The Centers for Medicare & Medicaid Services (CMS) on Thursday issued the Calendar Year 2023 Physician Fee Schedule proposed rule. If finalized, the rule would make significant changes to the Medicare Shared Savings Program and expand access to behavioral health services, cancer screening, and dental care, particularly in rural and underserved areas.
“Integrated coordinated, whole-person care—which addresses physical health, behavioral health, and social determinants of health—is crucial for people with Medicare, especially those with complex needs,” Meena Seshamani, M.D., Ph.D., CMS deputy administrator and director of the Center for Medicare, said in an announcement. “If finalized, the proposals in this rule will advance equity, lead to better care, support healthier populations, and drive smarter spending of the Medicare dollar.
Here are five things to know about the proposed rule:
1. Expands coverage for behavioral health services
To address the acute shortage of behavioral health practitioners, CMS wants to allow licensed professional counselors, marriage and family therapists, and other types of behavioral health practitioners to provider behavioral health services under general (rather than direct) supervision. CMS also proposes to pay for clinical psychologists and licensed clinical social workers to provide integrated behavioral health services as part of a patient’s primary care team.
Other proposed changes include bundling certain chronic pain management and treatment services into new monthly payments, which CMS believes will improve patient access to team-based comprehensive chronic pain treatment. CMS also proposes to cover opioid treatment and recovery services from mobile units, such as vans, to increase access for people who are homeless or live in rural areas.
2. Makes major changes to the Medicare Shared Savings Program to address social needs
CMS acknowledges that if the proposals are finalized, the changes to the program represent some of the most significant reforms since the program was established more than 10 years ago. CMS wants to incorporate advance shared savings payments to certain new Medicare Shared Savings Program accountable care organizations (ACO) that could be used to address Medicare beneficiaries’ social needs. This would be one of the first times that CMS would allow traditional Medicare payments to be used for such purposes and would allow providers in rural and other underserved areas to make the necessary investments to become an ACO and success in the program. In addition, CMS wants smaller ACOs to have more time to transition to downside risk to help grow participation in rural and underserved communities. Other changes would make a health equity adjustment to an ACO’s quality performance category score to reward excellent care delivered to underserved populations and allow benchmark adjustments to encourage more ACOs to participate and help CMS achieve its goal of having all those with traditional Medicare in an accountable care relationship with a health care provider by 2030.
3. Improves access to colon cancer screening
Colon and rectal cancer were the second-leading cause of cancer deaths in the United States in 2020, with higher colorectal cancer death rates for Black Americans, Indigenous people, and Alaska Natives. To reduce barriers to getting a colonoscopy, CMS proposes that a follow-up colonoscopy to an at-home test be considered a preventive service, which would waive cost sharing for Medicare beneficiaries. Medicare also plans to cover the service for individuals 45 years old and older in the wake of the newly lowered age recommendation for the procedure from the United States Preventive Services.
4. Expands dental coverage
Dental services that are integral to medically necessary services required to teach a Medicare member’s primary medical condition are covered under Medicare Part B. But CMS proposes to pay for additional services, such as a dental examination and treatment preceding an organ transplant. CMS is also asking for feedback on dental services for other medical conditions, such as cancer treatment or joint replacement surgeries.
5. Extends telehealth services beyond the public health emergency (PHE)
CMS wants to extend the time that services are temporarily included on the Medicare telehealth services list during the COVID PHE for 151 days following the end of the PHE. This would extend certain flexibilities to allow telehealth services to be provided in any geographic area and in any originating site setting, including the beneficiary’s home, allowing services to be provided via audio-only telecommunication systems, and allow physical therapists, occupational therapists, speech-language pathologists, and audiologists to provide services via telehealth.