The proposed rule reflects the Biden-Harris Administration’s vision for affordable, high-quality care for all Americans while driving innovation in the Medicare program.
Overall proposed payment amounts would be reduced by 2.93% compared to 2024.
Change to PFS conversion factor incorporates the 0.00% overall update, the expiration of the 2.93% increase for 2024, and a small 0.05% adjustment for work relative value.
2025 PFS conversion factor is $32.36, a decrease of $0.93, or 2.80%, from CY 2024.
Quality Payment
Proposes 6 merit-based incentive payment system value pathways for ophthalmology, dermatology, gastroenterology, pulmonology, urology and also for surgical care.
Additional new quality measure set and required reporting on quality measure sets.
Inflation Reduction
Incorporates new and revised policies for the inflation rebate program, as instated under the Inflation Reduction Act (Public Law 117-169), in the 2025 PFS proposed rule
Proposes new policies in both the Part B and Part D drug inflation rebate programs.
Compares quarterly pricing files by CMS to the inflation adjusted payment amount.
Establishes a method and process for reconciliation of a rebate amount and establishes a civil money penalty process for when a manufacturer fails to pay the rebate amount.
Prepaid Shared Savings
Changes to the shared savings program further advances Medicare’s value-based care.
Proposing a new prepaid shared savings option to assist eligible accountable care organizations (AC) with a history of earning shared savings to encourage investments.
Modifications encourage ACO participation in the shared savings program by removing barriers for ACOs serving underserved communities and by increasing incentives.
Incentives through application of a proposed health equity benchmark adjustment.
Several policies are proposed to align quality measure reporting with the Universal Foundation of quality measures and promote digital quality measure reporting.
Proposed methodology to account for the impact of improper payments in recalculating performance year and benchmark expenditures used in financial reconciliation.
Also proposed methodology for excluding payment amounts for codes exhibiting significant, anomalous, and highly suspect (SAHS) billing activity during CY 2024.
Whole-Person Care
2025 Medicare PFS proposals advance health equity and support whole-person care.
Whole-person care recognizes physical, behavioral, and oral health, social determinants, and caregiving supports, with a foundation of integrative primary care.
Includes proposals to strengthen primary care, expand access to behavioral health, oral health, and caregiver training services, and maintain telehealth flexibilities.
Also to expand access to colorectal cancer screenings and vaccinations for hepatitis B.
Consultation
Comments on proposed 2025 Medicare PFS rule are due by Sep. 9, 2024.
Shared savings program SAHS proposed rule comment period closes on Jul. 29, 2024.
Jul. 31, 2024 CMS Fed Reg Proposal
On Jul. 31, 2024, CMS published proposal in federal register, comments due by Sep. 9.
Nov. 2024 CMS Final Rule
On Nov. 1, 2024, CMS issued final rule, CY 2025 Medicare Physician Fee Schedule (PFS) Final Rule, that includes changes to the Medicare Shared Savings Program.
Published fact sheet on CY 2025 Physician Fee Schedule final rule; fact sheet on final changes to 2025 Quality Payment Program; and a summary of comments received.
Also published fact sheet on final changes to the Medicare Shared Savings Program, fact sheet on final changes to the Medicare Prescription Drug Inflation Rebate Program.
Generally, changes in final rule will become effective Jan. 1, 2025.
Dec. 2024 CMS Fed Reg Final Rule
On Dec. 9, 2024, CMS published the final CY 2025 Fee Schedule in the federal register.
