On July 19, 2018, The Centers for Medicare & Medicaid Services (CMS) published a proposed rule that would revise the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for calendar year 2019, and would update the payment rate for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury (AKI). The rule proposes a number of changes, including the following:
- Updating the 2019 ESRD PPS base rate to $235.82; the proposed amount reflects a productivity-adjusted market basket increase of 1.5 percent as required by section 1881(b)(14)(F)(i)(I) of the Social Security Act, multiplied by a wage index budget-neutrality adjustment factor
- Increasing the wage index floor to 0.5000 for areas with wage index values below the floor
- Updating the outlier policy to use the most current data, resulting in an increased fixed-dollar loss (FDL) amount of $47.88 for pediatric beneficiaries, and a decreased FDL of $69.73 for adult beneficiaries; additionally, the Medicare Allowable Payment (MAP) amounts for pediatric and adult beneficiaries would decrease to $35.62 and $40.25, respectively
- Revising the drug designation process and expanding the transitional drug add-on payment adjustment (TDAPA) to all new drugs, not just those in new functional categories, and changing the basis of determining the TDAPA
- Amending the low-volume payment adjustment regulations to allow for more flexibility with regard to attestation dates and cost reporting requirements, as well as updating the requirements for eligibility with respect to certain changes of ownership
- Updating the AKI payment rate for 2019 to $235.82, which is the same as the base rate proposed under the ESRD PPS for 2019
The rule also proposes a number of new requirements for the ESRD Quality Incentive Program (QIP), including updates to the ESRD QIP’s measure removal criteria, changes to the domains and domain weights that are used for scoring methodology, changes to policies governing when newly opened facilities must start reporting ESRD QIP data (4 months after the month during which the CMS Certification Number becomes effective), and several other policies related to increasing the number of facilities selected for data validation.
Finally, the rule adjusts the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule amounts for items and services furnished on or after January 1, 2019, and establishes new, separate payment classes for portable gaseous oxygen equipment, portable liquid oxygen equipment, and high flow portable liquid oxygen contents. CMS further proposes a new methodology for ensuring that the new payment classes for oxygen and oxygen equipment are budget neutral, payment rules for multi-function ventilators and ventilators that perform other DME functions, and payment methodology revisions for mail order items furnished in the Northern Mariana Islands.
The 112 page rule is available here. Comments to the rule must be received no later than 5 p.m. on September 10, 2018. Comments may be submitted electronically at http://www.regulations.gov (follow the "submit a comment" instructions), or by mail:
Centers for Medicare & Medicaid Services
Department of Health and Human ServicesA
P.O. Box 8010
Baltimore, MD 21244-8010