NAACOS Analysis of the CY 2025 Proposed Medicare Physician Fee Schedule

Executive Summary

On July 10, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS) Proposed Rule. It contains numerous changes for the Medicare Shared Savings Program (MSSP) that NAACOS has been advocating for.

In this analysis, we provide details on key proposals affecting ACOs. The rule is summarized in several fact sheets provided by CMS: PFS Fact Sheet, MSSP Fact Sheet and Quality Payment Program (QPP) Fact Sheet.

Comments to CMS in response to the proposed rule are due on September 9 and may be submitted on the regulations.gov website. NAACOS is seeking member input on the proposals in this rule, which will help shape our comments. Please share your feedback by emailing us at [email protected].  NAACOS will provide draft comments ahead of the deadline. CMS will review comments and issue a final rule later this year; typically, by November 1.

Medicare Physician Payment Proposals

• Decreases the Medicare conversion factor from $33.29 to $32.36 for 2025, a 2.8 percent decrease.
• Creates new billable codes for Advanced Primary Care Management services; participants in MSSP, CMS Innovation Center ACO models and advanced primary care models automatically meet certain practice capability requirements to bill these codes.
• Creates new coding and payment for caregiver training services (CTS) and allows the proposed CTS to be furnished via telehealth.
• Creates new billable codes for behavioral health crisis services and digital mental health treatment.
• Requests feedback on implementing advanced primary care hybrid payment within the fee schedule.
• Requests feedback on newly implemented community health integration services, principal illness navigation services, and SDOH risk assessment and how these codes are being furnished with community-based organizations.

Medicare Shared Savings Program Proposals
Anomalous and Highly Suspect Billing:

• Identifies and removes anomalous billings from Performance Year (PY) 2024 and future years if any billing codes trigger a necessary adjustment.
• Establishes a process for ACOs to request a reopening of shared savings calculations to account for improper payments identified beyond the three-month claims runout.

Benchmarks:

• Adds a Health Equity Benchmark Adjustment (HEBA) that upwardly adjusts an ACO’s historical benchmark based on proportion of beneficiaries who are enrolled in the Medicare Part D low-income subsidy (LIS) or dually eligible for Medicare and Medicaid. ACOs will receive the higher of either a positive regional adjustment, the prior savings adjustment, or the HEBA.

Assignment:

• Adds several new codes to the definition of primary care services used in assignment.
• Expands a limited exception to MSSP’s voluntary alignment policy; claims-based assignment for a disease-or condition-specific CMS Innovation Center model will take precedence over MSSP voluntary alignment.

Quality:

• Makes changes to the MSSP quality measure set to align with the Universal Foundation measure set. This would add two new measures for PY 2025 and incrementally add additional measures through PY 2028.
• Sunsets the Web Interface and MIPS CQM reporting options for MSSP ACOs in PY 2025.
• Extends the eCQM reporting incentive (lower quality performance standard) to continue encouraging ACOs to report via eCQMs.
• Adds a Complex Organization Adjustment beginning in PY 2025 for all APM Entities who report eCQMs, which would provide additional points added to an ACO’s final quality score.
• Changes the way Medicare CQM benchmarks are calculated to use flat benchmarks.

Other:

• Seeks additional comments on creating a higher risk track than Enhanced, including design of a discount and shared savings arrangements.
• Modifies beneficiary notification requirements to create a set deadline for follow-up communications and clarify the population of beneficiaries that ACOs under retrospective assignment must furnish the notice to.
• Creates a new “prepaid shared savings” option for ACOs with a history of earning shared savings to elect to receive prepaid shared savings to invest in beneficiary care and healthcare infrastructure.
• Updates MSSP application procedures and eligibility requirements.
• Refines Advance Investment Payment (AIP) policies.
• Seeks feedback through an RFI on a potential mandatory model to require specialist participation in MIPS Value Pathways (MVPs) to engage specialists in value-based care models.

Quality Payment Program Proposals

• Maintains the MIPS performance threshold of 75 points for PY 2025, which corresponds to 2027 payment adjustments.
• Modifies the Qualifying APM Participant (QP) Determinations to use claims for all covered professional services to identify attribution eligible beneficiaries for all Advanced APMs. Determinations are currently limited to evaluation and management (E/M) services.