The Consolidated Appropriations Act, 2021, passed with bipartisan majorities by Congress and signed into law by the President Dec. 27, addressed major American College of Radiology® (ACR®) legislative priorities.
ACR-backed updates regarding scheduled Medicare payment cuts, “surprise medical billing,” radiation oncology payment model delay and other issues are marked improvements on previous legislative framework(s).
Medicare Provider Payment Cuts
As a result of advocacy by an ACR-led coalition, representing more than a million healthcare providers, the year-end omnibus bill included significant reduced anticipated Medicare provider payment cuts due to evaluation and management coding changes. The bill rolls back the payment cuts to radiologists, by more than half — from 10% to approximately 4% for 2021 — with further, phased-in adjustments thereafter. This mitigation offers a reprieve from the disastrous cuts that were slated to start Jan. 1, and an opportunity for the ACR and its coalition partners to continue to address these cuts with the Centers for Medicare & Medicaid Services (CMS) and the new Congress.
As recommended by the physician community, including the ACR, the new law ensures that consumers are held harmless from “surprise medical bills” and establishes an equitable process for provider-insurer dispute resolution. At ACR urging, Congress:
- Removed the monetary threshold to access independent dispute resolution;
- Removed provisions using the median in-network rate as an initial benchmark for payment;
- Inserted language to explicitly exclude Medicare, Medicaid and workers’ compensation payment rates from consideration in the independent dispute resolution process; and
- Removed the problematic timely billing provisions.
Having secured these “surprise medical billing” revisions in the final weeks of the congressional session, the bill (as passed) represents a significant step forward for patients and providers compared to the original legislation introduced in early 2019. The ACR and others in the physician community will closely monitor the regulatory processes associated with the scheduled 2022 implementation of the bill and provide additional updates as relevant information becomes available.
Paycheck Protection Program
Congress also included in the 5,000-page bill a provision clarifying that small businesses can deduct payroll and other expenses paid for with forgiven Paycheck Protection Program (PPP) loans. The tax implications of PPP loans were previously in contention prior to Congress codifying its original intent for the program.
The bill reopened the PPP with flexible covered period options and additional expenses eligible for loan forgiveness for those who have not yet received PPP funds (e.g., business operations software/services, worker protections, looting damage and certain supplier costs). There will be a second draw of PPP loans in 2021 calculated at 2.5 times the average total monthly payroll in 2019, capped at $2 million. However, small business size standards for second draw PPP loans have been reduced from 500 employees down to 300 employees, and recipients would need to demonstrate they experienced a 25% drop in gross receipts during any 2020 quarter as compared to the same 2019 quarter, in addition to other eligibility changes. As of this writing, the Small Business Administration has not yet published new guidance on 2021 PPP loans.
Radiation Oncology Payment Model
As supported by the ACR, implementation of the Radiation Oncology Payment Model (RO Model) is delayed until Jan. 1, 2022. Under the RO Model, Medicare was to begin paying participating providers and suppliers a prospective, modality agnostic, site-neutral, episode-based payment for specified technical and professional RT services furnished during a 90-day episode to Medicare FFS beneficiaries diagnosed with 16 different cancer types.
The ACR will continue advocacy for additional improvements to the RO Model, as the College is still concerned with aspects of the model including the steep discount factor cuts. The ACR has repeatedly expressed concerns regarding the RO Model and its implementation date to CMS, sending the Agency letters in March, July and October of 2020 as the COVID-19 public health emergency (PHE) significantly impacted radiation oncology practices and cancer care.
Additionally, the ACR signed on to a stakeholder letter led by the American Society for Radiation Oncology urging CMS to delay the Model to Jan. 1, 2022, given challenges with the ongoing PHE. On Sept. 18, CMS released the RO Model final rule, which set the start date of the RO Model to January 1, 2021. Following advocacy efforts of the College and other stakeholder groups, CMS announced on Oct. 21 that the model would be delayed to July 1, 2021, and formally delayed the model through rulemaking. Inclusion of the full-year delay of the RO model builds upon these ongoing advocacy efforts and will allow for continued engagement with CMS.
Access to Critical Cancer-Related Screenings
The Omnibus features an extension (through Jan. 1, 2023) of the current delay in implementing the 2009 United States Preventive Services Task Force (USPSTF) screening mammography recommendations as they apply to Affordable Care Act coverage and any other laws that reference the recommendations.
This provision stems from the Protecting Access to Lifesaving Screenings Act which protects access to covered annual mammograms with no copay starting at age 40 by extending the moratorium on the USPSTF breast cancer screening guidelines. By contrast, USPSTF recommends that women 40–49 receive screening only selectively, and that women 50–74 should have mammograms only biannually.
Without this added protection, mammography coverage for women younger than 50 may have been impacted starting Jan. 1, 2022. The extension ensures that women ages 40 and older who want annual screening mammograms will retain insurance coverage with no copay.
In addition, the bill includes provisions to eliminate cost-sharing for Medicare beneficiaries for colorectal cancer screening tests where a polyp is detected and removed. This provision reflects HR 1570, the Removing Barriers to Colorectal Cancer Screening Act of 2020, which gradually eliminates cost-sharing for Medicare beneficiaries with respect to colorectal cancer screening tests regardless of the code billed for a resulting diagnosis or procedure. The bill ensures Medicare beneficiaries are not charged for colonoscopies that discover polyps or any subsequent colorectal cancer screening. Implementation of the bill will be phased in over an eight-year period with cost-sharing for patients reducing over time.
Expansion of Graduate Medical Education Program(s)
Marking the first expansion in nearly 25 years, the Omnibus included 1,000 new Medicare-supported GME positions. In the distribution of these new residency positions, the slots will be prioritized to teaching hospitals in rural areas, hospitals training residents over their cap, hospitals in states with new medical schools and hospitals that care for underserved communities. The legislation also includes fixes to enhance Rural Training Track programs to increase collaboration between rural and urban teaching hospitals while residents gain experience in providing care in rural communities. It also makes an adjustment to artificially low Medicare caps and per resident amounts that limit residency training in some hospitals through no fault of their own.
The ACR is continuing to assess additional provisions included in the 5,500-page year-end bill and will provide additional updates as necessary. Moving forward, the ACR and its coalition partners will work with regulators, the new Congress and new Administration to advance these policies in a manner that protects consumers, preserves access to care and eases the effects of payment adjustments on providers now reeling from the financial impact of COVID-19.