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Geographic Payment Amounts
The Proposed Rule continued...
the duration of the emergency period… whichever is later, be adjusted so that they are equal to a blend of 50 percent of 110 percent of the national average price for the item or service and 50 percent of the fee schedule amount for the area in effect on December 31, 2015, increased for each subsequent year beginning in 2016 by the annual update factors specified in sections 1834(a)(14).
What does this mean?
[ ]CMS-1738-P means rural areas and non-contiguous Alaska/Hawaii keep the 50/50 blend.
It means rural areas and non-contiguous Alaska/ Hawaii keep the 50/50 blend. The “transition” (temporary) blend was set to expire on April 1 or the end of the PHE, but this proposal makes it permanent—unless changed by future rulemaking. What about “non-rural” areas that are cities and large towns but not large enough to be competitively bid? Prior to the CARES Act, they were reimbursed at a regional rate, or RSPA, which stands for “regional single payment amounts.” Effectively, these areas were reimbursed for items at approximately the same rate as the larger CBAs within their region. However, Congress did approve a better benefit—that is, 75% of the RSPA and 25% of the much higher non-competitive bidding rate. These amounts continue today and will continue until April 2021, or until the PHE is declared over. However, this proposed rule does not allow for a continuation of this 75/25 blend at this time. It reads:
…(F)or items and services furnished on or after April 1, 2021, or the date immediately following the duration of the emergency period whichever is later, in all other nonrural non-CBAs within the contiguous
United States, we are proposing that the fee schedule amounts be equal to 100 percent of the adjusted payment amount established under §414.210(g)(1)(iv). This means these non-rural and non-bid areas revert to the lower-reimbursed RSPA amounts.
Geographic Payment Amounts
CMS established eight geographic regions and eight RSPAs. CMS calculates the RSPA for each region using the unweighted average of the SPAs for a DMEPOS item from all CBAs that are fully or partially located in that region, regardless of population. CMS averages the RSPAs, weighted by the number of states in that region, to calculate a national average RSPA. Here is a visual of the 130 CBAs (the red “footprint” includes all the counties within the CBA):
