CMS Round Up

CMS Roundup (Mar. 8, 2024)

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

CMS Releases Eighth Annual Evaluation Report of the Independence at Home Demonstration

February 23: CMS released its eighth annual report on the evaluation of the Independence at Home Demonstration (IAH). The IAH demonstration is Congressionally mandated and tests whether a payment incentive for providing home-based primary care for people with Medicare with multiple chronic conditions reduces health care spending for Medicare by forestalling the need for care in institutional settings. In Year 8, the second year of the COVID-19 pandemic, ambulatory care and support provided by the seven participating practices did not significantly reduce total spending or hospital utilization for people with Medicare. Home-based primary care provided by IAH practices has several features that differ from typical office-based care and may have been especially valuable to people with Medicare during the pandemic.

CMS Notifies State Medicaid Directors about Availability of Funds for Skilled Professional Medical Personnel and Nurse Advice Lines (NALs)

February 26: CMS issued guidance in a State Medicaid Directors Letter (SMDL) that allows states to expand the pool of skilled professional medical personnel (SPMP) to include certain additional behavioral health professionals. State Medicaid agencies employ SPMPs to ensure that the administration of the program is informed by and aligned with clinical best practices on behalf of people with Medicaid. This expansion will allow states to claim higher administrative federal match for their work. The guidance also informs states that they may claim administrative federal match dollars for nurse advice lines (NALs) a tool that builds a lifeline between coverage and critical health services, particularly in rural areas. 

CMS Approves Amendment to Montana’s Healing and Ending Addiction Through Recovery and Treatment Section 1115 Demonstration

February 26: CMS approved an amendment to Montana's Healing and Ending Addiction through Recovery and Treatment (HEART) section 1115 demonstration to expand Montana’s support of individuals with behavioral health conditions and other risk factors. This approval allows the state to provide pre-tenancy and tenancy support services to people with Medicaid with a serious mental illness or substance use disorder (SUD), who meet the state’s needs-based criteria and have certain risk factors, such as a history of homelessness. In addition, CMS approved expenditure authority for contingency management services to qualifying individuals with a stimulant use disorder. Lastly, Montana will now be able to provide a targeted set of services to certain incarcerated individuals for up to 30 days immediately prior to the individual’s expected release date from a state prison. To receive pre-release services, these Medicaid-eligible individuals need to meet health-related criteria, including having a mental illness health or SUD diagnosis or suspected SUD.  

CMS Releases Second Annual Evaluation Report for the Primary Care First Model 

February 26: CMS released its second annual report on the evaluation of the Primary Care First Model (PCF). Launched in 2021, PCF aims to improve quality, improve patient experience of care, and reduce expenditures by increasing patient access to advanced primary care services. In the first two years of PCF, practices used model funds to make care delivery changes, including continuing changes they started prior to joining the model, that they believe will ultimately reduce hospitalizations. Prior primary care transformation experience and affiliation with larger health care organizations facilitated these changes. As expected, this early in the model, there have been minimal effects on hospitalizations and Medicare expenditures. Future reports will focus on the trajectory of practice transformation to deepen CMS’ understanding of practices’ perception of the payment model and provide estimates for effects across a broader set of outcomes.

CMS Posts the 2024 National Impact Assessment Quality Measures Reports

February 28: CMS posted the National Impact Assessment Quality Measures Reports. CMS uses quality measures to support a patient-centered health care system anchored by quality, accessibility, affordability, innovation, and accountability. The report analyzes quality measure results from 2016 to 2021 across 26 quality and value-based incentive payment programs. The report also provides updates on how CMS reduces burden through the broad use of digital data sources. The quality reports examine data-driven results that support progress toward CMS objectives to improve public health, implement measures meaningful to patients and providers, minimize provider burden, focus on outcomes whenever possible, identify significant opportunities for improvement, and support a transition to population-based payment models. 

CMS’ Medicare Administrative Contractors Remove and Replace Billing Instruction for Blood Tests Used to Monitor for Organ Transplant Rejection 

February 29: CMS’ Medicare Administrative Contractors (MACs) issued revised provider billing instructions for blood tests used to monitor patients who are at risk of rejecting transplanted organs. Billing instructions help health care providers understand when and how to bill Medicare for a covered service. These billing instructions will help to reassure providers and patients with transplanted hearts, lungs, or kidneys who meet Medicare’s local coverage criteria have coverage for blood tests used to monitor for solid organ transplantation rejection when medically necessary and ordered by a physician. Additional information is here

CMS Approves Utah Section 1115 Demonstration Bundled Amendments 

February 29: CMS approved amendments to Utah’s Medicaid Reform 1115 Demonstration (formerly the “Primary Care Network”), giving the state Medicaid expenditure authority to provide fertility preservation services to certain people diagnosed with cancer, as well as in vitro fertilization (IVF) and genetic testing services for individuals with certain genetic traits. This amendment also approves an increase in the premium subsidy amount for individuals eligible for coverage under the state’s Children’s Health Insurance Program (CHIP) premium assistance program. Additionally, this amendment adds four risk factors that would be considered under the state’s Housing Related Services and Supports (HRSS) program, which provides coverage of tenancy support, community transition, and supportive living services to individuals experiencing homelessness, food or transportation insecurity, or interpersonal violence and trauma.  

CMS Approves New Yorks Application for a State Innovation Waiver Under the Affordable Care Act – the Essential Plan Expansion

March 1:CMS approved New York’s application for a State Innovation Waiver  under the Affordable Care Act (ACA) (referred to as a “section 1332 waiver”) for five years, from April 2024 through December (PY) 2028. New York’s section 1332 waiver application sought to create a new coverage program, the Essential Plan (EP) Expansion, that generally mirrors the State’s Basic Health Program (BHP), known as the EP,1 with expanded eligibility under its section 1332 waiver to certain residents with estimated household incomes up to 250% of the Federal Poverty Level (FPL). The EP Expansion will also include some individuals with incomes below 250% of FPL who would otherwise be enrolled in Medicaid coverage or in a state-funded health insurance program absent the waiver. This first-of-its-kind, innovative waiver aims to improve access to affordable coverage, provide additional benefits, help advance health equity, and smooth the affordability “cliff” for individuals transitioning from Medicaid during the unwinding period.

CMS Updates National Plan and Provider Enumeration System to Include Additional Gender Options and P.O. Boxes Instead of Home Addresses

March 4: CMS issued a Federal Register notice updating the gender options on the National Provider Identifier form in the National Plan and Provider Enumeration System (NPPES) to improve accuracy and inclusive data collection. Also, for providers who do not have a physical location other than their home address (for example, if exclusively furnishing telehealth services from their homes), the NPPES will allow for submission of a post office box or personal mailbox offered by a private delivery service as a practice location address. These changes will be effective in NPPES on April 3, 2024.

HHS Outlines Steps CMS Has Taken to Help Providers Continue to Serve Patients Following a Cyberattack on a Subsidiary of UnitedHealth Group - Change Healthcare  

March 5: HHS issued a statement about a recent cyberattack that happened in late February to Change Healthcare, which is a subsidiary of UnitedHealth Group’s division Optum, Inc. The effects of this attack have been felt across the health care sector – from pharmacies and hospitals to physician offices. More importantly, it has impacted some people’s ability to get the care or prescriptions they need. The statement includes immediate steps CMS is taking to assist providers in continuing to serve patients. Please refer to the HHS statement for specific flexibilities that have been put into place to assist the health care community with submitting claims and receiving payments. 

CMS Announces a National Coverage Determination (NCD) for Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndromes (MDS) 

March 6: CMS posted a Final National Coverage Determination (NCD) for Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndromes (MDS).  CMS will cover allogeneic HSCT for the treatment of myelodysplastic syndromes (MDS) in patients who have been designated as Intermediate-2, high-risk, or very high-risk of developing acute myeloid leukemia measured by specified risk stratification systems (IPSS, IPSS-R, IPSS-M) which are tools used to determine a patient’s risk for developing cancer. CMS will cover HSCT using FDA-approved bone marrow, peripheral blood, or umbilical cord blood stem cell products and eliminate the requirement for patients to participate in a Medicare-approved, prospective clinical study. Coverage for patients who do not meet these indications may be determined by Medicare Administrative Contractors (MACs). Read more about the Medicare Coverage Determination Process here

CMS Releases Request for Applications for Manufacturers Applying for the Cell and Gene Therapy Access Model 

March 7: CMS released the Request for Applications (RFA) for manufacturers applying for the Cell and Gene Therapy (CGT) Access Model. The CGT Access Model aims to improve health outcomes for people with Medicaid living with rare and severe diseases by increasing access to potentially life-changing treatments. The model was announced in January 2024 and will initially focus on gene therapies for sickle cell disease. The Manufacturer RFA is available on the model webpage and is open to all manufacturers of gene therapies for the treatment of sickle cell disease. Responses to the RFA are due by May 1, 2024. Another RFA and Notice of Funding Opportunity (NOFO) for states will follow in Summer 2024.

CMS Shares Strategies to Improve Delivery of Tobacco Cessation Services

March 7: CMS released a bulletin on strategies states have used to help more Medicaid and Children’s Health Insurance Program (CHIP) individuals quit smoking. The informational bulletin summarizes the burden of smoking and smoking-related diseases in the Medicaid and CHIP population, outlines the benefits of helping people quit smoking, and provides an overview of the evidence-based treatment services and opportunities available to help this population quit smoking. The bulletin also provides an overview of state tobacco cessation coverage requirements and authorities in Medicaid and CHIP. An overview of quality measures that state Medicaid and CHIP agencies can use to measure and drive improvement in their delivery of tobacco cessation services and several resources that can support states in their drive for improvement are also included. 

CMS Releases Accomplishments for 2023

March 8: CMS released its 2023 accomplishments on the CMS Strategy Page highlighting its work guided by the CMS strategic pillars. Inherent in CMS’ work is an unyielding focus on the customer experience to expand coverage and equitable access to those covered by one or more of our programs. To support the pillars, CMS has outlined a set of 13 cross-cutting initiatives that draw upon critical work done across the agency to drive results. These initiatives are high-level, multi-year Administration policy priorities that bring our Centers and Offices together to leverage their expertise and strengthen collaboration. In 2023, CMS continued to advance health equity, expand coverage, and improve health outcomes. 

Other Recent Releases: 

February 29: Biden-Harris Administration Issues Final Guidance to Help People with Medicare Prescription Drug Coverage Manage Prescription Drug Costs 

March 6: CMS Issues Statement on Change Healthcare Cyberattack 

March 8:  Biden-Harris Administration Announces Utah’s Medicaid and CHIP Postpartum Coverage Expansion; 45 States Now Offer Full Year of Coverage After Pregnancy  


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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