gov
New Residency Programs Request for Information: Submit Comments by October 15
In the FY 2025 Inpatient Prospective Payment System (PPS) and Long-Term Care PPS final rule (Section V.F), CMS solicited public input on the criteria for what constitutes a new residency program for Medicare payment purposes. Submit comments no later than October 15, 2024, for consideration.
Open Payments: Program Year 2023 Data
CMS posted Program Year 2023 Open Payments data. In 2023 1,776 companies made 15.64 million payments or transfers of value to 630,384 physicians, 309,438 non-physician practitioners, and 1,225 teaching hospitals, totaling $12.75 billion.
More Information:
- Visit the Open Payments Program webpage
- Contact the Help Desk if you have questions about the program
Claims, Pricers, & Codes
Seasonal Flu Vaccine Pricing for 2024–2025 Season
Get payment allowances and effective dates for the 2024–2025 season.
More Information:
- Flu Shot webpage: frequency, coverage, billing, codes, and resources
- Instruction to your Medicare Administrative Contractor (PDF)
Inpatient Rehabilitation Facility Prospective Payment System: FY 2025 Pricer Update
CMS published payment rates effective October 1, 2024, in the FY 2025 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) final rule.
We’re adopting the latest core-based statistical area delineations. For providers located in counties previously considered rural, which will be considered urban starting in FY 2025, we finalized a rural transition policy. They’ll get two thirds of the IRF PPS rural adjustment in FY 2025, one third of the rural adjustment in FY 2026, and no rural adjustment in FY 2027.
Effective FY 2023, CMS won’t reduce IRF final wage indexes by more than 5% compared to the prior FY. This doesn’t apply to new IRFs that open in FY 2025 because they didn’t have a prior wage index.
More Information:
- Section 140.2 Medicare Claims Processing Manual, Chapter 3 (PDF)
Instruction to your Medicare Administrative Contractor (PDF)
Home Health Prospective Payment System Grouper: October Update
Get the October 2024 release (Version 05.1.24 (ZIP)). See Home Health Prospective Payment System Grouper Software for a summary of changes.
More Information:
- Section 80 Claims Processing Manual, Chapter 10 (PDF)
- Instruction to your Medicare Administrative Contractor (PDF)
Publications
A Prescriber’s Guide to Medicare Prescription Drug (Part D) Opioid Policies — Revised
CMS added information on the expansion of the exempted patient definition (PDF) as of January 1, 2025.
Chronic Care Management Services — Revised
Learn what’s changed (PDF). CMS added:
- New codes describing chronic pain management and treatment
Information about other care management services
From Our Federal Partners
Increased Oropouche Virus Activity & Associated Risk to Travelers
The CDC issued this Health Alert Network Health Advisory to notify clinicians and public health authorities of an increase in Oropouche virus disease in the Americas region, originating from endemic areas in the Amazon basin and new areas in South America and the Caribbean. Countries reporting cases include Brazil, Bolivia, Peru, Colombia, and Cuba. In the U.S. and Europe in 2024, travel-associated cases have been identified in travelers returning from Cuba and Brazil.
This Health Advisory advises on evaluating and testing travelers who have been in impacted areas with signs and symptoms consistent with Oropouche virus infection. It also raises awareness of the possible risk of vertical transmission and associated adverse effects on pregnancy and highlights prevention measures to mitigate additional spread of the virus and potential importation into unaffected areas, including the U.S.
See the full Health Advisory for more information, including recommendations for health care providers.
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