The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), on Wednesday released the 2025 Medicare Physician Fee Schedule (PFS) proposed rule.
Although HHS and CMS say the proposed policies would increase value-based care and expand access to behavioral and oral health care, if finalized, physicians would face a cut in pay for the fifth year in a row. It also includes several provisions that would impact Medicare Advantage.
The 2,248-page proposed rule will be published in the Federal Register on July 31. Comments are due by September 9.
Under the proposed rule, CMS would:
- Reduce the conversation factor by 2.8 percent to $32.36 in calendar year 2025 compared to the current conversion factor of $33.29.
- Establish a new advanced primary care management bundle under the PFS. The proposed payment would use coding to describe services provided by advanced primary care teams, with adjustments for patient medical and social complexity to promote health equity. These services would be tied to primary care quality measures to improve health outcomes for Medicare recipients.
- Create new payment and coding for cardiovascular risk assessment and cardiovascular care management to better assess and manage heart health.
- Set up six new MIPS value pathways (MVPs): Ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care.
- Update MIPS scoring methodologies and measure inventories to ensure that all eligible clinician types can continue to meaningfully participate in MIPS as CMS transitions to MVPs.
- Allow eligible accountable care organizations (ACOs) with a history of success in the Medicare Shared Savings Program (Shared Savings Program) access to an advance on their earned shared savings to encourage investments in staffing, health care infrastructure, and additional services to Medicare recipients, such as nutrition support, transportation, dental, vision, hearing, and Part-B cost-sharing reductions.
- Incentivize participation in the Shared Savings Program by ACOs that serve Medicare recipients who are members of rural and underserved communities by adopting a health equity benchmark adjustment like that in the Innovation Center’s ACO REACH Model, which has been associated with increased safety net provider participation.
- Move the Shared Savings Program toward the Universal Foundation of quality measures, creating better quality measure alignment for providers and driving care transformation.
- Establish a methodology to account for the impact of improper payments when reopening an ACO’s shared savings and shared losses calculations, which is complementary to the Anomalous Increases in Billing on Medicare Shared Savings Program Financial Calculations Proposed Rule issued on(June 28). CMS said the proposed adjustments described in both rules would improve the accuracy, fairness, and integrity of Shared Savings Program financial calculations.
- Set up new payments for practitioners who assist people at high risk of suicide or overdose, including separate payment for safety planning interventions and post-discharge follow-up contacts. It also would create new payment and coding for use of digital tools that further support the delivery of specific behavioral health treatments, and new coding and payment to make it easier for practitioners to consult behavioral health specialists.
- Establish new codes under Opioid Treatment Programs for FDA-approved medications for the treatment of Opioid Use Disorder (OUD) and known or suspected opioid overdose, increased telecommunication flexibilities for periodic assessments and methadone treatment initiation, and an increase in payment for intake activities to provide more comprehensive services for the treatment of OUD, including assessing for unmet health-related social needs, harm reduction intervention needs, and recovery support service needs.
- Set up payment for certain dental services associated with dialysis treatments for end-stage renal disease and includes a request for comment about dental services related to diabetes care and covered services for individuals with autoimmune diseases receiving immunosuppressive therapies.
- Establish new payment for caregiver training services related to direct care services and supports and would allow caregiver training services to be provided virtually, as clinically indicated.
- Expand coverage of the hepatitis B vaccine for people with Medicare who have not received the hepatitis B vaccine or whose vaccination status is unknown, with no cost to the individual. In addition, it would allow Medicare recipients to get the hepatitis B vaccine from pharmacies and to allow pharmacies and mass immunizers to roster bill Medicare consistent with current billing for flu, pneumococcal, and COVID-19 vaccines.
- Set a fee schedule for drugs covered as additional preventive services since CMS has not yet covered or paid for any drugs under the benefit category of additional preventive services.
- Update and expand coverage of colorectal cancer screening to promote access and remove barriers for much needed cancer prevention and early detection, which may be especially important within rural communities and communities of color.
- Permit certain practitioners to provide virtual direct supervision to auxiliary personnel when required.
- Temporarily extend virtual supervision for a broader range of services when teaching physicians virtually supervise telehealth services provided by residents in teaching settings.
Industry expert Melissa Smith, founder of Newton Smith Group, said in a LinkedIn post that Medicare Advantage plans and risk-based providers should pay attention to the proposed overpayment rules that apply to risk adjustment upcoding and coding errors. In addition, she said, since Medicare Advantage plans must cover all FFS services, some proposals increase expense and will require operational adjustments.
Smith said that the proposals with the greatest impact to Medicare Advantage plans include, but aren’t limited to, those that involve reporting and returning overpayments to CMS, accelerated FFS alignment with Universal Foundation measures, and new payments for caregiver training and cardiovascular risk assessment, and expanded Part A and Part B dental coverage for dialysis patients with ESRD.
She advised Medicare Advantage plans to examine the impact of the proposals on their contracts and organization and submit comment to CMS; and ensure leaders know about the proposals and begin preparing and strategizing in the event the proposals are finalized.
For more information, click here for a fact sheet, here for the announcement, here for the unpublished proposed rule, and here for Smith’s LinkedIn post.