ACA Now

Implementation Status

By the end of 2012, CMS had begun implementing these provisions via the annual regulatory cycles for these providers. To access additional details regarding reimbursement for these fee-for-service providers, see CMS’s general information page for prospective payment systems in Medicare.

2013

On May 1, CMS issued its FY 2014 Skilled Nursing Facilities (SNF) Prospective Payment System (PPS) and Consolidated Billing proposed rule. This rule addresses provisions pertaining to sections 3108 and 3401 of the ACA.  Comments on the proposed rule are due by 5pm ET on July 1.

On May 2, CMS released its FY 2014 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) proposed rule. Among other things, CMS proposes revisions to the FY 2014 market basket (MB) update, as well as revises the list of diagnosis codes that are used to determine presumptive compliance under the “60% rule,” in addition to delineating changes to the quality measures and reporting requirements under the IRF quality reporting program (QRP).  Comments are due July 1.

On July 8, 2013, CMS released its CY14 hospital outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) payment system proposed rule in which it contemplates these provisions of the ACA in its proposal.  Comments on the underlying proposed rule are due by September 6, 2013.  A CMS press release is available here.

On July 2, 2013, CMS released its CY14 End-Stage Renal Disease (ESRD) proposed ruleimplementing an ATRA-required cut to the ESRD bundled payment of 12%, leading CMS to project a net year over year reduction to dialysis facilities of 9.4% for CY14 after taking into account a 2.9% MB update and -0.4% productivity adjustment called for under this provision of the law and some additional minor factors.  Comments are due by August 30, 2013.  A CMS press release is available here.

On July 31, CMS issued its FY 2014 skilled nursing facilities (SNFs) prospective payment system (PPS) and consolidated billing final rule for estimating that aggregate FY 2014 payments, relative to FY 2013, will increase by 1.3% (or $470M).  In the rule, the agency addressed the ACA-mandated productivity adjustment under section 3401; provisions pertaining to the permissibility of physician assistants to order post-hospital extended care services at section 3108; and hospice wage index improvements delineated at section 3137.

On July 31, CMS issued its FY 2014 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) final rule under which payments are projected to increase by 2.3% in FY14 , or by $170 million relative to FY13 figures.  The final rule includes a discussion of the ACA-mandated productivity adjustment at section 3401; hospice wage index improvements delineated at section 3137; and the IRF Quality Reporting Program (QRP) at section 3004.

On August 2, 2013, CMS issued its FY 2014 Medicare Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS final rule under which gross hospital payments will be $1.2 billion higher in FY 2014 than they were in FY 2013 – much higher than the $27 million increase initially proposed.  The final rule addresses a number of IPPS and LTCH payment and quality-related provisions authorized or amended by the ACA.

On Nov. 22, 2013, CMS issued its CY 2014 HH PPS final rule (slated to be published in the Federal Register on Dec. 2) in which the agency estimates home health agencies (HHAs) will see a 1.05 percent net cut—for an aggregate decline of $200M in Medicare payments to HHAs in CY 2014.  The net -1.05 percent cut reflects (as outlined in Table 33 on p. 214 of the proposed rule):  +2.3 percent in home health payment update percentage;  -2.73 percent due to ACA-mandated rebasing adjustments; and  -0.62 percent stemming from impacts of the HH PPS Grouper scoring changes.  Also: CMS press release and fact sheet.

Also on Nov. 22, CMS issued the CY 2014 ESRD final rule (slated to be published in the Federal Register on Dec. 2) in which – due to a phase in of the ATRA-mandated drug utilization adjustment – the “overall impact of the CY 2014 changes is projected to result in an average increase in payments of 0.0 percent from CY 2013 to CY 2014,” compared with an estimated net 9.4% cut foreseen in the proposed rule (which did not include a phase in).  A press release is available here.

On November 27, 2013, CMS released the CY14 Medicare Hospital Outpatient Department (HOPD) and Ambulatory Surgical Center (ASC) final rule. Most elements of the final rule were in line with what was proposed, except for CMS’s decision to delay by one year the creation of 29 new comprehensive APCs to replace 29 existing device-dependent APCs. Comments on the rule are due by January 27.

On November 27, 2013, CMS issued the CY14 Medicare Physician Fee Schedule (MPFS) final rule, in which it decided not to finalize proposed cuts to potentially misvalued codes with higher reimbursement rates than in the hospital outpatient setting. The rule did make some RVU changes that cut some specialties, however, and added a separate payment for non-face-to-face chronic care management services.

On November 22, 2013, CMS issued guidance (Change Request 8517), indicating that the annual update to the local clinical laboratory fees for CY 2014 is (-0.75%), in part due to the ACA productivity adjustment.

2014

On May 1, CMS issued a proposed rule updating FY 2015 Medicare payment policies and rates for inpatient stays at general acute care and LTCHs. Under the proposed rule, hospitals that participate in the Hospital Inpatient Quality Reporting (IQR) Program and are ‘meaningful users’ of EHRs would receive a 1.3% payment update. However, the 1.3% rate increase, when coupled with the payment policy reductions – including those under the Hospital Readmissions Reduction Program, the Hospital Acquired Condition (HAC) Reduction Program, Medicare DSH changes as well as “the expiration of certain statutory provisions that provided special temporary increases in payments to hospitals and other proposed changes” – would ultimately decrease IPPS operating payments by approximately 0.8% or $241 million over FY 2015 payment levels. Also of note, gross LTCH payments under the proposed rule would increase by 0.8% or $44 million over FY 2014 payments, with a delay (pursuant to the statutory mandate) in the full application of the 25% Rule patient threshold, among other key LTCH policy changes denoted further below. Comments are due by June 30, 2014. CMS fact sheets are available here and here. A CMS press release is available here.

On May 1, CMS issued its FY 2015 IRF PPS proposed rule under which the agency proposes a net increase of 2.2%, or roughly $160 million, in Medicare payments to IRFs in FY 2015 over the FY 2014 payment update. CMS indicates that the net update reflects a 2.1% increase (2.7% MB update less the 0.4% statutory productivity adjustment, further reduced by the 0.2% reduction called for by the ACA). However, “[a]n additional 0.1% increase to aggregate payments due to updating the outlier threshold results in an overall update of 2.2%…” A CMS fact sheet is available here. Comments are due June 30, 2014.

On May 2, CMS released the proposed FY 2015 hospice wage index and payment rate update (available here; fact sheet), in which the agency estimates that FY15 hospice payments would increase by an estimated $230 million, 1.3% net, reflecting the following factors: (1)   2.0% proposed payment update to the hospice per diem rates (a “hospital market basket” increase of 2.7 percent minus 0.7 percentage point for statutory reductions); and  -0.7% in hospice payments, stemming from “updated wage data and the sixth year of CMS’s seven-year phase-out of its wage index budget neutrality adjustment factor (BNAF),” the agency explains. The regulation addresses these ACA provisions. Comments are due by July 1.

On May 1, CMS issued its FY 2015 SNF PPS proposed rule, which proposes to increase Medicare payments to SNFs by 2%, or roughly $750 million, in FY 2015 – an increase over the 1.3% update effectuated under last year’s FY 2014 final regulation. CMS notes that the 2% update factor reflects a 2.4% MB increase less a 0.4% statutory productivity adjustment. A CMS fact sheet is available here. Comments are due by June 30, 2014.

On July 1, CMS issued its CY15 Medicare HHA PPS proposed rule under which CMS estimates that HHAs will see a -0.3% update – for an aggregate decrease of $58 million in Medicare payments to HHAs in CY 2015. A CMS fact sheet is available here.  These key ACA provisions are addressed in the underlying rule.  Comments on the proposed rule are due by September 2, 2014.

On July 2, CMS released its CY15 ESRD PPS proposed rule which, following an advance notice of proposed rule-making on the topic, also embeds separate proposals on implementing the ACA-mandated adjustments to DME to reflect competitively bid rates. CMS estimates that overall, ESRD facilities will experience a 0.3% increase in 2015 for an increase of about $30M in Medicare payments, which derive from updates to the outlier threshold amounts. CMS notes for CY15, under the proposal, hospital-based ESRD facilities have an estimated 0.5% increase in payments coed with freestanding facilities seeing an estimated 0.3% increase. CMS also “projects that urban ESRD facilities will receive an estimated increase in payments of 0.4% while rural facilities will receive a decrease of 0.5%.” Also, the proposed rule also contains proposals on establishing a methodology for adjusting DMEPOS payment amounts using information from the Medicare DMEPOS Competitive Bidding Program and adopting a phase-in of “special payment rules” for certain DME and enteral nutrition in certain areas. These key ACA provisions are addressed in the proposed rule. An agency fact sheet on the proposed rule, including the DME components, is available here. Comments on the proposed rule 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 August 4, CMS issued a final rule updating FY 2015 Medicare payment policies and rates for inpatient stays at general acute care and LTCHs. The final rule also codifies “two interim final rules with comment period relating to criteria for disproportionate share hospital [DSH] uncompensated care payments and extensions of temporary changes to the payment adjustment for low-volume hospitals and of the Medicare-Dependent, Small Rural Hospital (MDH) Program.”

Under the final rule, hospitals that participate in the Hospital Inpatient Quality Reporting Program and are ‘meaningful users’ of EHRs would receive a 1.4% payment update – up slightly from the agency’s 1.3% proposed increased. However, the 1.4% rate increase, when coupled with payment policy reductions enumerated further below – including reductions under the Hospital Readmissions Reduction Program, changes to Medicare DSH payments, and so forth – are projected to decrease IPPS operating payments by approximately 0.6%” (compared to the net decrease of 0.8% under the proposed rule) – or by roughly $756 million in FY 2015.

CMS also finalized its proposal to continue its slow phase-in of the ATRA’s coding intensity adjustment, leaving ~$8 billion to be recouped in FYs ‘15 and ‘16.

Gross LTCH payments under the final rule would increase by 1.1%  – up from the 0.8% CMS put forward in its proposed rule, with a delay (pursuant to the statutory mandate) in the full application of the 25% Rule patient threshold, among other key LTCH policy changes denoted further below.

CMS fact sheets are available here and here.  An agency press release is available here.

On August 11, CMS issued a MLN Matters article addressing hospice market basket revisions and quality reporting program provisions pursuant to the ACA.

On Oct. 31, CMS issued  its CY 15 ESRD final rule that also incorporates separate provisions finalizing a methodology – driven by the ACA – to adjust DMEPOS fee schedule payments based on competitively bid rates. The final regulation addresses the ACA productivity adjustment (at sec. 3401) as well as special payment rules for DME and enteral nutrition via sec. 3021 authority. Under the rule, CMS estimates that compared with CY14, ESRD facilities will see a 0.3% net increase in estimated CY15 Medicare payments – the same as estimated under the proposed rule. A fact sheet on the rule is available here.

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 Apr. 15, CMS issued a proposed rule (fact sheet) updating FY 2016 payments under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS). According to the proposals delineated in the rule, Medicare payments to SNFs are expected to increase by 1.4%, or $500 million, over FY 2015 rates

On Apr. 23, CMS proposed to increase Medicare payments to inpatient rehabilitation facilities (IRFs) by a net 1.7%, or roughly $130 million in FY 2016, which addressed these provisions in the law.

On Apr. 17, 2015 as part of a proposed rule updating FY 2016 Medicare payment policies and rates for inpatient stays at general acute care and LTCHs, CMS proposed “to extend the imputed floor policy (both the original methodology and the alternative methodology) for 1 additional year, through September 30, 2016, while [they] continue to explore potential wage index reforms.” The regulation addressed this provision of the ACA.

On Apr. 17, as part of a proposed rule updating FY 2016 Medicare payment policies and rates for inpatient stays at general acute care and LTCHs, CMS updated the national standardized amount for inpatient operating cost by a factor called the “applicable percentage increase” 2.7%, along with a -0.6 multifactor productivity adjustment, and a -0.2% “other” adjustment. The regulation addressed this provision of the ACA.

On Apr. 24, CMS released a proposed rule (fact sheet) on the FY16 inpatient psychiatric facility prospective payment system (IPF PPS) and rate update. CMS estimates that IPFs will see a 1.6% increase in FY16 payments, $80M above FY15. The regulation addressed this provision of the ACA

On June 24, the House voted to approve H.R. 1190 the Protecting Seniors Access to Medicare Act of 2015, which repeals the Independent Payment Advisory Review Board (IPAB).

On July 1, CMS released its CY 16 Medicare hospital OPPS and ambulatory surgical center proposed rule (fact sheet), which estimated that net CY 16 OPPS payments will decrease by -0.2%, or $43 million, compared with CY 15 payments. Comments are due by Aug. 31

On July, 6, CMS issued a proposed rule (press release; fact sheet) enumerating CY 16 payments under the Medicare Home Health Prospective Payment System (HH PPS). Under the proposed rule, CMS estimates that home health agencies (HHAs) will see a -1.8% update, for an aggregate decrease of roughly $350 million in Medicare payments to HHAs in CY 16. Comments are due Sept. 4.

On July 8, CMS posted the CY 16 Medicare Physician Fee Schedule (MPFS) proposed rule, which delineates payment policies impacting over one million physicians and other practitioners paid under the MPFS each year (see fact sheet here). Citing the latest doc fix (P.L. 114-10), the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS effectuates the statutory 0.5% increase. Comments are due Sept. 8.

On July 30, CMS released a final rule (fact sheet) updating the FY 16 Skilled Nursing Facility (SNF) Prospective Payment System (PPS). Under the final rule, Medicare payments to SNFs are expected to increase by 1.2% (versus 1.4% in April’s proposed rule), with aggregate FY16 payments rising by $430M compared with FY 15.

On July 31, CMS released the FY 16 inpatient prospective payment system (IPPS) and long-term care hospital PPS final rule affecting discharges beginning on Oct. 1, 2015.  The rule also includes an embedded interim final rule with comment period effectuating the statutory extension of the Medicare-dependent, small rural hospital Program and changes to the low-volume payment adjustment.

On July 31, CMS released an Inpatient Rehabilitation Facility (IRF) final rule in which it estimated that FY 16 payments will increase by 1.8% or $135 million across all IRFs compared with FY 2015.

On July 31, CMS finalized its proposal (fact sheet here) to update rates and certain policies related to the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) for FY 16. The final rule reflects a 1.5% increase in CMS’ estimated payments to IPFs relative to its FY 15 estimate.

On July 31, CMS released its final FY 16 hospice wage index and payment rate update (available here; fact sheet), estimating that net Medicare payments to hospices will increase by $160 million, or 1.1%.

2016

On Apr. 21, CMS released a proposal updating payment regulations for hospices. Under the proposed rule, net Medicare payments to hospices will increase by $330 million or 2.0 percent. The update is based on a market basket of 2.8 percent less a 0.5 percent productivity adjustment and a 0.3 percentage point adjustment set by the ACA.

On Apr. 21, CMS released a proposal updating payment regulations for Skilled Nursing Facilities. Under the proposal CMS estimates that overall payments to SNFs will increase by $800 million or 2.1 percent above FY 2016 levels.

On Apr. 21, CMS released a proposal updating payment regulations for Inpatient Rehabilitation Facilities (IRFs). Under the proposed rule, FY 2017 Medicare payments will increase by $125 million or 1.6 percent across all IRFs compared with FY 2016. This stems from an estimated 1.45 percent increase factor (an IRF-specific market basket estimate of 2.7 percent, minus a 0.5 percent multi-factor productivity adjustment and 0.75 percentage point statutory reduction) plus 0.2 percent for outlier threshold result updates. Table 21 on p. 158 of the public inspection copy provides fuller detail on the estimated payment impacts across facilities (by region, ownership status, etc.).

On Apr.19, CMS released the FY 2017 inpatient prospective payment system (IPPS) and long-term care hospital PPS and policy proposed rule that, once, finalized, will apply to discharges beginning on or after Oct. 1, 2016. Under the rule, CMS estimates a net average payment increase of 0.7 percent (a roughly $539 million increase in spending, including capital) in FY 2017 for the IPPS. For LTCH’s, and stemming largely from the application of statutory site-neutrality provisions in the Pathway for SGR Reform Act, CMS estimates that FY 2017 payments will decrease by an estimated $355 million or -6.9 percent in FY 2017.

On June 24, CMS released the calendar year 2017 proposed rule for the end-stage renal disease (ESRD) prospective payment system (PPS), which updates rates for renal dialysis services provided to Medicare beneficiaries on or after Jan. 1, 2017. CMS anticipates that aggregate ESRD PPS payments to dialysis facilities will increase by about $50 million in CY 2017, with $30 million stemming from the payment rate update and $20 million from updates to the outlier threshold amounts. This translates to an estimated +5 percent net rate update to ESRD facilities in CY 2017 compared with CY 2016. Comments are due by Aug. 23, 2016.

On June 27, CMS released its proposed rule on the calendar year (CY) 2017 home health prospective payment system rate update, which also proposes further policies for implementing a Home Health Value-Based Purchasing (HHVBP) Model beginning in CY 2018. CMS estimates that Medicare payments to home health agencies (HHAs) will decline by 1.0 percent in CY 2017, reflecting a $180 million decrease compared with CY 2016. Comments are due by Aug. 26, 2016.

On July 6, CMS released the calendar year (CY) 2017 hospital outpatient prospective system (OPPS) and ambulatory surgical center (ASC) payment system proposed rule. CMS estimates that overall, hospital outpatient departments (OPDs) will experience a 1.6 percent – or $5.1 billion – increase relative to CY 2016.

On July 28, 2016, CMS issued a notice updating fiscal year (FY) 2017 Medicare payment policies and rates for the Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS). CMS estimates IPF payments to increase by 2.2 percent or $100 million in FY 2017.

July 29, CMS released a final rule that says net Medicare payments to hospices will increase by $350 million or 2.1 percent. The update is based on a market basket (MB) of 2.7 percent less a 0.3 percent productivity adjustment and a 0.3 percentage point adjustment set by the ACA. The final rule reflects a $20 million increase over proposed levels.

On July 29, CMS announced Inpatient Rehabilitation Facility (IRF) rates in its annual payment rule. Under the rule, FY 2017 Medicare payments will increase by $145 million or 1.9 percent across all IRFs compared with FY 2016. This stems from an estimated 1.65 percent increase factor (an IRF-specific market basket estimate of 2.7 percent, minus a 0.3 percent multi-factor productivity adjustment and 0.75 percentage point statutory reduction) plus 0.3 percent for outlier threshold result updates. The final rule reflects a $20 million increase over proposed levels.

On July 29, CMS released the Skilled Nursing Facility payment rule. CMS estimates that overall payments to SNFs will increase by $920 million or 2.4 percent above FY 2016 levels. CMS clarifies that this estimate “is attributable to a 2.7 percent [MB] increase reduced by 0.3 percentage points, in accordance with the multi-factor productivity adjustment required by law.” The final rule reflects a $120 million increase over proposed levels.

On Aug. 2, CMS released the FY 2017 inpatient prospective payment system (IPPS) and long-term care hospital (LTCH) PPS and policy final rule. The final rule governs FY 2017 payments to approximately 3,330 acute care hospitals and 430 LTCHs through the IPPS and LTCH PPS, respectively, and effectuates key policy changes. Under the rule, net payments to inpatient hospitals will increase by 0.95 percent on average compared with FY 2016. For the IPPS, the rule finalizes the 1.5 percent documentation and coding recoupment cut, as proposed, and delays the proposed incorporation of S-10 data into uncompensated care calculations. LTCH PPS payments will decrease by 7.1 percent under the LTCH PPS amid the ongoing implementation of site neutrality and will increase by 0.7 percent for cases qualifying for the higher standard rate. The aforementioned provisions are addressed in this regulation.

On Oct. 31, CMS released the calendar year 2017 final rule for the ESRD PPS. The rule also addresses key policies related to the DMEPOS Competitive Bidding (CB) Program.

On Nov. 1, CMS released the CY 2017 HOPD/ASC payment system final rule. CMS estimates that overall, HOPDs will experience a 1.7 percent (up from 1.6 percent under the proposed rule) increase relative to CY 2016.

2017

On April 27, CMS released a proposed rule that would update the prospective payment rates for SNFs for FY 2018. This provision of the ACA is addressed in the rule.

On April 27, CMS released its proposal to revise the FY 2018 Medicare IPPS/LTCH PPS. This provision of the ACA is addressed in the rule.

On April 27, CMS released a proposed rule that would update the FY 2018 prospective payment rates for IRFs. This provision of the ACA is addressed in the rule.

On April 27, CMS released its hospice proposed rule updating the hospice wage index, payment rates, and cap amount for FY 2018. This provision of the ACA is addressed in the rule.

On June 29, CMS released its CY 2018 proposed rule updating the ESRD PPS. CMS expects to make about $10 billion in payments to 6,750 ESRD facilities in CY 2018. Proposals also address updates to outlier policy, including for pricing drugs and biologics. This provision of the ACA is addressed in the rule.

On July 14, CMS proposed updated payment policies applying to hospital outpatient departments and ASCs beginning on or after Jan. 1, 2018. CMS estimates that overall, hospital outpatient departments (OPDs) will experience a 2.0 percent increase ($5.7 billion) relative to CY 2017. This provision of the ACA is addressed in the rule.

On July 14, CMS released the CY 2018 Medicare Physician Fee Schedule (MPFS) proposed rule. The proposal updates rates and policies applicable to Medicare physicians and other professionals under Medicare Part B as of Jan. 1, 2018. This provision of the ACA is addressed in the rule.

On Aug. 1, CMS finalized rulemaking that would update the prospective payment rates for skilled nursing facilities (SNFs) for FY 2018. This provision of the ACA is addressed in the rule.

On Aug. 1, CMS released final rulemaking that to update the prospective payment rates for inpatient rehabilitation facilities (IRFs) for FY 2018. This provision of the ACA is addressed in the rule.

On Aug. 3, CMS finalized a rule to revise the Medicare hospital inpatient prospective payment system (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System for FY 2018. This provision of the ACA is addressed in the rule.