§ 512.250 - Determination of national base rates.

§ 512.250 Determination of national base rates.

Cross Reference

Link to an amendment published at 86 FR 63996, Nov. 16, 2021.

CMS determines a national base rate for the PC and TC for each included cancer type.

(a) National base rates are the historical average cost for an episode of care for each of the included cancer types prior to the Model performance period.

(b) National base rates are determined in the following manner:

(1) CMS excludes claims from RT suppliers and RT providers in Maryland and Vermont and all inpatient and ASC claims from the construction of episodes and;

(

episode pricing and RO episode pricing any claim containing an RT service furnished:

(i) In Maryland, Vermont, or any of the U.S. Territories;

(ii) In the inpatient setting;

(iii) By an entity classified as an ASC, CAH, or PPS-exempt cancer hospital; or

(iv) By an HOPD participating in the Pennsylvania Rural Health Model at the time the RT service was furnished.

(2) CMS excludes the following episodes from the determination of the national base rates:

(i) episodes with any RT services furnished by a CAH, Episodes that are not linked to a CBSA selected for participation in the RO Model;

(ii) episodes Episodes that are not attributed to an RT provider or RT supplier, and ;

(iii) episodes in which either the PC or TC is attributed to an RT provider or RT supplier with a U.S. Territory service location. Episodes that are not assigned an included cancer type; or

(iv) Episodes for which the total allowed amount for RT services listed on claims used to calculate an episode's payment amount is not greater than $0.

(3) CMS calculates the episode amount CMS paid on average to RT providers and RT suppliers for the PC and TC for each of the included cancer types in the HOPD setting, creating the RO Model's national base rates.

[85 FR 61362, Sept. 29, 2020, as amended at 86 FR 63996, Nov. 16, 2021]