CMS Physician Payment Rule Promotes Greater Access to Telehealth Services, Diabetes Prevention Programs

Nov 17, 2021 at 04:24 pm by pj

The Centers for Medicare & Medicaid Services (CMS) is announcing actions that will advance its strategic commitment to drive innovation to support health equity and high quality, person-centered care. CMS’ Calendar Year (CY) 2022 Physician Fee Schedule (PFS) final rule will promote greater use of telehealth and other telecommunications technologies for providing behavioral health care services, encourage growth in the diabetes prevention program, and boost payment rates for vaccine administration. The final rule also advances programs to improve the quality of care for people with Medicare by incentivizing clinicians to deliver improved outcomes.

“Promoting health equity, ensuring more people have access to comprehensive care, and providing innovative solutions to address our health system challenges are at the core of what we do at CMS,” said CMS Administrator Chiquita Brooks-LaSure. “The Physician Fee Schedule final rule advances all these strategic priorities and helps build a better Medicare program for the future.”

Expanding Use of Telehealth and Other Telecommunications Technologies for Behavioral Health Care

The final rule makes significant strides in expanding access to behavioral health care  ̶  especially for traditionally underserved communities  ̶  by harnessing telehealth and other telecommunications technologies. In line with legislation enacted last year, CMS is eliminating geographic barriers and allowing patients in their homes to access telehealth services for diagnosis, evaluation, and treatment of mental health disorders.

“The COVID-19 pandemic has highlighted the gaps in our current health care system and the need for new solutions to bring treatments to patients, wherever they are,” said Brooks-LaSure. “This is especially true for people who need behavioral health services, and the improvements we are enacting will give people greater access to telehealth and other care delivery options.”

CMS is bringing care directly into patients’ homes by providing certain mental and behavioral health services via audio-only telephone calls. This means counseling and therapy services, including treatment of substance use disorders and services provided through Opioid Treatment Programs, will be more readily available to individuals, especially in areas with poor broadband infrastructure.

In addition, for the first time outside of the COVID-19 public health emergency (PHE), Medicare will pay for mental health visits furnished by Rural Health Clinics and Federally Qualified Health Centers via telecommunications technology, including audio-only telephone calls, expanding access for rural and other vulnerable populations.

Promoting Growth in Medicare Diabetes Prevention Program

Prediabetes impacts over 88 million American adults, with many at risk for developing type 2 diabetes within five years. Many traditionally underserved communities  ̶̶  including African Americans, Hispanic/Latino Americans, American Indians, Pacific Islanders, and some Asian Americans  ̶̶  face an elevated risk of developing type 2 diabetes.

As the U.S. marks Diabetes Awareness Month this November, CMS is taking steps to improve its Medicare Diabetes Prevention Program (MDPP) expanded model, which was developed to help people with Medicare with prediabetes from developing type 2 diabetes.

Under the expanded model, local suppliers provide structured, coach-led sessions in community and health care settings using a Centers for Disease Control and Prevention-approved curriculum to provide training in dietary change, increased physical activity, and weight loss strategies. CMS is waiving the Medicare enrollment fee for all organizations that apply to enroll as an MDPP supplier on or after January 1, 2022. CMS has been waiving this fee during the COVID-19 PHE for new MDPP suppliers and has witnessed increased supplier enrollment. Next, CMS is shortening the MDPP services period to one year instead of two years. This change will make delivery of MDPP services more sustainable, reduce the administrative burden and costs to suppliers, and improve patient access by making it easier for local suppliers to participate and reach their communities. Finally, CMS is restructuring payments so MDPP suppliers receive larger payments for participants who reach milestones for attendance.

CMS expects these changes will result in more MDPP suppliers, increased access to MDPP services for people with Medicare in rural areas, and a decrease in the number of individuals with diabetes in both urban and rural communities.

Increased Access to Medical Nutrition Therapy Services

The PFS final rule also streamlines access to Medical Nutrition Therapy (MNT), which includes services provided by registered dietitians or nutrition professionals to help people with Medicare better manage their diabetes or renal disease. MNT establishes goals, a care plan, and interventions, as well as plans for follow-up over multiple visits to assist with behavioral and lifestyle changes relative to help address an individual’s nutrition needs and medical condition or disease(s).

CMS removed a requirement that limited who could refer people with Medicare to MNT services, allowing any physician (M.D. or D.O.) to do so. This change should particularly benefit people living in rural areas as the MNT services are provided to eligible individuals with no out of pocket costs and may be provided via telehealth.

Encouraging Proven Vaccines to Protect Against Preventable Illness

As the COVID-19 pandemic has so starkly demonstrated, access to safe and effective vaccines is vital to public health. CMS will maintain the current payment rate of $40 per dose for the administration of the COVID-19 vaccines through the end of the calendar year in which the ongoing PHE ends. Effective January 1 of the year following the year in which the PHE ends, the payment rate for COVID-19 vaccine administration will be set at a rate to align with the payment rate for the administration of other Part B preventive vaccines. CMS will also continue to facilitate vaccinations for common diseases such as influenza, pneumonia, and hepatitis B.

This year Medicare reviewed payments for vaccinations to ensure doctors and other health professionals are paid appropriately for providing vaccinations. This final rule will nearly double Medicare Part B payment rates for influenza, pneumococcal, and hepatitis B vaccine administration from roughly $17 to $30. CMS hopes this change will increase access to these potentially life-saving injections and lead to greater vaccination uptake.

Expanded Pulmonary Rehabilitation Coverage Under COVID

As part of CMS’ continuing efforts to address the current PHE, the agency finalized expanded coverage of outpatient pulmonary rehabilitation services, paid under Medicare Part B, to individuals who have had confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks. This goes beyond CMS’ PFS proposed rule which would have focused the expanded coverage to those hospitalized with COVID-19. CMS also finalized a temporary extension of certain cardiac and intensive cardiac rehabilitation services available via telehealth for people with Medicare until the end of December 2023.

Advancing the Quality Payment Program and MIPS Value Pathways

To further improve the quality of care for people with Medicare, the PFS final rule makes several key changes to CMS’ Quality Payment Program (QPP), a value-based payment program that promotes the delivery of high-value care by clinicians through a combination of financial incentives and disincentives.

For example, CMS finalized a higher performance threshold that clinicians will be required to exceed in 2022 to be eligible for positive payment incentives. This new threshold was determined in accordance with statutory requirements for the QPP’s Merit-based Incentive Payment System (MIPS).

CMS is also moving forward with the next evolution of QPP and officially introducing the first seven MIPS Value Pathways (MVPs)  ̶  subsets of connected and complementary measures and activities, established through rulemaking, that clinicians can report on to meet MIPS requirements. MVPs are designed to ensure more meaningful participation for clinicians and improved outcomes for patients by more effectively measuring and comparing performance within different clinician specialties and providing clinicians more meaningful feedback. This initial set of MVP clinical areas include: rheumatology, stroke care and prevention, heart disease, chronic disease management, lower extremity joint repair (e.g., knee replacement), emergency medicine, and anesthesia.

To incentivize high-quality care for professionals that are often a key point of contact for underserved communities with acute health care needs, CMS has also revised the current eligible clinician definition to include clinical social workers and certified nurse-midwives among those participating in MIPS.

Ensuring Accurate Payments Through Clinical Labor Update

CMS recognizes the importance of making accurate payments for services provided under Medicare to ensure the integrity of the program as well as to support continued access to care. For the first time in nearly 20 years, CMS is updating the clinical labor rates that are used to calculate practice expense under the PFS. As a result, payments to primary care specialists that involve more clinical labor, such as family practice, geriatrics, and internal medicine specialties, are expected to increase. This increase will to drive greater person-centered care for these services particularly for disadvantaged groups and underserved communities. There will be a four-year transition period to implement the clinical labor pricing update, which will help maintain payment stability and mitigate any potential negative effects on health care providers by gradually phasing in the changes over time.

Increasing Access to Physician Assistants’ Services

Finally, CMS is implementing a recent statutory change that authorizes Medicare to make direct Medicare payments to Physician Assistants (PAs) for professional services they furnish under Part B. For the first time, beginning January 1, 2022, PAs will be able to bill Medicare directly. As a result, more individuals with Medicare will have access to these services as PAs will have the same opportunity as certain other Medicare practitioners to bill Medicare for professional services.

For a fact sheet on the CY 2022 Physician Fee Schedule Final Rule, please visit:

For a fact sheet on final changes to the CY 2022 Quality Payment Program, please visit:

For a fact sheet on final changes to the Medicare Diabetes Prevention Program, please visit:

To view the CY 2022 Physician Fee Schedule, please visit: