On July 13, 2023, the Centers for Medicare & Medicaid Services (“CMS”) issued its proposed rule (the “Proposed Rule”) for the 2024 Medicare Physician Fee Schedule (“PFS”). The Proposed Rule, which was issued in the Federal Register on August 7, 2023, includes updated payment rates, changes to reimbursement for services related to health equity and social determinants of health, increases to payment for cancer care support, and changes to enrollment for mental health providers. CMS projects that the Proposed Rule will lead to growth in the Medicare Shared Savings Program (“MSSP”).
Takeaway Reimbursement Numbers
Pursuant to the Proposed Rule, PFS overall payment rates for 2024 will be 1.25% less than the PFS payment rates for 2023. The proposed PFS conversion factor for 2024 is $32.75, which is $1.14 lower than the 2023 conversion factor of $33.89. Notably, within this overall decrease, CMS is also proposing increases for certain forms of direct patient care, including primary care.
Impact to Health Equity Services
CMS is proposing to pay separately for Community Health Integration and Social Determinants of Health (“SDOH”) Risk Assessment services. This change is meant to account for the utilization of resources when clinicians involve community health workers, care navigators, and peer support specialists in furnishing medically necessary care to their patients. Previously care support staff have been able to serve as auxiliary personnel providing covered services that are incident to services provided by a billing physician or practitioner. The services described by the proposed codes in the Proposed Rule would be the first to describe services involving community health workers, care navigators, and peer support specialists.
Social Determinants of Health
The Proposed Rule includes coding and payment for SDOH risk assessments as well, and this is meant to recognize when practitioners assess SDOH that may impact their ability to treat a patient. There is a SDOH risk assessment that would be added to the annual wellness visit as an optional, additional element with an additional payment. Separately, there are codes and payment for SDOH risk assessments furnished on the same day as an evaluation and management visit.
Cancer Support
The Proposed Rule includes payment for certain dental services that would occur prior to and during certain cancer treatments, including chemotherapy. CMS is also proposing payment for “Principal Illness Navigation” services that are meant to help patients navigate cancer treatment and treatment for other serious illnesses. Such services can also include care via other peer support specialists, such as peer recovery coaches for individuals with substance use disorder.
Mental Health Care
The Proposed Rule would allow, for the first time, marriage and family therapists and mental health counselors, including addiction counselors, to enroll in the Medicare program and bill for their services. Increased payment for crisis care, substance use disorder treatment, and psychotherapy are also proposed.
Growth of MSSP
CMS projects that the Proposed Rule will increase participation in MSSP by roughly 10% to 20%. This is projected to occur through changes to the beneficiary assignment methodology which are meant to better promote access to accountable care for patients who see nurse practitioners, physician assistants, and clinical nurse specialists for their primary care services. The Proposed Rule also includes changes to the financial benchmarking methodology that is meant to encourage participation by accountable care organizations serving complex populations.
Comments and Deadline
CMS is soliciting public comments on the Proposed Rule and the policy changes included therein. The deadline for submitting comments is 5 p.m. on September 11, 2023.