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November 2, 2024 - The Centers for Medicare & Medicaid Services (CMS) announced on Friday new baseline health and safety requirements for hospitals and Critical Access Hospitals (CAHs) providing obstetrical (OB) services to make pregnancy, childbirth, and postpartum care safer. CMS is also removing barriers to expand access to care for those formerly incarcerated and others in underserved communities. These policies are included in the calendar year (CY) 2025 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) final rule released today, which also updates payment rates for hospital outpatient and ASC services for CY 2025 by 2.9% (3.4% market basket, less 0.5 percentage points for multifactor productivity). These payment updates are estimated to result in an additional $2.2 billion in CY 2025 OPPS payments for hospitals compared to CY 2024.

“CMS is committed to addressing our nation’s maternity care crisis. Today, we are establishing the first-ever maternal health and safety standards for hospitals,” said CMS Administrator Chiquita Brooks-LaSure. “Additionally, the CY 2025 hospital Outpatient Prospective Payment System final rule expands access to behavioral health services, increases access to certain high-cost drugs for those facing cancer in tribal communities, and addresses barriers to Medicare coverage for those formerly incarcerated.”

CMS has finalized new health and safety requirements for hospitals and CAHs providing obstetrical services, which set baseline standards for the organization, staffing, and delivery of care within obstetrical units, update the quality assessment and performance improvement (QAPI) program, and require staff training on evidence-based maternal health practices. 

“These new requirements build on CMS’ maternity care action plan,” said Dr. Dora Hughes, Chief Medical Officer and Director for CMS’ Center for Clinical Standards and Quality. “Additionally, CMS has established emergency services readiness and transfer protocol requirements for all patients, which will better prepare hospitals and CAHs to respond to obstetric emergencies. Of note, CMS is finalizing a phased-in implementation for all of these new requirements in an effort to balance the need for improved maternal health outcomes while addressing potential burden concerns raised in public comments.”

Additionally, the CY 2025 OPPS and ASC final rule implements policies to reduce the use of opioids and to increase access to high-cost drugs in tribal communities. CMS is finalizing the implementation of a provision from the Consolidated Appropriations Act, 2023 (CAA, 2023) that provides additional payment for certain non-opioid drugs and medical devices for pain relief, which have demonstrated that they reduce opioid usage that have FDA-approved indications to reduce post-operative pain or produce postsurgical analgesia, and medical devices that have demonstrated they reduce opioid usage when used in the postoperative setting. This policy supports the agency’s behavioral health goals of reducing opioid overdoses and helps ensure effective pain management. Medicare will make an additional payment for Indian Health Services (IHS) and tribal hospital outpatient departments to increase access to high-cost drugs, such as those involved in treating cancer. This policy supports the Biden-Harris Administration’s Cancer Moonshot and increases equity by reducing a barrier for tribal populations seeking access to cancer care.

Another way CMS is improving health equity for underserved communities in the final rule is by removing barriers to ensure that people with Medicare who are on bail, parole, probation, home detention, or who are required to live in halfway houses, can access Medicare services. CMS is also expanding the eligibility criteria for a special enrollment period for formerly incarcerated individuals to include individuals who have been released from incarceration or who are on bail, parole, probation, home detention, or live in halfway houses, to further support these individuals. 

“Together, these policies meaningfully impact health disparities by addressing equity and access barriers for underserved communities,” said Dr. Meena Seshamani, Deputy Administrator and Director of CMS’ Center for Medicare. “Patients deserve access to post-operative pain relief that can decrease their exposure to opioids, access to the care that will help bridge vulnerable transitions from incarceration to the community, and access to the care that will help fight their cancer, in every community across our country. This rule takes a significant step forward in reducing disparities and increasing access to care.”       

The final rule also expands coverage under Medicaid in several important ways that will improve access to care and reduce disparities for people with Medicaid coverage. The rule will expand the clinic services’ benefit for services provided outside the “four walls” of IHS and Tribal clinics, and also gives states the option to cover Medicaid clinic services outside the “four walls” of behavioral health clinics and clinics located in rural areas. The final rule also codifies the requirement of 12 months of continuous eligibility for children enrolled in Medicaid and CHIP, which was enacted as part of the CAA, 2023.

For a fact sheet on the CY 2025 OPPS/ASC Payment System Final Rule, please visit: https://www.cms.gov/newsroom/fact-sheets/cy-2025-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center-0

The CY 2025 OPPS/ASC Payment System Final Rule can be viewed here: https://www.federalregister.gov/public-inspection/2024-25521/medicare-and-medicaid-programs-hospital-outpatient-prospective-payment-and-ambulatory-surgical
Source: CMS