Today, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1711-P] that proposes routine updates to the home health payment rates for calendar year (CY) 2020, in accordance with existing statutory and regulatory requirements. This rule will also include: a proposal to modify the payment regulations pertaining to the content of the home health plan of care; a proposal to allow therapist assistants to furnish maintenance therapy; and a proposal related to the split percentage payment approach under the Home Health Prospective Payment System (HH PPS). Finally, this rule will include proposals related to the implementation of the permanent home infusion therapy benefit in 2021. These include proposed payment categories, amounts, and required and optional adjustments.
The proposed rule can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/
Proposed Payment Rate Changes under the HH PPS for CY 2020
This proposed rule sets forth implementation of the Patient-Driven Groupings Model (PDGM), an alternate case-mix adjustment methodology, and a 30-day unit of payment as mandated by the Bipartisan Budget Act of 2018 (BBA of 2018). CMS projects that Medicare payments to HHAs in CY 2020 will increase in aggregate by 1.3 percent, or $250 million, based on proposed policies. The increase reflects the effects of the 1.5 percent home health payment update percentage ($290 million increase) mandated by BBA of 2018. It also reflects a 0.2 percent decrease in aggregate payments due to reductions made by the new rural add-on policy mandated by the BBA of 2018 for CY 2020 (i.e., an estimated $40 million decrease in rural add-on payments). The rate updates also include adjustments for anticipated changes with implementation of the PDGM and a change to a 30-day unit of payment, 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.
Proposed Payment Rate Changes for Home Infusion Therapy Temporary Transitional Payments for CY 2020
Home infusion therapy temporary transitional payments are paid at amounts in accordance with the Physician Fee Schedule for items and services furnished during the year for identified codes and units of such codes, without geographic adjustment. As such, for CY 2020, temporary transitional payment rates will be updated based on the Current Procedural Terminology (CPT) code amounts in the CY 2020 Physician Fee Schedule (PFS).
Payment Proposals for New Home Infusion Therapy Benefit 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 is proposing to group home infusion drugs into three payment categories, each with a single unit of payment in accordance with specified infusion codes and units for such codes under the PFS. Additionally, CMS is proposing to adjust this single unit of payment by the Geographic Adjustment Factor (GAF) - a weighted composite of the three geographic practice cost indices used for the PFS. CMS is also proposing higher payment amounts for the first home infusion therapy visit, and in order to make these payment adjustments budget neutral, CMS is proposing a small decrease in the payment amounts for each subsequent visit.
Regulatory Burden Reduction – Patients Over Paperwork and Enhance and Modernize Program Integrity
In an effort to make improvements to the health care delivery system and to reduce potential program integrity risks, CMS proposes to eliminate the need to submit a Request for Anticipated Payment (RAP) for every period/episode. CMS is proposing to reduce the RAP split-percentage payment to 20 percent for existing HHAs beginning in CY 2020 with elimination of split-percentage payments for all HHAs in CY 2021. A one-time notice of admission (NOA) would be filed by all HHAs beginning in CY 2021 to alert the claims processing system that a beneficiary is under a home health episode of care. This is intended to prevent duplicate billing for supplies and therapy services that are bundled into the home health payment amount. CMS believes that phasing out the RAP may mitigate potential fraud and is an important step in paying responsibly and appropriately for home health services.
Paraprofessional Roles – Improving Access to Care
CMS is proposing to modify current regulations to allow therapist assistants to perform maintenance therapy under the Medicare home health benefit in accordance with individual state practice requirements. This proposed 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 proposed change would be consistent with regulations for skilled nursing facilities where therapist assistants can perform maintenance therapy; would allow therapist assistants to practice at the top of their state licensure; and would provide HHAs the flexibility to use either therapists or therapist assistants to meet the maintenance therapy needs of their patients. These burden reduction efforts would allow providers to spend more time on their chief responsibility: improving the health outcomes of their patients.
Finally, CMS is also proposing changes to the current payment regulations regarding the home health plan of care in order to align the regulations with current policy.
Home Health Quality Reporting Program (HH QRP) – Support MyHealthEData Initiative
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 IMPACT Act requirement to implement a quality measure addressing the transfer of health information, CMS is proposing to adopt two new quality measures that assess the transfer of health information. The two proposed measures are: (1) Transfer of Health Information to Provider-Post-Acute Care; and (2) Transfer of Health Information to Patient-Post-Acute Care. These proposed measures are designed to improve patient safety by ensuring that the patient’s medication list is accurate and complete at the time of transfer or discharge. These two proposed 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, as well as support the MyHealthEData Initiative.
In addition, CMS is proposing to adopt a number of standardized patient assessment data elements (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 in part 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.
CMS is proposing to remove the Improvement in Pain Interfering with Activity Measure (NQF #0177) from the HH QRP. CMS is proposing to remove pain-associated quality measures from its quality reporting programs in an effort to mitigate any potential unintended, over-prescription of opioid medications inadvertently driven by these measures.
CMS is proposing to remove Question 10, regarding pain communication, from the HHCAHPS Survey to avoid potential unintended consequences that may arise from its inclusion in CMS surveys and datasets. Finally, CMS is proposing to update 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 proposing 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
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 proposed rule can be viewed at https://www.federalregister.gov/public-inspection