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February 15, 2024 Anne Dwyer

This month, CMS released an updated State Medicaid and CHIP Telehealth Toolkit consolidating information from previous toolkits and providing additional guidance – as required by the Bipartisan Safer Communities Act – on issues from billing best practices to strategies for using telehealth in schools.

In addition to FAQs on issues such as benefit flexibility, financing, workforce, managed care, and quality reporting, the comprehensive updated toolkit also includes information on strategies for delivering specific services via telehealth to different populations. This includes employing telehealth to improve health equity, delivering services to specific populations, including children and youth, and using telehealth to deliver maternal and behavioral health services.

Highlighted state best practices from the toolkit related to telehealth and behavioral health include:

• Colorado, which has a dedicated website for school-based services that includes procedure codes for telehealth, and allows for the telehealth delivery of certain services including behavioral health.
• Iowa, which has employed targeted promotion of telehealth to members and providers in counties with lower utilization of behavioral health care, including utilization by geography and race/ethnicity to identify and address barriers.
• North Carolina, which during the COVID-19 public health emergency temporarily permitted Medicaid providers to provide perinatal care, maternal support services, and postpartum depression screening via telehealth and in 2023 permanently permitted the use of telehealth for prenatal and postpartum visits.
• Oregon, which leveraged the State Directed Payments Option under managed care to create an enhanced payment rate increase for behavioral health services delivered by culturally- and/or linguistically-specific behavioral health providers, including services delivered via telehealth.

The toolkit also includes strategies for delivering services via telehealth to address behavioral health provider shortages including leveraging Certified Community Behavioral Health Clinics, community-based mobile crisis units, and the Collaborative Care Model with telepsychiatry. For example, the toolkit notes that states may submit a request for a 90/10 enhanced Medicaid match for a number of IT initiatives to support mobile crisis units, including the provision of cell phones or iPads to state-staffed mobile crisis teams to facilitate telehealth with a clinic at another location during a crisis intervention.

The updated toolkit including additional state best practices and strategies as well as other information such as a state checklist, a state Medicaid telehealth assessment/action plan, and telehealth communication strategies can be found here.

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Time is running out for Congress to take action on pending legislation dealing with issues that would help primary care across the United States.

Six physician groups representing 590,000 doctors across the country sent a joint letter again urging congressional leaders to vote – soon – for bills relating to Medicare reimbursements, prior authorizations, children’s health insurance coverage, mental health, telehealth, and aid for resident physicians in primary care.

Time is of the essence, said the Dec. 2 letter by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association, and American Psychiatric Association.

“As we approach the end of the 117th Congress, we urge Congress to act on the important items described below to ensure our patients have access to quality, affordable, and accessible health care,” the letter said.

The issues

The bill: House Resolution (HR) 8800, the Supporting Medicare Providers Act of 2022

The issue: The Medicare Physician Fee Schedule (MFPS)

Physicians, health care administrators, and their supporters hope to avert a 4.42% cut to physician payments scheduled in 2023. Medicare reimbursement involves “a very complex set of budgetary rules and systemic flaws” in the MFPS “that, unless addressed in a comprehensive way, will continue to plague physicians for years to come.” Payment rates are not keeping up with inflation and are not sustainable for physicians to cover basic expenses such as staff salaries, rent, or new technology.

The bill: HR 3173, the Improving Seniors’ Timely Access to Care Act

The issue: The bill would standardize and streamline the prior authorization approval process in the Medicare Advantage program. The bill has passed in the House of Representatives and has at least 43 bipartisan cosponsors in the Senate. Proponents argue the bill would improve health care for seniors by speeding up access, while removing paperwork headaches for physicians and staff.

The issue: Medicaid’s Children’s Health Insurance Program (CHIP)

Medicaid and CHIP cover 42% of all births in the country. When the COVID-19 pandemic public health emergency (PHE) ends, so will coverage for an estimated 5 million children, along with postpartum females. Enacting 12 months of continuous eligibility for them “will ensure that children and new mothers can rely on coverage and will save states the administrative cost associated with churn,” or those who will lose insurance when the PHE ends.

The issue: Mental health care

A comprehensive legislative package must address growing mental health issues and substance use disorder (SUD). Four potential solutions:

• Promote behavioral health services in primary care.
• Strengthen the behavioral health workforce with money for graduate medical education for psychiatric residencies and for loan repayment programs.
• Enhance promotion, prevention, and early intervention with more money for community health and mental health centers and schools.
• Enforce mental health/SUD parity laws.

The issue: Telehealth

Congress should extend Medicare telehealth flexibilities at least to Dec. 31, 2024, including coverage for audio-only services, to ensure access for beneficiaries and financial stability and regulatory clarity for physicians. Medicare telehealth access will continue for 151 days after the end of the COVID-19 PHE, but that limited extension and ambiguity about the end of the PHE leaves physicians and patients in a state of uncertainty.

The issue: Teaching Health Center Graduate Medical Education (THCGME)

Residents who train through THCGME are more likely to focus on primary care and more likely to remain in underserved or rural communities. The program is successful in tackling physician maldistribution, but the medical groups “have grave concerns for the financial stability of programs for the upcoming year.” Flat funding could put programs at risk of closure, the medical groups said.

Recipients

The letter was sent to House Speaker Nancy Pelosi, House Minority Leader Kevin McCarthy, Senate Majority Leader Chuck Schumer, Senate Minority Leader Mitch McConnell; Rep. Frank Pallone and Rep. Cathy McMorris Rodgers of the House Energy & Commerce Committee; Rep. Richie Neal and Rep. Kevin Brady of the House Ways & Means Committee; Sen. Ron Wyden and Sen. Mike Crapo of the Senate Finance Committee; and Sen. Patty Murray and Sen. Richard Burr of the Senate Health, Education, Labor, & Pensions Committee.

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The CMS Behavioral Health Strategy covers multiple elements including access to prevention and treatment services for substance use disorders, mental health services, crisis intervention and pain care; and further enable care that is well-coordinated and effectively integrated.

The CMS Behavioral Health Strategy also seeks to remove barriers to care and services, and to adopt a data-informed approach to evaluate our behavioral health programs and policies. The CMS Behavioral Health Strategy will strive to support a person’s whole emotional and mental well-being and promotes person-centered behavioral health care.

CMS Behavioral Health Strategy: Goals, Objectives and Supporting Activities

Goal 1: Strengthen Equity and Quality in Behavioral Health Care

Objectives:

• Reduce disparities in health and health care among individuals CMS serves to improve access to high quality, affordable, person-centered behavioral health care, and ensure parity in access, coverage, and quality for physical and mental health services, including care enabled through telehealth and technology.
• Incorporate Health Equity into new care and payment models and optimize whole-person care for beneficiaries with and at risk of behavioral health conditions.
• Provide Effective Outreach and Education on CMS’s behavioral health services to inform beneficiaries, caregivers and providers utilizing culturally and linguistically appropriate materials that meet the needs of individuals with low literacy, low health literacy, and limited-English proficiency.
• Improve Quality Measurement in behavioral health and pain management across CMS programs.
• Consider Quality and Equity Implications across all objectives of the CMS Behavioral Health Strategy to ensure both underpin the CMS approach to improving substance use disorder services, pain management, behavioral health services and supports, and data and measurement.

Supporting Activities:

• Quality Measurement:  CMS uses quality measures across health care to drive health systems, providers, practices and clinicians, and community-based providers toward delivery of high value care for people covered by Medicare, Medicaid and private health insurance.
  • CMS released Final Report that summarizes National Quality Forum convened technical experts’ consideration of issues related to acute and chronic pain management and substance use disorders
  • CMS maintains the CMS Quality Measures Inventory which is a compilation of measures used by CMS in various quality, reporting and payment programs, including those measures for behavioral health to include depression, suicide risk and alcohol use.
  • include depression, suicide risk and alcohol use.
• Health Equity: CMS is advancing health equity and addressing disparities in opioid use disorders (OUD) treatment. CMS recently released:
  • Access to Medication for Opioid Use Disorder (MOUD) Among Medicare Fee-for-Service Beneficiaries: Influence of CARES Act Implementation (2020) (PDF)which looks at access to medication treatment for Medicare beneficiaries diagnosed with opioid use disorder before and after COVID-19 telehealth expansion; and
  • Changes in Access to Medication Treatment during COVID-19 Telehealth Expansion and Disparities in Telehealth Use for Medicare Beneficiaries with Opioid Use Disorder (PDF) which compares access to medication treatment for Medicare beneficiaries diagnosed with opioid use disorder before and after COVID-19 telehealth expansion was implemented.

Goal 2: Improve access to substance use disorders prevention, treatment and recovery services

Objectives

• Improve the Care Experience for beneficiaries and consumers with substance use disorders and increase strategic opportunities for enhanced access to high quality, affordable, whole-person care.
• Identify and Address Barriers that impede access for people with or at risk of substance use disorders to evidence-based treatment and recovery services for better detection, diagnosis, and management of such conditions.
• Strengthen Treatment and Recovery Services through innovative care and payment models, and dissemination of promising and best practices.
• Expand workforce capacity across provider types, including exploring options for training of residents and clinicians in the detection, diagnosis and management of substance use disorders.

Supporting Activities

• Report to Congress (PDF): Summary of Review and Recommendations for the Medicare and Medicaid Programs to Prevent Opioid Addictions and Enhance Access to Medication-Assisted Treatment with a CMS Action Plan (PDF) on suggested improvements to substance use disorders and pain care in Medicare and Medicaid. 
• Medicaid 1115 Substance Use Disorders Demonstrations -CMS created an opportunity under the authority of section 1115(a) of the Social Security Act (Act) for states to demonstrate and test flexibilities to improve the continuum of care for beneficiaries with substance use disorders (SUDs).  CMS created similar flexibility to test more comprehensive approaches to care for beneficiaries with serious mental illness (SMI) or serious emotional disturbance (SED). The states listed on this page have section 1115(a) demonstration programs approved in accordance with these new opportunities to address particular challenges raised the overdose crisis.
• Opioid Treatment Programs – CMS covers Opioid Treatment Programs through bundled payments for opioid use disorder treatment services in an episode of care provided to people with Medicare Part B. 
• Innovative Models – CMS’s Innovation Center is testing models to improve behavioral health care and improve quality while reducing cost, including the Integrated Care for Kids Model, which aims to meet physical and behavioral health needs in children, and the Value in Treatment Model, to increase access to OUD services and improve health outcomes in people with OUD.

Goal 3:  Ensure effective pain treatment and management

Objectives

• Improve the care experience for individuals with acute and chronic pain to identify strategic opportunities for enhanced access to high quality, equitable, affordable whole-person care.
• Expand access to evidence-based treatments for acute and chronic pain, including through guidance to states, exploration of new coverage pathways, and sharing practices that ensure individualized, effective care.
• Increase coordination between primary and specialty care through payment episodes, incentives, and care and payment models.
• Expand workforce capacity and capability including options for training residents and clinicians in the diagnosis and management of acute and chronic pain.

Supporting Activities

• CMS recognizes the impact of pain across its programs and has released the Chronic Pain Experience Journey Map to highlight the most prominent barriers experienced by people accessing care and the influencers acting on providers, ultimately affecting the person with chronic pain, their quality of care, and their quality of life. 
• CMS released a Final Report that summarizes National Quality Forum convened technical experts’ consideration of issues related to acute and chronic pain management and substance use disorders as part of the SUPPORT Act Section 6093.
• CMS is working with its HHS partners to prepare a Report to Congress that will contain key information about acute and chronic pain, help in understanding the current landscape of pain relief options for Medicare beneficiaries, and inform decisions about payment and overage for pain management interventions. 

Goal 4:  Improve access and quality of mental health care and services

Objectives

• Increase detection, effective management and/or recovery of mental health conditions through coordination and integration between primary and specialty care providers.
• Expand access to community-based mental health services and resources such as peer supports, community health workers, housing, home and community-based services, and social supports.
• Mitigate the adverse effects of emergencies and disasters such as the COVID-19 pandemic on the mental health of beneficiaries, consumers, and care providers.
• Expand workforce capacity and capability including exploring options for training of residents and clinicians in the detection, diagnosis and management of mental disorders.

Supporting Activities

• Medicaid Community-Based Mobile Crisis Services – CMS has launched community-based mobile crisis intervention services for people with Medicaid, helping states integrate these services into their programs – a critical component in establishing a sustainable and public health-focused support network.  In 2021, CMS awarded $15 million in planning grants to 20 states to support development of these crisis intervention services.
• Connecting Kids to Coverage – The Connecting Kids to Coverage Campaign launched a Mental Health Initiative to share information on the Medicaid and the Children’s Health Insurance Program (CHIP) and coverage of essential mental and behavioral health services for children and youth.
• Certified Community Behavioral Health Clinics (CCBHC’s)– CCBHCs are part of a comprehensive effort to integrate behavioral health with physical health care, increase consistent use of evidence-based practices, and improve access to high quality care for people with mental health and substance use disorders.
• Medicare and Behavioral Health– Medicare covers many behavioral health services (PDF) to include depression screening, psychological tests, alcohol screening and counseling, and treatment for substance use disorders. Medicare also covers the Annual Wellness Visit with no deductible.

Goal 5:  Utilize data for effective actions and impact on behavioral health

Objectives

• Evaluate the CMS Behavioral Health Strategy across Medicare, Medicaid, the Children’s Health Insurance Program and private health insurance including equity and quality; supplement evaluation with external data sources where necessary.
• Build on and Support Cross-Departmental & Interagency Collaborations related to data such as the HHS Behavioral Health Coordinating Council actions, Agency Priority Goals, and other federal partnerships.
• Support evidence generation and research through enhanced access to high quality data that improves health outcomes.

Supporting Activities

• Medicaid Substance Use Disorders Data – CMS released the third annual Substance Use Disorder (SUD) Data Book with data on Medicaid beneficiaries treated for any SUD, and the services they received. An interactive T-MSIS SUD Data Book data analytics interactive tool has static display of information in the Report.
• Mapping Medicare Disparities Tool – CMS has designed an interactive map, the Mapping Medicare Disparities Tool, to identify areas of disparities between subgroups of Medicare beneficiaries (e.g., racial and ethnic groups) in health outcomes, utilization, and spending. The tool includes options to search for depression, psychotic disorders and dementia.

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The Centers for Medicare & Medicaid Services (CMS) finalized new rules aimed at expanding access to behavioral health for Medicare beneficiaries.

On Tuesday, CMS announced it finalized rules that allow for greater flexibility in billing and supervising certain types of providers as well as permanently covering some telehealth services provided in Medicare beneficiaries’ homes.

They appear to largely be in line with the proposed rules released by the federal health care regulator. CMS released the proposed rules for the 2023 Physician Fee Schedule and the 2023 Hospital Outpatient Prospective Payment System in July.

All in all, these rules are meant to realize the Biden administration’s unity agenda and the U.S. Health and Human Services Department’s Roadmap to Behavioral Health Integration.

“Access to services promoting behavioral health, wellness, and whole-person care is key to helping people achieve the best health possible,” CMS Administrator Chiquita Brooks-LaSure said in a news release. “The Physician Fee Schedule final rule ensures that the people we serve will experience coordinated care and that they have access to prevention and treatment services for substance use, mental health services, crisis intervention, and pain care.”

Medicare Physician Fee Schedule final rule

The final rule for the physician fee schedule will authorize providers to bill for services provided by licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs). CMS created an exception to allow for these providers to bill under general supervision of a physician or non-physician practitioner, rather than direct supervision.

The final physician fee schedule rule also clarifies that any mental health or substance use disorder (SUD) treatment service is provided by and billed under general supervision.

In practical terms, this new rule would no longer require supervising clinicians to be on-site for certain behavioral health services to be billable to Medicare. Thus, it would be easier for Medicare beneficiaries to see these providers.

In 2024, CMS will address payments for new codes that describe “caregiver behavioral management training,” according to a fact sheet.

On the SUD front, Medicare will pay opioid treatment programs (OTPs) to start medication-assisted treatment (MAT) with buprenorphine via telehealth. OTPs may also bill for opioid treatment provided through mobile units.

CMS also created new codes for general behavioral health integration that tracks services provided by clinical psychologists and licensed clinical social workers in primary care settings. A psychiatric diagnostic evaluation may serve as the initiating visit for the new general BHI service, according to a news release.

Hospital Outpatient Prospective Payment System final rule

The final rule for the outpatient prospective payment system makes permanent a public health emergency era flexibility that allows hospital outpatient departments to bill for in-home telebehavioral health services.

It also requires that patients have an in-person visit within 6 months before the telehealth visit and again every 12 months thereafter. The rule allows for exceptions to the in-person requirement if patients and providers “agree that the risks and burdens of an in-person service outweigh the benefits of it,” a fact sheet states.

It also permits audio-only visits when a beneficiary isn’t able to use two-way audio and video technology.

Not included in the proposed rule, the outpatient prospective payment system final rule that new Healthcare Common Procedure Coding System (HCPCS) codes for telehealth will be recognized as partial hospitalization program (PHP) services.

A hospital may bill for non-PHP outpatient services furnished to a PHP patient such as therapy. But hospitals may not bill them as PHP services but will be required to comply with documentation requirements that apply to PHP patients.

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COVID-19 has exacerbated the nation’s struggle with mental health and substance use disorders (collectively called “behavioral health conditions”), fueling a full-blown crisis. For some Americans during the pandemic, this has meant feeling depressed and hopeless, making it challenging for them to perform everyday tasks. For older Americans and people with disabilities who may have already felt socially isolated, the pandemic has made it even harder to connect with family and friends. And for many people with substance use disorders, it has led to higher substance use, dangerous overdoses and even death, including suicides.

As doctors, we’ve seen firsthand how quality, affordable, and timely behavioral health care can be life changing. From urgently taking a woman to the operating room because a needle broke off into her neck while injecting drugs, to providing care to a man whose alcohol consumption caused him to develop liver disease and vomit blood, we have seen the central role of behavioral health care in keeping people healthy and saving lives.

To ensure that every American gets the behavioral health care they deserve, President Biden announced a strategy to address our national mental health crisis as part of the Administration’s Unity Agenda. Earlier this year, CMS issued our own Behavioral Health Strategy, seeking to adopt a data-informed approach that removes barriers to care and services and promotes person-centered behavioral health care, including emotional and mental wellbeing. With almost $1 trillion in claims and covering more than 63 million Americans, Medicare plays a critical role in implementing this strategy as evidenced by a series of new behavioral health policies in CMS’ recently finalized CY 2023 Physician Fee Schedule  and Outpatient Prospective Payment System rules.

Mobilizing the Behavioral Health Workforce

To start, we know that to help combat the behavioral health crisis in our country, we must mobilize the behavioral health workforce. So, we are finalizing changes to the Medicare program to ensure that behavioral health practitioners across the country can practice to the full extent of their license. We are creating an exception to supervision requirements, allowing marriage and family therapists, licensed professional counselors, addiction counselors, certified peer recovery specialists, and others to provide behavioral health services while being under general supervision rather than “direct” supervision. Practically speaking, this means that these behavioral health practitioners will be able to provide services without a doctor or nurse practitioner physically on site, expanding access to behavioral health services like counseling and cognitive behavioral therapy in additional communities, particularly rural or underserved communities where care can be hard to find.

We will also pay psychologists and social workers to help manage behavioral health needs as part of the primary care team, in addition to on their own, because it can be easier for a person to get behavioral health care like psychotherapy when the care is coordinated through their primary care provider. And we are making permanent one of our policies during the public health emergency to allow clinical staff of hospital outpatient departments to provide remote behavioral health services to patients in their homes, expanding access to behavioral health services for rural and other underserved communities.

Additionally, we want to mobilize the behavioral health workforce by giving them the ability to connect with people in different ways. For example, we know that sometimes people need significant care for their behavioral health condition, but rather than resorting to hospitalization, many people can benefit from intensive management in community settings. We received robust feedback from the public on a request for information regarding how Medicare should think about covering these services, and will take the feedback into consideration for future policies.

Making Care More Effective

Alongside mobilizing the behavioral health workforce, we need to make sure that these professionals are working in the most effective way. This means working in teams and making sure that behavioral health is integrated with other aspects of health care. Paying psychologists and social workers to help manage behavioral health needs as part of the primary care team is just one example of how we can encourage integrated care. We also want to ensure that people get access to comprehensive care for their chronic pain, which is something that affects more than 20% of Americans and can be debilitating. Medicare has not historically recognized the team-based approach to pain management and treatment — including aspects such as person-centered care planning, medication management, and coordination between providers — that is often needed to manage chronic pain in ways that result in better outcomes. So, for the first time, Medicare will provide payments for team-based, comprehensive management and treatment of chronic pain.

We are also finalizing several policies to strengthen and grow a program that has succeeded at providing high quality behavioral health care — the Medicare Shared Savings Program. Shared Savings Program Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers who join together voluntarily to give coordinated, high-quality care to people with Medicare. The program’s goal is to ensure that people receive the right care at the right time, keeping them healthy while preventing medical errors and avoiding unnecessary and duplicative tests and treatments. We have seen that this type of coordinated, whole-person care can have a greater impact on someone’s health. For example, if someone has diabetes and depression, that individual may not have the energy to get out of bed, exercise, keep track of their medications, or make healthy meals. Treating the diabetes alone, isolated from the other factors affecting that person’s health, may not be as effective as addressing both the diabetes and depression together. We are strengthening the whole-person capabilities of ACOs by making advanced shared savings payments to new, smaller ACOs, which could use the funds upfront to hire behavioral health practitioners and address the social needs of people with Medicare, such as food and housing.

Addressing the Nation’s Substance Use Disorder Crisis

To help combat the increase in overdoses that has marked this pandemic, we are clarifying that, in line with requirements of the Drug Enforcement Administration (DEA), Opioid Treatment Programs may bill Medicare for services performed by mobile units, such as vans, without obtaining a separate registration. This can improve treatment access for hard-to-reach populations, such as individuals who are homeless or who live in rural areas. We are also increasing our payment rates to Opioid Treatment Programs in order to better reflect the costs of individual therapy services, while also finalizing policies to pay for the initiation of buprenorphine (which treats opioid use disorder) using telecommunications, rather than just in person, to further improve access. Additionally, in response to the public comments received on the proposed rule, we are also extending allowing payment to Opioid Treatment Programs for periodic assessments furnished over audio-only telephone calls through the end of 2023.

These policies in Medicare will allow for important strides forward for behavioral health care in this country. However, the behavioral health crisis that continues to shake the nation cannot be solved by CMS alone. We look forward to continued partnership, working together to ensure that every American gets the behavioral health care that they need and deserve.

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On November 01, 2022, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates and policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2023.

The calendar year (CY) 2023 PFS final rule is one of several rules that reflect a broader Administration-wide strategy to create a more equitable health care system that results in better accessibility, quality, affordability, and innovation.

Background on the Physician Fee Schedule

Since 1992, Medicare payment has been made under the PFS for the services of physicians and other billing professionals. Physicians’ services paid under the PFS are furnished in various settings, including physician offices, hospitals, ambulatory surgical centers (ASCs), skilled nursing facilities and other post-acute care settings, hospices, outpatient dialysis facilities,

clinical laboratories, and beneficiaries’ homes. Payment is also made to several types of suppliers for technical services, most often in settings for which no institutional payment is made.

For most services furnished in a physician’s office, Medicare makes payment to physicians and other professionals at a single rate based on the full range of resources involved in furnishing the service. In contrast, PFS rates paid to physicians and other billing practitioners in facility settings, such as a hospital outpatient department (HOPD) or an ASC, reflect only the portion of the resources typically incurred by the practitioner in the course of furnishing the service.

For many diagnostic tests and a limited number of other services under the PFS, separate payment may be made for the professional and technical components of services. The technical component is frequently billed by suppliers, like independent diagnostic testing facilities and radiation treatment centers, while the professional component is billed by the physician or practitioner.

Payments are based on the relative resources typically used to furnish the service. Relative value units (RVUs) are applied to each service for work, practice expense, and malpractice expense. These RVUs become payment rates through the application of a conversion factor. Geographic adjusters (geographic practice cost index) are also applied to the total RVUs to account for variation in practice costs by geographic area. Payment rates are calculated to include an overall payment update specified by statute.

CY 2023 PFS Ratesetting and Conversion Factor

CMS is finalizing a series of standard technical proposals involving practice expense, including the implementation of the second year of the clinical labor pricing update. We also included a comment solicitation seeking public input as we develop a more consistent, predictable approach to incorporating new data in setting PFS rates. Per statutory requirements, we are also updating the data that we use to develop the geographic practice cost indices (GPCIs) and malpractice RVUs.

With the budget neutrality adjustments, which are required by law to ensure payment rates for individual services don’t result in changes to estimated Medicare spending, the required statutory update to the conversion factor for CY 2023 of 0%, and the expiration of the 3% supplemental increase to PFS payments for CY 2022, the final CY 2023 PFS conversion factor is $33.06, a decrease of $1.55 to the CY 2022 PFS conversion factor of $34.61.

Evaluation and Management (E/M) Visits

As part of the ongoing updates to E/M visit codes and related coding guidelines that are intended to reduce administrative burden, the AMA CPT Editorial Panel approved revised coding and updated guidelines for Other E/M visits, effective January 1, 2023. Similar to the approach we finalized in the CY 2021 PFS final rule for office/outpatient E/M visit coding and documentation, we finalized and adopted most of these AMA CPT changes in coding and documentation for Other E/M visits (which include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment) effective January 1, 2023. This revised coding and documentation framework includes CPT code definition changes (revisions to the Other E/M code descriptors), including:

• New descriptor times (where relevant). 
• Revised interpretive guidelines for levels of medical decision making. 
• Choice of medical decision making or time to select code level (except for a few families like emergency department visits and cognitive impairment assessment, which are not timed services). 
• Eliminated use of history and exam to determine code level (instead there would be a requirement for a medically appropriate history and exam).

We finalized the proposal to maintain the current billing policies that apply to the E/Ms while we consider potential revisions that might be necessary in future rulemaking. We also finalized creation of Medicare-specific coding for payment of Other E/M prolonged services, similar to what CMS adopted in CY 2021 for payment of Office/Outpatient prolonged services. These services will be reported with three separate Medicare-specific G codes.

Split (or Shared) E/M Visits

For CY 2023, we finalized  a year-long delay of the split (or shared) visits policy we  established in rulemaking for 2022.  This policy determines which professional should bill for a shared visit by defining the “substantive portion,” of the service as more than half of the total time. Therefore, for CY 2023, as in CY 2022, the substantive portion of a visit is comprised of any of the following elements: 

• History. 
• Performing a physical exam.
• Medical Decision Making.
• Spending time (more than half of the total time spent by the practitioner who bills the visit).

As finalized, clinicians who furnish split (or shared) visits will continue to have a choice of history, or physical exam, or medical decision making, or more than half of the total practitioner time spent to define the “substantive portion” instead of using total time to determine the substantive portion, until CY 2024.  

Telehealth Services

For CY 2023, we are finalizing a number of policies related to Medicare telehealth services, including making several services that are temporarily available as telehealth services for the PHE available at least through CY 2023 in order to allow additional time for the collection of data that may support their inclusion as permanent additions to the Medicare Telehealth Services List. We finalized our proposal to extend the duration of time that services are temporarily included on the telehealth services list during the PHE for at least a period of 151 days following the end of the PHE, in alignment with the Consolidated Appropriations Act, 2022 (CAA, 2022).

We confirmed our intention to implement the telehealth provisions in sections 301 through 305 of the CAA, 2022, via program instruction or other subregulatory guidance to ensure a smooth transition after the end of the PHE. These policies, such as allowing telehealth services to be furnished in any geographic area and in any originating site setting (including the beneficiary’s home); allowing certain services to be furnished via audio-only telecommunications systems; and allowing physical therapists, occupational therapists, speech-language pathologists, and audiologists to furnish telehealth services, will remain in place during the PHE for 151 days after the PHE ends. The CAA, 2022, also delays the in-person visit requirements for mental health services furnished via telehealth until 152 days after the end of the PHE.

We finalized the proposal to allow physicians and practitioners to continue to bill with the place of service (POS) indicator that would have been reported had the service been furnished in-person.  These claims will require the modifier “95” to identify them as services furnished as telehealth services. Claims can continue to be billed with the place of service code that would be used if the telehealth service had been furnished in-person through the later of the end of CY 2023 or end of the year in which the PHE ends.

The Telehealth Originating Site Facility Fee has been updated for CY 2023, which can be found with the list of Medicare Telehealth List of Services at the following website:  https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

Behavioral Health Services 

In light of the current needs among Medicare beneficiaries for improved access to behavioral health services, CMS has considered regulatory revisions that may help to reduce existing barriers and make greater use of the services of behavioral health professionals, such as licensed professional counselors (LPCs) and Licensed Marriage and Family Therapists (LMFTs). Therefore, CMS is finalizing the proposal to add an exception to the direct supervision requirement under our “incident to” regulation at 42 CFR 410.26 to allow behavioral health services to be provided under the general supervision of a physician or non-physician practitioner (NPP), rather than under direct supervision, when these services or supplies are furnished by auxiliary personnel, such as LPCs and LMFTs, incident to the services of a physician (or NPP). CMS is also clarifying that any service furnished primarily for the diagnosis and treatment of a mental health or substance use disorder can be furnished by auxiliary personnel under the general supervision of a physician or NPP who is authorized to furnish and  bill for services provided incident to their own professional services. CMS believes that this change will facilitate access and extend the reach of behavioral health services. Finally, CMS  indicated in the final rule that we intend to address payment for new codes that describe caregiver behavioral management training in CY 2024 rulemaking.

In the 2022 CMS Behavioral Health Strategy (https://www.cms.gov/cms-behavioral-health-strategy), CMS included a goal to improve access to, and quality of, mental health care services and included an objective to “increase detection, effective management, and/or recovery of mental health conditions through coordination and integration between primary and specialty care providers.” In CY 2017 and 2018 PFS rulemaking, CMS received comments that initiating visit services for behavioral health integration (BHI) should include in-depth psychological evaluations delivered by a clinical psychologist (CP), and that CMS should consider allowing professionals who were not eligible to report the approved initiating visit codes to Medicare to serve as a primary hub for BHI services. Considering the increased needs for mental health services and feedback we have received, we are finalizing our proposal to create a new General BHI code describing a service personally performed by CPs or clinical social workers (CSWs) to account for monthly care integration where the mental health services furnished by a CP or CSW are serving as the focal point of care integration. CMS is also finalizing the proposal to allow a psychiatric diagnostic evaluation to serve as the initiating visit for the new general BHI service.

Chronic Pain Management and Treatment Services 

We finalized new HCPCS codes, G3002 and G3003, and valuation for chronic pain management and treatment services (CPM) for CY 2023. We believe the CPM HCPCS codes will improve payment accuracy for these services, prompt more practitioners to welcome Medicare beneficiaries with chronic pain into their practices, and encourage practitioners already treating Medicare beneficiaries who have chronic pain to spend the time to help them manage their condition within a trusting, supportive, and ongoing care partnership.

The finalized codes include a bundle of services furnished during a month that we believe to be the starting point for holistic chronic pain care, aligned with similar bundled services in Medicare, such as those furnished to people with suspected dementia or substance use disorders. We have finalized the CPM codes to include the following elements in the code descriptor: diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and coordination between relevant practitioners furnishing care, such as physical and occupational therapy, complementary and integrative care approaches, and community-based care, as appropriate.

Opioid Treatment Programs (OTPs) 

In order to stabilize the price for methadone for CY 2023 and subsequent years, CMS is finalizing the proposal to revise our methodology for pricing the drug component of the methadone weekly bundle and the add-on code for take-home supplies of methadone. As proposed, CMS will base the payment amount for the drug component of HCPCS codes G2067 and G2078 for CY 2023 and subsequent years on the payment amount for methadone in CY 2021 and update this amount annually to account for inflation using the PPI for Pharmaceuticals for Human Use (Prescription).

Additionally, based on the severity of needs of the patient population diagnosed with opioid use disorder (OUD) and receiving services in the OTP setting, CMS is finalizing the proposal to modify the payment rate for the non-drug component of the bundled payments for episodes of care to base the rate for individual therapy on a crosswalk to a code describing a 45-minute session, rather than the current crosswalk to a code describing a 30-minute session. This will increase overall payments for medication-assisted treatment and other treatments for OUD, recognizing the longer therapy sessions that are usually required.

CMS is also finalizing the proposal to allow the OTP intake add-on code to be furnished via two-way audio-video communications technology when billed for the initiation of treatment with buprenorphine, to the extent that the use of audio-video telecommunications technology to initiate treatment with buprenorphine is authorized by the Drug Enforcement Administration (DEA) and Substance Abuse and Mental Health Services Administration (SAMHSA) at the time the service is furnished. CMS is also finalizing the proposal to permit the use of audio-only communication technology to initiate treatment with buprenorphine in cases where audio-video technology is not available to the beneficiary, and all other applicable requirements are met.

Additionally, CMS is allowing periodic assessments to be furnished audio-only when video is not available for the duration of CY 2023, to the extent that it is authorized by SAMSHA and DEA at the time the service is furnished. 

Additionally, CMS is clarifying that OTPs can bill Medicare for medically reasonable and necessary services furnished via mobile units in accordance with SAMHSA and DEA guidance. CMS is finalizing the proposal that locality adjustments for services furnished via mobile units would be applied as if the service were furnished at the physical location of the OTP registered with DEA and certified by SAMHSA.

Audiology Services 

CMS finalized a policy to allow beneficiaries direct access to an audiologist without an order from a physician or NPP for non-acute hearing conditions.  The finalized policy will use a new modifier ─ instead of using a new HCPCS G-code as we proposed ─ because we were persuaded by the commenters that a modifier would allow for better accuracy of reporting and reduce burden for audiologist. The service(s) can be billed using the codes audiologists already use with the new modifier, and include only those personally furnished by the audiologist. The finalized direct access policy will allow beneficiaries to receive care for non-acute hearing assessments that are unrelated to disequilibrium, hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids.  This modification in our finalized policy necessitates multiple changes to our claims processing systems, which will take some time to fully operationalize, but audiologists may use modifier AB, along with the finalized list of 36 CPT codes, for dates of service on and after January 1, 2023.

CMS finalized the proposal to permit audiologists to bill for this direct access (without a physician or practitioner order) once every 12 months per beneficiary.  Medically reasonable and necessary tests ordered by a physician or other practitioner and personally provided by audiologists will not be affected by the direct access policy, including the modifier and frequency limitation.   

Dental and Oral Health Services

Medicare payment for dental services is generally precluded by statute.  However, Medicare currently pays for dental services in a limited number of circumstances, specifically when that service is an integral part of specific treatment of a beneficiary’s primary medical condition. Some examples include reconstruction of the jaw following fracture or injury, tooth extractions done in preparation for radiation treatment for cancer involving the jaw, or oral exams preceding kidney transplantation. CMS proposed to clarify and codify certain aspects of the current Medicare fee-for-services payment policies for dental services. CMS also proposed and sought comment on payment for other dental services that were inextricably linked to, and substantially related and integral to, the clinical success of, an otherwise covered medical service, such as dental exams and necessary treatments prior to organ transplants, cardiac valve replacements, and valvuloplasty procedures. Effective for CY 2023, CMS 1) finalized our proposal to clarify and codify certain aspects of the current Medicare FFS payment policies for dental services when that service is an integral part of specific treatment of a beneficiary’s primary medical condition, and 2) other clinical scenarios under which Medicare Part A and Part B payment can be made for dental services, such as dental exams and necessary treatments prior to, or contemporaneously with, organ transplants, cardiac valve replacements, and valvuloplasty procedures. We are also finalizing payment for dental exams and necessary treatments prior to the treatment for head and neck cancers starting in CY 2024, and finalizing a process in CY 2023 to review and consider public recommendations for Medicare payment for dental service in other potentially analogous clinical scenarios. Finally, we are working to address commenters’ thoughtful feedback and questions regarding the operational aspects of billing and claims processing for these services.

Skin Substitutes 

CMS proposed several changes to the policies for skin substitute products to streamline the coding, billing, and payment rules and to establish consistency with these products across the various settings. Specifically, CMS proposed to change the terminology of skin substitutes to ‘wound care management products’, and to treat and pay for these products as incident to supplies under the PFS beginning on January 1, 2024.  After reviewing comments on the proposals, we understand that it would be beneficial to provide interested parties more opportunity to comment on the specific details of changes in coding and payment mechanisms prior to finalizing a specific date when the transition to more appropriate and consistent payment and coding for these products will be completed. We plan to conduct a Town Hall in early CY 2023 with interested parties to address commenters’ concerns as well as discuss potential approaches to the methodology for payment of skin substitute products under the PFS. We will take into account the comments we received in response to CY 2023 rulemaking and feedback received in association with the Town Hall in order to strengthen proposed policies for skin substitutes in future rulemaking.  

Colorectal Cancer Screening

For CY 2023, we are finalizing, as proposed, two updates to expand our Medicare coverage policies for colorectal cancer screening in order to align with recent United States Preventive Services Task Force and professional society recommendations. First, we are expanding Medicare coverage for certain colorectal cancer screening tests by reducing the minimum age payment and coverage limitation from 50 to 45 years. Second, we are expanding the regulatory definition of colorectal cancer screening tests to include a complete colorectal cancer screening, where a follow-on screening colonoscopy after a Medicare covered non-invasive stool-based colorectal cancer screening test returns a positive result. A functional outcome of our policy for a complete colorectal cancer screening will be that, for most beneficiaries, cost sharing will not apply for either the initial stool-based test or the follow-on colonoscopy. Both of these policies reflect our desire to expand access to quality care and to improve health outcomes for patients through prevention and early detection services, as well as through effective treatments. Our revised colorectal cancer screening policies directly advance our health equity goals by promoting access for much needed cancer prevention and early detection in rural communities and communities of color that are especially impacted by the incidence of colorectal cancer. Our policies also directly support President Biden’s Cancer Moonshot Goal to cut the death rate from cancer by at least 50 percent over the next 25 years and addresses his recent proclamation of March 2022 as National Colorectal Cancer Awareness Month.

Requiring Manufacturers of Certain Single-Dose Container or Single-Use Package Drugs to Provide Refunds with Respect to Discarded Amounts

Section 90004 of the Infrastructure Investment and Jobs Act (Pub. L. 117-9, November 15, 2021) amended section 1847A of the Act adding provisions that require manufacturers to provide a refund to CMS for certain discarded amounts from a refundable single-dose container or single-use package drug. The refund amount is the amount of discarded drug that exceeds an applicable percentage, which is required to be at least 10%, of total allowed charges for the drug in a given calendar quarter. The proposals to implement section 90004 of the Infrastructure Act included: how discarded amounts of drugs are determined; a definition of which drugs are subject to refunds (and exclusions); when and how often CMS will notify manufacturers of refunds; when and how often payment of refunds from manufacturers to CMS is required; refund calculation methodology (including applicable percentages); a dispute resolution process; and enforcement provisions. This refund applies to refundable single-dose container or single-use package drugs beginning January 1, 2023.

CMS is finalizing as proposed the definition of a refundable single-dose container or single-use package drug as a drug or biological for which payment is made under Part B and that is furnished from a single-dose container or single-use package. CMS is finalizing exclusions to this definition as required by statute for drugs that are either radiopharmaceuticals or imaging agents, drugs that require filtration during the drug preparation process, and drugs approved on or after the date of enactment of the Infrastructure Act (that is, November 15, 2021) for which payment under Part B has been made for fewer than 18 months.

For drugs with unique circumstances, CMS solicited comment on whether an increased applicable percentage would be appropriate for drug that is reconstituted with a hydrogel and administered via ureteral catheter or nephrostomy tube into the kidneys; in this circumstance, there is substantial amount of reconstituted hydrogel that adheres to the vial wall during preparation and not able to be extracted from the vial for administration. Based on comments received, CMS is finalizing an increased applicable percentage of 35 percent for this drug.

CMS also solicited comments on whether there are other drugs with unique circumstances that may warrant an increase in the applicable percentage.  As a result of public comments, CMS plans to collect additional information about drugs that may have unique circumstances along with what increased applicable percentages might be appropriate for each circumstance.  CMS will revisit additional increased applicable percentages through future notice and comment rulemaking. 

CMS is finalizing requirements for the use of the JW modifier, for reporting discarded amounts of drugs, and the JZ modifier, for attesting that there were no discarded amounts. CMS is finalizing that providers will be required to report the JW modifier beginning January 1, 2023 and the JZ modifier no later than July 1, 2023 in all outpatient settings. In the proposed rule, CMS proposed that an initial invoice for the refund to be sent to manufacturers in October 2023.  However, we believe it would be beneficial to create system efficiencies related to the reconciliation and invoicing system of the discarded drug refunds and the new inflation rebate programs under the Inflation Reduction Act, and so we are not finalizing the timing of the initial report to manufacturers or date by which the first refund payments are due. We are, however, finalizing that we will issue a preliminary report on estimated discarded drug amounts based on claims from the first two calendar quarters of 2023 no later than December 31, 2023 and will revisit the timing of the first report in future rulemaking.

Preventive Vaccine Administration Services

In this rule, CMS finalized refinements to the payment amount for preventive vaccine administration under the Medicare Part B vaccine benefit, which includes the influenza, pneumococcal, hepatitis B, and COVID-19 vaccine and their administration. CMS finalized the proposal to annually update the payment amount for vaccine administration services based upon the increase in the MEI, and to adjust for the geographic locality based upon the geographic adjustment factor (GAF) for the PFS locality in which the preventive vaccine is administered. CMS also finalized the proposal to continue the additional payment for at-home COVID-19 vaccinations for CY 2023. 

Additionally, in light of the distinction between a PHE declared under section 319 of the Public Health Service Act (PHS Act) and an Emergency Use Authorization (EUA) declaration under section 564 of the Food, Drug, and Cosmetic Act (FD&C Act), and the possibility that they will not terminate at precisely the same time, CMS is clarifying the policies finalized in the CY 2022 PFS final rule regarding the administration of COVID-19 vaccine and monoclonal antibody products, to reflect that those policies will continue through the end of the calendar year in which the EUA declaration for drugs and biological products is terminated. Lastly, CMS is finalizing the proposal to  permanently cover and pay for covered monoclonal antibody products used as pre-exposure prophylaxis for prevention of COVID-19 under the Medicare Part B vaccine benefit.

Updated Medicare Economic Index (MEI) for CY 2023 

We proposed to rebase and revise the MEI for CY 2023 and solicited comments regarding the future use of the 2017-based MEI weights in PFS ratesetting and the GPCIs. The proposed method for determining the 2017-based MEI relies on estimating base year expenses from publicly available data from the U.S. Census Bureau NAICS 6211 Offices of Physicians. The proposed methodology allows for the use of data that are more reflective of current market conditions of physician ownership practices, rather than only reflecting costs for self-employed physicians, and also would allow for the MEI to be updated on a more regular basis since the proposed data sources are updated and published on a regular basis.

Finalizing the use of the 2017-based MEI cost weights to set PFS rates would not change overall spending on PFS services, but would result in significant distributional changes to payments among PFS services across specialties and geographies. In consideration of our ongoing efforts to update the PFS payment rates with more predictability and transparency, and in the interest of ensuring payment stability, we proposed not to use the updated MEI cost share weights to set PFS payment rates for CY 2023. However, we solicited comments on the potential use of the proposed updated MEI cost share weights to calibrate payment rates and update the GPCI under the PFS in the future.

We finalized the proposed rebasing and revising of the 2017-based MEI with some technical revisions to the proposed method based on public comments.  The final CY 2023 MEI update is 3.8 percent based on the most recent historical data available. As noted above, the rebased and revised MEI weights were not used in CY 2023 PFS ratesetting. 

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)           

Chronic Pain Management and Behavioral Health Services

We are finalizing the addition of chronic pain management and behavioral health integration services to the RHC and FQHC specific general care management HCPCS code, G0511, which aligns with changes made under the PFS for CY 2023. Since the requirements for the chronic pain management and behavioral health integration services are similar to the requirements for the general care management services furnished by RHCs and FQHCs (which are the current services for which RHCs and FQHCs can use HCPCS code G0511) the payment rate for HCPCS code G0511 will continue to be the average of the national non-facility PFS payment rates for the RHC and FQHC care management and general behavioral health codes (CPT codes 99484, 99487, 99490, and 99491) and PCM codes (CPT codes 99424 and 99425) Payment will be updated annually based on the PFS amounts for these codes, which is how these updates are made currently.

Telehealth Services

We announced that we are implementing the telehealth provisions in the Consolidated Appropriations Act, 2022 (CAA, 2022) via program instruction or other subregulatory guidance to ensure a smooth transition after the end of the PHE. The CAA, 2022 extends certain flexibilities in place during the PHE for 151 days after the PHE ends, including allowing payment for RHCs and FQHCs for furnishing telehealth services as distant site practitioners (though note that mental health visits can be furnished virtually on a permanent basis) under the payment methodology established for the PHE, allowing telehealth services to be furnished in any geographic area and in any originating site setting, including the beneficiary’s home, and allowing certain services to be furnished via audio-only telecommunications systems. The CAA, 2022 also delays the in-person visit requirements for mental health visits via telecommunications technology, including those furnished by RHCs and FQHCs, until 152 days after the end of the PHE.

Conforming Technical Changes to the In-Person Requirements for Mental Health Visits

We finalized conforming regulatory text changes in accordance with section 304 of the CAA, 2022 to amend paragraph (b)(3) of 42 CFR 405.2463, “What constitutes a visit,” and paragraph (d) of 42 CFR 2469, “FQHC supplemental payments,” to include the delay of the in-person requirements for mental health visits furnished by RHCs and FQHCs through telecommunication technology under Medicare until the 152^nd day after the COVID-19 PHE ends.

Specified Provider-Based RHC Payment Limit Per-Visit 

Subsequent to the publication of the CY 2022 PFS final rule, which implemented changes to the RHC payment limit as required by the Consolidated Appropriations Act, 2021, interested parties requested clarification regarding the timing of cost reports used to set the RHC payment limit. We finalized the clarification that a 12-consecutive month cost report should be used to establish a specified provider-based RHC’s payment limit per visit. We believe 12-consecutive months of cost report data accurately reflects the costs of providing RHC services and will establish a more accurate base from which the payment limits will be updated going forward. 

Clinical Laboratory Fee Schedule (CLFS):

In accordance with section 4(b) of the Protecting Medicare and American Farmers from Sequester Cuts Act, we are finalizing certain conforming changes to the data reporting and payment requirements at 42 CFR part 414, subpart G. Specifically, we are finalizing revisions to § 414.502 to update the definitions of both the “data collection period” and “data reporting period,” specifying that for the data reporting period of January 1, 2023 through March 31, 2023, the data collection period is January 1, 2019 through June 30, 2019. We are also finalizing revisions to § 414.504(a)(1) to indicate that initially, data reporting begins January 1, 2017 and is required every 3 years beginning January 2023. In addition, we are finalizing conforming changes to our requirements for the phase-in of payment reductions to reflect the amendments in section 4(b) of this law. Specifically, we are finalizing revisions to § 414.507(d) to indicate that for CY 2022, payment may not be reduced by more than 0% as compared to the amount established for CY 2021, and for CYs 2023 through 2025, payment may not be reduced by more than 15% as compared to the amount established for the preceding year.

Additionally, after consideration of public comments and further analysis, we are finalizing an increase to the nominal fee for specimen collection based on the Consumer Price Index for all Urban Consumers (CPI-U).  Therefore, for CY 2023, the general specimen collection fee will increase from $3 to $8.574 and as required by PAMA, we will increase this amount by $2 for those specimens collected from a Medicare beneficiary in a SNF or by a laboratory on behalf of an HHA, which will result in a $10.57 specimen collection fee for those beneficiaries . In addition, we are finalizing a policy to update this fee amount annually by the percent change in the CPI-U.  We are also finalizing our proposals to codify and clarify various laboratory specimen collection fee policies in § 414.523(a)(1). This is because the policies implementing the statutory requirements under section 1833(h)(3)(A) of the Act for the laboratory specimen collection fee, which are currently described in the Medicare Claims Processing Manual Pub. 100-04, chapter 16, § 60.1., did not have corresponding regulations text and some of the manual guidance is no longer applicable.

Lastly, in light of questions we have received from interested parties, we are finalizing as proposed to codify in our regulations, and make certain modifications and clarifications to, the Medicare CLFS travel allowance policies. We are finalizing the addition of § 414.523(a)(2) “Payment for travel allowance” to reflect the requirements for the travel allowance for specimen collection. Specifically, in accordance with section 1833(h)(3)(B) of the Act, we are finalizing to include in our regulations the following requirements for the travel allowance methodology: (1) a general requirement, (2) travel allowance basis requirements, and (3) travel allowance amount requirements.

Medicare Ground Ambulance Data Collection System

CMS is finalizing a series of changes to the Medicare Ground Ambulance Data Collection System. First, we are finalizing our proposal to update our regulations at § 414.626(d)(1) and (e)(2) to provide the necessary flexibility to specify how ground ambulance organizations should submit the hardship exemption requests and informal review requests, including to our web-based portal once that portal is operational. Second, we are finalizing our proposed changes and additional clarifications  to the Medicare Ground Ambulance Data Collection Instrument. The changes and clarifications aim to reduce burden on respondents, improve data quality, or both. We grouped  these changes and clarifications into four broad categories: editorial changes for clarity and consistency; updates to reflect the web-based system; clarifications responding to feedback from questions from interested parties and testing; and typos and technical corrections.

Origin and Destination Requirements Under the Ambulance Fee Schedule

CMS is finalizing our interim final policy (85 FR 19276) that the expanded list of covered destinations for ground ambulance transports was for the duration of the COVID-19 PHE only.  These destinations include, but are not limited to, any location that is an alternative site determined to be part of a hospital, critical access hospital(CAH)or skilled nursing facility (SNF), community mental health centers, Federally qualified health centers, rural health clinics, physician offices, urgent care facilities, ambulatory surgical centers, any location furnishing dialysis services outside of an end-stage renal disease (ESRD) facility when an ESRD facility is not available, and the beneficiary’s home.

When the COVID-19 PHE ends, our regulations will reflect the long-standing ambulance services coverage for the following destinations only: hospital; CAH; SNF; beneficiary’s home; and dialysis facility for an ESRD patient who requires dialysis. In addition to these long-standing covered destinations, rural emergency hospitals (REH) will also be an allowed destination, in accordance with the Consolidated Appropriations Act, 2021, effective with services on or after January 1, 2023.

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Today, the U.S. Department of Health and Human Services (HHS), through its Centers for Medicare & Medicaid Services (CMS), is expanding access to behavioral health care, cancer screening coverage, and dental care. The Calendar Year 2023 Physician Fee Schedule (PFS) final rule announced today also promotes innovation and coordinated care in the Medicare program through Accountable Care Organizations (ACOs). This rule directly supports President Biden’s Cancer Moonshot Goal to cut the death rate from cancer by at least 50% and also supports the Administration’s commitment of strengthening behavioral health, which the President outlined in his first State of the Union Address and the comprehensive strategy to tackle the nation’s mental health crisis, which HHS leaders have furthered through the National Tour to Strengthen Mental Health.

“The Biden-Harris Administration is committed to expanding access to vital prevention and treatment services,” said HHS Secretary Xavier Becerra.  “Providing whole person support and services through Medicare will improve health and wellbeing for millions of Americans and even save lives.” 

“Access to services promoting behavioral health, wellness, and whole-person care is key to helping people achieve the best health possible,” said CMS Administrator Chiquita Brooks-LaSure. “The Physician Fee Schedule final rule ensures that the people we serve will experience coordinated care and that they have access to prevention and treatment services for substance use, mental health services, crisis intervention, and pain care.”

“Together, we are building a stronger Medicare program,” said Deputy Administrator and Director for the Center for Medicare, Dr. Meena Seshamani. “No matter who you are, or what diagnoses you have, these changes will help ensure that Medicare treats the whole person— caring for physical health, behavioral health, and social needs that are integral to health— and ensuring access to the high-quality care all people deserve.”

Coverage for Behavioral Health Services and Opioid Use Disorder Treatment

In line with the 2022 CMS Behavioral Health Strategy, CMS is strengthening access to vital behavioral health services. CMS is making it easier for Medicare beneficiaries to get behavioral health services, by allowing behavioral health clinicians like licensed professional counselors and marriage and family therapists to offer services under general (rather than direct) supervision of the Medicare practitioner. Medicare will pay Opioid Treatment Programs that use telecommunications with patients to initiate treatment with buprenorphine. CMS is also clarifying that Opioid Treatment Programs can bill for opioid use disorder treatment services provided through mobile units, such as vans, in accordance with Substance Abuse and Mental Health Services Administration (SAMHSA) and Drug Enforcement Administration (DEA) guidance.  These policies may increase access in rural and other underserved areas.

CMS is also finalizing policies to pay for clinical psychologists and licensed clinical social workers to furnish integrated behavioral health care as part of a primary care team. Finally, Medicare will provide a new monthly payment for comprehensive treatment and management services for patients with chronic pain. These new services offer a whole-person approach to care.

Expanding and Enhancing Accountable Care
CMS is finalizing changes to the Medicare Shared Savings Program, the nation’s largest Accountable Care Organization program, covering more than 11 million people with Medicare and including more than 500,000 health care providers. These policies represent some of the most significant reforms since the program was established in 2011, and the first Accountable Care Organizations (ACOs), which are groups of health care providers who come together to give coordinated, high-quality care to people with Medicare, began participating in 2012. Through these policies, which are central to the Medicare Value-Based Care Strategy, CMS will take important steps toward our 2030 goal of having 100% of Traditional Medicare beneficiaries in an accountable care relationship with their healthcare provider by 2030. CMS is finalizing proposals to incorporate advance shared savings payments to certain new ACOs that can be used to support their participation in the Shared Savings Program, including hiring additional staff or addressing social needs of people with Medicare. CMS is also finalizing a health equity adjustment to an ACO’s quality score, revising the benchmarking methodology, and allowing longer periods of time for ACOs to become accustomed to accountable care before being liable for downside risk, all of which are expected to increase participation in rural and underserved areas.

Reducing Barriers and Expanding Coverage for Colon Cancer Screening

Colon and rectal cancers continue to be a leading cause of death in the United States with even higher new cases and death rates for Black Americans, American Indians, and Alaska Natives. Medicare will now reduce the minimum age for colorectal cancer screening from 50 to 45 years, in alignment with recently revised policy recommendations by the U.S. Preventive Services Task Force. Additionally, Medicare will now cover as a preventive service a follow-on screening colonoscopy after a non-invasive stool-based test returns a positive result, which means that beneficiaries will not have out-of-pocket costs for both tests.

Finalizing Payment for Dental Services that are Integral to Covered Medical Services

CMS is codifying current policies in which Medicare Parts A and B pay for dental services when that service is integral to treating a beneficiary’s medical condition. Medicare will also pay for dental examinations and treatments in more circumstances, such as to eliminate infection preceding an organ transplant and certain cardiac procedures beginning in CY 2023 and prior to treatment for head and neck cancers beginning in CY 2024. Finally, CMS is establishing an annual process to review public input on other circumstances when payment for dental services may be allowed.

Payment Rates for CY 2023

The CY 2023 PFS conversion factor is $33.06, a decrease of $1.55 to the CY 2022 PFS conversion factor of $34.61. This conversion factor reflects the statutorily required update of 0% for CY 2023, expiration of the temporary 3% supplemental increase in PFS payments for CY 2022 provided by the Protecting Medicare and American Farmers From Sequester Cuts Act, and the statutorily required budget neutrality adjustment to account for changes in payment rates.

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