On the evening of June 28, 2021, the Centers for Medicare & Medicaid Services (CMS) released the CY 2022 proposed payment rule for home health agencies (HHAs). This proposed rule includes the annual payment update as well as proposed policies for the quality reporting program, value-based purchasing model, and supervision requirements. This proposed rule also includes updates for the home infusion therapy benefit that become permanent in CY 2021. Comments on the rule are due on August 27, 2021.

Payments to Home Health Agencies Expected to Increase in CY 2022

CMS estimates that home health payments for CY 2022 will increase by 1.7 percent, which accounts for a 1.8 percent payment update percentage and a 0.1 percent decrease in payments from a reduction in rural add-on percentages required by statute. Overall, CMS estimates that payments to HHAs will increase by an estimated $310 million, compared to CY 2021 levels.

The Patient-Driven Groupings Model (PDGM) began being used for home health agency payment 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. CMS proposes to recalibrate the PDGM case-mix weights, functional levels, and comorbidity adjustment subgroups for CY 2022 using CY 2020 data. However, low utilization payment amount (LUPA) thresholds will remain the same in CY 2022.

CMS is soliciting feedback on determining the impact on payment due to the difference between assumed behavior changes and actual behavior changes. Statute requires CMS to determine the impact of this difference annually from 2020 through 2026.

Minor Updates Proposed for Home Health Quality Reporting Program

CMS proposes the following for the Home Health Quality Reporting Program (HH QRP):

• Remove Drug Education on All Medications Provided to Patient/Caregiver During All Episodes of Care beginning measure in CY 2023;
• Replace the Acute Care Hospitalization During the First 60 Days of Home Health (NQF # 0171) and Emergency Department Use Without Hospitalization During the First 60 Days of Home Health (NQF #0173) measures;
  • These two measures will be replaced with the Home Health Within Stay Potentially Preventable measure, beginning in CY 2023;
• Begin publicly reporting in April 2022 the following two measures:
  • Percent of Residents Experiencing One or More Major Falls with Injury measure
  • Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function measure (NQF #2631);
• Update the compliance date to January 1, 2023 for the Transfer of Health Information to Patient-PAC measure, and certain Standardized Patient Assessment Data Elements.

CMS is also requesting information on advancing digital quality measure through the use of Fast Healthcare Interoperability Resources and closing the health equity gap. The request on closing the health equity gap mirrors a similar request for information included in the proposed fiscal year 2022 payment rules for post-acute care providers.

Aide Supervision Waivers Could Become Permanent

In response to the COVID-19 public health emergency (PHE), CMS adopted a series of blanket waivers for home health agencies and other providers. In this proposed rule, CMS proposes to make certain waivers related to home health aide supervision and the use of telehealth permanent for certain situations.

Currently, regulations require the 14-day supervisory assessment must be conducted by a registered nurse (RN) or other appropriate skilled professional who is familiar with the patient and the patient’s plan of care. In acknowledgement of permitting flexibility in the “rare circumstance” that an onsite visit cannot be coordinated within the 14 days, CMS proposes allowing the use of interactive telecommunications systems for the purpose of aide supervision to meet this requirement. HHAs will not be permitted to exceed 2 virtual supervisory assessments per 60-day period. CMS states that the agency expects HHAs to plan to conduct the assessment during on-site, in-person visits and that telehealth will only be used for “unplanned occurrences” that would interrupt scheduled in-person visits.

Regulations also currently require a registered nurse to make on-site visits to locations where home health aides are providing care to patients who are not receiving skilled care. CMS proposes to remove the requirement that a registered nurse must directly observe the home health aide during these visits.

In addition, occupational therapists will be permitted to conduct a home health initial assessment visit and do a comprehensive assessment when occupational therapy is on the home health plan or care with either physical or speech therapy, and when skilled nursing services are not initially in the plan of care. This policy was adopted in the Consolidated Appropriations Act (CAA), 2021.

CMS Proposes Expanding Home Health Value-Based Purchasing Model to All 50 States

CMS is proposing to expand the Home Health Value-Based Purchasing (VBP) Model, requiring HHAs in all 50 states, the District of Columbia, and U.S. territories to participate beginning in 2022. CY 2022 will be the first performance year, which will impact payment during CY 2024.  The rule proposes to use benchmarks, achievement thresholds, and improvement thresholds based on CY 2019 data in order to assess HHA performance on the relevant quality measures. CY 2019 was chosen to avoid any implications from the use of CY 2020 data affected by the COVID-19 PHE. For any new HHAs, the baseline year would be based on the first full calendar year of services after Medicare certification. However, CMS proposes an exception for HHAs certified during CY 2019 which would use CY 2021 as the baseline.

The expanded model would see HHAs competing nationally against facilities with similar volume, as defined by the number of complete unique beneficiary episodes. Performance data under the expanded model would be publicly reported. CMS proposes a maximum of 5 percent for payment adjustments, upward or downward, but says that the agency will consider changes to this percentage as additional evaluation data becomes available. The quality measures proposed for use in the expanded VBP Model also generally align with measures currently used in the HH QRP.

CMS is also proposing to end the original HHVBP Model early for the HHAs in the original nine states, meaning the CY 2020 performance data would not be used for a payment adjustment in CY 2022.

Hospice Health and Safety Requirements Related to Accrediting Organization Submission and Hospice Surveys to be Updated

The Consolidated Appropriations Act (CAA), 2021 established new hospice program survey and enforcement requirements. CMS is proposing a new strategy to enhance the hospice program survey process, increase accountability, and increase transparency.

First, accrediting organizations (AOs) will now have to use Form CMS-2567 Statement of Deficiencies and Plan of Correction, meaning the three CMS-approved hospice AOs will have to develop a way to incorporate this form into their data systems. The systems used by the AOs are proprietary so CMS cannot tell AOs exactly how to incorporate the form, but in the rule, CMS says that will work with AOs. The form currently does not have a place for the name of the AO, so CMS is seeking the appropriate approval from the Office of Management and Budget (OMB) to revise the form. Form CMS-2567 will also be required to be publicly posted and CMS proposes that AOs release deficiency reports for hospice program surveys to increase transparency. The agency is seeking public comments on how the data elements in Form CMS-2567 may be utilized and displayed.

A standard or abbreviated standard survey would have to be conducted when complaint allegations against a hospice are reported to CMS or a start or local agency. CMS proposes that a standard survey would have to be conducted no later than 36 months after the previous standard survey. A hotline that can receive complaints about HHAs or hospice programs in a state or locality is now required by statute. CMS proposes that all AO and SA hospice program surveyors will be required to take CMS-provided basic training and additional training as determined by CMS. The rule notes that state agency surveyors should already be in compliance with this requirement.

Further, CMS proposes that surveyors will not be allowed to survey a hospice program if they currently serve or have served, within the two previous years, on the staff or as a consulted to the program being surveyed. Survey entities will also be required to include diverse professional backgrounds among their surveyors and have professions involved in the hospice core services included among team members.

CMS proposes requiring agencies that review other entities’ survey finds for missed condition-level deficiency citations, to notify each survey entity of the rate of these disparities, and to have a formal corrective plan as part of the AO or SA Quality Assurance Program. CMS will also develop a Special Focus Program for hospices that have failed to meet applicable statutory requirements. Enforcement remedies, including civil monetary penalties, suspension of payment, appointment of temporary management, directed plan of correction, and termination, will be available to the agency for use with hospice programs that do not meet federal requirements.

Home Infusion Therapy Payments to be Adjusted in CY 2022, But Payment Categories to Remain Unchanged

CMS had previously established three payment categories for home infusion therapy. These categories were previously utilized under the temporary transitional payments for home infusion therapy services and maintained through the CY 2020 final rule. For CY 2022, CMS is proposing is continue the existing home infusion therapy payment categories unchanged for CY 2022

As required by law, CMS proposes adjustments to payments for home infusion therapy. A geographic adjustment factor will be used and the payment percentages for initial and subsequent visits that were finalized in the CY 2020 rule will be maintained. Specifically, for CY 2022, CMS is proposing to maintain the 20 percent increase calculated for the initial home infusion therapy service visits and the 1.3310 percent decrease calculated for subsequent visits after implementation of the changes mandated by the CAA.

In accordance with the CAA 2021, CMS will also adjust payment for CY 2022 to remove the 3.75 percent increase from the Physician Fee Schedule (PFS) amounts used to establish the CY 2021 home infusion therapy payment rates and use the unadjusted CY 2021 rates for the CY 2022 payment. This will be updated for CY 2022 using the percentage increase in the Consumer Price Index for all urban consumers (CPI-U) for the 12-month period ending in June 2021 reduced by the productivity adjustment, adjusted for multifactor productivity (MFP).

Inpatient Rehabilitation Facility and Long-Term Care Hospitals to Report Data on Certain Measures Beginning October 1, 2022

In response to the COVID-19 pandemic, CMS delayed the collection of quality reporting data for the following measures:

• Transfer of Health Information to Provider-PAC;
• Transfer of Health Information to Patient-PAC; and
• Certain Standardized Patient Assessment Data Elements for Inpatient Rehabilitation Facilities (IRF) and Long-Term Care Hospitals (LTCH).

Data collection was delayed until October 1 of the year after the public health emergency ends. However, CMS now believes that IRFs and LTCHs have the capacity to begin reporting data on these measures beginning on October 1, 2022, and CMS seeks feedback on its proposal to begin collecting the quality data.

CMS Proposes Codifying in Regulation Certain Provider and Supplier Enrollment Policies

CMS proposes to codify into regulation policies relating to effective date of billing privileges for nine additional provider and supplier types, certain provider enrollment transactions, and the deactivation of a provider or supplier’s billing privileges. The nine additional provider and supplier types are

• Part B hospital departments;
• Clinical Laboratory Improvement Amendment labs;
• Intensive cardiac rehabilitation facilities;
• Mammography centers;
• Mass immunizers/pharmacies;
• Radiation therapy centers;
• Physical therapists;
• Occupational therapists; and
• Speech language pathologists.

CMS also proposes clarifications to and the expansion of the list of possible scenarios for rejection, return, and deactivation of a provider’s or supplier’s enrollment in Medicare.