CMS Issues Proposed Rule to Implement New Medicare
Services Added by Health Reform
Affordable Care Act expands preventive services,
improves access to primary care in 2011
June
29, 2010 - The Centers for Medicare & Medicaid Services (CMS) issued a
proposed rule on Friday that would implement key provisions in the
Affordable Care Act of 2010 that expand preventive services for Medicare
beneficiaries, improve payments for primary care services, and promote
access to health care services in rural areas.
The proposed policies would apply to payments under
the Medicare Physician Fee Schedule for services furnished on or after
January 1, 2011.
“The rule we are proposing today is just one part
of the Administration’s efforts to improve the health status of Medicare
beneficiaries by expanding access to preventive services, and promoting
early detection and prompt treatment of medical conditions,” said
Jonathan Blum, deputy administrator and director of CMS’s Center for
Medicare.
“Beginning in 2011, Medicare will cover an annual
wellness visit that will offer an opportunity for the physician and
patient to develop a more comprehensive approach to maintaining or
improving the patient’s health and reducing risks of chronic disease.”
New Annual Wellness Visit
The proposed rule would implement provisions in the
Affordable Care Act that will eliminate out-of-pocket costs for
beneficiaries for most preventive services, including the new annual
wellness visit. This visit augments the benefits of the Initial
Preventive Physical Examination (IPPE or “Welcome to Medicare Visit”)
with an annual wellness visit that allows the physician and patient to
develop a personalized prevention plan that includes not only the
preventive services generally available to the Medicare population, but
additional services that may be appropriate because of the patient’s
individual risk factors.
The proposed rule would improve access to primary
care services by implementing an incentive payment for primary care
services furnished by primary care practitioners that can include
physicians, nurse practitioners, clinical nurse specialists and
physician assistants.
Incentive Pay for Surgeons
The proposed rule would also implement a payment
incentive program for general surgeons performing major surgery in areas
designated by the Secretary as Health Professional Shortage Areas (HPSAs),
would allow physician assistants to order post-hospital extended care
services in skilled nursing facilities, and would pay certified nurse
midwives for their services under the Medicare Physician Fee Schedule (MPFS)
at the same rates as physicians.
The proposed rule would also update other policies
and payment rates for services by physicians, nonphysician practitioners
(NPPs) and certain other suppliers that are paid under the MPFS during
calendar year (CY) 2011.
The proposed rule projects a -6.1 percent reduction
to physician payment rates in 2011 under the sustainable growth rate (SGR)
formula adopted in the Balanced Budget Act of 1997. This formula has
called for an across-the-board reduction in physician payment rates
every year beginning with CY 2002.
Beginning in CY 2003 through May 31, 2010, the cuts
have been averted by legislative action.
On June 25, the President signed the Preservation
of Access to Care for Medicare Beneficiaries and Pension Relief Act of
2010, which replaces the 21.3 percent reduction in physician payment
rates that was required by the SGR formula for CY 2010 with a 2.2
percent payment increase for services furnished on or after June 1, 2010
through November 30, 2010.
“We are very concerned about the impact the
continuing uncertainty about payment rates and cash flow disruptions may
have on physician practices and on beneficiary access to physicians’
services,” said Blum. “Although over 97 percent of physicians have
chosen to participate in Medicare for 2010 and therefore, have agreed to
accept Medicare’s payment rates as payment in full for the services they
provide to beneficiaries, we are hearing more stories of physicians
limiting the number of beneficiaries they will see.
“We are also concerned about the diversion of
scarce Medicare resources as we have to adjust our payment operations to
the constantly changing legislative landscape.”
The proposed rule would continue recent efforts by
CMS to improve the accuracy of physicians’ payment rates by implementing
Affordable Care Act mandates to identify services in categories that are
at significant risk for inaccurate payment and by further reducing
payments in CY 2011 for diagnostic imaging equipment used in diagnostic
computed tomography (CT) and magnetic resonance imaging (MRI) services.
It would also require physicians referring CT, MRI
and positron emission tomography (PET) services under the in-office
ancillary services exception to the physician self-referral prohibition,
to notify patients that they may receive the same services from other
suppliers in the area. The physician would also provide a list of
alternate suppliers.
CMS will accept comments on the proposed rule until
August 24, 2010, and will respond to them in a final rule to be issued
on or about November 1, 2010. Except as otherwise specified, the
payment policies and rates adopted in the final rule will be effective
for services on or after January 1, 2011.
The fact sheet issued by CMS on this rule is below.
Affordable
Care Act Provisions and the CY 2011 Medicare Physician Fee Schedule
Proposed Rule
OVERVIEW
The Centers for Medicare & Medicaid Services (CMS)
issued a proposed rule on June 25, 2010 that would update payment
policies and Medicare payment rates for services furnished by physicians
and nonphysician practitioners (NPPs) that are paid under the Medicare
Physician Fee Schedule (MPFS). In addition to payment policy and
payment rate updates, the MPFS includes a number of provisions of the
Patient Protection and Affordable Care Act of 2010, as amended by the
Health Care and Education Reconciliation Act of 2010 (collectively
referred to as the “Affordable Care Act”). While several of these
provisions directly affect payments provided under the MPFS, the
proposed rule also addresses a number of policies that are not directly
related to physician payment rates.
BACKGROUND
Since 1992, Medicare has paid for the services of
physicians, NPPs and certain other suppliers under the MPFS, a system
that pays for covered physicians’ services furnished to a person with
Medicare Part B. Under the MPFS, a relative value is assigned to each
of more than 7,000 types of services to capture the amount of work, the
direct and indirect (overhead) practice expenses, and the malpractice
expenses typically involved in furnishing the service. The higher the
number of relative value units (RVUs) assigned to a service, the higher
the payment. The RVUs for a particular service are multiplied by a
fixed-dollar conversion factor and a geographic adjustment factor to
determine the payment amount for each service.
Affordable Care Act Provisions INCLUDED IN
THE CY 2011 MPFS PROPOSED RULE
Primary Care & Prevention
● Elimination Of Deductible And
Coinsurance For Most Preventive Services: Effective January 1,
2011, the Affordable Care Act waives the Part B deductible and the 20
percent coinsurance that would otherwise apply to most preventive
services. Specifically, the provision waives both the deductible and
coinsurance for Medicare covered preventive services that have been
recommended with a grade of A (“strongly recommends”) or B
(“recommends”) from the U.S. Preventive Services Task Force (USPSTF), as
well as the initial preventive physician examination and the annual
wellness visit. The Affordable Care Act also waives the Part B
deductible for tests that begin as colorectal cancer screening tests
but, based on findings during the test, become diagnostic or therapeutic
services.
● Coverage Of Annual Wellness Visit
Providing A Personalized Prevention Plan: The Affordable
Care Act extends the preventive focus of Medicare coverage, which
currently pays for a one-time only initial preventive physical
examination (IPPE or the “Welcome to Medicare Examination”), to provide
coverage for annual wellness visits where beneficiaries receive
personalized prevention plan services (PPPS). The law requires the
annual wellness visit to include at least the following six elements:
► Establish or update the
individual’s medical and family history.
► List individual’s current
medical providers and suppliers and all prescribed medications.
► Record measurements of
height, weight, body mass index, blood pressure and other routine
measurements.
► Detect any cognitive
impairment.
► Establish a screening
schedule for the next 5 to 10 years including screenings appropriate for
the general population, and any additional screenings that may be
appropriate because of the individual patient’s risk factors.
► Furnish personal health
advice and coordinate appropriate referrals and health education.
CMS is proposing to develop separate Level II HCPCS
codes for the first annual wellness visit, to be paid at the rate of a
level 4 office visit for a new patient (similar to the IPPE), and for
the subsequent annual wellness visits, to be paid at the rate of a level
4 office visit for an established patient.
● Incentive Payments To Primary Care
Practitioners For Primary Care Services: The Affordable
Care Act provides for incentive payments equal to 10 percent of a
primary care practitioner's allowed charges for primary care services
under Part B. The law defines primary care practitioners as physicians
(1) who have a primary specialty designation of family medicine,
internal medicine, geriatric medicine, or pediatric medicine; as well as
nurse practitioners, clinical nurse specialists, and physician
assistants; (2) for whom primary care services accounted for at least 60
percent of the practitioner’s allowed charges under Part B for a prior
period as determined by the Secretary of Health and Human Services. The
law also defines primary care services as limited to new and established
patient office or other outpatient visits (CPT codes 99201 through
99215); nursing facility care visits, and domiciliary, rest home, or
home care plan oversight services (CPT codes 99304 through 99340); and
patient home visits (CPT codes 99341 through 99350). These incentive
payments would be made quarterly based on the primary care services
furnished in CY 2011 by the primary care practitioner, in addition to
any physician bonus payments for services furnished in Health
Professional Shortage Areas (HPSAs).
CMS is proposing to determine a practitioner’s
eligibility for incentive payments in CY 2011 using claims data and the
provider’s specialty designation from CY 2009. For subsequent years,
CMS is proposing to revise the list of primary care practitioners on a
yearly basis, based on updated data regarding an individual's specialty
designation and percentage of allowed charges for primary care
services.
Expanding Access
● Incentive Payments For Major Surgical
Procedures In Health Professional Shortage Areas: The
Affordable Care Act also calls for a payment incentive program to
improve access to major surgical procedures – defined as those with a
10-day or 90-day global period under the MPFS ‑ in HPSAs between January
1, 2011 and December 31, 2016. To be eligible for the incentive
payment, the physician must be enrolled in Medicare as a general
surgeon. The amount of the incentive payment is equal to 10 percent of
the MPFS payment for the surgical services furnished by the general
surgeon. The incentive payments would be made quarterly to the general
surgeon when the major surgical procedure is furnished in a zip code
that is located in a HPSA. CMS proposes to use the same list of HPSAs
that is used under the existing HPSA bonus program that is applicable to
all services furnished by physicians in HPSAs.
● Revisions To The Practice Expense
Geographic Adjustment: As required by the Medicare law, CMS
adjusts payments under the MPFS to reflect local differences in practice
costs. CMS assigns separate geographic practice cost indices (GPCIs) to
the work, practice expenses (PE), and malpractice cost components of
each of more than 7,000 types of physician services. The proposed rule
discusses CMS’ analysis of PE GPCI data and methods and incorporates new
data and GPCI cost share weights as part of the sixth GPCI update
proposed for CY 2011. The Affordable Care Act establishes a permanent
1.0 floor for the PE GPCI for frontier states (currently,
Montana
, Wyoming ,
Nevada , North Dakota ,
and South Dakota). The Affordable Care Act limits recognition of local
differences in employee wages and office rents in the PE GPCIs for CYs
2011 and 2012 as compared to the national average. Localities are held
harmless to any decrease in CYs 2011 and 2012 in their PE GPCIs that
would result from this alternative methodology. In addition, the
Affordable Care Act requires the Secretary of Health and Human Services
to analyze current methods of establishing PE GPCIs in order to make
adjustments that fairly and reliably distinguish the costs of operating
a medical practice in the different fee schedule areas.
● Permitting Physician Assistants To
Order Post-Hospital Extended Care Services: The Affordable Care
Act newly authorizes physician assistants to perform the level of care
certification that is one of the requirements for coverage under
Medicare’s skilled nursing facility (SNF) benefit.
● Payment For Bone Density Tests:
The Affordable Care Act increases the payment for two dual-energy x-ray
absorptiometry (DXA) CPT codes for measuring bone density for CYs 2010
and 2011. This provision revises payments for these preventive services
to use 70 percent of their CY 2006 RVUs, and the 2006 conversion factor
with the current year geographic adjustment.
● Improved Access To Certified
Nurse-Midwife Services: The Affordable Care Act increases the
Medicare payment for certified nurse-midwife services from 65 percent to
100 percent of the amount physicians are paid under the MPFS.
● Extension Of Medicare Reasonable
Costs Payments For Certain Clinical Diagnostic Laboratory Tests
Furnished To Hospital Patients In Certain Rural Areas:
The Affordable Care Act reinstitutes reasonable cost payment for
clinical diagnostic laboratory tests performed by hospitals with fewer
than 50 beds that are located in qualified rural areas as part of their
outpatient services for cost reporting periods beginning on or after
July 1, 2010 through June 30, 2011. For some hospitals whose cost
reports begin as late as June 30, 2011, this could affect services
performed as late as June 29, 2012, because this is the date those cost
reports will close.
● Physician Self-Referral For Certain
Imaging Services: The Affordable Care Act amends the in-office
ancillary services exception to the self-referral law as applied to
magnetic resonance imaging, computed tomography, and positron emission
tomography, to require a physician to disclose to a patient in writing
at the time of the referral that there are other suppliers of these
imaging services, along with a list of other suppliers in the area in
which the patient resides. CMS is proposing to require that the
referring physician provide the patient with a list of ten alternative
suppliers within a 25-mile radius of the physician’s office who provide
the same imaging services.
● Adjustments To The Medicare Durable
Medical Equipment, Prosthetics, Orthotics, And Supplies Competitive
Bidding Program: The Affordable Care Act expands round 2
of the durable medical equipment (DME) competitive bidding program from
70 metropolitan statistical areas (MSAs) to 91 MSAs by adding the next
21 largest MSAs by total population not already selected for rounds 1 or
2. The 2009 annual population estimates from the U.S. Census Bureau are
the most recent estimates of population that will be available prior to
the round 2 competition mandated to take place in CY 2011. CMS is
proposing to use these estimates to determine the additional 21 MSAs to
be included in round 2 of the program.
Improving Payment Accuracy
● Misvalued Codes Under The Physician
Fee Schedule: The Affordable Care Act requires CMS to
periodically review and identify potentially misvalued codes and make
appropriate adjustments to the relative values of the services that may
be misvalued. CMS has been engaged in a vigorous effort over the past
several years to identify and revise potentially misvalued codes and
includes a discussion of these activities in the proposed rule. CMS
also identifies additional categories of services that may be misvalued,
including codes with low work RVUs commonly billed in multiple units per
single encounter and codes with high volume and low work RVUs.
● Modification Of Equipment Utilization
Factor For Advanced Imaging Services: The Affordable Care Act
adjusts the equipment utilization rate assumption for expensive
diagnostic imaging equipment and, thereby, reduces payment rates for the
associated procedures. Effective January 1, 2011, CMS will assign a 75
percent equipment utilization rate assumption to expensive diagnostic
imaging equipment used in diagnostic computed tomography (CT) and
magnetic resonance imaging (MRI) services. In addition, beginning on
July 1, 2010, the Affordable Care Act increases the established MPFS
multiple procedure payment reduction for the technical component of
certain single-session imaging services to consecutive body areas from
25 to 50 percent for the second and subsequent imaging procedures
performed in the same session.
● Revision To Payment For Power-Driven
Wheelchairs – As required by the Affordable Care Act, CMS is
proposing to adjust the payment schedule for power-driven wheelchairs
under the Medicare Part B Durable Medical Equipment Orthotics and
Prosthetics (DMEPOS) fee schedule to pay 15 percent (instead of 10
percent) of the purchase price for the first three months under the 13
month rental period and 6 percent (instead of 7.5 percent) for the
remaining months. Payment is based on the lower of the supplier’s actual
charge and the fee schedule amount.
In addition, the Affordable Care Act eliminates the
lump sum (up-front) purchase payment option for standard power-driven
wheelchairs. CMS is proposing revisions to the regulations to conform
to this change, which permits payment for standard power-driven
wheelchairs only on a monthly rental basis effective for items furnished
on or after January 1, 2011. The Affordable Care Act also specifies
that these changes do not apply to power-driven wheelchairs furnished
pursuant to contracts entered into prior to January 1, 2011 as part of
the Medicare DMEPOS competitive bidding program. For complex
rehabilitative power-driven wheelchairs, the regulations will continue
to permit payment to be made on a lump sum purchase method or a monthly
rental method.
● Maximum Period For Submission Of
Medicare Claims Reduced To Not More Than 12 Months – To
implement the Affordable Care Act, CMS is proposing that Medicare
fee-for-service claims for services furnished on or after January 1,
2010 must be filed no later than 1 calendar year after the date of
service. This reflects a reduction in the maximum prior timely filing
deadline of 15 to 27 months. The current timely filing requirements
will continue to apply to claims for services furnished before January
1, 2010, except CMS is proposing that claims for services furnished
during the last three months of 2009 must be filed no later than
December 31, 2010.
CMS will accept comments on the proposed rule until
August 24, 2010, and will respond to them in a final rule to be issued
on or about November 1, 2010 that sets forth the policies and payment
rates effective for services furnished to Medicare beneficiaries on or
after January 1, 2011.
June
29, 2010 - The Centers for Medicare & Medicaid Services (CMS) issued a
proposed rule on Friday that would implement key provisions in the
Affordable Care Act of 2010 that expand preventive services for Medicare
beneficiaries, improve payments for primary care services, and promote
access to health care services in rural areas. 
Seniors don't need to give personal info to anyone,
checks being mailed automatically to eligible Medicare recipients - June
11, 2010