Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) proposed rule advances CMS’ commitment to increasing competition

As directed by President Trump’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors, CMS is proposing several policies that would give Medicare beneficiaries more choices in where they seek care and lower their out-of-pocket costs for surgeries. The proposed rule takes steps that would allow hospitals and ambulatory surgical centers to operate with better flexibility and patients to have what they need to make informed decisions on where they receive care.

“President Trump’s mandate is to put patients and doctors back in charge of health care,” said CMS Administrator Seema Verma. “Following through on that mandate entails loosening the stranglehold of government control that has accumulated over decades. Surgeries can be expensive. Patients should have as many options as possible for lowering their costs while getting quality care. These proposed changes, if finalized, would do exactly that, help put patients and doctors back in the driver’s seat and in a position to make decisions about their own care.”

For patients having surgery, hospital outpatient departments are subject to the same quality and safety standards as inpatient settings under Medicare rules. With this in mind, for 2021, CMS proposes to expand the number of procedures that Medicare would pay for in the hospital outpatient setting by eliminating the “Inpatient Only list,” which includes procedures for which Medicare will only make payment when performed in the hospital inpatient setting. This proposed change would remove regulatory barriers to give beneficiaries the choice to receive these services in a lower cost setting and convenience to go home as early as the same day after a procedure, when their clinician decides such a setting is appropriate. CMS would phase-in this proposal over three years and would gradually allow over 1,700 additional services to be paid when furnished in the hospital outpatient setting. In 2021, approximately 300 musculoskeletal services (such as certain joint replacement procedures) would be newly payable in the hospital outpatient setting. The proposed change would be the largest one-time reduction to the Inpatient Only list by far; from 2017 through 2020, approximately 30 services total were removed from the Inpatient Only list.

Medicare pays for most services furnished in ASCs at a lower rate than hospital outpatient departments. As a result, when receiving care in an ASC rather than a hospital outpatient department, patients can potentially lower their out-of-pocket costs for certain services. For example, for one of the most common cataract surgeries, currently, on average, a Medicare beneficiary pays $101 if the procedure is done in a hospital outpatient department compared to $51 if done in a surgery center.

CMS proposes to expand the number of procedures that Medicare would pay for when performed in an ASC, which would give patients more choices in where they receive care and ensure CMS does not favor one type of care setting over another. For CY 2021, we propose to add eleven procedures that Medicare would pay for when provided in an ASC, including total hip arthroplasty. Since 2018, CMS has added 28 procedures to the list of surgical services that can be paid under Medicare when performed in ASCs.

Additionally, we propose two alternatives that would further expand our goals of increasing access to care at a lower cost. Under the first alternative, CMS would establish a process where the public could nominate additional services that could be performed in ASCs based on certain quality and safety parameters. Under the other proposed alternative, we would revise the criteria used to determine the procedures that Medicare would pay for in an ASC, potentially adding approximately 270 procedures that are already payable when performed in the hospital outpatient setting to the ASC list. Under this alternative, we solicit comment on whether the ASC conditions for coverage (the baseline health and safety requirements for Medicare-participating ASCs) should be revised given the potential for a significant expansion in the nature of services that would be added under this alternative proposal.

As part of the Trump Administration’s commitment to lowering drug prices, CMS is proposing a change that would lower beneficiaries’ out-of-pocket drug costs for certain hospital outpatient drugs. In 2018 and 2019, CMS implemented a payment policy to help beneficiaries save on coinsurance for drugs that were administered at hospital outpatient departments and acquired through the 340B program, which allows certain hospitals to buy outpatient drugs at lower costs. Due to CMS’ policy change, which was recently upheld by the United States Court of Appeals for the D.C Circuit, Medicare beneficiaries now benefit from the steep discounts that 340B-enrolled hospitals receive when they purchase drugs through the 340B program.

For 2021, CMS would provide even larger discounts for beneficiaries by proposing to further reduce the payment rate for drugs purchased through the 340B Program based on hospital survey data on drug acquisition costs. CMS is proposing to pay for 340B acquired drugs at average sales price minus 28.7 percent. With this proposed change, CMS estimates that, in 2021, Medicare beneficiaries would save an additional $85 million on out-of-pocket payments for these drugs and that OPPS payments for 340B drugs would be reduced by approximately $427 million. The savings from this change would be reallocated on an equal percentage basis to all hospitals paid under the OPPS. We propose that children’s hospitals, certain cancer hospitals, and rural sole community hospitals would continue be excepted from these drug payment reductions. In the alternative, and in light of the court’s recent decision, we propose to continue our current policy of paying ASP minus 22.5% for 340B drugs.

In continuing the agency’s Patients Over Paperwork Initiative to reduce burden for health care providers, CMS is proposing to establish, update, and simplify the methodology to calculate the Overall Hospital Quality Star Rating (Overall Star Rating) beginning with CY 2021. The Overall Star Rating summarizes a variety of quality measures published on the Medicare.gov Hospital Compare tool for common conditions that hospitals treat, such as heart attacks or pneumonia. Along with publicly reported data on Hospital Compare, the Overall Star Rating helps patients make better informed health care decisions.

Responding to stakeholder feedback about the current methodology used to calculate the Overall Star Rating, CMS is proposing revisions on how to calculate the ratings and grouping hospitals in the Readmission measure group by the hospital’s percentage of patients who are dually enrolled in Medicare and Medicaid, which would help provide better insight on health disparities. These and other proposed changes are intended to reduce provider burden, improve the predictability of the star ratings, and make it easier to compare ratings between similar hospitals.

As part of the agency’s Rethinking Rural Health Initiative, in the FY 2020 Inpatient Prospective Payment System (IPPS) final rule, CMS increased the wage index for certain low wage index hospitals for at least four years, beginning in FY 2020. In the CY 2020 OPPS/ASC Payment System final rule, CMS adopted changes to the wage index for outpatient hospitals as were finalized in the FY 2020 IPPS final rule, including the increase in wage index for certain low wage index hospitals. The OPPS wage index adjusts hospital outpatient payment rates to account for local differences in wages that hospitals face in their respective labor markets. For 2021, under the OPPS, CMS proposes to continue to adopt the IPPS post-reclassified wage index, including the wage index increase for certain low wage index hospitals. The increase would address a common concern that the current wage index system contributes to disparities between high and low wage index hospitals. Overall, CMS estimates that payment for outpatient services in rural hospitals across the country would increase by 3 percent, which is 0.5 percent higher than the national average increase of 2.5 percent.

For More Information:

• Proposed Rule
• Fact Sheet

As we prepare to release the 2021 Assister Certification Training, the 2020 Assister Certification Training that is hosted on the Marketplace Learning Management System (MLMS), will be taken offline at 6:00 p.m. (ET) on August 28, 2020.  During this “go-dark” period, assisters will not be able to access the certification training.  We anticipate that the 2021 Assister Certification Training will be available later this summer.

Assisters who need to take the current training before the 2021 training is available should complete the 2020 Assister Certification training prior to its removal on August 28.

Please note: this is training for assisters in the Federally-facilitated Marketplace, and assisters in State-based Marketplace  or State-based Marketplace using the Federal platform should follow their state’s training and certification requirements.

Health Outreach Partners, a HRSA-funded National Training and Technical Assistance Partners (NTTAP), created this free, downloadable publication, Value-Based Care: A Primer for Outreach and Enabling Services Staff, to introduce value-based care and incentive payments to outreach and enabling services staff at community health centers. It describes the role of value-based care in outreach and provides specific examples of value-based care models and the relevance to health center outreach and enabling services staff.

The Pennsylvania Insurance Department, in partnership with the Pennsylvania Health Insurance Exchange Authority, received authorization to operate a Reinsurance Program under section 1332 of the Affordable Care Act, also known as a State Relief and Empowerment waiver, from 2021 through 2025. The reinsurance program will reduce premiums for consumers on the marketplace by approximately 5-10 percent for plan year 2021 and increase affordability and access to quality coverage. Reinsurance programs provide a direct benefit to consumers by paying a portion of provider claims that would normally be paid by consumers through higher premiums.

Legislation that increases transparency and consumer choice in the prescription drug marketplace is now law. HB 943 (Act 67) ends the long-standing “gag clause” imposed on pharmacists, barring them from informing customers of lower-cost alternatives at the pharmacy counter. Such a prohibition stems from language contained in some pharmacy contracts that disallows pharmacists from disclosing any information to their customers that could potentially reduce their out-of-pocket costs for medications. The bill was signed into law July 23 and becomes effective in 60 days.

On July 23, Gov. Wolf signed HB 672 (Act 65 of 2020) into law repealing provisions related to mental health treatment and release of medical records and adding new language providing for consent for voluntary inpatient and outpatient mental health treatment and for release of medical records. The law enables certain minors to consent to medical, dental and health services, declaring consent unnecessary under certain circumstances. The changes become effective in 60 days.

The Pennsylvania Department of Human Services (DHS) reported on July 16, 2020, that it will allow additional Medicaid providers to enroll as an opioid use disorder Center of Excellence (COE). Providers who enroll in the Medicaid program as a COE will be eligible to bill managed care organizations (MCOs) for care management services. DHS will continue to monitor the COE care model to ensure that new providers are meeting the standards. For more information, see related article above on PACHC’s call on this OUD-COE opportunity. Access the DHS Opioid Use Disorder Centers of Excellence Bulletin & Application.