Beginning in CY 2025, CMS has proposed to establish two (2) tiers for LVPA payment based on treatment volume with different payment adjustments for each tier.
Tier 1 – An ESRD facility that meets all the existing above referenced LVPA criteria will receive a 28.4 percent adjustment if it furnishes fewer than 3,000 treatments per year
Tier 2 – An ESRD facility that meets all the existing above referenced LVPA criteria will receive an 18.1 percent adjustment if it furnishes fewer than between 3,000 and 3,999 treatments per year.
A facility’s annual treatment count will be based on the median treatment volume over its most recent prior three (3) cost reporting years. Final policy will be applied based on the CY 2025 Final Rule, when published.
1. The facility has furnished less than 4,000 treatments in each of the 3 years preceding the payment year.
The 3 eligibility years are based on as-filed or final settled 12-consecutive month cost reports, whichever is most recent.
For the purpose of determining the number of treatments under paragraph (b)(1) of this section, the number of treatments considered furnished by the ESRD facility shall equal the aggregate number of treatments furnished by the ESRD facility and the number of treatments furnished by other ESRD facilities that are both under common ownership with, and five (5) road miles or less from the ESRD facility in question.
2. The facility has not opened, closed, or had a change of ownership (CHOW) that resulted in a change in PTAN in the 3 years preceding the payment year.
Beginning January 1, 2019, the definition of a low-volume facility in § 413.232(b)(2) will include CHOWs where the new owner accepts assignment of the existing Medicare provider agreement and a new PTAN is issued due to a change in facility type (for example, changing from a hospital based renal dialysis facility to an independent renal dialysis facility). This policy does not extend to CHOWs where a new PTAN is issued for any other reason and requires that the purchaser accepts assignment of the existing Medicare provider agreement, including assets and liabilities.
Change Request 8898 provides further details of the 4,000-treatment count for Hospitals that have multiple ESRD locations and changes to the 12-month Cost Report rule for provider's that have had a change of ownership with no change in PTAN. See also 42 CFR 413.232(g)(1) and (2).
ESRD facilities that change their fiscal year-end for cost reporting purposes outside of a CHOW can qualify for the LVPA if they otherwise meet the LVPA eligibility criteria. Under current policy (§ 413.24(f)(3)), facilities are able to change their cost reporting period when they request a change in writing from their MAC and meet specific criteria for approval. However, the current LVPA regulation § 413.232(g)(2)(ii) does not technically address requirements for changing cost reporting periods except as a result of a CHOW, which has prohibited facilities from receiving the LVPA if they make a business decision to adjust their cost reporting period. This policy has been expanded to provide direction when a change in a cost reporting period is approved. When this occurs, the MAC will combine the two nonstandard cost reporting periods of less than 12 months to equal a full 12-consecutive month period or combine the two non-standard cost reporting periods that in combination may exceed 12- consecutive months and prorate the data to equal a full 12-consecutive month period. See 42 CFR 413.232(g)(3).
The low volume adjustment applies only for dialysis treatments provided to adults (18 years or older).
To receive the Low Volume Adjustment, ESRD providers must submit an attestation signed by the Managing Director or Official of their organization by November 1st preceding the next ESRD PPS Payment Year that includes the following information:
Provider name
Medicare Provider Number (PTAN) and NPI
Provider's physical address (including building/suite/room number, etc.)
ESRD certification date
Is your facility a free-standing facility or hospital based?
Has the facility opened, closed, or had a change in ownership in the 3 years prior to the payment year?
If there was a change of ownership, did it result in a change of PTAN?
Is this ESRD part of common ownership?
If yes, please provide the following information:
Organization's name
Distance between ESRD provider and nearest commonly owned ESRD providers (within 5 miles or less)
Treatment counts for other commonly owned ESRD providers that are within 5 miles or less of each other.
Provider contact name (please print)
Provider contact phone number
Provider contact E-mail address
Director or official signature
In addition, providers should submit the following Cost Report worksheets: Cost Report worksheets C (for free standing ESRD providers) and Cost Report worksheet I-4 (for hospital based ESRD providers) for the three 12-month cost reporting periods immediately preceding the ESRD PPS payment year. For ESRD providers with a 12/31 FYE, please provide a projection of the number of treatments for the 3rd eligibility year. Once the current year 12/31 Cost report is received, treatment numbers will be verified.
We prefer you e-mail your application to:
JL: ReimbursementJL@novitas-solutions.com
JH: ReimbursementJH@novitas-solutions.com
You may also send a physical copy to:
Novitas Solutions
PARD Reimbursement
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
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