Home Health Quality Reporting Requirements

Statutory Authority for Use of the OASIS Data Item Set and Home Health Quality Reporting

The reporting of quality data by home health agencies (HHAs) is mandated by Section 1895(b)(3)(B)(v)(II) of the Social Security Act (“the Act”). This statute requires that ‘‘each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality. Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this clause.’’

Outcome and Assessment Information Set (OASIS) reporting is mandated in the Medicare regulations at 42 C.F.R.§484.250(a), which requires HHAs to submit OASIS assessments and Home Health Care Consumer Assessment of Healthcare Providers and Systems Survey (HH CAHPS) data to meet the quality reporting requirements of section 1895(b)(3)(B)(v) of the Act.

Section 1895(b)(3)(B)(v)(II) of the Act requires that, for 2007 and subsequent years, each home health agency (HHA) submit to the Secretary in a form and manner, and at a time, specified by the Secretary, such data that the Secretary determines are appropriate for the measurement of health care quality. To the extent that an HHA does not submit data in accordance with this clause, the Secretary shall reduce the home health market basket percentage increase applicable to the HHA for such year by 2 percentage points pursuant to section 1895(b)(3)(B)(v)(I) of the Act. As provided at section 1895(b)(3)(B)(vi) of the Act, depending on the market basket percentage increase applicable for a particular year, as further reduced by the productivity adjustment (except in 2018 and 2020) described in section 1886(b)(3)(B)(xi)(II) of the Act, the reduction of that increase by 2 percentage points for failure to comply with the requirements of the HH QRP may result in the home health market basket percentage increase being less than 0.0 percent for a year, and may result in payment rates under the HH PPS for a year being less than payment rates for the preceding year. Section 1890A of the Act requires that the Secretary establish and follow a pre- rulemaking process, in coordination with the consensus-based entity (CBE) with a contract under section 1890 of the Act, to solicit input from certain groups regarding the selection of quality and efficiency measures for the HH QRP. The HH QRP regulations can be found at 42 CFR 484.245 and 484.250.

The requirement that HHAs report quality data to CMS is contained in the Medicare regulations. Section 484.225(i) of Part 42 of the Code of Federal Regulations (C.F.R.) provides that HHAs that meet the quality data reporting requirements are eligible to receive the full home health (HH) market basket percentage increase. HHAs that do not meet the reporting requirements are subject to a two (2%) percentage point reduction to the HH market basket increase. Section 1895(b)(3)(B)(v)(III) of the Act states that ‘‘[t]he Secretary shall establish procedures for making data submitted under subclause (II) available to the public. Such procedures shall ensure that a home health agency has the opportunity to review the data that is to be made public with respect to the agency prior to such data being made public.’’

The Home Health conditions of participation (CoPs) which are contained in 42 C.F.R., section 484.55(d) require that HHAs must update and revise the comprehensive assessment (including the administration of the OASIS) no less frequently than: (1) The last 5 days of every 60 days beginning with the start of care date, unless there is a beneficiary elected transfer, significant change in condition, or discharge and return to the same HHA during the 60-day episode; (2) within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests; and (3) at discharge.

OASIS All-Payer Data Collection and Submission 

As finalized in the calendar year (CY) 2023 Home Health final rule and with further details provided in the CY 2025 Home Health final rule, OASIS all-payer data collection and submission will be implemented per the following schedule: 

• Prior to January 1, 2025 – Medicare and Medicaid Only OASIS Data Collection and Submission - Per the Home Health Conditions of Participation (CoPs) and OASIS guidance, agencies have been required to collect and submit OASIS assessments for all skilled Medicare and/or Medicaid patients, with some exemptions. 
• January 1-June 30, 2025 – Voluntary Phase-In Period for OASIS All-Payer Data Collection and Submission – For non-Medicare/non-Medicaid patients who are not exempt from OASIS data collection, and who begin receiving home health care services with an OASIS start of care (SOC) M0090 date from January 1, 2025, through June 30, 2025, OASIS data collection and submission are voluntary. When OASIS data collection and submission are started for a non-Medicare/non-Medicaid patient with the SOC OASIS assessment, HHAs may but are not required to complete all subsequent OASIS time point assessments related to the patient’s home health stay (that is, resumption of care, recertification, other follow up, transfer, discharge, and death at home) including assessments completed on or after July 1, 2025.
• Beginning July 1, 2025 – Mandatory OASIS All-Payer Data Collection and Submission - For patients with any pay source who are not exempt from OASIS data collection, and who begin receiving home health care services with an OASIS SOC M0090 date on or after July 1, 2025, OASIS data collection and submission to the internet Quality Improvement Evaluation System (iQIES) are required. This includes the SOC OASIS as well as any subsequent OASIS time point assessments relevant to the patient’s home health stay (that is, resumption of care, recertification, other follow up, transfer, discharge, and death at home).

The criteria for patients exempt from OASIS data collection continue to include patients under 18, patients receiving maternity services, and patients receiving only personal care, housekeeping or chore services.

Determining Provider Compliance with Home Health Quality Reporting Program Requirements

Section 1895(b)(3)(B)(v)(I) of the Act states that ''for 2007 and each subsequent year, in the case of a home health agency that does not submit data to the Secretary in accordance with subclause (II) with respect to such a year, the home health market basket percentage increase applicable under such clause for such year shall be reduced by 2 percentage points." This "pay-for-reporting" requirement was implemented on January 1, 2007. However, to date, the quantity of OASIS assessments each HHA must submit to meet this requirement has never been proposed and finalized through rulemaking or through the sub-regulatory process.

In the CY 2015 Home Health Final Rule, CMS proposed to establish a new “Pay-for-Reporting Performance Requirement” with which provider compliance with quality reporting program requirements can be measured. This proposal was made for several reasons.

First, we believe that defining a more explicit performance requirement for the submission of OASIS data by HHAs would better meet section 5201(c)(2) of the Deficit Reduction Act of 2005 (DRA), which requires that “each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality. Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this clause.”

Second, in February 2012, the Department of Health & Human Services Office of the Inspector General (OIG) performed a study to:

(1) Determine the extent to which HHAs meet Federal reporting requirements for the OASIS data;

(2) Determine the extent to which states meet federal reporting requirements for OASIS data, and

(3) Determine the extent to which the CMS oversees the accuracy and completeness of OASIS data submitted by HHAs. 

In a 2012 report entitled, “Limited Oversight of Home Health Agency OASIS Data" the OIG found that "CMS did not ensure the accuracy or completeness of OASIS data." The OIG recommended that CMS "identify all HHAs that failed to submit OASIS data and apply the 2-percent payment reduction to them." CMS believes that establishing a performance requirement for the submission of OASIS quality data would be responsive to the recommendations of the OIG.

This performance system is driven by the principle that each HHA will be expected to submit a minimum set of two "matching" assessments for each patient admitted to their agency. These matching assessments together create what is considered a "quality episode of care," which would ideally consist of a Start of Care (SOC) or Resumption of Care (ROC) assessment and a matching End of Care (EOC) assessment. However, several scenarios could meet this "matching assessment requirement" of the new pay-for-reporting performance requirement. These scenarios have been defined as quality assessments that create a quality episode of care during the reporting period or are consistent with creating a quality episode if the reporting period were expanded to an earlier reporting period or into the next reporting period. Seven types of OASIS assessments submitted by an HHA will fit this definition of a quality assessment. The seven OASIS assessments are:

• A Start of Care (SOC) or Resumption of Care (ROC) assessment that has a matching End of Care (EOC) assessment. EOC assessments are conducted at transfer to an inpatient facility (with or without discharge), death, or discharge from home health care. These two assessments (the SOC or ROC assessment and the EOC assessment) create a regular quality episode of care and both count as quality assessments.
• A SOC/ROC assessment could begin an episode of care but occurs in the last 65 days of the performance period. This is labeled as a "Late SOC/ROC" quality assessment.
• An EOC assessment that could end an episode of care beginning in the previous reporting period, (that is, an EOC that occurs in the first 65 days of the performance period.) This is labeled as an “Early EOC” quality assessment.
• A SOC/ROC assessment is followed by one or more follow-up assessments, the last of which occurs in the last 65 days of the performance period. This is labeled as a "SOC/ROC Pseudo Episode" quality assessment.
• An EOC assessment is preceded by one or more Follow-up assessments, the last of which occurs in the first 65 days of the performance period. This is labeled an "EOC Pseudo Episode” quality assessment.
• A SOC/ROC assessment is part of a known one-visit episode. This is labeled as a "One-visit episode" quality assessment.
• Follow-up assessments (that is, where the M0100 Reason for Assessment = ‘04’ or ‘05’) are considered “Neutral” assessments and do not count toward or against the pay for reporting performance requirement.
• SOC, ROC, and EOC assessments that do not meet any of these definitions are labeled as “Non-Quality” assessments.

All-Payer Related Changes to the Home Health Quality Reporting Program Annual Payment Update (APU)

With the CY 2023 and CY 2025 HH PPS Final Rules, CMS finalized (a) the end of the temporary suspension of OASIS data collection on non-Medicare/non-Medicaid HHA patients and (b) the requirement that HHAs submit OASIS on all patients with any pay source who are not exempt from OASIS data collection. Patients exempt from OASIS data collection include (1) patients under the age of 18, (2) patients receiving maternity services only, (3) patients receiving personal care, homemaker, or chore services only, (4) patients receiving outpatient therapy services provided by a HHA and billed under Medicare Part B benefit that do not have a home health plan of care in effect, (5) patients receiving a service from a company (other than the Medicare-certified HHA) using HHA staff under a loaned employee agreement, and (6) patients receiving only a single visit in a quality episode. For any patient not meeting an OASIS exemption who begins receiving skilled home health care services with an OASIS start of care (SOC) M0090 date on or after July 1, 2025, OASIS data collection and submission to the Internet Quality Improvement and Evaluation System (iQIES) are required. This includes the SOC OASIS and any subsequent OASIS time point assessments relevant to the patient's home health stay (that is, resumption of care, recertification, other follow up, transfer, discharge, and death at home). 

Currently, only OASIS data from Medicare and Medicaid payers are included in HH QRP Annual Payment Update (APU) calculation. To calculate APU, CMS intends to include patient data from all non-Medicare/non-Medicaid patients who begin receiving skilled home health care services with an OASIS SOC M0090 date on or after January 1, 2027. If the M0090 for the SOC is before January 1, 2027 for a non-Medicare/non-Medicaid patient, no OASIS data from any of their time points throughout their entire home health admission will be used for APU purposes, including any assessments that may be completed on or after January 1, 2027. The transition to using all-payer OASIS data for APU calculation does not impact how assessment data of skilled Medicare/Medicaid patients is utilized. 

Compliance with the pay-for-reporting performance requirement can be measured through the use of an uncomplicated mathematical formula. CMS have titled this formula the "Quality Assessments Only" (QAO) formula because only those OASIS assessments that contribute, or could contribute, to creating a quality episode of care are included in the computation. The formula based on this definition is as follows:

 QAO =                    # Quality Assessments x 100                     

               # Quality Assessments + # Non-Quality Assessments

We require all HHAs to achieve a quality reporting compliance rate of 90 percent or more regardless of payer source, as calculated using the QAO metric illustrated above.

For more information about the methodology of the “Pay-for-Reporting Performance Requirement” please review the document titled “Pay for Reporting: Quality Assessments Only Methodology” which is available in the Downloads section below. For more information about reconsideration, exemption, and extension, including in the case of natural disasters, please navigate to the Home Health Quality Reporting Reconsideration and Exemption & Extension webpage.

Useful Links:

• CY20 Home Health Final Rule
• FY22 Hospice Final Rule with HH rider
• CY22 Home Health Final Rule
• CY 23 Home Health Final Rule
• CY24 Home Health Final Rule
• CY25 Home Health Final Rule

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