In a move designed to help address the social determinants of health, changes to the yearly rule defining Medicare reimbursement rates for physicians and other health care providers promise to bring some important adjustments in 2024.

What is in the new rule for health care provider reimbursement?

Every year, the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) issues a Notice of Proposed Rule Making for the Physician Fee Schedule (PFS) that define services and reimbursement rates for physicians and other providers providing care to people with Medicare. The final calendar year 2024 PFS includes significant changes to the Medicare program that reimburse for person-centered assessments/services designed to address health-related social needs (HRSNs). When not addressed, these HRSNs, such as housing instability, food insecurity or lack of transportation, contribute to negative health outcomes and increased total cost of care.

The final rule also includes supportive language concerning providers contracting with community-based organizations (CBOs) and community care hubs (CCHs) to provide these services. The rule also requires initiating visits, such as an outpatient visit, prior to any billable care integration services. CMS has a summary Physician Fee Schedule of key provisions that go into effect on Jan. 1, 2024.

Reimbursement for health integration services

Many in the aging network have experience with integrating health and social care. Beginning in early 2024, CMS will allow “auxiliary personnel” such as community health workers employed by CCHs/CBOs to receive reimbursement for these care integration activities:

• Assessments to highlight how SDOHs may interact with the condition discussed during the visit with the billing practitioner
• Care coordination among the practitioner, the auxiliary personnel, and the beneficiary and/or their caregivers
• Facilitation of a person’s behavior changes necessary for meeting diagnostic and treatment goals
• Health care navigation
• Provision of social and emotional supports

The final rule defines the initiating visit as an evaluation and management (E/M) visit conducted by a physician, but does not allow a stand-alone Medicare Annual Wellness Visit to serve as such. In our comment letter, NCOA highlighted that other types of primary care clinicians like physician assistants should be able to perform the initiating E/M visit for any subsequent community health integration services. There is an initial code for 60 minutes of community health integration services per month, which can be spread out and aggregated throughout the month. An option for a 30-minute add-on code is also allowed.

The initiating E/M visit is only required once for commencing CHI services. The visit could help establish a treatment plan, highlight unmet HRSNs, and establish the kinds of subsequent CHI services that would be most helpful.

In the final rule, CMS defers to state auxiliary service personnel training requirements. In cases where such state requirements do not exist, CMS provides a fallback federal standards on page 78928 of the final rule. CMS indicates that the billing practitioner is responsible for ensuring that auxiliary service personnel meet training requirements.

CMS also finalizes language requiring verbal or written individual consent for CHI services, which we had asked CMS to require.

What else does the aging network need to know about the mental health provisions of the final rule?

The final rule implements 2022 legislation establishing Medicare coverage and reimbursement levels for marriage and family therapists (MFTs) and mental health counselors (MHCs). The rule adopted a flexible definition of an MHC that should allow more practitioners to bill and work with beneficiaries (see page 79002 of the final rule).

CMS also finalized new coding and payment for mental health care integration services performed by MFTs and MHCs—services CMS previously finalized for clinical psychologists and clinical social workers in the final calendar year 2023 Physician Fee Schedule (see pages 52362-4 of the proposed rule for Medicare’s definitions of MFT and MHC as well as what they can bill for).

CMS will reimburse mobile mental health crisis support services in which mental health teams provide services to people in their own homes or in sites outside traditional settings. Mobile crisis units have been shown to be effective at providing community mental health services as an alternative to law enforcement responses to mental health crises.

In our comments in response to the proposed rule, NCOA supported the CMS use of a flexible definition of "home" so people temporarily housed in hotels, for instance, can receive support. Also, CMS will in 2024 allow auxiliary personnel, including peer support specialists, to help provide these new services. We are grateful for CMS’s planned outreach to providers to educate or remind them that peer support specialists can participate in providing mental health crisis services and integration services.

Reimbursement for conducting SDOH risk assessments

Beginning in early 2024, CMS will reimburse for the administration of a standardized, evidence-based SDOH risk assessment. Possible evidence-based tools include the Protocol for Responding to & Assessing Patients' Assets (see page 79314 of the final rule). In our comments, NCOA supported the proposed risk domains of housing, nutrition needs, and transportation, but also expressed a wish for CMS to also require the collection of individual demographic information to better understand how these demographic characteristics influence the three SDOH risk domains. We hope CMS will consider requiring this collection in future rulemaking.

The final rule provides a separate opportunity for a standalone reimbursement for a SDOH risk assessment performed as part of and during the same day as an Annual Wellness Visit (AWV). CMS provides an exception to this and clarifies that "in some cases, for various reasons, elements of the AWV may be initiated and furnished over a period of multiple days (see page 79316). CMS will implement a new standalone SDOH risk assessment reimbursement that would be separate from the standalone AWV reimbursement with no additional cost sharing.

Of special importance to the aging network, CMS clarifies in the final rule that “a licensed clinical social worker, a health educator, a registered dietitian, or nutrition professional, or other licensed practitioner…or a team of such medical professionals, working under the direct supervision of a physician” can also receive reimbursement. This clarification provides new opportunities to collaborate with health care providers in assessing and addressing unmet SDOH needs.

Reimbursement for Principal Illness Navigation (PIN) services

Navigation services are an essential tool in addressing the needs of people with complex conditions. This population is considered high risk and is, for example, more likely to have emergency department visits. Navigators help identify appropriate providers and access timely care.

The final rule indicates that both an E/M visit and the Medicare AWV can serve as the initiating visit for subsequent PIN services if the AWV identifies high-risk health conditions. Reimbursement can include assessment for SDOH unmet needs, but this assessment cannot be separately billed.

The final rule allows peer support specialists to be reimbursed for PIN services when addressing mental health care needs. The final rule also highlights that PIN services can only include one 60-minute session, but this can be followed up with any number of reimbursable additional 30-minute PIN services performed the same month. Practitioners billing PIN services can also separately bill for care management services that are necessary for managing or treating an illness.

CMS indicates PIN service provider training standards should be set by states. In cases where states lack such standards, CMS indicates that training standards should align with the National Model Standards for Peer Support Certification published by Substance Abuse and Mental Health Services Administration.

NCOA also applauds CMS’s finalizing the requirement that individual consent for PIN services must be obtained annually. Consent may be obtained by auxiliary personnel either before or at the same time as they begin providing PIN services.

NCOA is grateful for CMS’s leadership in addressing HRSNs. We look forward to continuing to support community health workers, care navigators, peer support specialists, and community-based organizations, among others, who are supporting older adults, as these important changes are being implemented across the U.S.