The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), is proposing new policies that aim to reduce maternal mortality and morbidity, which disproportionally affect underserved communities. In the Calendar Year (CY) 2025 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule, CMS is also proposing policies that would increase access to care and advance health equity. The steps being taken include: proposing exceptions to the Medicaid clinic services “four walls” requirement; codifying the requirement of 12 months of continuous eligibility for children enrolled in Medicaid and CHIP as included in the Consolidated Appropriations Act, 2023 (CAA, 2023); proposing an add-on payment to the All-Inclusive Rate (AIR) for certain Indian Health Services (IHS) and tribal facilities to increase access to certain high-cost drugs; expanding the hospital outpatient, ASC and rural emergency hospital quality program measure sets to include equity measures consistent with other provider types; and supporting individuals returning to the community from incarceration through the elimination of barriers for these individuals to enroll in and maintain their Medicare coverage.
“President Biden and I are fully committed to addressing a maternal health crisis in which women across America – disproportionately Black women, Native women, and women in rural communities – are dying before, during, and after childbirth at higher rates than in any other developed nation. That is why I called on states to extend Medicaid postpartum coverage from two months to 12 months – with 46 states taking action – and why we launched the White House Blueprint for Addressing the Maternal Health Crisis, an unprecedented whole-of-government strategy to improving maternal care,” said Vice President Harris. “Today, we are building on this critical work by proposing new policies that will strengthen maternal health and increase access to high-quality care for millions of women and children throughout the country.”
“For too long, too many women in the United States have been dying during pregnancy or in the postpartum period, and this crisis has disproportionately affected women of color,” said HHS Secretary Xavier Becerra. “HHS is taking additional steps to improve maternal health by strengthening the care new moms and their babies receive at our nation’s hospitals. The Biden-Harris Administration continues to be committed to making pregnancy and childbirth safer.”
“The proposed hospital outpatient rule builds on the Biden-Harris Administration’s commitment to reducing the nation’s high maternal mortality rate and actions outlined in the White House Blueprint for Addressing the Maternal Health Crisis, increasing access to services in tribal, rural, and other underserved communities, and addressing barriers to Medicare coverage for those recently incarcerated. This proposed rule is proof that we are committed to ensure people aren’t just covered, but that coverage is meaningful,” said CMS Administrator Chiquita Brooks-LaSure.
Every year, CMS reviews and updates payment rates and policies for the OPPS and the ASC payment system. CMS is proposing to update OPPS payment rates for CY 2025 for hospitals that meet applicable quality reporting requirements by 2.6%. This update is based on the projected hospital market basket percentage increase of 3%, reduced by 0.4 percentage points for the productivity adjustment. Using the proposed hospital market basket update, CMS also proposes to update the ASC rates for CY 2025 by 2.6% for ASCs that meet relevant quality reporting requirements.
For the first time, CMS is proposing baseline health and safety requirements for hospitals and critical access hospitals (CAHs) for obstetrical services. The new proposal, informed by stakeholder input and requests for information in the FY 2023 and FY 2025 IPPS proposed rules, introduces new requirements for maternal quality improvement efforts. These include baseline standards for the organization, staffing, and delivery of care within obstetrical units, emergency services readiness, transfer protocols for obstetrical patients, and annual staff training on evidence-based maternal health practices and cultural competencies, among other topics.
“CMS is using all of our tools to improve the safety, quality, and timeliness of the care that hospitals provide to pregnant women,” said Dr. Dora Hughes, Acting CMS Chief Medical Officer and Acting Director for CMS’ Center for Clinical Standards and Quality. “Through these proposals, we will ensure people get timely access to quality care in their communities, leading to improved outcomes and better health.”
Building on the Biden-Harris Administration’s commitment to support underserved communities, the CY 2025 OPPS proposed rule includes policies aimed at those formerly incarcerated or not otherwise in physical custody of penal authorities. Currently, many formerly incarcerated people who are eligible for Medicare may not be able to enroll in Medicare coverage immediately following their release, which can significantly hamper access to care during a vulnerable period. Likewise, individuals who have been released from jail or prison on parole or sentenced to probation or home detention without jail time must prove they have a legal obligation to pay for their health care for Medicare to pay. CMS is proposing to narrow the definition of “custody” to remove real or perceived barriers to ensure that people with Medicare who are no longer incarcerated or not otherwise in the physical custody of penal authorities can have access to Medicare coverage for care. CMS also proposes to revise the eligibility criteria for the special enrollment period for formerly incarcerated individuals to include individuals who have been released from incarceration or who are on parole, probation, or home detention.
The proposed rule further supports the agency’s behavioral health goals of reducing opioid overdoses and ensuring effective pain management. CMS is implementing the access to non-opioid treatments for pain relief provision of the CAA, 2023, and is proposing to pay separately in hospital outpatient departments and ASCs for six drugs and one device that are non-opioid treatments for pain relief.
In response to stakeholder concerns and building upon COVID-19 flexibilities, CMS is also taking action to support IHS and tribal facilities by proposing to allow certain Medicaid-covered clinic services to be provided outside the clinic. Under the proposal, states would be required to provide an exception to the four walls requirement for Medicaid clinic services provided by IHS and tribal clinics. They would have the option to create exceptions from the four walls requirement for Medicaid clinic services provided by behavioral health clinics and clinics located in rural areas. The optional exception for Medicaid clinic services provided by behavioral health clinics would help to advance the HHS Roadmap for Behavioral Health and CMS Behavioral Health Strategy.
Additionally, to increase access to cancer services and other services that utilize high-cost drugs furnished in IHS and tribal hospital outpatient departments, CMS proposes for Medicare to pay an add-on to the AIR for high-cost drugs and biologics that significantly exceed the AIR. Addressing equity and access barriers is a critical part of the Biden Administration’s Cancer Moonshot, which the President and First Lady reignited as a national effort to prevent more than 4 million cancer deaths by 2047 and improve the experience of people who are touched by cancer. With this proposed rule, the Biden-Harris Administration is taking a significant step to support IHS and Tribal facilities in providing cancer care, and, importantly, establish a pathway for Tribal facilities seeking to expand the breadth of health care services, including oncology, that they provide to their communities to decrease health inequities and improve outcomes for those facing cancer.
“With this proposed rule, we are helping make sure that all people can access care more equitably,” said Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare. “The Medicare program is meant to work for everyone – including those transitioning from incarceration and those accessing care at IHS and tribal hospitals and the policies in this proposed rule represent a significant step forward in doing just that.”
The CY 2025 OPPS/ASC Payment System proposed rule has a 60-day comment period that ends on September 9, 2024. The proposed rule can be downloaded from the Federal Register at:https://www.federalregister.gov/public-inspection/2024-15087/medicare-and-medicaid-programs-hospital-outpatient-prospective-payment-and-ambulatory-surgical
For a fact sheet on the CY 2025 OPPS/ASC Payment System proposed rule, please visit:https://www.cms.gov/newsroom/fact-sheets/cy-2025-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center
