CMS final rule for CY 2025: Key updates impacting Medicare payments, quality programs

Editor's Note

The Centers for Medicare & Medicaid Services (CMS) issued its final rule for the 2025 calendar year, updating payment systems and quality reporting requirements across healthcare settings, JD Supra November 19 reports. Effective January 1, 2025, the rule outlines significant changes to Medicare payments and conditions for participation in key programs.

Here’s a summary of the most impactful updates affecting eight areas:

1. Payment system updates

• Both hospital outpatient and ambulatory surgical center (ASC) payment rates will increase by 2.9%, factoring in a 3.4% market basket adjustment offset by a 0.5% productivity reduction.
• Wage Index Adjustments: CMS will maintain a distinct wage index for the Hospital Outpatient Prospective Payment System (OPPS), increasing rates for hospitals below the 25th percentile.

2. Behavioral and mental health services

• Intensive Outpatient Programs (IOPs) and Partial Hospitalization Programs (PHPs) retain existing rate structures, with payments based on updated claims and cost report data.
• Medicare will now reimburse for digital mental health devices used alongside treatment.

3. Maternal health and obstetrical services

CMS introduced new conditions for hospitals providing obstetrical services, including:

• Staffing standards: Requires specialized staff and integration with other hospital services.
• Training requirements: Facilities must document biennial training to improve maternal care.
• Emergency readiness: Hospitals must maintain equipment, supplies, and protocols for obstetric emergencies.

4. Nonopioid pain management

• Temporary payments for nonopioid treatments will be implemented, capped at 18% of the service payment rate.

5. Telehealth and virtual supervision

• Telehealth services, including caregiver training and crisis interventions, will be reimbursed under new codes.
• Virtual supervision for certain services will remain in place through 2025, with some policies made permanent.

6. Quality reporting programs

CMS expanded and adjusted quality reporting requirements, including:

• New health equity measures for hospitals and ASCs.
• Updates to screening metrics for social determinants of health.

7. High-cost radiopharmaceuticals

• Medicare will now separately reimburse diagnostic radiopharmaceuticals costing over $630 per day.

8. Preventive services and cancer screening

• Coverage was expanded for hepatitis B vaccines and colorectal cancer screening methods, such as computed tomography colonography.

The final rule will be published in the Federal Register on December 9, 2024, noted the article.