NAACOS Analysis of the CY 2025 Medicare Physician Fee Schedule Final Rule

Executive Summary

On November 1, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2025 Medicare Physician Fee Schedule (MPFS) Final Rule. This regulation contains numerous changes for  the Medicare Shared Savings Program (MSSP) that NAACOS has been advocating for, including  establishing permanent policies for anomalous billing and easing beneficiary notification requirements. 

In this analysis, we provide details on key policies affecting ACOs. The rule is summarized in several fact  sheets provided by CMS: MPFS Fact Sheet, MSSP Fact Sheet, and Quality Payment Program (QPP) Fact  Sheet (download). 

NAACOS provided detailed comments in response to the proposed 2025 MPFS rule, with key input from  members. Most policies were finalized as proposed. 

Medicare Physician Payment Policies 

• Decreases the Medicare conversion factor from $33.29 to $32.35 for 2025, a 2.83 percent  decrease. 
• Creates new billable codes for Advanced Primary Care Management (APCM) services;  participants in MSSP, CMS Innovation Center ACO models and advanced primary care models  automatically meet some practice capability requirements to bill these codes. 
• Creates new coding and payment for caregiver training services (CTS) and allows the proposed  CTS to be furnished via telehealth. 
• Creates new billable codes for behavioral health crisis services and digital mental health  treatment. 

Medicare Shared Savings Program Policies 

Anomalous and Highly Suspect Billing:  

• Identifies and removes anomalous billings from Performance Year (PY) 2024 and future years if any billing codes trigger a necessary adjustment.
• Establishes a process for ACOs to request a reopening of shared savings calculations to account for improper payments identified beyond the three-month claims runout.

Benchmarks:  

• Adds a Health Equity Benchmark Adjustment (HEBA) that upwardly adjusts an ACO’s historical  benchmark based on the proportion of beneficiaries who are enrolled in the Medicare Part D  low-income subsidy (LIS) or dually eligible for Medicare and Medicaid. 

Assignment:  

• Adds several new codes to the definition of primary care services used in assignment.
• Creates a limited exception to MSSP’s voluntary alignment policy; claims-based assignment for a  disease-or condition-specific CMS Innovation Center model will take precedence over MSSP  voluntary alignment.  

Quality: 

• Creates the APP Plus quality measure set to align with the Universal Foundation quality  measures. ACOs must begin reporting the APP Plus set beginning in 2025 and it will  incrementally increase to a total of 11 measures, including the current six measures in the  existing set and five new measures over PY 2025 to PY 2028. Recognizing that eCQM  specifications are not yet available for two measures (Screening for Social Drivers of Health and  Adult Immunization Status), their inclusion may be delayed until a year after the specifications  are released.  
• Maintains the MIPS CQM reporting option for PY 2025 and 2026.  
• Sunsets the Web Interface reporting options for MSSP ACOs in PY 2025.  
• Plans on sunsetting the Medicare CQMs no sooner than five years from now. CMS will evaluate  when to sunset this option based on broad ACO reporting of eCQMs and ACOs’ capability to  leverage FHIR API technology to aggregate quality reporting data.  
• Scores performance for Medicare CQM using flat benchmarks for the measures’ first two  performance periods in MIPS. 
• Extends the eCQM reporting incentive (lower quality performance standard) to continue  encouraging ACOs to report via eCQMs for PY 2025 and subsequent performance years.  • Extends the reporting incentive for MIPS CQMs for PY 2025 and 2026. 
• Establishes a Complex Organization Adjustment beginning in PY 2025 for all APM Entities who  report eCQMs, which would provide additional points added to an ACO’s final quality score.

Other:  

• Modifies beneficiary notification requirements to create a set deadline for follow up  communications and clarifies the population of beneficiaries that ACOs under retrospective  assignment must furnish the notice to.  
• Creates a new “prepaid shared savings” option for ACOs with a history of earning shared savings  to elect to receive prepaid shared savings to invest in beneficiary care and healthcare  infrastructure.  
• Updates MSSP application procedures and eligibility requirements.  
• Refines Advance Investment Payment (AIP) policies.  

Quality Payment Program Policies 

• Maintains the MIPS performance threshold of 75 points for PY 2025, which corresponds to 2027  payment adjustments.
• CMS is not finalizing any changes to the QP determination and indicates it will propose a new  approach in future rulemaking.