United States: CMS Releases FY 2023 IPPS And LTCH Proposed Rule

Highlights

• The Centers for Medicare & Medicaid Services (CMS) on April 18, 2022, published its annual proposed rule for the federal fiscal year (FY) 2023 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System (PPS).
• In addition to annual payment updates, CMS put forth several other proposals, including health equity-focused measures in hospital quality programs, stakeholder input related to documenting social determinants of health (SDoH) in inpatient claims data and a new "birthing friendly" hospital designation.
• Comments on the Proposed Rule are due June 17, 2022. A final rule is expected by Aug. 1, 2022, and as required by statute, the final rule must be effective by Oct. 1 annually.

The Centers for Medicare & Medicaid Services (CMS) on April 18, 2022, published its annual proposed rule for the federal fiscal year (FY) 2023 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System (PPS).

In addition to annual payment updates, CMS put forth several other proposals, including health equity-focused measures in hospital quality programs, stakeholder input related to documenting social determinants of health (SDoH) in inpatient claims data and a new "birthing friendly" hospital designation.

The CMS released the Proposed Rule, a fact sheet and an additional fact sheet on the maternal health and equity measures. 

Comments on the Proposed Rule are due June 17, 2022. A final rule is expected by Aug. 1, 2022, and as required by statute, the final rule must be effective by Oct. 1 annually.

This Holland & Knight alert details several of the Proposed Rule's most noteworthy components.

Proposed Key Payment Updates

Proposed IPPS Payment Updates: CMS proposes a projected 3.2 percent increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users. This reflects a FY 2023 projected hospital market basket update of 3.1 percent reduced by a projected 0.4 percentage point productivity adjustment and increased by a 0.5 percentage point adjustment required by statute.

When all proposed changes are considered, the rule is expected to result in a net decrease because of proposed cuts to disproportionate share hospital (DSH) and other payments later discussed in this summary.

Proposed Changes to Payment Rates Under LTCH PPS: For FY 2023, CMS expects LTCH PPS payments to increase by approximately $25 million. LTCH PPS payments for FY 2023 for discharges paid the standard LTCH payment rate is expected to increase by approximately 0.7 percent due primarily to the annual standard federal rate update for FY 2023 of 2.7 percent and a projected decrease in high-cost outlier payments.

Proposed Wage Index and Geographic Changes

Proposed Continuation of the Low Wage Index Hospital Policy: To help mitigate wage index disparities between high-wage and low-wage hospitals, CMS adopted a policy in the FY 2020 IPPS/LTCH PPS rule to increase wage index values for certain hospitals with low-wage index values. In this rule, CMS is proposing that the low-wage index hospital policy continue for FY 2023, and is also proposing to apply this policy in a budget-neutral manner by applying an adjustment to the standardized amounts.

Proposed Permanent Cap on Wage Index Decreases: CMS adjusts the IPPS standardized amounts for area differences in hospital wage levels by a factor (established by the U.S. Department of Health and Human Services Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level, and update the wage index annually based on a survey of wages and wage-related costs of short-term, acute care hospitals.

In consideration of comments received during the FY 2022 rulemaking cycle, for FY 2023 and subsequent years, CMS proposes applying a 5 percent cap on any decrease to a hospital's wage index from its wage index in the prior fiscal year, regardless of the circumstances that caused the decline. That is, CMS is proposing that a hospital's wage index for FY 2023 would not be less than 95 percent of its final wage index for FY 2022, and that for subsequent years, a hospital's wage index would not be less than 95 percent of its final wage index for the prior FY.

Proposed DSH Payment Changes

Proposed DSH Payment Adjustment and Additional Payment for Uncompensated Care: CMS proposes to update its estimates of the three factors used to determine uncompensated care payments for FY 2023. CMS is also proposing to continue to use uninsured estimates produced by CMS' Office of the Actuary (OACT) as part of the development of the National Health Expenditure Accounts (NHEA) in conjunction with more recently available data in the calculation of Factor 2.

For FY 2023, CMS proposes using the two most recent years of audited data on uncompensated care costs from Worksheet S-10 of the FY 2018 cost reports and the FY 2019 cost reports to calculate Factor 3 in the uncompensated care payment methodology for all eligible hospitals.

In addition, for FY 2024 and subsequent fiscal years, CMS is proposing to use a three-year average of the data on uncompensated care costs from Worksheet S-10 for the three most recent fiscal years for which audited data are available. Beginning in FY 2023, CMS is proposing to discontinue the use of low-income insured days as a proxy for uncompensated care to determine Factor 3 for Indian Health Service (IHS) and tribal hospitals, and hospitals located in Puerto Rico. In addition, CMS is proposing certain methodological changes for calculating Factor 3 for FY 2023 and subsequent fiscal years.

Policy Change Restricting Inclusion of Section 1115 Waiver Days in Medicaid Fraction for Future Years: After previously proposing but not finalizing a policy change in the FY 2022 rule, CMS again proposes to revise the DSH regulation to further limit the inclusion in the Medicaid fraction of the DSH calculation of inpatient days for patients who are made eligible for Medicaid through a Section 1115 expansion waiver. Under this proposal, CMS would revise the regulation to explicitly reflect its interpretation of the language "regarded as" "eligible" for Medicaid to mean patients who receive health insurance authorized by a Section 1115 demonstration, or patients who pay for all or substantially all of the cost of such health insurance with premium assistance authorized by a Section 1115 demonstration, where state expenditures to provide the health insurance or premium assistance may be matched with funds from Title XIX.

Proposed COVID-19-Related Changes

Proposed Use of FY 2021 Data and Proposed Methodology Modifications for the FY 2023 IPPS and LTCH PPS Rate-setting:  CMS proposes using FY 2021 data for FY 2023 Medicare rate-setting. For IPPS and LTCH PPS, the U.S. Department of Health and Human Services (HHS) primarily uses two data sources, claims data and cost report data, both of which were significantly impacted by COVID-19. Because the agency expects some Medicare beneficiaries to be hospitalized with COVID-19 in FY 2023, HHS determined that it is more appropriate to use FY 2021 data as the most recent available data during the period of the COVID-19 public health emergency (PHE). However, recognizing that there may be fewer COVID-19 hospitalizations in FY 2023 than in FY 2021, the agency also proposed modifications to its usual rate-setting methodologies to account for the anticipated decline in COVID-19 hospitalizations of Medicare beneficiaries as compared to FY 2021. In particular, CMS proposed to modify the calculation of the FY 2023 Medicare Severity Diagnosis-Related Groups (MS-DRG) and Medicare Severity Long Term Care Diagnosis-Related Groups (MS-LTC-DRG) relative weights by initially calculating two sets of weights, one including and one excluding COVID-19 claims. CMS would then average the two sets of relative weights to calculate the proposed FY 2023 relative weights, which CMS believes would reduce the effect of COVID-19 cases on the relative weights to account for the expected drop in Medicare COVID-19 hospitalizations. CMS also proposed to modify the calculation of the outlier fixed-loss threshold by using charge inflation factors and cost-to-charge ratio adjustment factors calculated using pre-pandemic data from March 2019 and March 2020 as opposed to the later data that would ordinarily be used to calculate these factors. The agency believes that using older pre-pandemic data would better measure these factors because CMS does not believe that the charge inflation that has occurred during the COVID-19 pandemic will continue. HHS is also requesting comments on the potential use of FY 2021 data without the proposed modifications for purposes of FY 2023 rate-setting.

Condition of Participation (CoP) Requirements for Hospitals and Critical Access Hospitals (CAHs) to Report Data Elements to Address Any Future Pandemics and Epidemics as Determined by the Secretary: CMS is proposing to revise the hospital and CAH infection prevention and control CoP requirements to continue COVID-19 reporting requirements commencing either upon the conclusion of the current COVID-19 PHE declaration or the effective date of this proposed rule, whichever is later and lasting until April 30, 2024 (unless the Secretary determines an earlier end date). CMS also proposes additional requirements to address future PHEs related to epidemics and pandemics. Specifically, when the Secretary has declared a PHE, CMS proposes to require hospitals and CAHs to report specific data elements to the Centers for Disease Control and Prevention's (CDC) National Health Safety Network (NHSN), or other CDC-supported surveillance systems, as determined by the Secretary. The proposed requirements of this section would apply to local, state and national PHEs as declared by the Secretary.

Potential Payment Adjustment for N95 Respirators Made Domestically: CMS requests comments on the appropriateness of an IPPS and Outpatient Prospective Payment System (OPPS) payment adjustment for N95 respirators that are wholly domestically made. CMS notes that wholly domestically made National Institute for Occupational Safety and Health (NIOSH)-approved surgical N95 respirators, while critical to pandemic preparedness and protecting healthcare workers and patients, can result in additional costs for hospitals as they are generally more expensive than foreign-made masks. CMS is considering a payment adjustment to apply to 2023 and potentially subsequent years. There are two possible frameworks for a payment adjustment on which CMS seeks feedback. Under the first approach, CMS would provide biweekly, interim lump-sum payments to hospitals that would be reconciled at cost report settlement. Alternatively, CMS could develop a claims-based approach wherein Medicare could establish an MS-DRG add-on payment that could be applied to each applicable Medicare IPPS discharge (or an Ambulatory Payment Classification (APC) add-on payment for each non-telehealth OPPS service).

Proposed MS-DRG Changes

Proposed MS-DRG Documentation and Coding Adjustment: The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaced the single positive adjustment that CMS intended to make in FY 2018 with a 0.5 percent positive adjustment to the standardized amount of Medicare payments to acute care hospitals for FYs 2018 through 2023. Therefore, for FY 2023, CMS is proposing to make a positive adjustment of 0.5 percent to the standardized amount. CMS is not proposing any new MS-DRGs for FY 2023, which means the number of MS-DRGs would be maintained at 767 for FY 2023.

Proposed New Deadline for MS-DRG Requests: CMS proposes to change the deadline to request Medicare Severity Diagnosis Related Group (MS-DRG) changes to Oct. 20 of each year, and to accept MS-DRG-related requests through a new electronic application intake system, beginning with FY 2024. CMS is required by statute to adjust the DRG classifications and relative weights at least annually to reflect changes in treatment patterns, technology and any other factors that may change the relative use of hospital resources. Stakeholders can submit MS-DRG change requests for CMS to consider in the annual rate-setting process. In recent years, CMS has updated the deadline to request MS-DRG changes to allow more review time. For FY 2023, CMS maintained the deadline of Nov. 1. Beginning with FY 2024, CMS proposes to change the deadline to request MS-DRG changes to Oct. 20 of each year to allow additional time for review and evaluation. CMS also proposes to change the submission process by implementing a new electronic intake system, Medicare Electronic Application Request Information System (MEARIS). MEARIS is now live and available for users to submit requests for ICD-10-PCS procedure codes and other requests. Beginning with FY 2024, CMS will only accept MS-DRG classification change requests submitted via MEARIS and will no longer receive such requests via email.

Proposed MS-DRG Classification Changes: CMS proposes to delay further implementation of a significant modification to the MS-DRG classification. The current MS-DRGs provide up to three levels of severity for a particular condition based on a complication or comorbidity (CC) or a major complication or comorbidity (MCC). In FY 2021, CMS finalized a proposal to apply expanded three-way severity split criteria. CMS believes that using these criteria would better reflect resource stratification and avoid low volume counts for the non-CC level MS-DRGs. In FY 2022, CMS finalized a delay in implementing this proposal because of the PHE. For FY 2023, CMS proposes to further delay the implementation of the three-way split criteria because of the magnitude of the impact during the ongoing PHE. CMS' analysis shows that approximately 41 MS-DRGs would be subject to change based on the three-way severity level split criteria finalized in FY 2021. CMS found that applying these criteria would result in the deletion of 123 MS-DRGs and the creation of 75 new MS-DRGs. These updates would also involve a redistribution of cases, which would impact the relative weights. CMS proposes to maintain the current MS-DRG classification for FY 2023. CMS is also requesting comments on classifications for rare diseases and conditions that generally experience low volume.

Proposed SDoH Reporting to Improve MS-DRG System: CMS seeks comments on how reporting SDoH diagnosis codes may help improve the MS-DRG system and how the reporting of certain Z codes may improve the agency's ability to recognize severity of illness, complexity of illness and resource use under the MS-DRGs. Effective Oct. 1, 2021, the CDC's National Center for Health Statistics added 11 new diagnosis codes describing SDoH to provide additional information regarding determinants such as housing, food insecurity and transportation. CMS solicits public comments on how the reporting of SDoH diagnosis codes may improve the ability of the MS-DRG system to recognize the severity of illness, the complexity of service and/or utilization of resources. CMS is also interested in receiving feedback on documenting and reporting of the diagnosis codes describing social and economic circumstances to more accurately reflect each healthcare encounter and improve the reliability and validity of the coded data.

Medicare Severity Long-Term Care Diagnosis-Related Group (MS-LTC-DRG): CMS proposes to update the MS-LTC-DRG classifications to be consistent with MS-DRGs under the PPS. Additionally, CMS is proposing a 5 percent cap on decreases to the LTCH wage index to enhance the predictability of payments. The agency is also proposing a 10 percent cap on reductions in MS-TLC-DRG's relative weight year-over-year starting in 2023, which includes a budget neutrality proposal for this provision. CMS is also proposing a 0.0000 relative weight for certain MS-LTC-DRGs, including, but not limited to: simultaneous pancreas and kidney transplants, simultaneous pancreas and kidney transplants with hemodialysis, and other kidney transplants.

New Technology Add-On Payment (NTAP) Applications for FY 2023

NTAP Applications for FY 2023: A total of 13 devices and drugs applied through the traditional pathway, and 13 went through the alternative pathways. The number of FY 2023 NTAP applications reviewed represents a 29.7 percent decrease over applications reviewed for FY 2022, due in part to 11 withdrawn applications. With no proposed extension of the NTAP eligibility period, CMS proposes to continue add-on payments for 15 technologies.

In response to the PHE and because of the development of new drugs and biologics for COVID-19 treatment, CMS established a new COVID-19 treatment add-on payment (NCTAP) in FY 2021, starting with discharges on or after Nov. 2, 2020, that met specific criteria. Acknowledging the pandemic's continued financial impact on hospitals, CMS proposes to continue the NCTAP for qualified technologies that do not qualify for the NTAP. Where technologies qualify for NCTAP and NTAP, CMS proposes reducing the NCTAP by any incremental payment through the NTAP pathway. Consistent with the policy established in FY 2022, the NCTAP would remain in effect until the end of the fiscal year following the end of the PHE.

NTAP Policy Proposals for FY 2023: CMS proposes to post NTAP applications online starting in FY 2024. Historically, CMS has published tracking forms completed for each device or drug for which an applicant seeks an NTAP. These forms present a high-level overview of the technology and give insight into applications for stakeholders in advance of the publication of the proposed rule. Based on feedback from stakeholders and to increase transparency, CMS proposes to publicly post completed applications and relevant materials starting with FY 2024, except for cost data, volume data and any materials not releasable to the public due to copyright. By posting these materials online, CMS proposes to streamline the discussion of the applications in the proposed rule to highlight any questions or concerns raised as part of the application review.

Proposed National Drug Codes (NDCs): CMS proposed national drug codes for reporting therapeutic agents eligible for NTAP. To qualify for NTAP on a case-by-case basis, hospitals must report the assigned ICD-10-PCS code for the eligible drug or device. CMS proposes to use NDCs to identify NTAP-eligible therapeutic agents rather than ICD-10-PCS. This policy, if finalized, would be phased in over a two-year transition period with eligible therapeutic agents reported by NDC or ICD-10-PCS in FY 2023 and by NDC only in FY 2024.

Hospital Quality Reporting Proposed Changes

Reduction of Hospital Payments for Excess Readmissions: CMS recommends modifying the Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) following Pneumonia Hospitalization measure to exclude COVID-19 diagnosed patients from the measure denominator, beginning with the Hospital Specific Reports (HSRs) for the FY 2023 program year. CMS also recommends modifying all six condition/procedure-specific measures to include a covariate adjustment for patient history of COVID-19 within one year prior to the index admission beginning with the FY 2023 program year. CMS is also seeking comment on key considerations to improve data collection to better measure and analyze disparities across our programs and policies, and approaches for updating the Hospital Readmissions Reduction Program to encourage providers to improve performance for socially at-risk populations.

Hospital Value-Based Purchasing (VBP) Program: For FY 2023, CMS is proposing to suppress the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and five Hospital Acquired Infection (HAI) measures. Additionally, CMS proposes to update the baseline periods for specific measures for the FY 2025 program year.

CMS further proposes revising the scoring and payment methodology for the FY 2023 program year such that hospitals will not receive Total Performance Scores (TPSs). Instead, CMS proposes awarding each hospital a payment incentive multiplier that results in a value-based incentive payment to the amount withheld for the fiscal year (2 percent).

Hospital-Acquired Condition (HAC) Reduction Program: For FY 2023, CMS proposes nine recommendations to the HAC Reduction Program:

• suppress the CMS PSI 90 measure and the five CDC National Healthcare Safety Network (NHSN) HAI measures from the calculation of measure scores and the Total HAC Score, thereby not penalizing any hospital under the HAC Reduction Program FY 2023 program year
• publicly and confidentially report CDC NHSN HAI measure results but not calculate or report measure results for the CMS PSI 90 measure for the HAC Reduction Program FY 2023 program year
• suppress CY 2021 CDC NHSN HAI measures data from the FY 2024 HAC Reduction Program Year
• update the measure specification to the minimum volume threshold for the CMS PSI 90 measure beginning with the FY 2023 program year
• update the measure specifications to risk-adjust for COVID-19 diagnosis in the CMS PSI 90 measure beginning with the FY 2024 HAC Reduction Program Year
• request information from stakeholders on the potential adoption of two digital NHSN measures: the NHSN Healthcare-associated Clostridioides difficile Infection Outcome measure and NHSN Hospital-Onset Bacteremia & Fungemia Outcome measure.
• request information on overarching principles for measuring healthcare quality disparities across CMS Quality Programs
• update the CDC NHSN HAI data submission requirements for newly opened hospitals beginning in the FY 2024 HAC Reduction Program Year
• clarify removing the no mapped location policy beginning with the FY 2023 program year

Hospital Inpatient Quality Reporting (IQR) Program: For FY2023, CMS is proposing the adoption of 10 new measures:

• Hospital Commitment to Health Equity beginning with the Calendar Year (CY) 2023 reporting period/FY 2025 payment determination
• Screening for Social Drivers of Health beginning with voluntary reporting for the CY 2023 reporting period, and mandatory reporting beginning with the CY 2024 reporting period/FY 2026 payment determination
• Screen Positive Rate for Social Drivers of Health beginning with voluntary reporting for the CY 2023 reporting period, and mandatory reporting beginning with the CY 2024 reporting period/FY 2026 payment determination
• Cesarean Birth electronic clinical quality measure (eCQM) with inclusion in the measure set beginning with the CY 2023 reporting period/FY 2025 payment determination, and mandatory reporting beginning with the CY 2024 reporting period/FY 2026 payment determination
• Severe Obstetric Complications eCQM with inclusion in the measure set beginning with the CY 2023 reporting period/FY 2025 payment determination, and mandatory reporting beginning with the CY 2024 reporting period/FY 2026 payment determination
• Hospital-Harm - Opioid-Related Adverse Events eCQM beginning with the CY 2024 reporting period/FY 2026 payment determination
• Global Malnutrition Composite Score eCQM beginning with the CY 2024 reporting period/FY 2026 payment determination
• Hospital Level, Risk-Standardized Patient-Reported Outcomes Performance Measure Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) beginning with two voluntary periods, followed by mandatory reporting for the reporting period, which runs from July 1, 2025, through June 30, 2026, impacting the FY 2028 payment determination
• Medicare Spending Per Beneficiary (MSPB) Hospital beginning with the FY 2024 payment determination
• Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary THA/TKA, beginning with the FY 2024 payment determination

For FY 2023, CMS is proposing refinements to two current measures starting with the FY 2024 payment determination:

• Hospital-Level, Risk-Standardized Payment Associated with an Episode-of-Care for Primary Elective THA/TKA, and
• Excess Days in Acute Care (EDAC) After Hospitalization for Acute Myocardial Infarction (AMI)

Additionally, CMS is requesting comment on the potential future development and inclusion of two NHSN measures:

• Healthcare-Associated Clostridioides difficile Infection Outcome, and
• Hospital-Onset Bacteremia & Fungemia Outcome

Further, CMS is proposing changes to current policies related to eCQMs and hybrid measures:

• modify the eCQM reporting and submission requirements to increase the number of eCQMs to be reported beginning with the CY 2024 reporting period/FY 2026 payment determination
• remove the zero denominator declarations and case threshold exemption policies for hybrid measures beginning with the FY 2026 payment determination
• data submission and reporting requirements for patient-reported outcome-based performance measures (PRO-PMs) beginning with the FY 2026 payment determination
• Modify the eCQM validation policy to increase the requirement from 75 percent to 100 percent of requested medical records, beginning with the FY 2025 payment determination

Lastly, CMS is proposing to establish a hospital designation related to maternity care to be publicly reported on a public-facing website beginning in fall 2023.

PPS-Exempt Cancer Hospital Quality Reporting Program: For FY 2023, CMS proposes adopting a patient safety exception?into the measure removal policy. CMS is also proposing to begin public display of the 30-Day Unplanned Readmissions for Cancer Patients measure (PCH-36), the Proportion of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life measure (PCH-32), the Proportion of Patients Who Died from Cancer Not Admitted to Hospice measure (PCH-34), the Proportion of Patients Who Died from Cancer Admitted to the ICU in the Last 30 Days of Life measure (PCH-33), and the Proportion of Patients Who Died from Cancer Admitted to Hospice for Less Than Three Days measure (PCH-35).

Medicare Promoting Interoperability Program: CMS wants to establish new requirements and revise existing requirements in the Medicare Promoting Interoperability Program. Specifically, CMS proposes to make mandatory and expand the Electronic Prescribing Objective's Query of Prescription Drug Monitoring Program measure; add a new Enabling Exchange under the Trusted Exchange Framework and Common Agreement measure under the Health Information Exchange Objective as a yes/no attestation measure as an optional alternative to the three existing measures; and add a new Antimicrobial Use and Resistance Surveillance measure and require its reporting under the Public Health and Clinical Data Exchange Objective, among other measures.

Medical Education Proposed Changes

Proposed Changes to Graduate Medical Education (GME) Payments Based on Litigation: The U.S. District Court for the District of Columbia struck down CMS' method of calculating direct GME payments to teaching hospitals when those hospitals' weighted full-time equivalent (FTE) resident counts exceed their direct GME FTE cap. In the case, the court ordered CMS to recalculate reimbursement owed, holding that CMS' regulation impermissibly modified the statutory weighting factors.

After reviewing the statutory language regarding the direct GME FTE cap and the court's opinion, CMS is proposing a modified policy to be applied prospectively for all teaching hospitals and retroactively to the providers and cost years in the case. The proposed modified policy would address situations for applying the FTE cap when a hospital's weighted FTE count is greater than its FTE cap. Still, it would not reduce residents' weighting factor beyond their initial residency period to an amount less than 0.5.

Specifically, effective for cost reporting periods beginning on or after Oct. 1, 2022, CMS is proposing that if the hospital's unweighted number of FTE residents exceeds the FTE cap, and the number of weighted FTE residents also exceeds that FTE cap, the respective primary care and obstetrics and gynecology weighted FTE counts and other weighted FTE counts are adjusted to make the total weighted FTE count equal the FTE cap.

Additionally, CMS is proposing to allow an urban and a rural hospital participating in the same rural track program (RTP) to enter into an "RTP Medicare GME affiliation agreement" effective for the academic year beginning July 1, 2023.

Requests for Information (RFIs)

Maternal Health Quality Designation and Equity RFI: CMS proposes establishing the first-ever publicly reported hospital quality designation focused on maternal health, also referred to as a "birthing friendly" designation. The measure intends for patients to easily identify high-quality and safe maternity care. Hospitals would be identified based on their response to the maternal morbidity structural measure. The measure would assess whether a hospital participates in a Statewide or National Perinatal Quality Improvement (QI) Collaborative initiative and implements patient safety practices and/or bundles related to maternal morbidity from that QI Collaborative.

CMS seeks input on how policies, programs, quality measures and conditions of participation (CoPs) can improve maternal health outcomes, enhance the quality of maternity care and reduce maternal health disparities. In this section of the proposed rule, CMS also proposes to revise the hospital and CAH infection prevention and control CoP requirements to continue COVID-19 reporting requirements commencing either upon the conclusion of the current COVID-19 PHE declaration or the effective date of this proposed rule, whichever is later, and lasting until April 30, 2024 (unless the Secretary determines an earlier end date).

Overarching Principles for Measuring Healthcare Quality Disparities Across Quality Programs RFI: CMS seeks public input on establishing policies to measure healthcare quality disparities across CMS quality programs. CMS seeks input on stratifying measures, prioritizing measures, using social risk factors and demographic data selection, identifying meaningful differences in performance results, and how to best report measure results.

Climate Change RFI: CMS seeks comments on how hospitals, nursing homes, hospices, home health agencies and other providers can better prepare for climate change and what CMS can do to support these efforts. The agency requests information from providers on how CMS can help mitigate:

• the effect of climate change on patients
• the effect of and planning for climate-related emergencies, and
• emissions tracking and reduction

Trusted Exchange Framework and Common Agreement RFI: Last year, the National Coordinator for Health Information Technology Office released the Trusted Exchange Framework and Common Agreement (TEFCA). CMS proposes to add a new Enabling Exchange Under TEFCA measure in the Medicare Promoting Interoperability Program. This proposed measure would allow eligible hospitals and CAHs to earn credit for the Health Information Exchange objective if they are a signatory to a "Framework Agreement," as that term is defined in the Common Agreement, and meet other exchange requirements. Beyond this measure, CMS is considering other ways that available CMS policy and program levers can advance information exchange under TEFCA. The proposed rule notes that these efforts can apply to payers and providers, and seeks specific use cases that may be appropriate to advance TEFCA.

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