Coverage Updates
February 6, 2024: FAQs Related to Coverage Criteria & Utilization Management Requirements for MA Plans
CMS sent a FAQ document to all Medicare Advantage Organizations and Medicare-Medicaid Plans related to Coverage Criteria and Utilization Management Requirements in the CMS Final Rule (CMS-4201-F) issued on April 5, 2023. They note since this rule has been issued, they have received questions regarding application of the rules. This document is meant to provide clarification about how CMS expects MA plans to comply with the new rules. https://www.aha.org/system/files/media/file/2024/02/faqs-related-to-coverage-criteria-and-utilization-management-requirements-in-cms-final-rule-cms-4201-f.pdf
Compliance Education Updates
January 2024: MLN Booklet: Health Equity Services in the 2024 Physician Fee Schedule Final Rule (MLN9201074)
CMS framework on health equity lists 5 priorities for reducing disparities in health. The 2024 Physician Fee Schedule Final Rule has 4 services to help address these priorities including:
- Caregiver Training Services (CTS),
- Social Determinants of Health Risk (SDOH) Assessment,
- Community Health Integration (CHI), and
- Principal Illness Navigation (PIN).
This MLN booklet reviews all four services including who can provide the service and documentation and billing guidance.
https://www.cms.gov/files/document/mln9201074-health-equity-services-2024-physician-fee-schedule-final-rule.pdf-0
January 2024: MLN Booklet: Federally Qualified Health Center (MLN006397)
CMS has added information about marriage and family therapists and mental health counselors or practitioners, added services, updates to mental health in-person visit rules, and COVID-19 and other vaccine billing instructions to this MLN booklet. https://www.cms.gov/files/document/mln006397-federally-qualified-health-center.pdf
February 2024: MLN Booklet: Information for Rural Health Clinics (MLN006398)
CMS has made additions to this booklet, for example information about marriage and family therapists and mental health counselors as practitioners and social determinants of health has been added. https://www.cms.gov/files/document/mln006398-information-rural-health-clinics.pdf
February 2024: MLN Fact Sheet: Telehealth Services (MLN901705)
Changes made to this MLN product includes adding new CPT and HCPCS codes for CY 2024, adding new and expanded telehealth services, information about extended use of modifier 95 and the CY 2024 originating site facility fee amount which is $29.96. https://www.cms.gov/files/document/mln901705-telehealth-services.pdf
February 2024: MLN Fact Sheet: Proper Use of Modifiers 59, XI, XP, XS, & XU (MLN1783722)
This CMS Fact Sheet has been updated to include information on the use of modifier 59 and a single Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC). https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xe-xp-xs-and-xu.pdf
