On July 11, 2019, the Centers for Medicare and Medicaid Services released the CY 2020 proposed payment rule for home health agencies (HHAs). The rule outlines the proposed payment update for HHAs for CY 2020 as well as proposals related to episode of care length, quality reporting, and the home infusion benefit.

Comments on the rule are due on September 9, 2019.

Home Health Payments to Increase by $250 Million in CY 2020

CMS is estimating that home health agencies will receive an increase in payments of $250 million in CY 2020. The proposed home health payment update percentage is 1.5 percent for CY 2020; this percent is required by statute. HHAs that do not submit the required quality data would receive a payment update of -0.5 percent.

CMS currently uses unadjusted wage index data gathered from inpatient hospitals to set the home health wage index. In the past, stakeholders have expressed concerns with this method, so CMS is soliciting comments to both fully understand the concerns, and to gather suggestions on how to better make geographic adjustments to home health payments.

Patient-Driven Groupings Model to Begin in CY 2020

After finalizing the Patient-Driven Groupings Model (PDGM) in the CY 2019 rule, CMS is moving ahead with implementation of the system for CY 2020 as required by statute. This system uses clinical characteristics and other patient information to put patients into payment categories instead of using therapy service thresholds. PDGM case-mix adjustment is applied to each 30-day period of care and each period of care is place into one of three functional impairment levels. In line with statute, CMS is proposing to change the fixed-dollar loss ratio to 0.63 under the PDGM for CY 2020. This is intended to ensure that outlier payments are closer to 2.5 percent of total payments.

Also in the CY 2019 rule, CMS finalized rural add-on percentages for CYs 2020 through 2022 as required by statute. The CY 2020 proposed rule makes no changes to these percentages, which depend on rural county classification and are in the table below.

Category	CY 2020	CY 2021	CY 2022
High Utilization	0.5%	None	None
Low Population Density	3.0%	2.0%	1.0%
All other	2.0%	1.0%	None

 

In addition, CMS is proposing to recalibrate the CY 2020 case-mix weights for 30-day periods of care using the PDGM methodology.

CMS Proposes Formally Changing Episodes of Care to 30 Days, Uses Behavioral Assumptions within New Unit Length

Currently, CMS makes home health payments based on a standardized 60-day episode rates that includes the six home health disciplines. A case-mix classification system is then assigned to attribute patients to a home health resource group (HHRG), in which payments are further adjusted based on resource utilization and functional severity level.

The Bipartisan Budget Act of 2018 mandated that episodes of care move from 60-day episodes to 30-day episodes of care for 2020. As such, CMS is required to calculate a 30-day payment amount for CY 2020 in a budget-neutral manner. CMS estimates a total of $16.2 billion in HH payments for CY 2020 using a 30-day unit under PDGM.

When calculating this estimate, CMS made several predicted behavioral assumptions they felt reflected clinician’s behaviors under a 30-day episode of care: variances in the low utilization payment adjustment (LUPA) threshold, clinical group coding, and comorbidity coding.  CMS is specifically seeking comment on these assumptions and whether they accurately account for potential changes in behavior due to the new 30-day unit.

Additionally, CMS proposes that the 30-day unit initiate on January 1, 2020, however, episodes that initiated prior to January 1, 2020 will continue to use a 60-day unit, even if that episode extends past January 1, 2020. CMS proposes that these episodes will not be recalibrated using case-mix rates.

Elimination of Split-Percentage Payments Proposed

CMS is proposing a reduction in split-percentage payments to HHAs enrolled in Medicare prior to January 1, 2019 for CY 2020 and complete elimination of split-percentage payments for all HHAs in CY 2021. Currently, there is a split-percentage payment approach to 60-day episodes of care where the first bill is submitted for 60 percent of the anticipated final claim payment amount and the second bill is submitted for the remaining 40 percent. Subsequent episodes are paid at 50/50 split-percentage payment. In CY 2020, the initial split-percentage payment will be reduced to 20 percent for all 30-day periods of care. CMS states this will help HHAs transition from receiving split-percentage payments to receiving full payments in subsequent 30-day periods of care. This proposal is intended to limit instances of Medicare fraud through pre-payments to HHAs.

The Agency also proposes to require all HHAs to submit Notice of Admissions (NOA) at the beginning of the first 30-day period of care (within 5 days) and to receive a 1/30 reduction in payment for every day that the NOA is late.

New Items Proposed for Inclusion Within Plans of Care

CMS proposes the inclusion of new items within a patient’s Plan of Care (POC): language that incorporates how home health services meet a patient’s specific needs identified within patient assessment, identification of the responsible discipline(s), and the frequency and duration of visits. CMS proposes that these new additions be added to the existing mandated items within POCs to receive payment.  The Agency is specifically seeking comment on these new items for inclusion.

Medicare to Allow Therapist Assistants to Perform Maintenance Therapy

Aligning with the other post-acute care settings, CMS proposes to allow therapist assistants to perform maintenance therapy services. A qualified therapist must still supervise the therapy assistant and provide the initial assessment, the plan of care, and reassessment every 30 days.  Therapist assistants are already able to provide restorative therapy under the Medicare home health benefit.

CMS is soliciting comments on revising the therapy codes to indicate maintenance services provided by a qualified therapist or a therapy assistant.

Home Health Value-Based Purchasing Total Performance Scores to be Publicly Reported

CMS is proposing to publicly report on their website two data points from the CY 2020 performance year (PY) 5 annual report for providers that participated in the Home Health Value-Based Purchasing Model:

• Total Performance Score (TPS); and
• TPS Percentile Ranking.

TPS is comprised of performance on the following: a set of measures reported via the Outcome and Assessment Information Set (OASIS), completed Home Health CAHPS surveys, select claims data elements, and three new measures for which points are given for reporting. CMS is soliciting feedback on public reporting of TPS and the percentile ranking from the PY 5 Annual Report.

Two Measures Proposed for Adoption in Home Health Quality Reporting System for CY 2022

Two process measures are being proposed for adoption in the Home Health Quality Reporting Program (HH QRP) in the Transfer of Health Information measure domain for CY 2022:

• Transfer of Health Information to Provider- Post-Acute Care: this measure assesses whether a current reconciled medication list is given to a provider when a patient is discharged or transferred.
• Transfer of Health Information to Patient- Post-Acute Care: this measure assesses whether a current reconciled medication list is provided to the patient, family, or caregiver when the patient was discharged from a PAC setting.

These measures have been proposed for inclusion in the quality reporting programs of other post-acute care providers. CMS is also proposing to update the specifications for the Discharge to Community- Post Acute Care measure to exclude baseline nursing facility residents from the measure.

In addition, CMS is proposing to remove one quality measure from the HH QRP to align with the agency-wide Meaningful Measures Initiative. Beginning with CY 2022, the Improvement in Pain Interfering with Activity Measure (NQF 0177) would be removed from the HH QRP. Pain-associated quality measures are being removed from quality reporting programs to mitigate any potential unintended over-prescription of opioid medications.

If this removal is finalized, HHAs would no longer have to submit the Frequency of Pain Interfering with Patient’s Activity or Movement OASIS item beginning on January 1, 2021.

Finally, CMS is seeking comment on the importance, relevance, appropriateness, and applicability of quality measures and measure concepts for the HH QRP related to potentially-preventable hospitalization, functional improvement and maintenance outcome, opioid use and frequency, and exchange of electronic health information and interoperability.

Proposed Permanent Rules for Home Infusion Largely Mirror Transitional Payments, Rates Based on 5 Hours of Office-Based Infusion

The 21st Century Cures Act established a new home infusion therapy benefit for Medicare beneficiaries, covering nursing services, patient training and education, and remote and other monitoring services. Since January 1, 2019, these services have been covered under a temporary transitional payment, which will continue until January 1, 2021. Rates for these services will be adjusted in CY 2020 based on the 2020 physician fee schedule rates.

Beginning in 2021, CMS proposes to make rules for these payments permanent, based largely upon the existing transitional payment structure. CMS’ proposal carries forward the three existing payment categories and sets payment rates equal to 5 hours of infusion therapy in a physician’s office for each administration calendar day. The first visit would receive an increased payment based on the relative new patient to existing patient E/M rates.

In the 2019 proposed rule CMS solicited comments on whether prior authorization would be appropriate for home infusion and based on these comments has decided not to include a prior authorization requirement. Also based on comments received, CMS will also not set outlier payment rules at this time but is reiterating its previous proposal to have home infusion claims billed to the relevant A/B (rather than DME) MAC.