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As revised by section 10406 of the Senate Manager’s Amendment, beginning January 1, 2011, waives beneficiary cost-sharing under Medicare for most preventive services, including services recommended by the USPSTF with a grade of A or B. Also waives the Medicare deductible for certain colorectal cancer screening tests.
2011-2013
Prior to January 2013, CMS effectuated these requirements – both with respect to the elimination of coinsurance and/or Part B deductible for most preventive services with a grade A or B by the USPSTF as well as with respect to waiving the deductible for certain colorectal cancer screening tests – via annual PPS rulemaking and subsequent provider related guidance and transmittals (e.g., see here). See the applicable MPFS final rules (CYs 2011 and 2013) HOPPS/ASC final rules (CYs 2011, 2012, and 2013) as well as related changes delineated here.
2013
In a related note, in early 2013, AHRQ released its Guide to Clinical Preventive Services, which serves as a pocket guide for practitioners and others, and includes USPSTF recommendations on screening, counseling, and preventive medication topics and includes clinical considerations for each topic. For details, see here. See also related FAQ, issued on February 20 by CCIIO, on coverage of preventive health services as it pertains to Title I provisions.
On February 7, 2013, CMS released a report titled, The Affordable Care Act: A Stronger Medicare Program in 2012, in which it highlighted several of the reforms enacted under the ACA, including various Medicare Part D reforms, premium savings, preventive services (including the annual wellness visit provided for under the ACA, as well as tobacco cessation counseling, among others), and various program integrity related provisions.
On September 18, 2013, CMS released a proposed rule to establish a PPS methodology and payment rates for FQHC services under Medicare Part B, noting the proposed PPS system is “estimated to have an overall impact of increasing total Medicare payments to FQHCs by approximately 30 percent” compared with the reasonable-cost-based methodology currently employed for reimbursing these facilities. The rule addresses certain preventive services as defined in section 4104 of the ACA. The FQHC PPS takes effect on October 1, 2014. Comments on the proposed rule are due by November 18, 2013; CMS anticipates releasing a final rule in 2014. A press release and fact sheet are available.
On December 17, 2013, CMS released statewide data (available here) indicating that, due to the provisions of the ACA, more than 25.4 million Medicare FFS beneficiaries received at least one or more preventive benefits at no out of pocket cost to them in 2013 (Jan.-Nov.) – slightly above the 2012 figure of 24.7 million individuals. In addition, of this 2013 total, CMS announced that more than 3.5 million individuals utilized the ACA-authorized Annual Wellness Visit (AWV) – compared to 2.76 million individuals last year.
2014
On June 27, 2014, HHS announced that, as a result of the ACA, roughly 76 million individuals with private coverage were able to access expanded preventive services. A copy of the ASPE report on which the HHS press release is based is available here.
On July 2, CMS issued its CY15 Medicare Physician Fee Schedule (MPFS) proposed rule delineating a number of payment policies impacting over one million physicians and other practitioners paid under the MPFS each year. The proposed rule also sets payment policies for the Clinical Laboratory Fee Schedule (CLFS) and other Part B payments for the upcoming year. These key ACA provisions are addressed in the underlying rule. See also: CMS’ accompanying facts sheets on the rule (here and here). Comments are due by September 2, 2014.
On July 3, CMS issued its CY15 HOPPS/ASC proposed rule in which the agency estimates that CY15 payments would increase hospital OPPS payments by 2.2% compared with CY14 payments, with ASCs to see an estimated 1.2% increase. These key ACA provisions are addressed in the underlying rule. An agency fact sheet is available here. Comments are due by September 2, 2014.
On Oct. 31, CMS posted the CY 15 Medicare Physician Fee Schedule (MPFS) final rule with comment (fact sheet) addressing a number of ACA provisions related to physician payment and quality. Citing the April 1 doc fix, the Protecting Access to Medicare Act (PAMA) of 2014, CMS notes that a 0.0% update applies between Jan. 1, 2015, and March 31, 2015, for a conversion factor (CF) of $35.8013 during that period (after budget neutrality adjustments). The SGR calculation applies thereafter (April 1, 2015-Dec. 31, 2015), with the final rule conveying a 21.2% payment reduction for this period relative to the CY14 CF, with a CF of $28.2239.
On Oct. 31, CMS released the CY 15 OPPS/ASC final rule (fact sheet), estimating that net OPPS payments will increase by 2.3% (vs. 2.2% in the proposed rule) compared with CY 14 payments. This represents a $5.1B increase or $900M when changes stemming from enrollment, utilization, and case-mix are excluded. The final rule addresses these provisions of the ACA.
2015
On Feb. 24, HHS announced that roughly 39 million people took advantage of free Medicare preventive services in 2014 due to the ACA, with 4.8 million people obtaining an Annual Wellness Exam. State-specific information regarding Part D savings and preventive services use is available here and here respectively.
In early July, CMS addressed this provision in its CY 16 Medicare Physician Fee Schedule proposed rule (for which comments are due Sept. 8) with respect to Rural Health Clinic (RHC) billing for an approved preventive service. CMS also addressed this provision in its CY 16 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule (for which comments are due Aug. 31).
SEC. 4104. REMOVAL OF BARRIERS TO PREVENTIVE SERVICES IN MEDICARE. (a) DEFINITION OF PREVENTIVE SERVICES.
Section 1861(ddd) of the Social Security Act (42 U.S.C. 1395x(ddd)) is amended— (1) in the heading, by inserting ‘‘; Preventive Services’’ after ‘‘Services’’; (2) in paragraph (1), by striking ‘‘not otherwise described in this title’’ and inserting ‘‘not described in subparagraph (A) or (C) of paragraph (3)’’; and (3) by adding at the end the following new paragraph: ‘‘(3) The term ‘preventive services’ means the following: ‘‘(A) The screening and preventive services described in subsection (ww)(2) (other than the service described in subparagraph (M) of such subsection). ‘‘(B) An initial preventive physical examination (as defined in subsection (ww)). ‘‘(C) Personalized prevention plan services (as defined in subsection (hhh)(1)).’’. (b) PAYMENT AND ELIMINATION OF COINSURANCE IN ALL SETTINGS.—øReplaced by section 10406¿ Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by section 4103(c)(1), is amended— (1) in subparagraph (T), by inserting ‘‘(or 100 percent if such services are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population and are appropriate for the individual)’’ after ‘‘80 percent’’; (2) in subparagraph (W)— (A) in clause (i), by inserting ‘‘(if such subparagraph were applied, by substituting ‘100 percent’ for ‘80 percent’)’’ after ‘‘subparagraph (D)’’; and (B) in clause (ii), by striking ‘‘80 percent’’ and inserting ‘‘100 percent’’; (3) by striking ‘‘and’’ before ‘‘(X)’’; and (4) by inserting before the semicolon at the end the following: ‘‘, and (Y) with respect to preventive services described in subparagraphs (A) and (B) of section 1861(ddd)(3) that are appropriate for the individual and, in the case of such services described in subparagraph (A), are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population, the amount paid shall be 100 percent of (i) except as provided in clause (ii), the lesser of the actual charge for the services or the amount determined under the fee schedule that applies to such services under this part, and (ii) in the case of such services that are covered OPD services (as defined in subsection (t)(1)(B)), the amount determined under subsection (t)’’. (c) WAIVER OF APPLICATION OF DEDUCTIBLE FOR PREVENTIVE SERVICES AND COLORECTAL CANCER SCREENING TESTS.—Section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)), as amended by section 4103(c)(4), is amended— (1) in paragraph (1), by striking ‘‘items and services described in section 1861(s)(10)(A)’’ and inserting ‘‘preventive services described in subparagraph (A) of section 1861(ddd)(3) that are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population and are appropriate for the individual.’’; and (2) by adding at the end the following new sentence: ‘‘Paragraph (1) of the first sentence of this subsection shall apply with respect to a colorectal cancer screening test regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as the screening test.’’. (d) EFFECTIVE DATE.—The amendments made by this section shall apply to items and services furnished on or after January 1, 2011.
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