The Center for Medicare & Medicaid Services (CMS) issued the of the final Calendar Year 2025 Physician Fee Schedule on November 1, 2024, which included three new Healthcare Common Procedure Coding System (HCPCS) codes for advanced primary care management (APCM). The new APCM codes will take effect on January 1, 2025.

Over the last decade, the CMS Innovation Center has tested over 50 payment and service delivery models designed to stabilize the cost of care and increase quality. Consistent with the U.S. Department of Health and Human Services’ (HHS) “Initiative to Strengthen Primary Health Care,” CMS conducted a retrospective review of the more successful programs related to primary care. Based on its analysis, CMS determined that primary care practitioners needed additional and separate compensation for time spent on care management and coordination outside of evaluation and management visit, resulting in three APCM codes.

The APCM Codes

The three APCM codes generally have the same basic requirements for the billing practitioner, however, they vary based on patient complexity:

Level 1 [HCPCS G0556]	Level 2 [HCPCS G0557]	Level 3 [HCPCS G0558]
Patients with one or fewer chronic conditions	Patients with two or more chronic conditions	Patients with two or more chronic conditions and who are Qualified Medicare Beneficiaries

Unlike the five non-complex and complex chronic care management (CCM) and principal care management (PCM) codes finalized by CMS since 2013 (which are billed based on time spent by the practitioner), the APCM codes are billed monthly and are not tied to a specific number of minutes. The APCM codes also differ from the Comprehensive Primary Care, Comprehensive Primary Care Plus, and Primary Care First programs run through the CMS Innovation Center, which all paid practices a prospective, monthly payment per Medicare beneficiary. However, CMS intentionally designed the APCM services to be consistent with certain existing codes because the complex overlapping patient populations have similar management needs. Therefore, practitioners in the same practice cannot bill APCM codes concurrently with fifteen overlapping codes for CCM, PCM, communication technology-based service, and transitional care management. Examples of these overlapping services include interprofessional specialist consults, remote evaluation videos and images submitted by patients, virtual check-ins, and communications between patients and practitioners through an online portal.

Requirements to Bill

To bill the APCM codes, the following requirements must be satisfied:

1. Patient consent (inform the patient of the services, their right to stop, and of the potential cost sharing obligations[1]);
2. Initiating visit (required for new patients and patients not seen by the practice in the last three years);
3. 24/7 access and continuity of care (access to team member for urgent needs at all times and continuity through the use of a dedicated team member);
4. Comprehensive care management (systematic needs assessment, system-based approaches to ensure preventative services are provided, and medication reconciliation, and oversight of patient self-management of medications);
5. Patient-centered comprehensive care plan (the plan should be timely available to those involved with a patient’s care, routinely updated, and provided to the patient and/or caregiver);
6. Management of care transitions (ensuring timely exchange of electronic health information and patient follow-up after emergency room visits and hospital discharges);
7. Practitioner, home-, and community-based care coordination (coordinated referral management with specialists and other health care organizations through developing processes and procedures in the form of collaborative care agreements and electronic consultations);
8. Enhanced communication opportunities (for patients and caregivers to communicate with team members through additional asynchronous methods);
9. Patient population-level management (manage preventative and chronic care for the practice’s patient population and develop and implement strategies to improve outcomes); and
10. Performance measurement (quality, cost of care, and meaningful use of certified electronic health records technology).

Some of these requirements may be satisfied by participation in another CMS program. For example, the initiating patient requirement is consistent with the standards for the Shared Savings Program, ACO REACH Model, Making Care Primary, and Primary Care First. Therefore, the billing practitioner will generally meet the ACPM initiating visit requirement by virtue of participating in one of these four programs. Similarly, the practice-level performance measurements substantially overlap with the reporting requirements for the Shared Savings Program, REACH ACO, Primary Care First, Making Care Primary, and Merit-based Incentive Payment System eligible practitioners who report the Value in Primary Care MVP. As such, billing practitioner will meet the practice-level ACPM reporting requirements if they participate in and report the metrics required for participating in these existing programs.

Team Based Approach for Successful Care Management

APCM encourages a team-based approach that allows for accessibility and alternative methods for patients to communicate with the primary billing practitioner and auxiliary personnel outside of in-person visits. For example, while the APCM codes can only be reported once a calendar month per patient, the billing practitioner can change from month to month based on the actual physician, nurse practitioner, physician assistant, certified nurse midwife or clinical nurse specialist assumes the management role during that period. Designated care management services can also be performed by auxiliary personnel under general supervision of the billing practitioner.

Conclusion

While these new codes come with a number of administrative requirements, the APCM codes provide additional opportunities for practitioners to collect reimbursement for care management services, some of which they may already performing. HHS has long noted that effective primary care services and relationships are critical to improve health equity and access to care and as early as 2014, CMS recognized care management as a key component of primary care. As such, CMS’s goal in offering these codes is that it will allow practices to enhance or expand their care management services, which in turn will improve population-level mortality and reduce disparities.

Payor/Provider Convergence Blog Series

For additional resources on the intersection of payor/provider convergence and the issues that plague insurance and health companies, payors, and providers, click here to read the other articles in our series.

Â鶹´«Ă˝ is here to help you address the short- and long-term impacts in the wake of regulatory changes. We have the resources to help you navigate these and other important legal considerations related to business operations and industry-specific issues. Please reach out to the authored, your Â鶹´«Ă˝ relationship partner, our Payor/Provider Convergence Area of Focus, or to our Health Care Practice Group with any questions.

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[1] These codes do not qualify as additional preventative services at this time; therefore, coinsurance obligations still apply.

health have increasingly emphasized how non-medical factors such as socioeconomic status, education, employment, housing, food security, and community support have an outsized impact on health outcomes. By , clinical care accounts for only 20% of county-level variation of health outcomes in the United States, with the social determinants of health (SDOH) responsible for as much as 50%. SDOH are now widely acknowledged as critical not only to improving individual health and population health, but also to meeting federal . Yet conventional models of health care delivery still (HRSN). One reason is that health plans and health care providers must look to nontraditional partnerships with organizations that have not historically been part of the health care industry to meet these needs.

We highlight three trends associated with partnerships to address HRSNs:

• Medicaid and Medicare health plan initiatives;
• Local and regional data sharing efforts; and
• Risk mitigation in collaborations between health care providers and community partners.   

Health care providers and health plans involved in any of these trends — or looking to become involved — must navigate complex and interrelated reimbursement, privacy, compliance, and fraud and abuse issues. It is critical to consult with counsel when developing new initiatives targeting the SDOH and HRSNs to ensure legal concerns are evaluated and addressed.  

Medicaid and Medicare Health Plan Initiatives

The Centers for Medicare & Medicaid Services (CMS) have begun to incorporate new tools to foster “whole person” care for Medicaid and Medicare beneficiaries and have implemented policies to encourage and pay for appropriate community partnerships.

Late last year, CMS published discussing opportunities for states to cover services and supports to address health-related social needs in Medicaid and the Children’s Health Insurance Program. describes the authority for health plans in a state’s Medicaid managed care delivery system to cover “in lieu of services” that address HRSN. For example, “in lieu of services” may address housing and the home environment by covering a tenant’s first month’s rent, caregiver respite services, home remediations, and sobering centers, and may address nutrition needs by covering nutrition counseling and home-delivered meals. The bulletin highlights recent CMS approvals in seven states for evidence-based housing and nutritional services designed to mitigate the negative health impacts of unmet social needs. Since the bulletin was published, , which includes Medicaid opportunities for New York to address HRSN by covering similar housing supports, enhanced case management, nutrition supports, cooking supplies, and private and public transportation to HRSN services.

Interested parties should also consult on SDOH opportunities in Medicaid, which trumpets Medicaid’s flexibility while cautioning that federal principles require services to be provided based on individual assessments of need, typically making Medicaid the payor of last resort (states must assess all available public and private funding streams before using Medicaid to cover unmet social needs), and require that services addressing SDOH be economic and efficient. CMS specifically identifies how state Medicaid programs may address SDOH through managed care, such as by sharing managed care savings with Medicaid beneficiaries in the form of additional health-related services, directing health plans to implement alternative payment models rewarding improvements in SDOH, offering incentive payments for health plans that make investments in SDOH, and using waiver authorities to incorporate SDOH services into the managed care contract and plan capitation rates. A also proposed to make significant changes to Medicaid managed care authorities to cover “in-lieu of services,” and its finalization is later this year.

A 2023 CMS for Medicare Advantage (MA) also addresses how MA plans may impact the SDOH. Over the last five to ten years, CMS has revised MA regulations to to cover services that compensate for physical impairments, reduce avoidable emergency room visits, and address SDOH-related needs for chronically ill enrollees. In some circumstances, such as home-delivered meals, transportation, pest control, access to community-sponsored programs, and home modifications. These changes have allowed MA plans to take a more holistic approach and connect enrollees to interventions targeting social factors impacting their health.

Local and Regional Data Sharing Efforts Implicate Privacy Laws

Leveraging data is critical for both health plans and health care providers to identify and address HRSN. While some data may be available from public sources such as census records and community needs assessments, key information that is confidential and protected by privacy laws is likely to be controlled by health care organizations, governmental service providers, and community partners. Integrating and analyzing this information can be essential to quantify the prevalence of issues like food insecurity, housing instability, and transportation barriers. Integration across health and social service sectors also enables a comprehensive view of individuals’ needs and supports targeted interventions to high-risk populations. This makes data partnerships between health care entities and community organizations especially critical.

Efforts to collect and share data related to SDOH implicate a range of privacy laws. At the federal level, health care providers and plans must navigate the complex and ever-evolving landscape of laws such as the (HIPAA) and substance-use disorder confidentiality law (frequently known as Part 2). Many states also impose their own health information privacy laws, which may exceed the floors set by federal minimum requirements. In some cases, health care privacy restrictions must be balanced against an evolving set of federal and state legal requirements to share health information, such as the and California’s recent statewide data sharing framework. And because SDOH extend well beyond health information, other privacy laws addressing information such as and must be considered. Addressing privacy laws may involve data use agreements, patient authorizations, de-identification techniques, and the design of physical, technical, and administrative safeguards to secure data and appropriately restrict the sharing of identifiable information.

Risk Mitigation in Collaborations between Health Care Providers and Community Partners

Health care providers and plans also need to collaborate with community partners to address HRSN by coordinating care and resources for individuals served by multiple providers and partners (who are also often high utilizers with high costs). Collaboration could involve multi-party arrangements with partners such as housing agencies, food banks, transportation services, government agencies, and social service organizations.

One legal challenge in developing such partnerships is adherence to health care fraud and abuse laws. For example, the federal Anti-Kickback Statute (AKS) and physician self-referral law (Stark) may be implicated by any exchange of remuneration, including in-kind services, between health care entities and community partners who work with Medicaid and Medicare patients.

In addition, Medicare and Medicaid anti-supplementation provisions must be considered when designing payments to incentivize the use of health care services, including non-traditional services. Health care partnerships must be carefully designed to fit within regulatory exceptions and safe harbors to mitigate these risks.

When addressing HRSN for federal health care program beneficiaries, risk mitigation may involve leveraging the promulgated by CMS and the Office of Inspector General for the Department of Health and Human Services (OIG). Value-based exceptions can shield from AKS and Stark liability certain arrangements between partners who are jointly pursuing value-based purposes such as coordinating and managing care, improving quality of care, and appropriately reducing health care costs. As with any fraud and abuse issue, it is important to consult legal counsel and establish robust compliance safeguards.

Payor/Provider Convergence Blog Series

For additional resources on the intersection of payor/provider convergence and the issues that plague insurance and health companies, payors, and providers, click here to read the other articles in our series.

Â鶹´«Ă˝ is here to help you navigate the complex legal issues involved in addressing the social determinants of health. To learn more, please reach out to the authors, your Â鶹´«Ă˝ relationship partner, our Payor/Provider Convergence Area of Focus, or to our Health Care Practice Group with any questions.

On September 26, 2023, the Departments of Health & Human Services (HHS), Labor, and the Treasury (collectively, the Departments) jointly  (September Rule) updating the administrative fee and Certified Independent Dispute Resolution (IDR) entity fee ranges for the Federal IDR Process under the No Surprises Act. The new proposed fees of $150 (from $50) will take effect on January 1, 2024, after a notice and comment period. Comments on the rule are due by October 26, 2023. This rule comes as a relief to both payors and providers who have been waiting to hear when the Federal IDR Process will restart after the portal has been partially paused due to recent litigation.

What is the Federal IDR Process?

The Federal IDR Process was created under the No Surprises Act (NSA) to resolve payment disputes between payors and out of network providers relating to claims subject to the NSA. These NSA-covered claims include:

• emergency services furnished by a nonparticipating provider or nonparticipating facility;
• an item or service provided by a nonparticipating provider at a participating health care facility; or
• air ambulance service provided by a nonparticipating air ambulance provider.

For more information on the IDR Process, please see our prior post available here or listen to our recorded webinar which can be accessed .

Background on the September Rule

The rule proposed this September was developed in response to the Texas Medical Association case discussed in our prior blog issued in August (TMA IV). The root of that litigation was when the Departments issued an amendment to the IDR process increasing the nonrefundable administrative fee for IDR from $50 to $350, an increase of 600%. On August 3, 2023, a United States District Judge in the Eastern District of Texas issued an  vacating the IDR administrative fee increase from $50 to $350 because the amendment was (i) issued without notice and comment period, and (ii) it was found to be arbitrary and capricious.

As a result of the Texas District Court’s decision, HHS temporarily suspended the Federal IDR process again, including the ability to initiate new disputes, until the Departments could provide additional instruction, causing more delays and headaches for providers and payors. However, on September 21 the Departments  certified IDR entities to resume processing all single and bundled disputes submitted on or before August 3, 2023 so that disputes would be ready when the Federal IDR Process reopens.

After TMA IV, the Departments proposed two rules related to the Independent Dispute Resolution Process.  The Office of Management and Budget added these rules to its list of regulatory actions under review and held 10 meetings with constituents and private parties to discuss the proposals. Ultimately, the Departments published a proposed rule, “”,  on September 26^th. To both payor and provider’s relief alike, the rule proposes to reopen the IDR process in early 2024. Comments on the proposed rule are due October 26, 2023. 

Want to Learn More?

For more information on recent developments and trends related to the NSA, please view our webinar titled “A Year After the No Surprises Act: What We’ve Learned and What to Watch Out For” from Thursday, September 28. The presentation can be accessed .

Payor/Provider Convergence Blog Series

For additional resources on the intersection of payor/provider convergence and the issues that plague insurance and health companies, payors, and providers, click here to read the other articles in our series.

Â鶹´«Ă˝ is here to help you address the short- and long-term impacts in the wake of regulatory changes. We have the resources to help you navigate these and other important legal considerations related to business operations and industry-specific issues. Please reach out to the authors, your Â鶹´«Ă˝ relationship partner, our Payor/Provider Convergence Area of Focus, or to our Health Care Practice Group with any questions.

On September 5, 2023, the Centers for Medicare & Medicaid Services (CMS)  a new all-payor, total-cost-of-care model that is designed to tackle growing health care costs, boost population health functions, and reduce disparities in health outcomes. The model is based on learnings from the Maryland Total Cost of Care model, the Pennsylvania Rural Health Model, and the Vermont All-Payer Accountable Care (ACO) Model.

Up to eight states will be selected by CMS to participate and implement an all-payor model, known as the Advancing All-Payer Health Equity Approaches and Development (AHEAD) model. The model will run for 11 years, commences on one of three start dates, and will conclude in December 2034. Each selected state will receive up to $12 million to implement the model. CMS expects to begin the pre-implementation period for the initial participating states in July 2024.

What are the aims of the AHEAD model?

The total-cost-of-care model seeks to drive state and regional health care transformation and multi-payor alignment. A key goal is improving the total health of a state population and lowering health care costs. With the AHEAD model, CMS is testing how state-led payor alignment efforts can slow the growth of health care costs while propelling transformative change within health care delivery systems. Each participating state will receive targets for Medicare total-cost-of-care growth from CMS; develop its own all-payor targets; and implement strategies to control spending by promoting preventative care and managing site of care costs.

When the application available?

CMS anticipates releasing the notice of funding opportunity in late Fall 2023 followed by a second application period in Spring 2024.

Who is eligible to participate in the AHEAD model?

State agencies with the authority and capacity to enter into an agreement with the Secretary on behalf of their state and accept funding are eligible applicants. These may include a state Medicaid agency, state public health agency, state insurance agency, or other entity with rate-setting or budget authority.

How will hospitals be paid under the AHEAD model?

Participating hospitals will receive prospective fixed payments for traditional Medicare and Medicaid services tied to global budgets. Other participating payors can choose to pay participating hospitals based on a global budget tied to enrollee populations. The global budget methodologies will incentivize participating hospitals to improve performance and increase efficiencies.

How will primary care providers participate in the AHEAD model?

Primary care practices located in a participating state will have the option of participating in the primary care component of the model – the Primary Care AHEAD. Participating primary care practices will receive a Medicare care management fee and will engage in transformation efforts for person-centered care. Practices will be responsible for meeting quality-based performance goals.

Payor/Provider Convergence Blog Series

For additional resources on the intersection of payor/provider convergence and the issues that plague insurance and health companies, payors, and providers, click here to read the other articles in our series.

Â鶹´«Ă˝ is here to help you address the short- and long-term impacts in the wake of regulatory changes. We have the resources to help you navigate these and other important legal considerations related to business operations and industry-specific issues. Please reach out to the authors, your Â鶹´«Ă˝ relationship partner, our Payor/Provider Convergence Area of Focus, or to our Health Care Practice Group with any questions.