In the hospital Outpatient Prospective Payment System (OPPS) and Physician Fee Schedule (PFS) proposed rules released early this month, CMS continues to make health equity and Health Related Social Needs (HRSN) a top priority. In OPPS, CMS is proposing new Conditions of Participation (CoP) for obstetrical and emergency services, as well as adopting the same quality measures on HRSN that currently exist in the inpatient setting for outpatient care. In PFS, CMS is proposing changes to several telehealth policies and adding a Health Equity Benchmark Adjustment for the Medicare Shared Savings Program (MSSP). In both proposed rules, CMS proposes aligning the definition of “custody” with the Social Security Act to expand access to formerly incarcerated individuals.

Outpatient Prospective Payment System:

Maternal Health

Proposes new Conditions of Participation (CoP) for hospitals and Critical Access Hospitals (CAH) providing OB services outside of the emergency department. The rule would establish new baseline standards for staffing, organization, and delivery of care.

As part of the new CoP, CMS is proposing updates to the Quality Assessment and Performance Improvement measures. Facilities offering OB services will need to identify areas of improvement for staff trainings and be able to demonstrate that the staff not only completed but also understood the training.

Hospital Outpatient Quality Reporting Program

CMS proposes to add three new quality measures relating to health equity within the OQR program that had been previously adopted within other Medicare quality reporting programs, including the Hospital Inpatient Quality Reporting (IQR) program.:

  • Hospital Commitment to Health Equity (HCHE) measure, beginning with the CY 2025 reporting period/CY 2027 payment determination
  • Screening for Social Drivers of Health (SDOH) measure, beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination
  • Screen Positive Rate for Social Drivers of Health (SDOH) measure, beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination

Physician Fee Schedule

Telehealth

For CY 2025, CMS is proposing to add more services to the Medicare Telehealth Services List on a provisional basis, including caregiver training and home INR monitoring; and for permanent status, Pre-Exposure Prophylaxis (PrEP) for HIV.

Also proposed: permanently allowing supervising practitioners to supervise certain services virtually, and continuing to allow teaching physicians to have virtually supervise services furnished by residents when those services are provided virtually (e.g. a three-way telehealth visit) through CY 2025. One of the most significant proposals is that CMS is changing the definition of “interactive communication system” to allow audio-only for any service delivered via telehealth. For a detailed summary of all the telehealth proposals, click here.

Medicare Shared Savings Program

Citing experiences within the ACO REACH model, CMS is proposing to establish a Health Equity Benchmark Adjustment (HEBA) to support ACOs in underserved communities. This adjustment would be based on the proportion of an ACO’s beneficiaries who are either enrolled in the Medicare Part D Low-Income Subsidy or who are eligible for dual enrollment in Medicare and Medicaid. CMS proposes that the adjustment apply to an ACO’s historical benchmark using the highest of three values: a positive regional adjustment, prior savings adjustments, or the HEBA.

Request for Information (RFI) on Health-Related Social Needs

In the RFI, CMS is seeking recommendations for potential policy refinements to the Community Health Integrations (CHI) services, Principal Illness Navigation (PIN) services, and Social Determinants of Health (SDOH) Risk Assessments’ payments. For example, what other certification and training requirements should be captured in the current coding and payment, how to improve utilization of these services in rural communities, and how these codes are being furnished in conjunction with community-based organizations.

OPPS and PFS

In both proposed rules, CMS plans to align the definition of “custody” with the Social Security Act’s definition, which excludes individuals on parole, probation, or home detention who would otherwise be ineligible for Medicare. Along with this definition update, CMS plans to initiate a special enrollment period for formerly incarcerated individuals to enroll in Medicare. By aligning the definitions, this would increase access to care to individuals who are no longer incarcerated but unable to access health care services due to lack of coverage.