CMS Proposed Policy Changes affecting RHC’s in CY2025
As of July 10, 2024 the Centers for Medicare and Medicaid Services (CMS) announced proposed policy changes to Medicare payments under the Physician Fee Schedule (PFS) and other Medicare Part B issues, effective on or after January 1, 2025. These proposed rules reflect a broader Administration-wide strategy to create a more equitable health care system with better accessibility, quality, affordability, empowerment, and innovation for all Medicare beneficiaries. Here’s a summary of five of the most impactful proposed rules that will affect Rural Health Clinics (RHCs) specifically:
Removing the RHC Productivity Standards
RHC’s productivity standards are currently set to annual visit volumes of at least 4,200 visits per full-time equivalent physician and 2,100 visits per FTE nurse practitioner, PA, and certified nurse midwife. These targets can impact their All Inclusive Payment Rate (AIR), if they are not met. CMS believes that these productivity standards are outdated and redundant when compared to the restructured payment limits for RHCs that was implemented on April 1st, 2021, via Section 130 of the CAA.
Payment for Preventative Vaccine Costs
RHC’s are reimbursed for vaccines during the Cost Report reconciliation. Wait times between purchasing and administering vaccines and the Cost Report settlements are creating cash flow challenges. The intent of this proposal is to improve the timeliness of payments for critical preventative vaccine administration by allowing the clinics to bill for the vaccines services at the time of service. Payments for these claims will be made according to Part B preventative vaccine payment rates as in other settings, to be annually reconciled at a later time with the clinic’s actual vaccine costs on their cost reports.
Revamping RHC Care Coordination Services and the Elimination of G0511
CMS is proposing for RHC’s to report individual CPT and HCPCS codes that describe care coordination services instead of the single HCPCS code G0511. The proposal will also allow for permit billing of the add-on codes associated with these services. This will improve payment accuracy and help beneficiaries better understand which services they are receiving. In addition, CMS is also proposing to adopt the coding and policies regarding Advanced Primary Care Management (APCM) services for RHC payment.
Clarification of Dental Services provided in the RHC
CMS is seeking alignment between the policies for dental services furnished in the physician office that are inextricably linked to certain covered services. In clarifying those scenarios CMS would consider those services to be RHC services to be paid under the RHC All-Inclusive Rate (AIR) methodology.
RHC Telehealth Policy Extension Through December 31, 2025
CMS is proposing to continue to delay any changes to the telehealth flexibilities and the telehealth policies (G2025 methodology) which includes in-person visit requirements for mental health services via communication technology until December 31st, 2025.
RHC Conditions for Certification Changes in Primary Care vs. Specialty
CMS is proposing changes to the RHC Conditions for Certification to increase flexibility and decrease burden for providers and ultimately improve access to services for patients. CMS is proposing to explicitly require that RHC’s provide primary care services to more closely align with the intent of the sub-regulatory guidance while preserving access to primary care services in rural communities. This would not prevent RHCs from providing or continuing to provider specialty services. It is simply meant to clarify that RHCs must provide Primary Care Services.
Intensive Outpatient (IOP) Services in RHCs
CMS is proposing to provide a different payment rate when there are four or more services are furnished in a day as compared to the current payment amount based on only three services.
Changes in Required Lab Services
CMS is proposing to remove the need for Hemoglobin and Hematocrit from the list of required lab service’s equipment and supplies for RHCs.
Please note that these are proposed changes to take place in 2025, if, and only if, they are independently approved and made final. CMS makes these proposed changes known to the public to broaden the conversation, gain helpful feedback and solicit public comments to the policy changes.
For more detailed information regarding these and all the proposed changes, please refer to the link below:
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