On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) published its calendar year (CY) 2019 proposed rule for Medicare payment updates and proposed quality reporting changes for home health agencies (HHA) under the home health prospective payment system (HH PPS). CMS proposes certain changes to Medicare payment and quality reporting standards for HHAs, as well as the home infusion therapy benefit and remote patient monitoring. These proposed changes are based on three goals: “empowering patients, increasing competition, and fostering innovation.” Highlights from the proposed rule are explained in further detail below.
Home Health Payment Rate Update
Rebasing and Revising of Home Health Market Basket
CMS proposes to rebase and revise the home health market basket to reflect 2016 Medicare cost report data. The current estimate for the CY 2019 HHA payment update is 2.1 percent, which reflects a 2.8 percent market basket update minus a 0.7 percent multifactor productivity adjustment.
Rural Add-On Payments
The Bipartisan Budget Act of 2018 (BBA), Section 50208, requires CMS to classify rural counties into one of three categories based on high home health utilization, low population density, and all other rural counties not classified as having high home health utilization or low population density. Rural add-on payments will vary based on each county’s category classification.
Implementation of Patient-Driven Groupings Model for CY 2020
Currently, HHAs are paid for each 60-day period of home health care provided. Section 51001(a)(1) of the BBA requires CMS to pay HHAs for each 30-day unit of service beginning in CY 2020. In compliance with the BBA, CMS proposes to implement the Patient-Driven Groupings Model (PDGM), which would establish a 30-day unit of payment and no longer use the number of therapy visits to determine payment under the HH PPS.
Similar to the current payment system, CMS would continue to classify periods of care as “early” or “late” for purposes of determining the amount of payment to be made for a period of home health care. Under the PDGM, only the first 30-day period in a sequence would be considered “early,” and all following 30-day periods would be considered “late.” In addition, 30-day periods would be considered as being in the same sequence as long as there are no more than 60 days between each 30-day period. In determining a gap, CMS would only consider whether the beneficiary was receiving home health care from traditional fee-for-service Medicare.
CMS also proposes classifying each 30-pay period of care into one of two categories (community or institutional) depending on what healthcare setting was utilized by a patient in the 14 days before home health admission. A 30-day period of care would be categorized as institutional if an acute or post-acute care stay occurred in the 14 days prior to home health admission and categorized as community if no acute or post-acute care stay occurred in the 14 days prior to home health admission. The institutional admission source category would include beneficiaries with inpatient acute care hospital stays, skilled nursing facility stays, inpatient rehabilitation stays, and long term care hospital stays. CMS further explained that the institutional admission source category would also apply to beneficiaries discharged to an acute care hospital stay during a 30-day period of home health care so long as the beneficiary was not discharged and readmitted to the HHA. However, CMS would not categorize post-acute care stays (i.e. skilled nursing facility, inpatient rehabilitation, or long term care hospitalization) during a 30-day period of home health care as institutional, because CMS expects HHAs to discharge a patient from home health if post-acute care is required in a different healthcare setting and for the patient to be readmitted to the HHA after being discharged from such a post-acute care setting.
Further, the proposed PDGM would rely more heavily on clinical characteristics and other patient information to place patients in the correct payment categories. The PDGM would group 30-day periods into the following six clinical groups based on the principal diagnosis:
- Musculoskeletal Rehabilitation
- Neuro/Stroke Rehabilitation
- Wounds—Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care
- Complex Nursing Interventions
- Behavioral Health Care (including Substance Use Disorders)
- Medication Management, Teaching and Assessment (MMTA)
Certifying and Recertifying Patient Eligibility for Medicare Home Health Services
CMS proposes to amend the regulatory requirements on physician certification and recertification for consistency with existing sub-regulatory guidance. If finalized as proposed, the regulations would allow HHA medical records to be used as supporting documents for physician certification of home health eligibility if the HHA documentation can be corroborated by other medical record entries and the certifying physician signs and dates the HHA documents to indicate they were considered when determining patient eligibility for Medicare home health services.
CMS also proposes to eliminate the requirement that a certifying physician must provide an estimate of how much longer skilled services are required when recertifying a patient’s need for continued home health care.
Remote Patient Monitoring
CMS proposes to define remote patient monitoring under the Medicare home health benefit as “the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the HHA.” Under this new definition, the expenses of remote patient monitoring used by a HHA to supplement the care planning process would be an allowable administrative cost. This would enable HHAs to report remote patient monitoring costs on the HHA cost report as allowable administrative costs that are factored into the costs per visit.
Home Health Value-Based Purchasing Model
For CY 2019, CMS proposes to remove five measures and add two new composite measures to the applicable criteria for the Home Health Value-Based Purchasing Model (HHVBP) model used to adjust HHA Medicare payment rates.
For CY 2020 and the following performance years, CMS proposes to remove “Influenza Immunization Received for Current Flu Season” and “Pneumococcal Polysaccharide Vaccine Ever Received” from the set of applicable measures. CMS describes that the “Influenza Immunization Received for Current Flu Season” measure does not fully capture HHA performance in the administration of the flu vaccine and the “Pneumococcal Polysaccharide Vaccine Ever Received” measure does not fully reflect the current Advisory Committee on Immunization Practices (ACIP) guidelines.
CMS proposes to replace three Outcome and Assessment Information Set (OASIS) measures (Improvement in Bathing, Improvement in Bed Transferring, and Improvement in Ambulation-Locomotion) with two composite measures (Total Normalized Composite Change in Self-Care and Total Normalized Composite Change in Mobility). The new composite measures would be scored to ensure the relative weighting of the assisted daily living (ADL)-based measures would stay the same.
CMS is considering public reporting for the HHVBP model, and is soliciting further comment on what information should be made publicly available.
Home Health Quality Reporting Program
CMS proposes to replace the existing six criteria used to evaluate a quality measure for removal from the list of Home Health Quality Reporting Program (HH QRP) measures with seven factors. CMS also proposes to adopt an additional eighth factor to consider when evaluating potential measures for removal from the HH QRP measure set: Whether the costs associated with a measure outweigh the benefits of its continued use.
To address the Meaningful Measures Initiative, CMS proposes to remove seven measures from the HH QRP beginning with the 2021 HH QRP, including improvement in the status of surgical wounds measure, emergency department use without hospital readmission during first 30 days of home health measure, and prehospitalization during the first 30 days of home health measure.
Medicare Coverage of Home Infusion Therapy Services
Section 5012 of the 21st Century Cures Act established the new home infusion therapy benefit and covers the nursing, patient education, and monitoring services associated with administering infusion drugs in a patient’s home. CMS explains that in order to address the current inconsistency in standards for home infusion therapy, the agency proposes universal standards for Medicare-participating qualified home infusion therapy suppliers. CMS would monitor home infusion therapy suppliers to ensure that services are provided safely, and establish health and safety standards to maintain consistency in coverage. CMS also proposes a framework for approving home infusion therapy accreditation organizations (AOs) and requirements that a home infusion therapy supplier must meet in order to participate in the Medicare program. CMS proposes to publish a solicitation notice in the Federal Register, inviting national AOs to apply to accredit home infusion therapy suppliers for the Medicare program.
As required by section 50401 of the BBA, CMS proposes to establish a temporary transitional payment for home infusion therapy services in coordination with the furnishing of transitional home infusion drugs. The transitional payment would begin in CY 2019 and end the day before full implementation of the home infusion therapy benefit in CY 2021. The temporary payment would cover the cost of the same items and services related to the administration of home infusion drugs and is set to be equal to four hours of infusion in a physician’s office. CMS would only pay a home infusion therapy supplier for the day on which a nurse (or other qualified skilled professional) is in a patient’s home and the drug is actually being infused, even if other professional services related to the treatment were administered on a different day, a proposal that is certain to elicit public comments.
Accreditation Requirements for Certain Medicare Certified Providers and Suppliers
CMS proposes adding two new requirements for AOs. The first requirement would permit Medicare-certified providers and suppliers voluntarily terminating an AO’s services to continue their term of accreditation until the effective date of withdrawal identified by the facility or the expiration date of the term of accreditation, whichever comes first. CMS would implement this requirement by requiring AOs to provide a written statement to this effect in their application to CMS. The second requirement would add new requirements for training AO surveyors that certify providers and suppliers for compliance with the statutory requirements of the Medicare program. CMS would require AO surveyors to complete initial program-specific CMS online training and to routinely complete additional online training in accordance with requirements established by CMS for state surveyors.
CMS will accept comments on the HHA CY 2019 proposed rule until 5:00 PM on August 31, 2018.
*Many thanks to Summer Associate Rachel Park in preparing the draft of this blog post.
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