Issue Brief

CMS’ Proposed 2025 PFS Rule Would Cut Overall Payments by 2.8%

In its proposed rule for the calendar year (CY) 2025 physician fee schedule, the Centers for Medicare & Medicaid Services recommends reducing the conversion factor by 2.8% to $32.36 in CY 2025, compared with $33.29 in CY 2024. This change reflects the expired 2.93% statutory payment increase for CY 2024; a 0.00% conversion factor update under the Medicare Access and Children’s Health Insurance Program Reauthorization Act; and a .05% budget-neutrality adjustment.

Proposed New Behavioral Healthcare Services

Released July 10, the lengthy rule includes these proposals to improve payment for and access to behavioral healthcare services:

• For people determined to have elevated suicide or overdose risk, a new payment for safety planning interventions and post-discharge follow-up contacts;

• New digital tools payment for:
  • Post-discharge telephonic follow-up;
  • Software devices that treat a mental health condition in conjunction with ongoing treatment; and

• Extending evaluation and management services payment to allow clinical psychologists, clinical social workers, marriage and family therapists, and mental health counselors to conduct interprofessional consultations among themselves, as well with psychiatrists and other physicians.

Proposed Payment Updates by Specialty

Table 128 in the proposed rule lists these and other proposed updates by specialty:

• +3.0% for clinical psychologists;
• +1.0% for psychiatrists;
• +4.0% for clinical social workers;
• +1.0% for family practice physicians;
• +1.0% for internal medicine physicians; and
• No change for nurse practitioners.

Opioid Treatment Programs (OTPs)

Telehealth Extended for Methadone Treatment
Regarding methadone treatments, CMS proposes extending current telehealth flexibilities permanently for periodic assessments and initiation of treatment. For beneficiaries lacking permanent access to two-way audio-video communications technology, CMS would allow periodic assessments to be furnished via audio-only communications when applicable requirements are met. To support this proposal, CMS cites evidence that audio-only visits produce many of the same benefits as video-based visits. The rule also notes that this provision would advance the agency’s health equity goals.

For initiation of treatment with methadone for any new patient, audio-visual telehealth may be used if an OTP can conduct an adequate evaluation of the patient. Audio-only telehealth is not permitted. Such telehealth evaluations would use OTP intake add-on code (HCPCS code G2076) and must comply with the Drug Enforcement Administration, the Substance Abuse and Mental Health Services Administration (SAMHSA), and other requirements. These OTP provisions also are intended to align with SAMHSA’s goals for reducing barriers to access.

Payment for Patient Intakes
The rule proposes payment updates for intake activities (HCPCS code G2076) by OTPs, which align with recent SAMHSA reforms to advance patient-centered and evidence-based paradigms of care for Opioid Use Disorder (OUD) treatments such as harm-reduction interventions and recovery support services. Specifically, the rule would implement payment for social determinants of health risk assessments (HCPCS code G0136) to identify unmet health-related social needs or the need for OUD-related harm-reduction interventions and recovery support services. In addition, CMS seeks feedback on how OTPs currently coordinate care and make referrals to community-based organizations that address unmet Health Related Social Needs (HRSNs), provide harm-reduction services, and/or offer recovery support services.

Opioid Agonist and Antagonist Medications
CMS proposes to establish payment for new opioid agonist and antagonist medications that the U.S. Food and Drug Administration approved recently. Specifically, the rule would create a new add-on code to the bundled payment to reflect take-home supplies for nalmefene hydrochloride (nalmefene) nasal spray (Opvee®). The agency also proposes paying for a new extended-release injectable buprenorphine product (Brixadi®), indicated to treat moderate to severe OUD using a new weekly bundled payment code to reflect the weekly formulation of Brixadi®. In addition, the rule would update payment for the existing bundled payment for monthly injectable buprenorphine (HCPCS G2069) in order to reflect payment for the monthly formulation of Brixadi®. CMS’ goals for these changes are to help prevent additional opioid overdose deaths, reduce illicit opioid use, and retain more individuals with an OUD in treatment.

Billing Clarification
The rule also clarifies that for billing, an OUD diagnosis code is required on claims submitted under the Medicare OTP benefit, which helps ensure that payments for Part B OTP services are for the treatment of OUD.

Additional Telehealth Proposals

Permanent Expansion of Audio-only Telehealth
CMS proposes to permanently expand the allowable forms of telehealth “interactive telecommunications systems” to include audio-only communication technology if the patient is not capable of, or does not consent to, the use of video technology.

Temporary Telehealth Expansions
In addition, CMS is proposing temporary changes for the use of audio-visual (not audio-only) telehealth for the purpose of physician/practitioner supervision. Specifically, the rule would expand through CY 2025 the allowance for supervising practitioners to be “immediately available” through audio-visual telehealth. In addition, for CY 2025 only, teaching physicians could continue to supervise audio-visual telehealth services furnished by residents in all teaching settings, such as through a 3-way telehealth visit. Also for CY 2025, the agency will continue to permit physicians to use their currently enrolled practice location instead of their home address when providing telehealth services from home.

The rule also extends through CY 2025 the pandemic-originating coverage of telehealth services provided by federally qualified health centers and rural health clinics. This extension also includes the waiver allowing for reporting of enrolled practice addresses, rather than home addresses, when providers perform services from their home, and the waiver for virtual supervision for residents in all teaching settings when the services are provided virtually.

NABH is displeased that beginning Jan. 1, 2025 – in compliance with federal law – the rule repeals crucial telehealth flexibilities that would subject most digital care to pre-pandemic regulations.

Permanent Audio-visual Telehealth for Low-Risk Services
For services furnished after December 2025, CMS proposes that physician/practitioner oversight via audio-visual telehealth shall be limited to services that are “low risk by their nature, do not often demand in-person supervision, and are typically furnished entirely by the supervised personnel.” CMS’ stated goal for approving remote supervision for these particular low-risk services is that they already are known to balance patient safety concerns with the need to expand access and optimize workforce capacity:

• Services with the underlying HCPCS code that has been assigned a PC/TC indicator of ‘5’; and
• Services described by CPT code 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional).

In addition to CMS’ proposed telehealth expansions, Congress is also considering extending telehealth flexibilities beyond this year, most likely through a two-year extension. NABH strongly endorses these flexibilities.

Quality

For reporting in 2025, CMS proposes six new, optional metrics for the quality payment program.

Please see the agency’s news release to read a high-level summary of the rule. CMS will accept comments on the proposed rule through Sept. 9.

The Centers for Medicare and Medicaid Services (CMS) has proposed a hospital-based partial hospitalization program (PHP) payment rate of $228.20 for 2020, up from the 2019 rate of $220.86, in the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System (OPPS/ASC) proposed rule the agency released on July 29.

CMS also proposed an increase for community mental health centers (CMHCs), which could see a payment rate of $124.59 in 2020 if the rule is made final. By comparison, CMHCs received a payment rate of $120.58 in 2019.

The rates set in the proposed CY 2020 rule are not based on the most recent average cost data from the PHP program, a deviation from CMS’ long-standing policy. When CMS calculated the average PHP program cost for the CY 2020 proposed rule, the agency found it had decreased by nearly 15 percent for CMHCs and 11 percent for hospitals-based PHPs.

After finding this decrease, CMS reviewed the data sets and found that a single provider in the CMHC set and a single provider in the hospital-based set had such dramatically lower-reported costs that it significantly skewed the average cost for both data sets.

Because the lower average costs were the result of single providers and could significantly reduce access for beneficiaries, CMS decided to use the CY 2019 cost average as a floor for both type of PHP rates in the CY 2020 rule. If not for this change, the rate for both types of PHPs would have been significantly lower than what CMS proposed in the rule.

It is important to note that CMS stressed that it does not intent to carry this policy forward: “To be clear, this policy would only apply for the CY 2020 rate setting,” the agency said in the rule.

CMS will accept comments on the CY 2020 proposed rule until September 27.

CY 2020 Rates
Level 1 Health and Behavior Services                                                         $28.59
Level 2 Health and Behavior Services                                                         $81.06
Level 3 Health and Behavior Services                                                         $130.27
Partial Hospitalization (3 or more services) for CMHCs                               $124.59
Partial Hospitalization (3 or more services) for Hospital-based PHPs         $228.20

The Centers for Medicare and Medicaid Services (CMS) on Monday issued a proposed rule for establishing a Medicare Part B benefit and payment bundles for opioid use disorder (OUD) treatment services in opioid treatment program (OTP) settings and new HCPCS codes and bundled rates for office-based treatment of OUD.

OTP Bundled Payment

The proposal implements Section 2005 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act.

The rule proposes:

• A definition of OUD treatment services and OTPs, including an explanation that services include access to all FDA-approved medications, counseling and therapy, and toxicology testing;
• Enrollment policies that align with SAMHSA OTP regulation and that do not have additional conditions of participation;
• Bundled payment methodologies that separate drug from non-drug treatment components, account for different medications and variable intensity of services, provide for service add-ons and partial- and full-billing for weekly episodes;
• Use of audio-video communication technology; and
• Zero beneficiary cost-sharing requirement for a time-limited period.

Office-based Care Bundled Payment

The agency also proposed a bundled payment for office-based OUD treatment services, to encourage the expansion of access to OUD care, including:

• Coverage of OUD management, care coordination, psychotherapy, and counseling; medication to be billed and reimbursed under existing Medicare Part B or D; toxicology testing to be billed under Clinical Lab Fee Schedule;
• Bundled payment methodologies that are based on monthly billing cycles to better align with office-based practices; one bundle for the initial month of treatment that is more service-intensive; and a second bundle for subsequent “maintenance months,” service add-on codes, and not restricted to addiction specialists;
• Three new HCPCS codes to Category I of the list of Medicare telehealth services for office-based substance use disorder (SUD)/OUD services, permits a patient’s home as a telehealth originating site; and
• No changes to cost-sharing.

Emergency Departments

Also of interest, the proposed rule requests information on emergency department practice patterns related to the initiation and use of MAT, and referral or follow-up care, for developing such bundles in future rulemaking.

Comments are due September 27, 2019. NABH has engaged a consulting firm to help analyze the proposed bundled payment methodology and payment rates, and the association will submit comments.