This evening, the Centers for Medicare and Medicaid Services (CMS) released the final calendar year (CY 2020) payment rule for home health agencies (HHAs). The rule also includes policies for episode of care length, quality reporting, and the home infusion benefit.
Provisions of the final rule will go into effect on January 1, 2020.
Payments to Home Health Agencies to Increase by $250 Million
Overall payments to home health agencies are expected to increase by $250 million, in CY 2020. CMs finalized a home health payment update percentage of 1.5 percent for CY 2020, which is required by statute. Statute also requires a 0.2 percent aggregate decrease from changes in the rural add-on percentages also required by statute. Home health agencies that do not report the required quality data will receive a payment update of -0.5 percent.
In addition, statute mandates the below rural add-on percentages for CYs 2020-2022, which are applied to any case-mix and wage index adjustments.
| 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 |
Patient-Driven Groupings Model Begins in 2020
The Patient-Driven Groupings Model (PDGM) will begin for home health agencies in CY 2020 as required by statute. This model uses clinical characteristics and other patient information to put patients into payment categories instead of using therapy service threshold. The PDGM case-mix adjustment is applied to each 30-day period of care with each period of care being placed into one of 12 clinical groups and into one of three functional impairment levels. Implementation of the PDGM will be budget-neutral. CMS states they intend to closely monitor utilization patterns PDGM as it goes into effect.
CMS Formally Changes Episodes of Care to 30 Days
In this year’s proposed rule, CMS announced its’ intention to formally move from a 60-day episode of care to a 30-day episode of care to become compliant with the Bipartisan Budget Act of 2018. CMS has finalized this change, estimating a total of $16.6 billion in home health payments for CY 2020 using this new 30-day episode under PDGM. In the proposed rule, the Agency estimated $12.6 billion in payments; CMS says this $4 billion increase is due to the use of more recent data.
Home health payments based on a 30-day episode of care are made upon behavioral assumptions that CMS is statutorily required to consider. In 2019, CMS finalized the behavioral assumptions of: variances in the low utilization payment adjustment (LUPA) threshold, clinical group coding, and comorbidity coding. The Agency stated their intention to revisit these assumptions in future rulemaking, citing potential feedback from MedPAC.
Elimination of Split-Percentage Payments Finalized
CMS finalized their proposal for 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 and CY 2022. 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. This Agency continues to cite that these practices are intended to limit instances of Medicare fraud through pre-payments to HHAs.
The Agency also finalized the requirement for all HHAs to submit Notice of Admissions (NOA) at the beginning of the first 30-day period of care (within 5 days). Those that fail to do so will receive a 1/30th reduction in wage-adjusted 30-day payment for every day that the NOA is late.
New Items Added to Plans of Care
CMS is finalizing its proposal to include 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. These new additions will be added to the existing mandated items within POCs to receive payment. Public comments on the proposal were supportive of the changes.
Medicare to Allow Therapist Assistant to Perform Maintenance Therapy
In this final rule, CMS affirmed its proposal to allow therapist assistants to perform maintenance therapy services, which will align home health with other post-acute care settings. 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.
Total Performance Score for Home Health Value-Based Purchasing Program to be Publicly Reported
CMS finalized the two provisions proposed for the home health value-based purchasing program (HH VBP). CMS will publicly report:
- The Total Performance Score (TPS) of the competing HHAs, and
- The TPS Percentile Ranking from the Performance Year 5.
The 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.
One Measure Removed, Two New Measures Adopted in Home Health Quality Reporting Program
CMS is removing one measure from the home health quality reporting program (HH QRP):
- Improvement in Pain Interfering with Activity Measure (NQF #0177) beginning with the CY 2022.
CMS is also finalizing the adoption of two new measures:
- Transfer of Health Information to Provider–Post-Acute Care (PAC); and
- Transfer of Health Information to Patient–Post-Acute Care (PAC), beginning with the CY 2022.
The Discharge to Community- Post Acute Care (PAC) measure will be modified to exclude baseline nursing facility residents from the measure. CMS also finalized the requirement for HHA’s to report standardized patient assessment data beginning with the CY 2022.
CMS had proposed to remove a pain related question from the CAHPS survey: “In the last 2 months of care, did you and a home health provider from this agency talk about pain?” After reviewing comments and internal concerns, CMS decided not to remove the question partly because of commenter’s concern but also because Health and Human Services staff determined that removing the question might invalidate the overall survey.
Transitional Payment Continues to Home Infusion Benefit; CMS Outlines Policies for Permanent Payment Beginning in CY 2021
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. These services have been covered under a temporary transitional payment since January 1, 2019, which will continue through January 1, 2021. The transitional payment rates will be adjusted in CY 2020 based on the 2020 Physician Fee Schedule rates.
In order to give providers and suppliers enough time to prepare for the full implementation of the benefit in CY 2021, the agency has finalized payment policies in the CY 2020 rule, largely based off the existing transitional payment rates, that will take effect in CY 2021. Home infusion drugs will be grouped into three payment categories, each paid at amounts related to rates in the Physician Fee Schedule. Payment amounts will be adjusted for geography. Payment rates will be higher for the first home infusion therapy visit to account for the costs to initiate this type of service.
In addition, CMS is soliciting additional comments on ways to enhance coverage of eligible drugs under the home infusion benefit. Comments are due to CMS by December 30, 2019.