Within its proposed CY 2025 Physician Fee Schedule (PFS) rule (the Proposed Rule), CMS is proposing to implement new payment policies intended to advance health equity and support whole-person care. CMS expects these new payment policies will strengthen primary care, expand access to various health care services, and maintain telehealth flexibilities.

CMS is proposing new quality-driven payment policies in an effort to expand access to quality and affordable care. These policies are intended to improve “whole-person care” through various payment and coding initiatives. Dr. Seshamani, a Deputy CMS Administrator, explained that whole-person care is intended to recognize “each unique aspect of a person and their wellbeing, including physical health, behavioral health, oral health, social determinants of health, and caregiving supports.”

Strengthening Primary Care

Under the Proposed Rule, CMS is proposing to implement various new payment and coding initiatives designed to strengthen access to and utilization of comprehensive primary care. CMS is proposing a new, advanced primary care management bundle. This proposed payment bundle uses coding describing certain primary care services that would be provided by advanced primary care teams, with adjustments for patient medical and social complexity to promote health equity. These services would be tied to primary care quality measures to improve patient health outcomes.

CMS also proposes new payment and coding for cardiovascular-focused risk management and cardiovascular disease risk assessment furnished in conjunction with an evaluation and management visit. CMS proposes six new Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) centering around ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care. CMS is also proposing to update the MIPS scoring methodologies and measure inventories to give all clinicians the opportunity to achieve positive scores and continued improvement.

CMS also issued proposals with respect to accountable care organizations (ACOs). Eligible ACOs with a history of success in the Medicare Shared Savings Program will be allowed advances on their earned shared savings, also knowns as prepaid shared savings, in order to encourage investment in staffing, health care infrastructure, and additional services related to nutrition support, transportation, dental, vision, hearing, and Part-B cost-sharing reductions. For ACOs that serve individuals within rural and underserved communities, CMS also proposes a health equity benchmark adjustment similar to the approach utilized by the Innovation Center’s ACO REACH Model for ACOs. CMS is also proposing a methodology to account for the impact of improper payments when reopening an ACO’s shared savings and shared losses calculation.

Expanding Access to Certain Health Care Services

In an effort to expand access to behavioral health, oral health, and caregiver training services, CMS is proposing new payments in the Proposed Rule for the following:

• Practitioners assisting people at high risk of suicide or overdoes, including separate payment for safety planning interventions and post-discharge follow-up contacts;
• Use of digital tools that support the delivery of specific behavioral health treatments;
• In connection with services furnished by Opioid Treatment Programs, FDA-approved medications for the treatment of Opioid Use Disorder (OUD) and known or suspected opioid overdose, increased telecommunication flexibilities for periodic assessments and methadone treatment initiation;
• Intake activities to provide more comprehensive services for the treatment of OUD;
• Certain dental services associated with dialysis treatments for end-stage renal disease; and
• Caregiver training services related to direct care services and supports and allowing caregiver training services to be provided virtually.

Expanding Preventive Services

In an effort to expand coverage of the hepatitis B vaccine, CMS is proposing to provide free hepatitis B vaccines to those individuals who have not received a vaccine or where the vaccination status of the individual is unknown. Under the Proposed Rule, these expanded coverage initiatives will allow individuals to receive hepatitis B vaccines from pharmacies. Pharmacies and mass immunizers will also be allowed to roster bill consistent with the current roster billing process for flu, pneumococcal, and COVID-19 vaccines.

In addition, CMS is proposing to institute a fee schedule for drugs covered as additional preventive service. These drugs are currently not covered by CMS under the benefit category of additional preventative services.

Maintaining Telehealth Flexibilities

Under the Proposed Rule, CMS will maintain certain flexibilities to telehealth services and payments that are otherwise set to expire at the end of the year. For example, CMS is proposing to continue allowing certain practitioners to provide virtual direct supervision to auxiliary personnel when required. CMS is also proposing to continue its current billing and payment policies allowing virtual supervision by teaching physicians for services furnished virtually by residents in all teaching settings (for example, a 3-way telehealth visit, with the patient, resident, and teaching physician in separate locations).

The fact sheet summarizing these new payment and coding rules is available here and the Proposed Rule containing these new policies is available here. Comments are due by September 9, 2024.