CMS Posts CY2020 Home Health Final Rule

October 31 2019 |Marian Essey
CMS Posts CY2020 Home Health Final Rule

Today, the Centers for Medicare & Medicaid Services (CMS) issued a final rule with comment period [CMS-1711-FC] that finalizes routine updates to the home health payment rates for calendar year (CY) 2020, in accordance with existing statutory and regulatory requirements. This rule with comment period also includes: a modification to the payment regulations pertaining to the content of the home health plan of care; allows therapist assistants to furnish maintenance therapy; and finalizes policies related to the split percentage payment approach under the Home Health Prospective Payment System (HH PPS). This rule with comment period also includes final policies related to the implementation of the permanent home infusion therapy benefit in CY 2021, including payment categories, amounts, and required and optional adjustments, and solicits comments on options to enhance future efforts to improve policies related to coverage of eligible drugs for home infusion therapy.

The final rule with comment period can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/

Payment Rate Changes under the HH PPS for CY 2020

This final rule with comment period sets forth implementation of the Patient-Driven Groupings Model (PDGM), an alternate case-mix adjustment methodology with a 30-day unit of payment, mandated by the Bipartisan Budget Act of 2018 (BBA of 2018). CMS projects that aggregate Medicare payments to HHAs in CY 2020 will increase by 1.3 percent, or $250 million. This increase reflects the effects of the 1.5 percent home health payment update percentage ($290 million increase), mandated by the BBA of 2018; and a 0.2 percent aggregate decrease (-$40 million) in payments to HHAs due to the changes in the rural add-on percentages, also mandated by the BBA of 2018. The rate updates also include a budget-neutral adjustment to the CY 2020 30-day payment amount to offset anticipated provider behavior changes upon implementation of the PDGM; the use of updated wage index data for the home health wage index; and updates to the fixed-dollar loss ratio to determine outlier payments. Given the scale of the PDGM payment system changes for CY 2020, it may take HHAs more time before they fully implement the behavior assumed by CMS; therefore, we applied the three previously outlined behavior change assumptions to half of the 30-day periods in our analytic file, resulting in a smaller adjustment to the 30-day payment amount needed to maintain budget neutrality, as required by law.

CMS is finalizing a CY 2020 30-day payment amount (for those HHAs that report the required quality data) of $1,864.03.

Payment for Home Infusion Therapy for CY 2021

In order to provide sufficient time for providers and suppliers to prepare for the full implementation of the new home infusion therapy benefit in CY 2021, CMS finalized related payment policies in the CY 2020 HH PPS final rule with comment period. CMS will group home infusion drugs into three payment categories, each with a unit of single payment, paid at amounts in accordance with specified infusion codes and units for such codes under the Physician Fee Schedule (PFS). CMS will adjust these payment amounts by the Geographic Adjustment Factor - a weighted composite of the three geographic practice cost indices used for the PFS. CMS also finalized paying higher payment amounts for the first home infusion therapy visit to account for costs to initiate these services. In response to public feedback, CMS is soliciting comments in this final rule with comment period on ways to enhance coverage of eligible drugs under the home infusion benefit. A home infusion drug must be administered intravenously in the home through a pump that is an item of DME.

Enhance and Modernize Program Integrity While Reducing Regulatory Burden

In an effort to make improvements to the health care delivery system and to reduce potential program integrity risks, CMS will reduce the split-percentage payment amount, paid in response to a Request for Anticipated Payment (RAP), to 20 percent for existing HHAs beginning in CY 2020 with elimination of split-percentage payments for all HHAs in CY 2021. For CY 2021, there will be no up-front payment made in response to a RAP; however, RAPs will still be submitted by all HHAs every 30 days to alert the claims processing system that a beneficiary is under a home health period of care. HHAs must submit the zero-pay RAP within 5 calendar days of each 30-day period or be subject to a late penalty. For CY 2021, CMS is reducing administrative burden by streamlining the information required in order to submit the RAP. CMS believes that phasing out the RAP payments will mitigate potential fraud and is an important step in paying responsibly and appropriately for home health services. Finally, CMS is finalizing a requirement for a one-time submission of a Notice of Admission (NOA) beginning in CY 2022 to replace RAP submissions every 30-days to further reduce provider paperwork burden while protecting the Medicare trust funds. HHAs must submit the NOA within 5 calendar days of the home health start of care or be subject to a payment penalty.

Paraprofessional Roles – Improving Access to Care

CMS is modifying current regulations to allow therapist assistants to perform maintenance therapy under the Medicare home health benefit in accordance with individual state practice requirements. This change is in response to comments received on a Request for Information (RFI) in the CY 2018 HH PPS proposed rule on regulatory flexibilities and efficiencies.  Commenters noted that the Medicare regulations pertaining to the provision of maintenance therapy were inconsistent amongst the various settings of care. This change is consistent with regulations for skilled nursing facilities (SNFs) where therapist assistants can perform maintenance therapy; will allow therapist assistants to practice at the top of their state licensure; and will provide HHAs the flexibility to use either therapists or therapist assistants to meet the maintenance therapy needs of their patients. 

CMS is also finalizing changes to the current payment regulations regarding the home health plan of care in order to align the regulations with proposed policy.

Home Health Quality Reporting Program (HH QRP)

Under the Home Health Quality Reporting Program (HH QRP), which began in CY 2007, home health agencies are required to submit quality measure and standardized patient assessment data or are subject to a 2 percent reduction to their market basket increase for the year involved. There are 19 measures currently adopted in the HH QRP. Measures adopted for the HH QRP are publicly reported on the Home Health Compare website. 

As part of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act requirement to implement a quality measure addressing the transfer of health information, CMS is finalizing the adoption of two new quality measures that assess the transfer of health information.  The two measures are: (1) Transfer of Health Information to Provider-Post-Acute Care; and (2) Transfer of Health Information to Patient-Post-Acute Care.  These finalized measures are designed to improve patient safety by ensuring that the patient’s medication list is provided to a provider and the patient as part of the discharge process.  These two finalized measures also fulfill CMS’s strategic initiatives to promote effective communication and coordination of care, specifically in the Meaningful Measure Initiative area of transfer of health information and interoperability.

The IMPACT Act also requires the reporting of standardized patient assessment data with regard to quality measures and standardized patient assessment data elements (SPADEs). CMS is finalizing the adoption of a number of SPADEs to fulfill IMPACT Act requirements.  These SPADEs are designed to assess cognitive function and mental status, special services, treatments and interventions, medical conditions and comorbidities, impairments, and social determinants of health (race and ethnicity, preferred language and interpreter services, health literacy, transportation, and social isolation).  The addition of these SPADEs to the Outcome and Assessment Information Set (OASIS) will improve coordination of care and facilitate communication between HHAs and other members of the healthcare community, which is in alignment with CMS’s strategic initiative to improve interoperability.

Furthermore, CMS is finalizing the removal of the Improvement in Pain Interfering with Activity Measure (NQF #0177) from the HH QRP.  In the spirit of alignment with the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (P.L. 115-271), CMS is removing this pain-associated quality measure in an effort to mitigate any potential unintended, over-prescription of opioid medications inadvertently driven by this measure.

In response to stakeholder feedback about the importance of monitoring pain in home health care settings and the concerns raised that the removal would impact the validity of the survey, CMS is not finalizing the removal of Question 10, “In the last 2 months of care, did you and a home health provider from this agency talk about pain,” from the Home Health Care Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey.

Finally, CMS is finalizing the update to the specifications for the Discharge to Community PAC HH QRP measure to exclude baseline nursing home residents.

Home Health Value-Based Purchasing (HHVBP) Model

One of the goals of the HHVBP Model is to enhance the current public reporting process for home health.  CMS believes that publicly reporting HHVBP Model performance data would contribute to more meaningful and objective comparisons among HHAs on their level of quality relative to their peers, incentivize HHAs to improve their quality performance and could enable beneficiaries to make better informed decisions about where to receive care.  

For CY 2020, we are finalizing our proposal to publicly report the Total Performance Scores (TPS) and TPS Percentile Ranking from the Performance Year 5 (CY 2020) Annual TPS and Payment Adjustment Report (Annual Report) for each Home Health Agency (HHA) in the nine Model states that qualified for a payment adjustment for CY 2020.

We expect that these data would be made public after December 1, 2021, the date by which we intend to complete the CY 2020 Annual Report appeals process and issuance of the final Annual Report to each HHA.

For additional information about the Home Health Prospective Payment System, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/index.html and https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html

For additional information about the Home Health Patient-Driven Groupings Model, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM.html

For additional information about the Home Infusion Therapy benefit, visit - https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Home-Infusion-Therapy/Overview.html

For additional information about the Home Health Quality Reporting Program, visit https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Home-Health-Quality-Reporting-Requirements.html

For additional information about the Home Health Value-Based Purchasing (HHVBP) Model, visit: https://innovation.cms.gov/initiatives/home-health-value-based-purchasing-model

The final rule with comment period can be viewed at https://www.federalregister.gov/documents/2019/11/08/2019-24026/medicare-and-medicaid-programs-cy-2020-home-health-prospective-payment-system-rate-update-home

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