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Centers for Medicare & Medicaid ServicesCMS Roundup

Today, the Centers for Medicare & Medicaid Services (CMS) provides an at-a-glance summary of news from around the agency.

*CMS Publishes Case Study on How it Prevented Payment of Potentially Fraudulent Claims*

September 23: CMS' Center for Program Integrity published a case study [ https://www.cms.gov/files/document/cpi-urinary-catheter-case-study.pdf ] detailing how CMS identified potential fraud and took swift action, including using payment suspensions and revocations, to keep more than $4.2 billion from being paid on potentially fraudulent claims for urinary catheters.

*CMS Final Rule Extends Efforts to Address Significant, Anomalous, and Highly Suspect Billing Activity with Accountable Care Organizations*

September 24: CMS issued a final rule [ https://www.federalregister.gov/documents/2024/09/27/2024-22054/medicare-program-mitigating-the-impact-of-significant-anomalous-and-highly-suspect-billing-activity ] entitled, “Medicare Program: Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in Calendar Year 2023” (CMS-1799-F). This final rule is part of a larger strategy to address significant, anomalous, and highly suspect (SAHS) billing activity within Accountable Care Organizations’ reconciliation. A proposal in the calendar year (CY) 2025 Physician Fee Schedule proposed rule [ https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-medicare-physician-fee-schedule-proposed-rule ] addresses SAHS billing activity for CY 2024 onwards. Further information is available in this fact sheet [ https://www.cms.gov/newsroom/fact-sheets/final-rule-mitigating-impact-significant-anomalous-and-highly-suspect-billing-activity-medicare ].

*CMS Awards Grants totaling $1.4 Million to Six Institutions in Support of Health Equity Research*

September 24: CMS’ Office of Minority Health announced the six recipients of the 2024 Minority Research Grant Program [ https://www.cms.gov/priorities/health-equity/grants-awards/minority-research ] (MRGP) awards. Each recipient will receive awards of up to $237,500, for a total of $1.4 million, which will examine critical public health disparities and increase health equity research capacities at those institutions. The MRGP supports researchers at minority-serving institutions through funding to explore and address health care disparities affecting racial and ethnic minority groups, people with disabilities, members of the Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) community, individuals with limited English proficiency, individuals residing in rural areas, and individuals adversely affected by persistent poverty or inequality.

*CMS Approves Five-Year Extension of Healthier Mississippi Section 1115 Demonstration *

September 24: CMS approved a five-year extension of the Healthier Mississippi section 1115 demonstration [ https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ms-healthier-mississippi-appvl-09242024.pdf ] through September 30, 2029. This extension allows Mississippi to continue to cover individuals who are aged, blind, and disabled with income at or below 135 percent of the federal poverty level (FPL) who are not eligible for Medicare and are not eligible under the Medicaid state plan. The state did not request changes with this extension but rather sought to continue the operations of the current demonstration without any changes.

*CMS Approves New York’s Request to Offer Additional Cost-Sharing Subsidies in its Health Insurance Marketplace®*

September 25: CMS approved New York's request to amend [ https://www.cms.gov/files/document/new-york-state-1332-waiver-amendment-approval-letter-and-stcs.pdf ] its existing section 1332 waiver, which created the Essential Plan (EP) Expansion, to expand the affordability programs under its waiver plan to include new cost-sharing subsidies for certain Health Insurance Marketplace® enrollees. The amended waiver will include three new state subsidies beginning in 2025: (1) state cost-sharing subsidies for on-Health Insurance Marketplace® silver plan enrollees with estimated household incomes up to 400% of the federal poverty level; (2) state cost-sharing subsidies for certain diabetes-related services for all Health Insurance Marketplace® enrollees; and (3) state cost-sharing subsidies for certain pregnancy and postpartum outpatient care, inclusive of mental health services, for all Health Insurance Marketplace® enrollees. Additional information can be found on this fact sheet [ https://www.cms.gov/files/document/ny-1332-amendment-fact-sheet.pdf ]. Earlier in September CMS also issued $10 billion [ https://www.cms.gov/files/document/1332-ny-2024-ptf-letters.pdf ] in pass-through funding to implement this waiver.

*CMS Issues Notice of Funding Opportunity for States to Promote Continuity of Care for People Transitioning Out of Carceral Settings*

September 27: CMS issued a notice of funding opportunity (NOFO) to operationalize Section 206 of the Consolidated Appropriations Act. Through this NOFO, eligible state Medicaid and CHIP Agencies can apply for planning grants to develop operational capabilities to promote continuity of care for individuals in a public institution who are eligible for medical assistance under the state Medicaid program or Children’s Health Insurance Program (CHIP). NOFO information can be found here [ https://www.medicaid.gov/medicaid/benefits/reentry-services-for-incarcerated-individuals/state-planning-grants-promote-continuity-of-care-for-medicaid-chip-beneficiaries-following-incarceration/index.html ] and additional background here [ https://www.medicaid.gov/medicaid/benefits/reentry-services-for-incarcerated-individuals/index.html ].

*CMS Posts National Coverage Determination for PrEP to Prevent HIV Infection*

September 30: CMS posted a final National Coverage Determination [ https://www.cms.gov/medicare/coverage/prep ] (NCD) for Pre-exposure Prophylaxis (PrEP) Using Antiretroviral Drugs to Prevent Human Immunodeficiency Virus (HIV) Infection. Under this NCD, Medicare will cover oral and injectable forms of PrEP and other related services to prevent HIV without cost-sharing (i.e., deductibles or co-pays) under Medicare Part B, expanding access to these preventive medications. NCDs are made through an evidence-based process with multiple opportunities for public participation. NCDs are posted on the CMS Medicare Coverage Center [ https://www.cms.gov/medicare/coverage/center ] website and provide stakeholders with the Medicare coverage criteria for each technology, a summary of the evidence considered, and CMS’ rationale for the decision. Information on Medicare coverage of PrEP for HIV prevention can be found on this fact sheet [ https://www.cms.gov/files/document/fact-sheet-potential-medicare-part-b-coverage-preexposure-prophylaxis-prep-using-antiretroviral.pdf ] and on this consumer summary [ https://www.cms.gov/files/document/prep-hiv-prevention.pdf ].

*CMS Publishes Blog Detailing Efforts to Expand Access to High-Quality Primary Care*

September 30: CMS published a blog [ https://www.healthaffairs.org/content/forefront/expanding-permanent-pathways-medicare-accountable-care ] in Health Affairs Forefront detailing efforts to expand access to high-quality primary care through Accountable Care Organization (ACO) initiatives and CMS Innovation Center models. The article describes how CMS aims to bring accountable care to all people with Medicare through permanent changes to ACO initiatives and the Medicare Physician Fee Schedule.

*CMS Reports on Study of the Acute Hospital Care at Home Initiative *

September 30: CMS posted a report [ https://qualitynet.cms.gov/acute-hospital-care-at-home/reports ] on the study of the Acute Hospital Care at Home (AHCAH) initiative on a CMS website. This report was required by the Consolidated Appropriations Act, 2023 (CAA, 2023). The study of the AHCAH initiative used the best-available quantitative and qualitative data on AHCAH, beginning with data collected in 2020, to draw comparisons between the AHCAH and brick-and-mortar hospital inpatient comparison groups. Information can be found on this fact sheet [ https://www.cms.gov/newsroom/fact-sheets/fact-sheet-report-study-acute-hospital-care-home-initiative ].

*CMS Highlights Agency Policies Supporting CMS Strategic Pillars *

October 1: CMS released a report [ https://www.cms.gov/files/document/cms-accomplishments-2021-2024.pdf ] highlighting the policies and programs the agency has implemented from 2021 to the present in support of the six CMS Strategic Pillars of advancing equity and addressing disparities; expanding access to affordable coverage and care; engaging with partners and communities; driving innovation to provide value-based care; protecting programs for future generations and fostering excellence in all aspects of CMS operations. 

*CMS Posts 2025 Medicare Advantage and Part D Plan Options for Review in Advance of Open Enrollment*

October 1: CMS published Medicare Advantage and Part D plan information for 2025 on Medicare.gov [ https://www.medicare.gov/ ]. This provides people with Medicare, and those who offer them assistance with enrollment, the opportunity to begin reviewing their coverage options for 2025 in advance of the open enrollment period.

*CMS Spotlights Information on Children with **Attention-Deficit/Hyperactivity Disorder*

October 1: CMS released an infographic [ https://www.medicaid.gov/medicaid/benefits/downloads/2024-ADHD-infographic.pdf ] with information on children with Medicaid and Children's Health Insurance Program (CHIP) coverage diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD). The infographic spotlights topics such as demographics, age of diagnosis, co-occurring conditions, and treatments received. Approximately 13% of children with Medicaid or CHIP coverage are currently reported to have ADHD, which is significantly higher than children covered by private insurance or children without insurance coverage.

*CMS Spotlights Patient & Provider Stories Illustrating the Benefits of Value-Based Care*

To highlight the benefits of value-based care, CMS publishes a series of stories spotlighting [ https://www.cms.gov/priorities/innovation-center/value-based-care-spotlight ] the experiences of patients and providers. The latest addition to the collection of patient and provider stories features a social worker and pediatrician who explain how the Integrated Care for Kids (InCK) Model [ https://www.cms.gov/priorities/innovation-center/value-based-care-spotlight/patient-provider-voices/integrated-care-for-kids-glorias-story ] and value-based care have helped children and their families.

*Other Recent Releases: *

September 20: Biden-Harris Administration Advances Women’s Health Through Affordable Care Act Grants in 14 States, D.C. [ https://www.cms.gov/newsroom/press-releases/biden-harris-administration-advances-womens-health-through-affordable-care-act-grants-14-states-dc ]

September 26: Biden-Harris Administration Releases Historic Guidance on Health Coverage Requirements for Children and Youth Enrolled in Medicaid and the Children’s Health Insurance Program [ https://www.cms.gov/newsroom/press-releases/biden-harris-administration-releases-historic-guidance-health-coverage-requirements-children-and ]

September 27: CMS Announces Resources and Flexibilities to Assist with the Public Health Emergency in the State of Florida Georgia, North Carolina, Tennessee, and South Carolina [ https://www.cms.gov/newsroom/news-alert/cms-announces-resources-and-flexibilities-assist-public-health-emergency-state-florida-2 ] 

September 27: Medicare Advantage and Medicare Prescription Drug Programs to Remain Stable as CMS Implements Improvements to the Programs in 2025 [ https://www.cms.gov/newsroom/press-releases/medicare-advantage-and-medicare-prescription-drug-programs-remain-stable-cms-implements-improvements ]  

September 30: HHS Announces Cost Savings for 54 Prescription Drugs Thanks to the Medicare Inflation Rebate Program Established by the Biden-Harris Administration’s Lower Cost Prescription Drug Law [ https://www.cms.gov/newsroom/press-releases/hhs-announces-cost-savings-54-prescription-drugs-thanks-medicare-inflation-rebate-program ]

October 2: CMS to Provide Hurricane Helene Public Health Emergency Accelerated and Advance Payments to Medicare Fee-for-Services Providers and Suppliers [ https://www.cms.gov/newsroom/news-alert/cms-provide-hurricane-helene-public-health-emergency-accelerated-and-advance-payments-medicare-fee ]

October 2: HHS Releases Final Guidance for Second Cycle of Historic Medicare Drug Price Negotiation Program [ https://www.cms.gov/newsroom/press-releases/hhs-releases-final-guidance-second-cycle-historic-medicare-drug-price-negotiation-program ]

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CMS, an agency within the U.S. Department of Health and Human Services, serves the public as a trusted partner and steward, dedicated to advancing health equity, expanding coverage, and improving health outcomes. The agency protects public health by administering the Medicare program and working in partnership with state governments to administer Medicaid, CHIP, and the Health Insurance Marketplace.

 

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