Major Health Initiatives and Current Year Rate Changes to Know for 2025

The Biden-Harris Administration has recently unveiled several significant health initiatives to improve access to essential medical services and reduce healthcare costs for Americans.

These initiatives span various areas, including Medicare, HIV treatment, opioid recovery, and rural healthcare, and will directly benefit the patients served by Federally Qualified Health Centers (“FQHC”) and Rural Health Centers (“RHC”). In addition, the Centers for Medicare and Medicaid Services (“CMS”) released the Calendar Year 2025 Physician Fee Schedule Final Rule Effective January 1, 2025, with several provisions directly affecting payment policies for FQHCs and RHCs.

The Inflation Reduction Act (the “Act”) introduces substantial changes to Medicare, aiming to alleviate financial burdens on beneficiaries. Key measures include a $35 monthly cap on insulin, free recommended adult vaccines, and a $2,000 annual cap on out-of-pocket prescription drug costs starting in 2025. Additionally, the Act empowers Medicare to negotiate drug prices and imposes rebates on pharmaceutical companies that raise prices faster than inflation. These provisions are expected to reduce prescription drug costs for millions of Americans significantly.

In a major boost for HIV treatment, the Biden-Harris Administration has allocated over $1.4 billion to the Health Resources and Services Administration for the Ryan White HIV/AIDS Program. This funding will support more than 290,000 low-income individuals living with HIV, ensuring they receive essential medications and healthcare services. The program covers costs such as HIV medication, co-pays, and insurance premiums, which will help individuals achieve viral suppression and lead healthier lives.

Further emphasizing the administration’s commitment to rural health, a $75 million investment has been announced to support healthcare services across rural America. This funding will facilitate the launch of new opioid treatment and recovery services, expand maternal healthcare in the Delta Regions of the South (such as Mississippi, Louisiana and surrounding areas), and help rural healthcare providers remain operational. The initiative aims to improve access to high-quality healthcare in underserved rural communities, addressing critical gaps in the healthcare system.

Beginning January 1, 2025, care coordination services for FQHCs and RHCs have been expanded to include advanced primary care management services. Other services that comprise care coordination services include transitional care management, chronic care management, primary care management, chronic pain management, general behavioral health integration, remote physiologic monitoring, remote therapeutic monitoring, community health integration, principal illness navigation, and principal illness navigation peer-support. For care coordination services, FQHCs and RHCs will bill each service as an individual CPT/HCPCS base code and any applicable add-on codes to replace HCPCS code G0511. Payment for services will be at the national non-facility PFS payment rates. FQHCs and RHCs can begin individually billing on January 1, 2025, if billing systems can be updated or may continue to bill G0511 through July 1, 2025.

CMS continues to provide flexibility for FQHCs and RHCs to provide services through telehealth arrangements. CMS will keep allowing direct supervision via interactive audio and video telecommunications. Through December 31, 2025, real-time audio and visual interactive telecommunications will qualify within the definition of immediate availability. However, audio-only services were excluded from this definition. In addition, the in-person visit requirement for mental health services provided through telehealth by FQHCs and RHCs to beneficiaries in their homes has been delayed until January 1, 2026.

CMS’s update focused on payment for vaccination services. Beginning January 1, 2025, hepatitis B vaccines and administration will be paid at 100% of the reasonable cost to FQHCs and RHCs. Starting July 1, 2025, FQHCs and RHCs will be able to bill and be paid for Part B preventative vaccines, which include pneumococcal, flu, hepatitis B, and COVID-19, at the time of service. Payments will then be reconciled annually for overall vaccination costs with the filing of the annual cost report.

The other key service update involved dental services. The clarification stated that FQHCs and RHCs can be billed and paid on the same day as a qualified medical visit. As noted in the table below, non-PPS rates continue to decrease year over year to offset the expansion of eligible services. As noted earlier, G0511 will be replaced with billings to separate CPT/HCPCS codes for individual services to better reflect the cost of care.

The initiatives and billing changes collectively represent a significant step forward in addressing some of the most pressing healthcare challenges in the United States. By focusing on reducing costs, expanding access to essential services, and supporting vulnerable populations, these measures are working to create a more equitable and effective healthcare system for all Americans. With the different changes in billing codes and procedures, Withum has a team of professionals who can assist with implementing updates to billing platforms or perform billing and coding reviews to ensure your FQHC or RHC is maximizing potential revenue.

Authors: James Trubenbach-Byrne, CPA | [email protected] and Carol Arroyo | [email protected]