CMS proposes CY 2025 OPPS, ASC payment system rule

CMS has proposed the calendar year (CY) 2025 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) payment rule, seeking to increase Medicare payments to the facilities while expanding health equity and behavioral health access.

The proposed rule looks to increase the OPPS payment rates for hospitals by 2.6% if they meet quality reporting requirements. CMS said the increase is based on a projected hospital market basket percentage increase of 3.0%, less a 0.4 percentage point productivity adjustment.

ASCs are also slated to see a 2.6% Medicare payment update in CY 2025 as long as facilities meet relevant quality reporting requirements. The update also includes a market basket percentage increase of 3.0% less a 0.4 percentage point productivity adjustment.

Additionally, the proposed rule would also maintain the current rate structure for intensive outpatient program services and partial hospitalization programs in hospital outpatient departments and community mental health centers.

The rule would also implement a temporary additional payment for certain non-opioid treatments for pain relief in the hospital outpatient department and ASC settings, starting January 1, 2025, and ending December 31, 2027. CMS plans to finalize seven drugs and one device for the additional payment, which will not exceed the estimated average of 18% of the OPPS payment for the service or group of services with which the non-opioid treatment is furnished, CMS clarified in the rule.

Other payment policies to be updated by the CY 2025 OPPS and ASC payment rule include refinements to the existing packaging policy for specialized diagnostic radiopharmaceuticals, additional payment for domestically produced Technetium-99m and an extension of coding and payment for drug and device trials meeting coverage with evidence development requirements.

CMS also emphasized that the proposed rule seeks to advance health equity and expand access to behavioral health services. The agency plans to achieve those goals through several proposals including:

• Establishing 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
• Creating 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
• Eliminating barriers for individuals to enroll in and maintain their Medicare coverage after incarceration

The proposed rule also contains policies aimed at improving maternal health. Specifically, CMS proposed baseline health and safety requirements for hospitals and critical access hospitals for obstetrical services. The baseline standards are related to the organization, staffing and delivery of care within obstetrical units, as well as emergency services readiness, transfer protocols for obstetrical patients and annual staff training on evidence-based maternal health practices and cultural competencies.

Experts have deemed US maternal mortality a crisis, with the US having the highest rate of maternal deaths of any high-income nation. Black birthing people experience the highest mortality rate despite over 80% of deaths likely preventable.

“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,” HHS Secretary Xavier Becerra said in an announcement. “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.”

Comments are open on the proposed rule through September 9, 2024. CMS expects to issue a final rule in early November.