News

On Nov. 1, the Centers for Medicare and Medicaid Services (CMS) released final Medicare rates payable under the Physician Fee Schedule, and a number of changes to Organ Acquisition Cost (OAC) rules that had been proposed in the 2023 Hospital Outpatient Payment System (HOPPS) Proposed Rule earlier this year.

Wins for transplant surgery include:

• Effective in 2023, Medicare will pay for dental examinations and treatment needed prior to transplant surgery, including payment for hospital outpatient services necessary for those who require anesthesia for medically necessary dental work. 
• CMS clarified that Medicare will provide payment for the OAC of organs that, while subject to a research protocol, are transplanted into a recipient (e.g. HIV+/HIV+ transplants) under the same cost accounting rules applicable to other organs.
• CMS also reaffirmed its longstanding policy to allow OAC associated with organs procured with the intent to transplant but subsequently found to be unusable.
• As urged by ASTS, CMS did not finalize a proposed “clarification” of cost apportionment rules that would have precluded the costs of organs purchased from an OPO or another transplant center from being included in the statistics used to allocate Administrative and General (A&G) costs, a change that would have reduced Medicare payment for OAC by $178 million, according to an estimate prepared by a group of concerned transplant administrators. 
  

While the final rules do not implement the A&G “clarification” at this time, CMS indicated that it may return to the idea in future years.  Also, to be addressed is the potential revision of the “Medicare ratio” methodology—a revision that has the potential to slash OAC payments, especially for transplant hospitals that procure a substantial number of organs transplanted elsewhere. ASTS plans to meet with CMS officials to discuss both issues.

At long last, Medicare coverage for immunosuppressive drugs for transplant recipients with no other source of coverage will be implemented on Jan. 1, 2023.  Features of the new immunosuppressive drug benefit include:

• There will be no specific enrollment periods; if an individual is eligible, they can enroll (or disenroll) at any time.
• The benefit will only cover immunosuppressive drugs and will not include coverage for any other Part B benefits or services.
• An individual will be required to attest that they are not enrolled in, and do not expect to enroll in, certain other types of coverage (e.g., group health plan, TRICARE, or Medicaid that covers immunosuppressive drugs) and that they will provide notification to the Social Security Administration within 60 days if they sign up for such other coverage (thereby ending their enrollment in the Part B-ID benefit).
• The monthly premium will be less than the standard Part B premium, and enrollees will not be subject to late enrollment penalties.  Enrollees will also have to pay the annual deductible. Once the deductible is met, enrollees pay 20% of the Medicare-approved amount for immunosuppressive drugs. 
• Individuals eligible for certain Medicare Savings Programs (MSPs) can have states cover the immunosuppressive drug benefit premium, and for Qualified Medicare Beneficiaries (QMBs), co-insurance, deductibles and cost sharing as well.
  
  

ASTS strongly supported the enactment of extended immunosuppressive drug coverage beyond thirty-six months and is delighted that implementation is proceeding as scheduled.

We still have a lot of work to do. While RVUs for transplant procedures will remain relatively unchanged, CMS finalized a 4.5% reduction in the conversion factor used to determine Medicare payment for all physicians. This reduction is attributable in large measure to budget neutrality adjustments necessitated by prior and new increases in Medicare payment for Evaluation and Management (E&M) services. The House of Medicine/Surgery, including ASTS, is urging Congress to block the reduction, and it is anticipated that the result of this effort will be known by the end of the year.