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Medicare Graduate Medical Education and Organ Acquisition Payment Policy Changes

January 10, 2022

On Monday December 27, CMS published Federal Register / Vol. 86. No. 245 [CMS–1752–FC3. This Final Rule with comment period includes new teaching slots for graduate medical education, modifications to organ acquisition reimbursement, and postpones potential changes related to Section 1115 waiver days for empirical DSH payments. February 25 is the deadline to submit comments to CMS for the issues (discussed below) whereby CMS is seeking feedback.

Graduate Medical Education

CMS’s changes for graduate medical education new teaching slots are directed by legislation provided in the Consolidated Appropriations Act (CAA), 2021. The CAA provides three new opportunities for teaching hospitals: 1) Additional 1,000 FTE cap slots for indirect medical education (IME) and direct graduate medical education (GME); 2) New opportunities for rural training track programs; and 3) Reset of FTE caps or per-resident reimbursement amounts that were established for hospitals using fewer than one or three FTEs, depending on the base year of the existing teaching cap or per-resident amounts. More about these respective changes are detailed below.

1) Additional IME and GME Slots (Section 126 of CAA)

Important Deadline: March 31, 2022 to Apply for Slots in Federal Year 2023

CMS finalized rules on the distribution of 1,000 new resident FTE cap slots over five years (200 per year) under Section 126 of the CAA for hospitals looking to establish or expand residency programs. Hospitals may apply for up to five new FTE cap slots by March 31, 2022 for distribution in Federal Year 2023 (March 31 preceding the federal fiscal year is the deadline for each of the applicable five fiscal years). Further instructions and the application for FTE cap slots will be available on the CMS DGME website.

The additional cap slots will be distributed to hospitals that are included in the following four categories (with at least 10% of slots going to each category):

Hospitals located in rural areas or that are treated as being in a rural area.
Hospitals that are training residents over their cap amount.
Hospitals located in the 35 states (listed in the rule) with new medical schools or additional locations and branches of existing campuses.
Hospitals that train residents in a program where at least 50 percent of the residents’ training time occurs at site(s) physically located in (a) geographic Health Professional Shortage Area(s) (HPSA).

HPSA scores will be a key criterion for all four categories, not just category four. Hospitals can find information about the HPSA or HPSAs associated with their training program locations using the HRSA search tool at: https://data.hrsa.gov/tools/shortage-area/by-address. CMS will prioritize applications by descending HPSA score. When hospitals have the same HPSA score, applications are next prioritized for hospitals with fewer than 250 beds. CMS is seeking comment on the dependence of geographic HPSA residents on health services provided outside of their HPSA, and a feasible alternative for potential use in future rulemaking.

2) Rural Training Track Programs (Section 127 of CAA)

Beginning Federal Year 2023

For cost reporting periods beginning on or after October 1, 2022, non-rural hospitals (“primary clinical sites”) and their rural hospital partners (“rural hospital participation sites”) with “rural track” residency programs may receive resident FTE cap slots. This FTE adjustment is intended to provide flexibility for both rural and urban hospitals focusing on additional physicians in rural markets. In its Final Rule, CMS codified four changes to the rural training track (“RTT”) program rules, as follows:

Each time an RTT program begins or is expanded between an urban and rural hospital, both may receive an adjustment to the FTE resident limit, regardless of whether the RTT program meets the newness criteria for Medicare payment purposes. Eligible expanded programs include new tracks (rural participating sites) added to an existing rural track program, but exclude expansion of existing tracks at an existing rural participating site.
Urban hospitals with existing RTT caps can receive RTT cap adjustments for additional qualifying RTT programs. Rural hospitals would also receive an RTT cap increase.
The requirement that a new rural track must be ‘‘separately accredited” is nullified, provided that the program in its entirety is accredited by the ACGME, and at least 50% of the RTP (“rural track program”) residents’ time is spent in rural areas. If these conditions are met, then it may qualify as an RTT and both hospitals (urban and rural) will receive RTT caps.
RTT program residents will not be included in the hospital’s 3-year rolling average resident cap calculation or subject to the IRB ratio during the build-up period.

3) Hospitals Qualifying to Reset Their PRAs and/or FTE Resident Caps (Section 131 of CAA)

Important Deadline: July 1, 2022 to Correct Medical Education FTE Counts in

CMS’s New (Upcoming) Public Use File

Certain hospitals with low or $0 per resident amounts (PRAs) may reset and establish new PRAs if the hospital trains more than the threshold number of resident(s) in a cost reporting period beginning on or after December 27, 2020 and before December 26, 2025. Certain hospitals with low caps may be eligible for revised FTE caps, if the hospital starts a brand-new program after December 27, 2020. Eligible hospitals fall into two categories:

Category A – hospitals whose PRA and/or resident cap was set based on less than 1.0 FTE in a cost reporting period beginning before October 1, 1997.
Category B – hospitals whose PRA and/or resident cap was established based on training fewer than 3.0 FTEs in a cost reporting period beginning on or after October 1, 1997 and before December 27, 2020.

CMS will post a public use file here on its website containing an extract of the HCRIS cost report worksheets on which the FTE counts, caps, and PRAs, if any, would have been reported, starting with cost reports beginning in 1995. If a hospital wishes to receive a PRA or cap determination from its MAC for a possible reset of an open or reopenable cost report, the hospital must first check the posted public use file. CMS is seeking comment on treatment of PRAs or FTE caps from cost reports beyond the 3-year reopening period that do not agree with data in the forthcoming public use file.

Providers have a one-time deadline of July 1, 2022 to request MAC reconsideration if the provider is a Category B hospital, has an open or reopenable cost report, and believes its PRA in CMS’s public use file is incomplete or incorrect (i.e., FTEs are actually based on not more than 3.0 FTEs, or its IME and/or DGME FTE caps were based on not more than 3.0 FTEs).

Providers qualifying to reset their PRA will establish the replacement PRA resulting from the lower of:

The hospital’s actual cost per resident incurred in connection with the GME program(s) based on the cost and resident data from the hospital’s replacement base year cost reporting period; and
The updated weighted mean value of per resident amounts of all hospitals located in the same geographic wage area, calculated using all per resident amounts (including primary care and obstetrics and gynecology and nonprimary care) and FTE resident counts from the most recently settled cost reports of those teaching hospitals^[1].

Please contact Tom Hubner with questions at 888.514.9312, or tom.hubner@toyonassociates.com.

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^[1] If there are fewer than three existing teaching hospitals with per resident amounts that can be used to calculate the weighted mean value per resident amount, for base periods beginning on or after October 1, 1997, the per resident amount equals the updated weighted mean value of per resident amounts of all hospitals located in the same census region.

Organ Acquisition Payment Policy

CMS finalized their policy regarding Medicare-certified transplant hospitals and non-transplant hospitals’ charges for services to cadaveric donors. CMS also codified and clarified organ acquisition policies, including definitions, acquisition charges, coverage of living donor complications by the Medicare program, Medicare as a secondary payor for organ acquisitions, and paired donations for kidney transplants. The CMS proposal for both organ counting policy and research facility organ counting will be considered in future rulemaking.

The Federal Year 2022 IPPS Proposed Rule contained Section X. of the preamble which included proposed changes pertaining to Medicare’s share of organ acquisition costs for organs transplanted into Medicare beneficiaries and the charges for services provided to cadaveric organ donors by donor community hospitals and transplants hospitals. Listed below are the rules codified by CMS.

Change to Organ Acquisition Policy: CMS finalized the codification and compilation of Medicare organ acquisition policies under a new 42 CFR Part 413 subpart L, which was mentioned in the proposed rule. This new section will include changes to policies and creation of new policies from the Medicare Modernization Act (Pub. L. 108-173) and the 21st Century Cures Act (Pub. L. 114-255). CMS recognizes the need for a more coordinated approach across all organ types (kidney, liver, heart, lung, pancreas, or intestine)^[2].

Clarifying Definitions: CMS will define the term in the new section (42 CFR §413.400) “organ” for Medicare purposes and will exclude organs procured for research. The definition of organ for Medicare payment purposes differs from the definition set forth in 42 CFR §486.302 for Organ Procurement Organizations (OPOs). For Medicare payment purposes, an organ procured for research is not counted as a Medicare organ in Medicare’s share of organ acquisition costs, except where explicitly required by law.

Additional clarification to existing definitions of OPO, hospital-based OPO (HOPO), independent OPO (IOPO), transplant hospital/HOPO (TH/HOPO), and histocompatibility laboratory are added to 42 CFR §413.400.

Organ Acquisition Costs: New Section L will include CFR 42 §413.402(a) specifying costs which are incurred in the acquisition of organs from a living donor or a cadaver by either the hospital or OPO are considered organ acquisition costs. Also, CFR 42 §413.402(b) will codify the 12 elements regarding costs incurred in the acquisition of organs (living/cadaveric by hospital or an OPO) and apply the existing elements of kidney acquisition costs to all organs and include additional revisions that would apply to kidney acquisition only.

Standard Acquisition Charges: CMS also codifies current Medicare policies on Standard Acquisition Charges (SACs) for THs, HOPOs, and IOPOs (CFR 42 §413.404). SACs are amounts that represent the estimated costs that a TH and/or OPO expect to incur during the acquisition of the organ. It is generally the average rather than the actual organ acquisition costs.

Accurate Organ Count (No Current Changes; Medicare and Non-Medicare): CMS, in their proposed rule, suggested revisions to the overall counting of organs used to determine Medicare’s share of organ acquisition costs. CMS planned to follow through with one of two solutions, withdraw the proposal or finalize the proposal but with a delay during the transition period. CMS is not applying changes to organ counting, as further analysis is needed to understand the concerns of all parties. CMS notes changes to organ counting may bear costs that apply to non-Medicare patients.

Please contact Scott Besler with questions at 888.514.9312, or scott.besler@toyonassociates.com.

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^[2] Currently, Medicare reimburses Transplant Hospitals (THs) for organ acquisition costs, the transplant surgery, inpatient, and post-transplant costs for the Medicare recipients, but through different payment systems. Medicare Part A pays for hospital costs of a transplant surgery and certain follow-up care through a DRG payment, and the organ acquisition costs associated with a transplant on a reasonable cost basis. Medicare B pays for the physician and other services related to the procedure.

Section 1115 Demonstration Waiver Days for Empirical DSH Payments

CMS is not currently addressing proposed revisions on the treatment of Section 1115 waiver days for purposes of the DSH adjustment. In the Federal Year 2022 IPPS Proposed Rule, CMS proposed that Section 1115 waiver days can only be claimed in the Medicaid fraction if the patient directly receives inpatient hospital insurance coverage under an approved waiver. This excludes from the Medicaid fraction patient days for which hospitals received a payment from a UC pool. CMS expects to revisit the issue of Section 1115 waiver days in future rulemaking, and encourages stakeholders to review the future proposal and to submit their comments at that time.

Please contact Dylan Chinea with questions at 888.514.9312, ext. 3121, or dylan.chinea@toyonassociates.com

FFY 2022 IPPS Proposed Rule Webinar

May 8, 2021

Toyon Associates invites you to a

complimentary one-hour webinar

10:00 a.m. PDT on May 21.

Toyon Associates invites you and your team to a live conversation on the FFY 2022 IPPS Proposed Rule. Our discussion will dive into the components of proposed FFY 2022 IPPS rates, highlighting areas of significance for providers. Please join us for this important conversation. A news alert will also be issued soon, summarizing Toyon’s Take on critical topics.

This is an important session you won’t want to miss.

Toyon University® is a virtual ‘university’ created for our clients. For further information on our curriculum, contact Tim Vanderford at tim.vanderford@toyonassociates.com or 888.514.9312.

Medicare DSH – Uncompensated Care (UC) Financial Assistance Policy Recommendations

December 5, 2020

Thank you for working with Toyon Associates and our Uncompensated Care Recognition Services (UCRS). CMS’s requirements for reporting UC cost, and subsequent UC Disproportionate Share (DSH) payments, rely heavily on ever-changing regulations and language in the financial assistance policy (FAP). Importantly, as recently reported in the FFY 2021 IPPS Final Rule, CMS states:

“(CMS) does not set charity care criteria policy for hospitals, and within reason, hospitals can establish their own criteria for what constitutes charity care in their charity care and/or financial assistance policies.”

A hospital’s determination of its own financial charity care criteria – likely within reason of patients qualifying under federal poverty level [FPL] thresholds – provides hospitals discretion on how patient financial discounts are articulated in the FAP.

To compliantly position hospitals for this important impact on reimbursement, Toyon is sharing recommended language for FAP consideration as it relates to Medicare UC DSH. Toyon’s recommendations[1] are to assist hospitals compliantly report core areas of UC cost on worksheet S-10 of the Medicare cost report.

For assistance on implementing best practices for FAP language and associated means of capturing the charges written off as charity care, please contact Toyon’s lead of Uncompensated Care Recognition Services, Fred Fisher at 888.514.9312, fred.fisher@toyonassociates.com.

Toyon’s recommendations are focused on the following UC cost areas:

Charity care for insured and underinsured
Self-pay discounts
Discounts to insurers with no contractual or inferred contractual relationship[2]
Presumptive charity eligibility process
Non-covered and denied Medicaid as charity care
Bad Debt and Implied Price Concessions

Below are Toyon’s updated recommendations for FAP language related to Medicare cost report worksheet S-10 and UC DSH. Some of Toyon’s recommendations include FAP language italicized in blue. Any language changes considered by hospitals and health systems should follow the appropriate approval procedure with hospital leadership / board of directors.

Non-Covered Charges for Medicaid or other Indigent Care Program

Medicare cost report instructions allow charges related to “non-covered services for Medicaid eligible patients” to be included as UC cost, provided this coverage is specified in the FAP. There are different industry interpretations regarding the level of specificity of non-covered Medicaid that must be in an FAP. Toyon recommends hospitals consider FAP language stating:

“Non-covered and denied services provided to Medicaid eligible beneficiaries are considered a form of charity care. Medicaid beneficiaries are not responsible for any forms of patient financial liability and all charges related to services not covered, including all denials, are charity care. Examples may include, but are not limited to:

Services provided to Medicaid beneficiaries with restricted Medicaid (i.e., patients that may only have pregnancy or emergency benefits, but receive other hospital care)
Medicaid-pending accounts
Medicaid or other indigent care program denials
Charges related to days exceeding a length-of-stay limit
Out-of-state Medicaid claims with no payment”

Presumptive Charity Care

In the FFY 2021 IPPS Final Rule, CMS affirmed presumptive eligibility tools are not allowable to determine patient financial status for Medicare bad debt reporting[3]. Toyon recommends the following regarding presumptive charity care determinations are applied by hospitals:

Presumptive charity care is applied to everyone except indigent Medicare fee for service patients.
For all patients receiving presumptive eligibility to qualify for financial assistance, it is recommended hospitals maintain a log of each instance, as well as any documentation from an outside agency to support presumptive eligibility (such as PARO like resources).

Patient Billing – External Collection Agencies

Hospitals may discover additional charity care associated with patient accounts in collections. Typically, outstanding patient receivables relate to coinsurance, copayment and deductible (C+D) amounts. This is a significant population, considering when C+D are reported as charity care, these amounts are not reduced by the cost to charge ratio.

Toyon recommends hospitals consider updating the FAP language to include additional information when charity is discovered during the collections process. Example language may state:

“Discovery of Patient Financial Assistance Eligibility During Collections – Determination of patient financial assistance as close to the time of service as possible is optimal. However, additional time and resources are sometimes required to determine eligibility, and therefore some patients eligible for financial assistance may have not been identified as eligible for patient financial assistance prior to initiating external collection action. Collection agencies shall be made aware of this possibility and are requested to refer-back patient accounts that may be eligible for financial assistance. When it is discovered an account is eligible for financial assistance, [Hospital | Health System] will reverse the account out of bad debt and document the respective discount in charges as charity care.”

Insured Patients Not Under Contract with the Hospital

CMS permits UC costs can include “patients with coverage from an entity that does not have a contractual relationship with the provider who meet the hospital’s FAP.”

For cost reports beginning on after October 1, 2020, CMS clarifies providers may report amounts related to inferred contractual relationships. CMS defines an inferred contractual relationship in new cost report instructions [4] as:

“a contractual relationship between an insurer and a provider will be inferred where a provider accepts an amount from an insurer as payment, or partial payment, on behalf of an insured patient”

Also importantly, the Terms and Conditions (T&C) for providers receiving CARES Provider Relief Funding prohibit billing in excess of:

“…an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network Recipient”.

Toyon recommends hospitals update FAP language to:

Stipulate when a carrier is “under contract” vs. obligated to reimburse the hospital as an “inferred contractual relationship”; and
Confirm “out of network” for a presumptive or actual case of COVID-19 is provided at an amount no greater than if the care was provided at an in-network provider.
Listed below is FAP language for hospital consideration:

“Insured Patients Not Under Contract with the Hospital” – Negotiations with insurance carriers involving inferred contractual relationships, for insured patients not under contract with [hospital / health system] will be conducted by executive management at [hospital/health system]. Although [hospital / health system] may agree to the terms of the negotiations with insurance companies, an inferred contractual relationship is not representative of a patient “under contract” with [hospital / health system]. All unreimbursed amounts are a form of patient financial assistance and determined as the difference between gross hospital charges and hospital reimbursement. Any care provided to a presumptive or actual case of COVID-19 is provided at an amount no greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.”

Financial Assistance for Patients with Insurance

Medicare cost report instructions allow and differentiate[5] the reporting of financial assistance for insured patients as:

Amounts related to charity C+D amounts. These amounts have a material impact on the determination of uncompensated care cost, as they are not reduced by the cost to charge ratio.
Charges representing an insured patient’s liability for medically necessary hospital services, other than Charity C+D amounts. These amounts are reduced to cost using a hospital’s overall cost to charge ratio.

Toyon recommends hospitals consider updating FAPs, articulating insured patients are eligible for discounts related to charity C+D amounts as well as charge discounts to an insured patient’s liability for medically necessary hospital services.

Access to Healthcare Crisis FAP Language

In recognition for the extraordinary demand pandemics have on the healthcare system (including COVID-19), Toyon has crafted the FAP language below. This is draft template language to assist hospitals if necessary.

“An Access to Healthcare Crisis must be proclaimed by [hospital leadership / approved by the board of directors] and attached to this patient financial assistance document as an addendum. An Access to Healthcare Crisis may be related to an emergent situation whereby state / federal regulations are modified to meet the immediate healthcare needs of [hospital / health system’s] community during the Access to Healthcare Crisis. During an Access to Healthcare Crisis [hospital / health system] may “flex” its patient financial assistance policy to meet the needs of the community in crisis. These changes will be included in the patient financial assistance policy as included as an addendum. Patient discounts related to an Access to Healthcare Crisis may be provided at the time of the crisis, regardless of the date of this policy (as hospital leadership may not be able to react quickly enough to update policy language in order to meet more pressing needs during the Access to Healthcare Crisis).”

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We appreciate the opportunity to provide regulatory and reimbursement services to you and your team. At any point in time, should you have any questions about our work, or need any further assistance, please contact Fred Fisher at 888.514.9312, fred.fisher@toyonassociates.com.

Respectfully,

Toyon Associates, Inc.

[1] FAP language changes should follow the approval procedure with hospital leadership / board of directors.

[2] A contractual relationship between an insurer and a provider will be inferred where a provider accepts an amount from an insurer as payment, or partial payment, on behalf of an insured patient.

[3] Per the FFY 2021 IPPS Final Rule, related to Medicare Bad Debts “Although presumptive eligibility tools may reduce a provider’s burden when evaluating indigence, we disagree that presumptive eligibility tools should be used to determine a Medicare beneficiary’s indigence status for Medicare bad debt purposes.”

[4] https://www.govinfo.gov/content/pkg/FR-2020-11-10/pdf/FR-2020-11-10.pdf

[5] For cost reports beginning on/after October 1, 2020.

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