Medicare

About Medicare

The federal Medicare program is an essential pillar of the state’s health care system, supporting more than 6 million Californians over the age of 65 and younger Californians with disabilities. One in five hospitals is at risk of closing, in part because Medicare reimbursement rates are far lower than the cost of providing care. It’s essential that future federal Medicare policy protects patient care.

CMS Initiates Collection of SNF Ownership Information

What’s happening: The Centers for Medicare & Medicaid Services (CMS) has begun notifying skilled-nursing facilities (SNFs) of new requirements to report detailed information about ownership and management.  

What else to know: SNFs must disclose this information on the updated Medicare Enrollment Application (CMS-855A) form attachment, for which CMS has provided additional guidance. Over the next few months, CMS will give all SNFs, including hospital-based SNFs, direction on submitting a revalidation application with the information. 

CMS Reduces Medicare Payments to Physicians in Final Rule

What’s happening: The Centers for Medicare & Medicaid Services (CMS) issued its calendar year (CY) 2025 Medicare physician fee schedule (PFS) final rule, in which the final CY 2025 PFS conversion factor is $32.35 — a decrease of 2.8% from CY 2024.  

What else to know: CMS published a fact sheet on the CY 2025 Medicare PFS that shares the rate setting and conversion factor, and much more. 

CMS Guidance Clarifies Hospital Respiratory Illness Data Reporting Requirements Effective Nov. 1

What’s happening: The Centers for Medicare & Medicaid Services (CMS) issued guidance to hospitals and state surveyors that underscores the importance of following reporting requirements for new hospital respiratory illness data reporting conditions of participation (CoP). 

What else to know: CMS also clarifies in the guidance that psychiatric hospitals and rehabilitation hospitals will report their daily COVID-19, influenza, and respiratory syncytial virus data annually rather than weekly. 

Senate Subcommittee Issues Scathing Report on Medicare Advantage Plans

What’s happening: The U.S. Senate Permanent Subcommittee on Investigations (PSI) released a report revealing that the three largest Medicare Advantage (MA) plans intentionally target costly stays in post-acute care facilities to increase profits.  

What else to know: These MA plans denied prior authorization (PA) requests for post-acute care requests at far higher rates than they did for other types of care, resulting in diminished access to post-acute care for MA beneficiaries and an increase in the number of post-acute care services subject to PA. The PSI’s investigation also provided insight into automation and predictive technologies in the PA process.  

Noridian Shares Resource for Outpatient Therapy Providers

What’s happening: Noridian, the Medicare administrative contractor (MAC) for California, has provided a one-page resource for outpatient therapy service providers, including physical therapy, occupational therapy, and speech/language pathology services. 

What else to know: The resource includes information on coding and claim processing, therapy accruals, certification for therapy plan of care, advance beneficiary notice of noncoverage and more.   

CMS Issues Final Rule on Appeals of Observation Status

What’s happening: The Centers for Medicare & Medicaid Services (CMS) has issued a final rule that establishes an appeals process for Medicare enrollees who are initially admitted as hospital inpatients but are subsequently reclassified as outpatient observation patients. 

What else to know: The new regulations create processes for both retrospective appeals and prospective appeals. CMS expects the retrospective appeals to become operational in January 2025 and the prospective appeals to become operational in mid-February 2025.  

CMS Finalizes Medicare Observation Appeals Processes

What’s happening: The Centers for Medicare & Medicaid Services (CMS) has established appeals processes for Medicare beneficiaries who were admitted as inpatient but whose status changed to outpatient observation during their hospital stay.  

What else to know: The appeals processes only apply to patients enrolled in traditional Medicare, not patients enrolled in Medicare Advantage.