The Centers for Medicare & Medicaid Services (CMS) Nov. 1 issued its calendar year (CY) 2025 final rules on the following:
1. Final rule for the home health (HH) prospective payment system (PPS) – Changes from this rule go into effect Jan. 1, 2025
- Increase net HH payments by an estimated $85 million (0.5%) in CY 2025, relative to CY 2024, based upon:
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- A 3.2% market basket increase, reduced by a 0.5% productivity adjustment.
- A 1.8% behavioral adjustment reduction is designed to achieve budget neutrality under the transition to the Patient-driven Groupings Model (PDGM).
- An adjustment to the fixed-dollar loss ratio for outlier payments which will result in an estimated 0.4% decrease in payments.
- Adopt new core-based statistical areas (CBSAs) for wage indexes.
- Require HH agencies (HHAs) to report four new patient assessment items in the HH agency Outcome and Assessment Information Set (OASIS) under the social determinants of health category beginning with CY 2027.
- Add a new standard within the Medicare Conditions of Participation (CoP) that will require HH agencies to develop, implement and maintain a patient acceptance to service policy that is consistently applied to each prospective patient referred for home health care.
- Adopt requirements for long-term care (LTC) facilities to report certain data related to respiratory elements as part of their infection control programs.
2. Final rule that will update physician fee schedule (PFS) payments – The rule also includes policies related to the Medicare Shared Savings Program (MSSP) and the Quality Payment Program (QPP), both of which were created by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Additionally, the rule includes policies related to the Medicare Prescription Drug Inflation Rebate Program and Medicare Parts A and B overpayment provisions of the Affordable Care Act.
- Reduce the PFS conversion factor by 2.8% in CY 2024 compared to CY 2025, which reflects the expiration and removal of the 2.93% statutory payment increase for CY 2024, a 0.00% conversion factor update and a budget-neutrality adjustment.
- Extend certain telehealth waivers through CY 2025, including the waiver allowing for reporting of enrolled practice addresses instead of home addresses when providers perform services from their homes.
- Codify items originally outlined in the revised guidance documents for the Part B Drug Inflation Rebate Program and the Part D Drug Inflation Rebate Program, and create new policies for the inflation rebate program.
- Revise the data reporting period and phase-in of payment reductions for clinical laboratory tests under the Clinical Laboratory Fee Schedule per statutory requirements.
- Suspend the 60-day deadline for reporting and returning Medicare Parts A and B overpayments under certain circumstances to allow time for providers to investigate and calculate overpayment.
- Exclude suspected anomalous spending from financial calculations for the MSSP.
- Revise the MSSP quality measure set and streamline reporting options.
- Add five new Merit-Based Incentive Payment System (MIPS) Value Pathways for CY 2025.
3. Final rule – Outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) – The rule increases OPPS rates by a net 2.9% in CY 2025 compared to CY 2024. The policies and payment rates in the rule will generally take effect on Jan. 1, 2025.
- Increase Medicare hospital OPPS rates by a net 2.9% in CY 2025.
- Pay separately for diagnostic radiopharmaceuticals with per-day costs above $630.
- Exclude qualifying cell and gene therapies from comprehensive ambulatory payment classification (C-APC) packaging.
- As required by law, implement temporary additional payments for certain non-opioid treatments for pain relief dispensed in the hospital outpatient department (HOPD) and ASC settings.
- Adopt three measures related to health equity for the Outpatient, ASC and Rural Emergency Hospital (REH) Quality Reporting Programs (QRP) and extend voluntary data reporting for two hybrid measures in the Inpatient Quality Reporting Program.
- Establish a new Condition of Participation (CoP) for hospitals and critical access hospitals (CAHs) offering obstetrical services, and update quality assessment performance improvement (QAPI), emergency services and discharge planning CoPs.
- Cover and pay for HIV Pre-Exposure Prophylaxis (PrEP) drugs and related services in HOPDs as additional preventive services under the OPPS.
