ANA Weighs in on Annual Medicare Payment Rulemaking

  

UPDATE: CMS released four final rules on Friday, 11/1.

Starting each Spring, the Centers for Medicare & Medicaid Services (CMS) begins its annual rulemaking process to determine payment for Medicare services by provider type. These payment rules also include proposals for quality measurement and improvement, addressing health equity, and other CMS policy priorities.  

These proposed rules typically have a 60-day comment period—allowing stakeholders to review the proposals and submit comments through regulations.gov. ANA’s Policy Team reviews each proposed rule, determines which proposals impact nurse practice and/or profession, and submits comment letters detailing the association’s positions on the proposed provisions.   

Comments on the last proposed rule of the 2025 Medicare payment rulemaking cycle were submitted to CMS in early September. Below we detail the payment rules ANA focused on during this year’s rulemaking process and highlight our comments on each. 

Physician Fee Schedule (PFS) 

The PFS sets payment rates for physicians and other billing professionals, such as Advanced Practice Registered Nurses (APRNs). This year’s proposed rule included several proposals around billing codes, telehealth, screening for social determinants of health (SDOH), vaccines, quality programs, and bolstering access to behavioral health services. ANA comments focused on ensuring that the agency adequately and appropriately value the nurse in all payments, urged CMS to make permanent all telehealth flexibilities, recognize the critical role of the nurse and nurse practice, and continue to provide incentives to support and bolster the nurse workforce. Comments were due at the beginning of September, and we expect CMS to release the final rule in the coming months. 

Hospital Inpatient Prospective Payment System (PPS) 

CMS issued the proposed IPPS rule, which covers significantly more than inpatient hospital visits, in May. ANA’s comments covered a wide range of issues including payment incentives, health equity, public health, maternity care, climate change, and access to essential medicines. Additionally, ANA urged CMS to ensure access and payment parity for APRNs in maternal health. CMS issued the final IPPS final rule in early August, which largely finalized CMS’ proposals.   

Hospital Outpatient Prospective Payment System (HOPPS) 

In late July, CMS issued their calendar year 2025 HOPPS proposed rule. In addition to provisions related to outpatient care, the rule included a proposal to create an obstetric-specific Conditions of Participation (CoP). ANA’s comments urged the agency to ensure that any CoP include safe staffing levels for nurses and ensure access to APRNs, who are critical to patient access to obstetric and maternal health care. ANA also commented on raising the reimbursement rate for Esketamine, which ANA staff met with CMS about earlier this year. In addition, the comment letter included ANA’s positions on provisions related to telehealth, PPE, and health equity. Comments on this proposed rule were due in early September, and we expect CMS to issue a final rule in the coming months. 

Skilled Nursing Facility (SNF) PPS 

CMS issued the SNF proposed rule in May—updating SNF payment rates, quality programs, and enforcement policies. ANA expressed support for CMS’ proposals the Quality Reporting Program (QRP) and Value-Based Purchasing (VBP) programs to address gaps in quality across SNFs and health inequities experienced by Medicare beneficiaries. In addition, we urged the agency to leverage SNF quality data to inform implementation of separate rulemaking instituting minimum staffing standards in SNFs and explore options to increase transparency on SNF spending on nursing care. CMS issued the final rule in late July, largely finalizing provisions as proposed. 

Home Health (HH) PPS 

The HH proposed rule, issued in late June, targets payments to HH agencies (HHAs) for services provided to beneficiaries. CMS’ proposals focused on timely admission to home health services, quality reporting and improvement programs, health equity, and other agency priorities. ANA detailed support for the proposed provisions regarding advancing health equity and improving quality. ANA also weighed in on the need for CMS to ensure nurses are part of any process or requirements to determine HHA availability and to bar therapists from conducting nursing care assessments. Comments were due at the end of August, and we expect CMS to release the final rule in the coming months. 

Hospice PPS 

CMS issued a May proposed rule updating hospice payments and proposing changes to quality reporting programs. ANA focused its comments on urging the agency to address gaps in quality to reduce health disparities for hospice beneficiaries. ANA also highlighted the key role of the nurse in the new Hospice Outcomes and Patient Evaluation (HOPE) assessment tools. CMS finalized the rule in July, adopting its proposed changes. 

Inpatient Psychiatric PPS 

In April, CMS released their annual proposed rule updating payment and policy in inpatient psychiatric programs. ANA’s comments supported CMS’ continued attention to health equity focused interventions and highlighted the importance of psychiatric mental health nurses (PMHN) to implementing patient assessment data collection. ANA also supported a new quality measure tracking a patient’s visit to an emergency room within 30 days of discharge from an inpatient psychiatric facility. Finally, we urged CMS to update this payment system to accurately account for the value of nurses and appropriately reimburse nursing care. The final rule was released in August adopting these proposals. 

End-Stage Renal Disease PPS 

CMS’ ESRD proposed payment rule was released in July and continues to try and fix pervasive access issues to in home dialysis. ANA comments remind CMS every year that solutions to in home access and staffing problems in the ESRD program must be created with nephrology nurses’ leadership. The agency proposed a health equity payment adjustment for clinicians that serve beneficiaries dually eligible for Medicare and Medicaid that ANA strongly supported. The final rule should be released in the next few months. 

ANA’s Advocacy before the August Recess – Q2 Legislative Roundup

  

Ahead of the congressional recess in August, the American Nurses Association has been hard at work advocating for the profession on Capitol Hill.

Here is what you need to know: 

The House Appropriations Committee recently advanced its Fiscal Year (FY) 2025 Labor, Health and Human Services, and Education (LHHS-ED) bill. The bill proposes an $18.343 million decrease in funding to the Title VIII Nursing Workforce Development Programs, elimination of the Nursing Workforce Diversity Program, and the elimination of the National Institute of Nursing Research (NINR) as part of a proposed restructuring of the National Institutes of Health (NIH).

ANA and its allies in the nursing community continue to urge Congress to appropriate at least $530 million to the Title VIII Programs and at least $210 million to NINR. 

In other news, the House Education and Workforce Committee recently advanced the Improving Access to Workers’ Compensation for Injured Federal Workers Act (H.R. 618). The bill would eliminate outdated barriers in the Federal Employees’ Compensation Act (FECA) that limit the ability of nurse practitioners (NPs) to provide care and treatment for injured or ill federal employees. HERE is the letter that ANA submitted to the committee ahead of the markup. 

ANA engaged Congress in a variety of other ways throughout the second quarter of 2024: 

Establishing Long-Term Care Staffing Standards

ANA recently submitted a letter to House and Senate Leadership that urges Congress to oppose ongoing efforts on Capitol Hill to overturn the Centers for Medicare and Medicaid Services’ final rule that would establish safe staffing standards in long-term care facilities. The final rule was issued by CMS in April. The House Ways and Means Committee passed HR 7513 in March to prevent the implementation of the rule, and a pair of resolutions (HJ Res. 139 / SJ Res. 91) were introduced in May that would fast-track the process for overturning the final rule pursuant to the Congressional Review Act. 

Improving Access to APRNs

ANA recently sent a letter to the Senate Finance Committee that highlights ways that Congress can ensure Medicare patients’ access to nursing care through Medicare Part B Payment Reform. 

ANA recently submitted a letter to Senators Sheldon Whitehouse (D-RI) and Bill Cassidy, MD (R-LA) that highlights how Congress can expand Medicare patients’ access to primary care services provided by APRNs. In the letter, ANA calls on Congress to reform how CMS determines reimbursement rates for APRNs and ensure that nurses have a seat at the table when those decisions are made. 

Improving Care and Access to Nurses Act (ICAN) Congressional Briefing

ANA co-hosted a congressional briefing with American Association of Nurse Anesthesiology (AANA), the American Association of Nurse Practitioners (AANP), and the American College of Nurse-Midwives (ACNM) to bring awareness of the Improving Care and Access to Nurses (ICAN) Act (H.R. 2713/S. 2418) and its effort to remove regulatory barriers that Medicare patients face when attempting to see advanced practice registered nurses (APRNs). 

Minority Fellowship Program Congressional Briefing

ANA participated in a congressional briefing with the American Psychological Association, the American Psychiatric Association, and the National Board for Certified Counselors to commemorate the 50th anniversary of the Minority Fellowship Program (MFP). Administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), the MFP provides training, career development, and mentorship to mental health professionals from minority and ethnic backgrounds who are dedicated to serving patients of color and other marginalized communities. 

One Year Later – ANA Continues the Fight for Workplace Violence Prevention

  

As workplace violence (WPV) in health care continues to rise, nurses cannot wait for solutions. Last year, the Occupational Safety and Health Administration (OSHA) finally started work on a WPV prevention standard. According to OSHA’s own data, health care and social assistance workers now face six times the risk of WPV than all other industries. This is an increase from 2018 data which showed a risk of five times that of other industries.  

Yet it has been over a year and no further progress has been made.  

To urge action from the agency, ANA led a sign-on letter to OSHA from nearly 60 nursing organizations across the country last month. Acting Secretary of Labor Julie Su was questioned about the lack of progress on this standard in a Congressional hearing on May 1st of the Committee on Education and the Workforce.  

During the hearing, Rep. Joe Courtney, champion of the Workplace Violence Prevention for Health Care and Social Service Workers Act, underlined the importance of the standard’s quick release by highlighting the murder of nurse Joyce Grayson late last year. Joyce Grayson was a home health nurse killed by her patient despite many previous warnings to her employer that the patient was aggressive and dangerous. While OSHA did expedite an investigation into this case, and has cited the employer for failing to protect their employees from known hazards, it comes too late for Joyce Grayson.   

Nurses need and deserve a safe workplace. This requires robust evidence-based prevention programs nurses can rely on, no matter where they work. We are extremely disappointed that OSHA continues to deprioritize this live-saving standard and will not stop advocating for nurses’ safety and for OSHA to do its job.  

In addition to the regulatory work, ANA kept up the pressure and conversation on a state level through collaboration with the National Lieutenant Governor’s Association (NLGA). The NLGA represents the elected officials first in the line of succession to the governors in all 50 states and five U.S. territories. The bipartisan organization’s mission is to promote interstate cooperation and knowledge sharing as well as improve the efficiency of the office of lieutenant governor.  

At the April 2024 NLGA meeting hosted by Lieutenant Governor (LG) Pamela Evette, the Executive Committee and other attending LGs unanimously approved our Consensus Resolution (updated 7/19/24) on Workplace Violence Prevention in Health Care. The resolution acknowledges the severe nature of workplace violence in health care, urging members to recognize and support programs aimed at mitigating the issues.  

The consensus resolution demonstrates ANA’s commitment to addressing workplace violence through state and national advocacy and, supporting the implementation of comprehensive prevention strategies. This continued effort is vital to ensure the safety and well-being of nurses and other health care professionals. 

From left to right: Top Row: LG Kim Driscoll (D-MA), LG Tahesha Way (D-NJ), LG David Zuckerman (P/D- VE), LG Stavros Anthony (R-NV), LG Sabina Matos (D-RI), LG Jeanette Nuñez (R-FL), LG Deidre Henderson (R-UT), LG Larry Rhoden (R-SD), LG Josh Tenorio (D-Guam). Bottom Row: Secretary of State Omar Marrero (Puerto Rico), LG Garlin Gilchrist (D-MI), LG Pamela Evette (R-SC), LG Adam Gregg (R-IA), LG Aruna Miller (D-MD), Secretary of State Chuck Gray (R-WY) 

You can urge your federal legislators to support the Workplace Violence Prevention for Health Care and Social Services Workers Act through our Action Center. You can also sign up for alerts on all our campaigns at RN Action and stay tuned for more work on this issue at every level of government.