Compliance Monitor (03/07/2025)
Your source for federal updates
March 2025 Compliance Activity
| The completed form must be posted for three months, from February 1 until April 30 The completed form must be submitted to OSHA by early March | OSHA Form 300-A form Form 300-A is the Summary of Work-Related Injuries and illnesses At the end of each calendar year, Form 300- A must be completed and certified by a company executive as correct and complete and posted in the workplace annually, where notices to workers are usually posted. Establishments under Federal OSHA jurisdiction can use the ITA Coverage Application to determine if they are required to electronically report their injury and illness information to OSHA. Establishments under State Plan jurisdiction should contact their State Plan. https://www.osha.gov/news/newsreleases/tr ade/01092023 Form 300-A https://www.osha.gov/recordkeeping/forms |
| March 1, 2025, if any breaches in 2024 | HIPAA Breach Reporting HIPAA-covered entities and their business associates are required annually to notify the Office for Civil Rights (OCR) of breaches of unsecured protected health information (PHI) that affect under 500 individuals. Report breaches of unsecured protected health information that affect fewer than 500 individuals utilizing the web portal in the link. Submitting a notice of breach to the HHS secretary https://www.hhs.gov/hipaa/for- professionals/breach- notification/breach- reporting/index.html |
| Usually posted in late March – early April | CMS Hospice Payment Update Rule (Proposed Rule) Usually posted in late March – early April Annual FY issuance Includes proposed annual payment update and quality program information Other proposed regulations or changes to standing regulations may be included with the opportunity for comments (as applicable) |
| Posted in mid-March | MedPAC report to Congress Annual issuance Includes data analysis of Medicare hospice utilization and spending and recommendations to Congress There is a specific home health and hospice chapter |
| March 3, 2025 | Section 1557 Requirement and Provision must be implemented § 92.9 Training – https://www.federalregister.gov/documents/2024/05/06/2024-08711/nondiscrimination-in-health-programs-and-activities#h-62 § 92.210(b), (c) Use of patient care decision support tools – page 37701 https://www.govinfo.gov/content/pkg/FR-2024-05-06/pdf/2024-08711.pdf |
| Extension expires Mar 31, 2025 | Telehealth extension Removing geographic requirements and expanding originating sites for telehealth services (42 USC § 1395m(m)); Telehealth services can be delivered to any location in the U.S., including the home of an individual. Extending the use of telehealth to conduct face-to-face encounters prior to recertification of eligibility for hospice care (42 USC § 1395f(a)(7)(D)(i)(II)); Telehealth encounters prior to recertification of eligibility for hospice care are covered and reimbursable. |
| April 2025 Preview | |
| Implements with April decedents | Update hospice CAHPS survey implementation Updated QAG V11.0 Survey Materials CHAP blog – Countdown to the Updated Hospice CAHPS Survey |
CDC Respiratory Illnesses Data Channel
Overall respiratory illness activity in the United States
https://www.cdc.gov/respiratory-viruses/data/index.html
Top Items
CMS Postpones Quality Conference
CMS announced that the upcoming CMS Quality Conference, scheduled for March 17-19, 2025, has been postponed. Future conference dates will be announced at a later time. Please monitor the conference website for updates at https://www.cmsqualcon.com/.
Medicare Cost Report E-Filing System Webinar — March 19
March 19, 2025, from 1–3 pm ET
Learn about new and upcoming functionality for Medicare Part A cost reports and hospice cap determinations in the Medicare Cost Report e-filing (MCReF) system, including:
- Ready-made Provider Statistical & Reimbursement summary reports on the home page
- New dashboard for tracking hospice cap status, review dates, and documentation for cap determinations
- Tips and reminders on common questions, like how to e-file Home Office Cost Statements, get feedback on cost report exhibits, and avoid common problems
- Quick refresher on how to e-file one cost report or many
The webinar will include a live Q&A session and an opportunity to provide feedback. You may also send questions in advance to OFMDPAOQuestions@cms.hhs.gov with “MCReF Webinar” in the subject line. We’ll answer your questions during the webinar or use them to develop educational materials.
FY 2026 Hospice Wage Index, Payment Rate Update, and Quality Reporting Requirements (CMS-1835)
The FY 2026 Hospice Wage Index, Payment Rate Update, and Quality Reporting Requirements proposed rule is at the Office of Management and Budget for review. Please watch CHAP communication for more information when the rule posts to the Federal Register.
Hospice Provider Updates
HQRP Public Reporting Quarterly Refresh – February 2025
The February 2025 quarterly refresh for the Hospice Quality Reporting Program is now available on the Compare tool on Medicare.gov.
In this refresh, HIS measure scores are based on HIS data submitted by hospices from Quarter 2, 2023 through Quarter 1, 2024. CAHPS measure scores are based on CAHPS data submitted from Quarter 2, 2022 through Quarter 1, 2024. CAHPS Star Ratings are calculated based on data from Quarter 2, 2022 through Quarter 1, 2024. The claims-based measures reflect claims data collected from Quarter 1, 2022 through Quarter 4, 2023.
Home Health Provider Updates
Expanded HHVBP Model: Final January 2025 Interim Performance Reports (IPRs) are Available on iQIES
Final January 2025 Interim Performance Reports (IPRs) are Available on iQIES
The Final January 2025 Interim Performance Reports (IPRs) for the expanded HHVBP Model have been published on the Internet Quality Improvement and Evaluation System (iQIES). The quarterly IPRs provide home health agencies (HHAs) with the cohort assignment, performance year measure data for the 12 most recent months, and the interim Total Performance Score (TPS). Using the IPR, an HHA can assess and track their performance relative to peers in their respective cohort throughout the expanded Model performance year.
The January 2025 IPRs include a new worksheet (“CY 2025 Baseline”) that reports on your HHA’s preliminary Improvement Thresholds for the CY 2025 applicable measure set. Note that Improvement Thresholds are based on CY 2023 data for all measures in the CY 2025 measure set other than the DTC-PAC measure. For the DTC-PAC measure, CY 2022 and CY 2023 data are used.
An HHA receives a January 2025 IPR if the HHA:
- Was Medicare certified prior to January 1, 2023, and
- Meets the minimum threshold of data for at least one (1) quality measure in the quarterly reporting period for the performance year.
Accessing IPRs
- IPRs are available via iQIES in the “HHA Provider Preview Reports” folder, by the CMS Certification number (CCN) assigned to the HHA. If your organization has more than one (1) CCN, then a report will be available for each CCN. Only iQIES users authorized to view an HHA’s reports can access expanded HHVBP Model reports. For assistance with downloading your HHA’s IPR, please contact the iQIES Service Center at 1-800-339-9313, Monday through Friday, 8:00 AM-8:00 PM ET, or by email (iqies@cms.hhs.gov). To create a ticket online or track an existing ticket, please go to CCSQ Support Central.
All Providers
CMS Public Engagement Announcement
CMS will host a series of public engagement events this spring as part of the Medicare Drug Price Negotiation Program. The virtual public engagement events will provide an opportunity for patients, beneficiaries, caregivers, consumer and patient organizations, and other interested parties, such as clinicians and researchers, to share input relevant to the drugs selected for the second cycle of negotiations.
CMS is interested in input relevant to the selected drugs, the condition(s) that the selected drug may be used to treat, and other medications that may be used to manage those conditions. This includes information related to the clinical benefits of the selected drugs compared to therapeutic alternatives, how the selected drugs address unmet need, and how the selected drugs impact specific populations.
CMS will use the information shared during the roundtable events to better understand patients’ experiences with the conditions and diseases treated by the selected drugs and patients’ experiences with the selected drugs themselves. CMS will use the information shared during the town hall meeting to better understand clinicians’ experiences prescribing and/or managing treatment with the selected drugs or therapeutic alternatives and clinicians’ considerations that drive treatment choice between the selected drugs and therapeutic alternatives. The information shared during both the town hall meeting and the roundtable events will also inform CMS’ identification of therapeutic alternatives, key outcomes, and adjustment of the starting point to develop the initial offer in negotiating with manufacturers of selected drugs. CMS will release redacted transcripts for the town hall meeting and each of the roundtable events, omitting participant names and other identifying information after all the events have ended.
Dates: The public engagement events will be held April 16 – April 30, 2025. Participant registration will be open until March 12, 2025.
Attendance: Anyone from the public may attend the town hall meeting livestream as a listener. Registration is not required, and the link to the livestream will be available here on April 30, 2025. Accommodation for people with disabilities and language assistance (e.g., interpretation) may be available.
Public Input Opportunities: There are two ways the public can share feedback and input with CMS:
- Public Engagement Events:
- CMS will host one livestreamed town hall meeting for all selected drugs, focused on the clinical considerations related to the selected drugs. CMS encourages practicing clinicians and researchers, as well as other interested parties, to register to speak.
- CMS will host 15 private (i.e., not livestreamed or open to press or general public) patient-focused roundtable events, one for each selected drug, which will be open to patients, patient advocacy organizations, and caregivers selected to speak at the events, and will allow for discussion among speakers.
Those who wish to make a public statement in the town hall meeting or to participate in a private roundtable event should register for the opportunity to speak at the public engagement events. Additional information to register for the events can be found here. For more information about the public engagement events, please see the Frequently Asked Questions document linked here.
If you are selected to speak at the event for which you registered, you will have 4 days after receiving the confirmation email to confirm your availability to participate at the selected event date and time, and any language interpretation services you need.
- Submitted Statement: CMS encourages the public to submit written input, if interested, in response to the CMS request for information about selected drugs and evidence about alternative treatments. Information can be submitted here by 11:59 PM PT March 1, 2025.
The public engagement events are subject to change, including postponement and/or cancellation.
Additional information on the public engagement events can be found here. Additional information about the Medicare Drug Price Negotiation Program can be found here.