Today, the Centers for Medicare and Medicaid Services (CMS) finalized its CY 2019 Home Health Prospective Payment System Rate Update and CY 2020 Case Mix Adjustment Methodology Refinements. The rule implements a payment update, changes to the Home Health Value-based Purchasing Model (HHVBP), a new alternative case-mix model, and provisions related to home infusion therapy services. Overall, CMS estimates that payments to home health agencies (HHAs) will increase by approximately $420 million (or +2.2 percent) in calendar year 2019.
The rule will be published in the Federal Register on November 13, 2018 and will become effective January 1, 2019. CMS will accept comments on the definition of “infusion drug administration calendar day” until 5pm on December 31, 2018.
Home Health Agencies to See Payment Increase, New Methodology for Rural Add-On Payments
For CY 2019, CMS is finalizing an increase of 2.2 percent to update the payment rate in the Home Health Prospective Payment System (HH PPS). This percentage includes the proposed 2016-based HHA market basket update of 3.0 percent minus a 0.8 percentage point for the multifactor productivity adjustment, and is 0.1 percent higher than proposed. Any HHAs that do not submit the required quality data will receive only a + 0.2 percent update for CY 2019. In addition, the rule updates the CY 2019 home health wage index using FY 2015 hospital cost report data.
The proposed new methodology for applying rural add-on payments will be implemented for CYs 2019 through 2022, as required by the Bipartisan Budget Act of 2018. Add-on amounts will depend on the rural county classification. Each rural county will be classified into one of three categories based on the CY 2015 HH PPS wage index file.
Patient-Driven Groupings Model Scheduled to Begin in January 2020, Aims to Better Align Payment with Resource-Intensive Care
CMS will finalize their proposal to refine the case-mix methodology, with a goal of better aligning payment with patient care needs and ensure that clinically complex and ill patients have adequate access to care. The new methodology will be named the Patient-Driven Groupings Model (PDGM) and will use 30-day periods of care rather than 60-day periods of care, eliminate the use of the number of therapy visits provided to determine payment, and will rely more heavily on clinical characteristics and patient diagnosis, functional level, comorbidities, and admission source to determine a payment category.
The methodology will use a combination of cost per minute data from Medicare Cost Reports, and non-routine supplies in order to determine payment. These data sources are more specific to home health providers (rather an aggregate information from a geographic area) and are more comprehensive in the types of costs and data they capture. Further, each 30-day session would be separated based on whether the patient was discharged to home health from an institution (hospital or post-acute care) or community (no hospital or post-acute care within 14 days of the start of home health services).
Sessions would be further assigned to one of six clinical groups: musculoskeletal rehabilitation, neuro/stroke rehabilitation, wounds/post-op wound aftercare and skin/non-surgical aftercare, complex nursing interventions, behavioral health care, and medication management, teaching, and assessment. 30-day sessions would then be assigned to one of three functional impairment levels and would be subject to a comorbidity diagnosis based on the presence of a secondary diagnosis.
CMS stated in the rule that the agency plans to provide education and support to home health providers in advance of the change.
Remote Patient Monitoring Costs to be Paid for Augmenting the Care Planning Process
In the proposed rule, CMS defined remote patient monitoring in the HH PPS as “the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the HHS.”
CMS is finalizing this definition without changes, along with the proposal to include the expense of remote patient monitoring as allowable administrative costs if the monitoring is used to “augment” the care planning process. The final rule clarifies that visits solely for the purpose of connecting or training patients on remote monitoring are not separately payable.
Removal of Seven Measures for HH QRP Finalized as Proposed
In this final rule, CMS is adopting changes to the Home Health Quality Reporting Program (HH QRP) as proposed. CMS will remove seven measures beginning with the CY 2021 program year, a decision support by most commenters. 30 measures for the CY 2020 program year are being kept. CMS is updating regulations to specify that not all OASIS survey data submitted is used for HH QRP compliance but may be used for other purposes, such as payment. Thirdly, CMS is changing the public display period for the Medicare Spending per Beneficiary (MSPB) measure from 1 to 2 years, aligning it with other quality programs.
CMS is delaying the release of two measures on the transfer of health information, mandated under the IMPACT Act, until January 2020. Lastly, CMS is adding an 8th measure removal factor, also to align with the measure removal factors of other quality programs. A measure will be considered for removal when the costs outweigh benefits.
CMS Makes Changes to Home Health Value-Based Purchasing Model
Each year, CMS evaluates measures in the Home Health Value-Base Purchasing (HHVBP) Model. For CY 2019, the fourth performance year of the model, two measures related to immunization were removed because they did not appropriately measure HHA performance. Overall, there was support for the removal, as they were reported as burdensome to clinicians and did not accurately capture robust quality data.
Three quality measures pertaining to activities of daily living (ADLs) were reduced to two quality measures, and their composite scoring method was adjusted accordingly.
In this final rule, three of these OASIS-based measures were replaced with two that more accurately and more broadly describe a change in patient status. The composite scoring method for these measures were also adjusted accordingly. The weighting of measure categories within OASIS was reweighted, with more emphasis on claims-based measures to emphasize the quality of care within home healthcare.
Maximum Score Reduced to 9 Points
In previous years, and HHA could earn a maximum of 10 improvement points based on performance. This quality year finalized the reduction to a 9-point maximum.
Transitional Payment for Home Infusion Services Finalized for CYs 2019 and 2020
The 21st Century Cures Act established a new home infusion therapy benefit that covers the professional services associated with administering infusion drugs through an item of durable medical equipment (DME) in a patient’s home. The infusion pump and supplies will continue to be covered under the DME benefit. The law specifically excludes insulin pumps and those drugs on self-administered exclusion lists.
The permanent benefit becomes effective January 1, 2021, but temporary transitional payments will be used for CYs 2019 and 2020, as mandated by BBA of 2018. A new HCPCS G-code will be created for each of the three payment categories: nursing, education, and monitoring. Suppliers will submit a G-code for each infusion drug administration calendar day. These can be billed separately from or on the same claim as the DME, supplies, and infusion drug.
CMS is defining “infusion drug administration calendar day” to mean payment for the day on which home infusion therapy services are furnished by skilled professional(s) in the individual’s home on the day of infusion drug administration. After some commenters expressed concern, CMS stated that they will monitor the impact on access and engage in additional rulemaking or guidance if necessary.
Health and Safety Standards Established for Infusion Benefit
The rule finalizes various health and safety standards for this benefit. In response to comments, CMS decided to include an additional provision requiring all home infusion therapy suppliers to provide services in accordance with nationally recognized standards of practice and with applicable state and federal laws and regulations.
CMS Finalizes Only One of Two Proposed Requirements for Accrediting Organizations
CMS had proposed to add two new requirements for Accrediting Organizations (AO) but only one was finalized. AOs for Medicare-certified providers and suppliers will now be required to include a written statement in any initial or renewal application that they will not immediately terminate the accreditation of a facility in good standing if the facility wishes to voluntarily withdraw from the AO’s accreditation program. AO’s are required to continue the facility’s current accreditation until the effective date of withdrawal or the expiration date of the term of accreditation, whichever comes first.
The agency did not finalize the proposal to modify AO oversight regulations to require all AO surveyors to complete the same program-specific online trainings as state surveyors.