Health Reform WK-EDGE Shorter home health episode-of-care proposed (again) for 2020
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Thursday, July 12, 2018

Shorter home health episode-of-care proposed (again) for 2020

By Kayla R. Bryant, J.D.

CMS proposed a 2.1 percent home health (HH) prospective payment system (PPS) update for calendar year (CY) 2019, which would result in Medicare payment increases of about $400 million overall. The advance release of the Proposed rule, which publishes July 12, 2018 in the Federal Register, also proposes implementing the required change in unit of payment from 60-day to 30-day episodes of care beginning January 1, 2020.

Payment update. The Proposed rule updates the payment rates by the CY2019 HH payment update percentage of 2.1, resulting in a national, standardized 60-day episode payment of $3,151.22. For HHAs that do not submit required quality data, the update is reduced by 2 percentage points, resulting in a payment of $3,089.49. The payment add-on for services furnished in rural areas remains at an increase of 3 percent for episodes and visits ending before January 1, 2019. The Bipartisan Budget Act of 2018 (BBA) (P.L. 115-123) provides for the rural add-on for episodes and visits ending during CYs 2019 through 2022, but this extension of the rural add on provides varying amounts depending on which of three categories the rural area is placed in by county, depending on population density and the number of episodes of care furnished per eligible beneficiary.

Unit of care. The proposed rule updated the unit of care requirements mandated by section 51001 of the BBA, beginning January 1, 2020. CMS proposes to do so via implementing the Patient-Driven Groupings Model (PDGM), which shares many features of the alternative case mix-adjustment methodology the agency proposed in the CY2018 HH PPS Proposed rule in the form of the Home Health Groupings Model (HHGM), which was ultimately not implemented (see Home health rule eases quality reporting burdens, puts groupings model on hold, November 2, 2017). In addition to changing the length of the unit of care, the proposed PDGM does not use the number of therapy visits in determining payment, which removes the financial incentives to provide additional therapy to receive a higher payment. Instead, case-mix adjustment would be solely based on patient characteristics.

Home infusion therapy. The Medicare home infusion therapy benefit was established by the 21st Century Cures Act (Cures Act) (P.L. 114-255). This benefit provides substantial improvements for patient care. The rule establishes transitional payment for home infusion therapy services for CYs 2019 and 2020, required by section 50401 of the BBA. It also proposes health and safety standards for home infusion therapy as well as an oversight process as required by the Cures Act. The oversight process requires that (1) all patients have a plan of care established and updated by a physician that prescribes the necessary infusion therapy; (2) remote monitoring services associated with administering infusion drugs are provided; and (3) education and training for medications and equipment used in this process is provided to each patient.

Eligibility certification. As required by the BBA, CMS proposes that it may use documentation in the medical record of the HHA as supporting material as appropriate for certifications or recertifications for HH care, in addition to the documentation in the medical record provided by the certifying physician or the acute or post-acute care facility. Such information must be corroborated by other medial record entries, resulting in a "clinically consistent picture" of eligibility for HH services. CMS proposes amending 42 C.F.R. §424.22(c) to align the text with sub-regulatory guidance.

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