Is 340B rate cuts reversed by CMS for 2023?
Asked by: Dr. Violet Schiller | Last update: September 27, 2023Score: 4.6/5 (8 votes)
Becerra and its statements in the 2023 Outpatient Prospective Payment System (OPPS) Proposed Rule, the Centers for Medicare & Medicaid Services (CMS) has finalized its proposal to return payments for 340B drugs under OPPS to the full average sales price (ASP) plus 6% rate, reversing the ASP minus 22.5% rate that was ...
What is the 340B drug pricing program 2023?
The 340B Drug Pricing Program (340B Program) requires drug manufacturers to sell outpatient drugs at discounted prices to covered entities (including certain types of hospitals) for the manufacturers' drugs to be covered by Medicaid. More than 2,600 hospitals were participating in the 340B Program as of January 2023.
What is opps proposed rule 2023 340B?
In the CY 2023 OPPS/ASC final rule, CMS finalized a general payment rate of ASP plus 6% for drugs acquired through the 340B Program, consistent with the agency's policy for drugs not acquired through the 340B program.
What did the Supreme Court rule on CMS 340B?
In June, SCOTUS ruled unanimously that it was illegal for the Trump administration to cut payment rates for drugs acquired through the 340B program, and ordered it to pay back billions to hospitals.
What is the JG modifier for 2023?
When applicable, providers are required to report either modifier “JG” or “TB” on OPPS claims (bill type 13X) beginning January 1, 2023. The presence of modifier “JG” or “TB” on a claim indicates that a drug has been acquired through the 340B program.
340B Simplified
What are the CPT changes for 2023?
There are coding and guideline changes in every section of the CPT® 2023 code set, except anesthesia. The most significant changes are to the evaluation and management (E/M), percutaneous pulmonary artery revascularization, hernia repairs, lab and pathology, and COVID-19 vaccination codes.
How many HCPCS codes were revised in 2023?
Overall, these updates include 182 new and 101 revised codes. Also, 47 codes were deleted. Three new modifiers were added, and two modifiers were revised. These changes go into effect January 1, 2023.
What is the controversy with 340B?
Hospitals, clinics, and other providers dispute that the 340B program's growth is inappropriate. A significant amount of the care provided to America's millions of uninsured people goes uncompensated, they point out, and policymakers intentionally expanded the program to address this.
What is the court decision on 340B?
340B Medicare Payment Remediation
The Supreme Court recently found the Medicare payment cuts to be unlawful, and a trial court has directed the Centers for Medicare and Medicaid Services (CMS) to remedy affected hospitals.
What is 340B drug pricing reform?
Section 340B of the Public Health Service Act requires pharmaceutical manufacturers participating in Medicaid to sell outpatient drugs at discounted prices to health care organizations that care for many uninsured and low-income patients.
What is the 2023 CMS rule?
On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that revises the Medicare Advantage (MA or Part C), Medicare Prescription Drug Benefit (Part D), Medicare Cost Plan, and Programs of All-Inclusive Care for the Elderly (PACE) regulations to implement changes related to Star Ratings ...
What is the CMS 2023 final rule conversion factor?
On January 5, 2023, the Centers for Medicare & Medicaid Services (CMS) announced an updated CY 2023 physician conversion factor (CF) of $33.8872.
What is CMS Proposed Rule 2023 Medicare?
Specifically, in CY 2023, CMS finalized: 1) our proposal to clarify and codify certain aspects of previous Medicare FFS payment policies for dental services, 2) payment for dental services that are inextricably linked to other covered medical services, such as dental exams and necessary treatments prior to organ ...
What are the Medicare drug cost limits in 2023?
The initial coverage limit (ICL) will increase from $4,430 in 2022 to $4,660 in 2023. This means you can purchase prescriptions worth $4,660 before entering what's known as the Medicare Part D Donut Hole, which has historically been a gap in coverage.
How often does 340B pricing change?
Operational Changes: OPAIS Pricing System
Overview: The 340B OPAIS pricing component captures pricing data from manufacturers and CMS and then calculates and verifies 340B ceiling prices through a quarterly process.
What are the challenges of 340B program?
The 340B program has been examined regularly by the Government Accountability Office (GAO) and the Department of Health and Human Services Office of Inspector General (OIG), and their reports have highlighted several issues with the program, including limited oversight, lack of transparency, concerns stemming from DSH ...
How do hospitals profit from 340B?
Consequently, these providers can generate 340B profits by pocketing the difference between the discounted price that they paid for the drugs and the higher reimbursement paid by insurers and patients.
Does 340B apply to Medicare Advantage plans?
For 340B facilities, CMS reimburses 340B status indicator K drugs and biologics at a discounted rate of ASP minus 22.5%. CMS requires Medicare Advantage plans to reimburse non-contracted providers using these Original Medicare rates.
What drugs are not 340B eligible?
General exceptions to 340B drug eligibility
There are a few exceptions, which include vaccines and Orphan Drugs (which are, by definition, medications specifically developed to treat rare diseases or conditions — and drugs that have only recently been granted New Drug Status by the FDA).
How do 340B pharmacies make money?
The pharmacy would typically receive a dispensing fee agreed to by the 340B entity by contract. Other financial arrangements between the pharmacy and 340B entity may include first-time inventory coverage payments, a percent of the drug cost, or other contractually agreed upon terms.
Are 340B pharmacies profitable?
We estimate that in 2019, 340B created over $40 billion in profits which were shared between covered entities, contract pharmacies, and possibly patients (in the form of reduced-price medicines). Oncology drugs dominate the 340B program, accounting for a large and growing share of total program profits.
Are vaccines excluded from 340B?
Yes, You Can Purchase Vaccines on Your 340B Account (Hint: it's not a 340B price, it's a PVP value-added price)
What codes are deleted for Medicare 2023?
- Hospital observation services codes 99217—99220, 99224–99226.
- Consultation codes 99241, 99251.
- Nursing facility service 99318.
- Domiciliary, rest home (eg, boarding home), or custodial care services, 99324—99328, 99334-99337, 99339, 99340.
- Home or resident services code 99343.
What code has been deleted for 2023?
Deleted CPT® 2023 Codes
Under the Consultations heading, office consultation code 99241 and inpatient consultation code 99251 are deleted. Other nursing facility services code 99318 is deleted.
What are the changes to the ICD 10 2023 guidelines?
The April 2023 updates include 42 ICD-10-CM additions, seven deletions, and one revision. For ICD-10-PCS, there are 34 additions, no deletions, and no revisions. The updates are effective beginning April 1, 2023.