CMS Finalizes Physician Payment Rule that Advances Health Equity

Final policies will expand behavioral health services, advance the President’s Cancer Moonshot, support family caregivers, and accelerate value-based care

The Centers for Medicare & Medicaid Services (CMS) announced it is finalizing policies to support primary care, advance health equity, assist family caregivers and expand access to behavioral and certain oral health care. These policies are included in the calendar year (CY) 2024 Medicare Physician Fee Schedule (PFS) final rule, which also provides payment for principal illness navigation services to help patients and their families navigate cancer treatment and treatment for other serious illnesses, supporting the Biden-Harris Administration’s Cancer Moonshot mission to accelerate the fight against cancer.

“The policies announced today aim to strengthen Medicare and advance health equity by expanding access to care and services for people who are part of underserved communities,” said U.S. Department of Health and Human Services Secretary Xavier Becerra. “In addition, we are bolstering our commitment to Biden-Harris Administration priorities including behavioral health care, supporting family caregivers, promoting value-based care, and advancing the President’s Cancer Moonshot.”

The CY 2024 PFS final rule includes updates to PFS payments for clinicians as required by law. In accordance with update factors specified by law, finalized payment amounts under the PFS will be reduced by 1.25% overall compared to CY 2023. CMS is also finalizing increases in payment for visits for many services, such as primary and longitudinal care. Overall, the finalized CY 2024 PFS conversion factor is $32.74, a decrease of $1.15, or 3.4%, from CY 2023.

“CMS remains steadfast in our commitment to supporting physicians and ensuring that people with Medicare have access to the care they need to stay healthy as well as navigate health conditions they are facing,” said CMS Administrator Chiquita Brooks-LaSure. “CMS is taking important steps toward those goals in this rule by improving payment for primary care and access to mental health care, paying for new navigation services to help people with cancer and other serious illnesses navigate their treatment, supporting family caregivers, paying for services involving community health workers to address health-related social needs that impact care, and enhancing access to dental care for people with certain cancers.”

“The impact of these changes means that people with Medicare will be able to access Marriage and Family Therapists and Mental Health Counselors for behavioral health treatment, access culturally-sensitive care from community health workers, care navigators, and peer support workers, access primary care where the provider is invested in a long-term, trusting relationship, and that caregivers for persons with Medicare will have access to appropriate training,” said Meena Seshamani, MD, CMS Deputy Administrator and Director of the Center for Medicare. “Taken holistically, these are some of the largest changes ever towards a Medicare that recognizes people with Medicare as whole persons, with their own families and unique life stories. After all, people are more than the sum of their ailments and diagnoses.”

Advancing Health Equity and Caregiver Support

Building on the agency’s commitment to health equity, and the Biden-Harris Administration’s Executive Order to support caregivers, CMS is finalizing separate coding and payment for several new services to help underserved populations, including addressing unmet health related social needs that can potentially interfere with the diagnosis and treatment of medical problems. First, CMS will pay for certain caregiver training services in specified circumstances, so that practitioners are appropriately paid for engaging with caregivers to support people with Medicare in carrying out their treatment plans.

CMS is also finalizing separate coding and payment for community health integration services, which include person-centered planning, health system coordination, promoting patient self-advocacy, and facilitating access to community-based resources to address unmet social needs that interfere with the practitioner’s diagnosis and treatment of the patient. These are the first Physician Fee Schedule services designed to specifically include care involving community health workers, who link underserved communities with critical health care and social services in the community, and expand equitable access to care, improving outcomes for the Medicare population.

CMS is finalizing coding and payment for principal illness navigation services, which describe similar care navigation services for individuals with high-risk conditions, including cancer. A new diagnosis like cancer can be simultaneously challenging, confusing, and emotionally distressing — this action takes a large and important step in fulfilling the Cancer Moonshot goal of making navigation services available for every American with cancer. In addition, CMS is finalizing a subset of principal illness navigation services to support individuals with behavioral health conditions through use of auxiliary personnel such as peer support specialists.

This rule also finalizes coding and payment for social determinants of health risk assessments, which can be furnished as an add-on to an annual wellness visit or in conjunction with an evaluation and management or behavioral health visit.

Supporting Whole-Person Care

The CMS Behavioral Health Strategy endeavors to support a person’s emotional and mental well-being through their behavioral health care. This rule finalized some of the most important changes to improve access to behavioral health care in the Medicare program’s history. The rule allows marriage and family therapists and mental health counselors, including eligible addiction, alcohol, or drug counselors who meet qualification requirements for mental health counselors, to enroll for the first time in Medicare starting today and bill for their services starting January 1, 2024. (See link here for enrollment). The rule also increases payment for crisis care, substance use disorder treatment, and psychotherapy. Based on public comments, CMS is also finalizing increased payment for psychotherapy performed in conjunction with an office visit and for Health Behavior Assessment and Intervention services.

Primary care is instrumental in the delivery of high-quality, whole-person care. CMS is recognizing the value and inherent complexity in primary and longitudinal care by implementing payment and coding to more accurately and appropriately pay for these services, which aligns with the goals articulated in the HHS Initiative to Strengthen Primary Care. Based on interested party feedback, CMS also recognized that the redistributive impact could be lower than previously estimated for the originally finalized policy given that many office visits involve care that is discrete or time-limited, not the kind for which additional payment would be made.

CMS is also continuing to promote whole-person care in the Medicare Shared Savings Program, the largest Accountable Care Organization (ACO) program in the country. CMS is finalizing changes to the assignment methodology that will better promote access to accountable care for individuals who see nurse practitioners, physician assistants, and clinical nurse specialists for their primary care services. CMS is also finalizing changes to the financial benchmarking methodology to better encourage participation by ACOs serving complex populations, as well as changes that continue to support ACOs in their transition to digital quality measurement and use of interoperable digital data. In total, these changes are expected to increase participation in the Shared Savings Program by roughly 10% to 20%, which will provide additional opportunities for beneficiaries to receive coordinated care from ACOs.

CMS received over 20,000 comments on the proposed rule and values stakeholder feedback. Based on feedback, and recognizing that the CY 2017-2019 performance periods for the Quality Payment Program may not be truly reflective of clinicians’ performance, because many transition polices were still in place and recovery was ongoing from those significantly impacted by the COVID-19 Public Health Emergency, CMS is retaining the performance threshold for the CY 2024-Merit-Based Incentive Payment Systems (MIPS) performance period/2026 MIPS payment year at 75 points. However, CMS plans in the future, over time, to set the MIPS performance threshold to better reflect MIPS eligible clinicians’ performance and continue to encourage participation in Advanced Alternative Payment Models.

Payment for Dental Services Related to Certain Cancer Treatments

Access to oral and dental health services that promote health and wellness allows people with Medicare to achieve the best health possible. In this final rule, CMS is supporting the Biden-Harris Administration’s Cancer Moonshot initiative by finalizing that payment can be made for certain dental services linked to several different cancer treatments, including, but not limited to, chemotherapy.

Dentists who are interested in enrolling in Medicare to provide these services can find more information on the CMS website.

Medicare Diabetes Prevention Program (MDPP) Expanded Model Enhancements

In addition, CMS finalized changes to promote care for individuals with diabetes by enhancing the Medicare Diabetes Prevention Program (MDPP) Expanded Model to further increase participation and access in underserved communities. This rule will extend the MDPP Expanded Model’s Public Health Emergency Flexibilities for four years, which will allow all MDPP suppliers to continue to offer MDPP services virtually through December 31, 2027, as long as suppliers maintain an in-person Centers for Disease Control and Prevention organization code.

View a fact sheet on the CY 2024 Physician Fee Schedule final rule.

View a fact sheet on final changes to the CY 2024 Quality Payment Program.

View a fact sheet on final changes to the Medicare Shared Savings Program.

View the CY 2024 Physician Fee Schedule and Quality Payment Program final rule.

View frequently asked questions on the Marriage and Family Therapists (MFT) and Mental Health Counselors (MHC) Provider Enrollment and information on how to enroll.