On October 31, 2019, the Centers for Medicare & Medicaid Services (CMS) released its final rule with comment period that sets forth updates to the home health prospective payment system (HH PPS) for calendar year (CY) 2020 and includes other policy changes for home health agencies (HHA). This final rule also finalizes payment policies for the new CY 2021 home health infusion therapy services benefit. In its press release, CMS states that this final rule eliminates burdensome regulatory requirements that are “more stringent than relevant Federal and State laws for maintenance therapy” and is consistent with President Trump’s recent executive order to improve and protect Medicare, which was summarized in a previous article in the Health Law Pulse.
Regarding payment rate changes under the HH PPS, this final rule refines and implements the Patient-Driven Groupings Model (PDGM), which is a new case-mix methodology that Congress mandated in the Bipartisan Budget Act of 2018 (BBA). CMS explains in the final rule that “the PDGM relies more heavily on clinical characteristics and other patient information to place patients into meaningful payment categories and eliminates the use of therapy service thresholds.” The final rule also implements a change in the unit of payment under HH PPS for CY 2020 from 60-day episodes of care to 30-day episodes of care. Other relevant HH PPS updates include: (i) a budget-neutral manner to calculate the 30-day payment amount to ensure that estimated aggregate expenditures under the HHS PPS CY 2020 are equal to the estimated amount that they would have been had the 30-day unit of payment change not been made and to account for provider behavior changes that could occur as a result of the new case-mix adjustment factors; (ii) a change to the fixed-dollar loss ratio for outlier payments that was created by using updated claims data; and (iii) the use of updated wage index data for the home health wage index.
CMS concludes that the CY 2020 30-day payment rate will be $1,864.03. CMS predicts in its fact sheet that Medicare payments to HHAs will increase by roughly 1.3 percent, or $250 million, for CY 2020. CMS further states that this projected “increase reflects the effects of the 1.5 percent home health payment update percentage ($250 million increase) mandated by Congress in the BBA; and a 0.2 payment aggregate decrease (-$40 million) in payments to HHAs due to the changes in the rural add on percentages, as required in the BBA.”
This final rule with comment period also creates payment policies for the new CY 2021 home health infusion therapy services benefit. According to CMS’ press release, home infusion therapy is “the administration of certain types of medication, through a durable medical equipment (DME) pump, in the patient’s home.” To implement this new therapy service benefit starting on January 1, 2021, CMS states that it finalized these payment policies to provide providers and suppliers with enough time to prepare for the full roll out. CMS further explains in its fact sheet the payment policies, including that this new therapy service benefit 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).” The new home health infusion benefit will also include services such as the training and education on the care and maintenance of vascular access devices, patient assessment and evaluation, medication and disease management education, and remote monitoring services. CMS requests comments in this final rule about potential policies and criteria related to the coverage of eligible drugs under this new benefit.
In addition, currently under the Home Health Quality Reporting Requirements (HH QRP), HHAs that meet the quality data reporting requirements must submit this data and patient assessment data to CMS or they are subject to a 2% point reduction to the home health market basket percentage increase. In this final rule, CMS finalizes updates to the HH QRP by adopting two new quality measures, referred to as the Transfer of Health Information to Provider-Post-Acute Care and the Transfer of Health Information to Patient-Post-Acute Care quality measures. CMS believes that these transfer of health information quality measures will ensure that patients’ medication lists are provided to the patient and the provider upon discharge and that these measures will further promote the coordination of care. CMS also adopts changes to the Home Health Value-Based Purchasing Model (HHVMP), which is a model that became effective on January 1, 2016 and was implemented by the CMS Innovation Center “to support the Department of Health and Human Services’ efforts to build a health care system that delivers better care, spends health care dollars more wisely, and results in healthier people and communities.” CMS believes that reporting HHAs’ performance data under the HHVMP contributes to a meaningful choice, and comparisons between HHAs, by patients. In the final rule, CMS describes that it will publicly report each HHAs’ Total Performance Scores (TPS) and TPS Percentile Ranking from the Performance Year 5 (CY 2020) Annual TPS and Payment Adjustment Report in the nine model states that qualified for a payment adjustment for CY 2020.
In an attempt to curb fraud in the Medicare program, CMS will reduce the Request for Anticipated Payment (RAP) to 20 percent in CY 2020 and then completely eliminate these payments by 2021. However, in 2021, the zero-pay RAPs will still have to be submitted within 5 calendar days of each 30-day period, or be subject to a late penalty, so that CMS is aware of a beneficiary under a home health period of care. In 2022, CMS will then replace the RAP with a one-time submission of a Notice of Administration (NOA). CMS states in its press release that it has “seen a marked increase in RAP fraud schemes,” and that “eliminating RAP payments over the next two years would serve to mitigate potential fraud schemes while minimally impacting HHAs due to implementation of the PDGM, which increases the frequency of payment for services to HHAs.”
Finally, CMS in the final rule revises current regulations in accordance with individual state practice requirements so that therapist assistants, and not just therapists, can perform maintenance therapy under the Medicare home health benefit. In its press release, CMS states that this will ensure that “HHAs have enough staff available to provide the appropriate amount of therapy to their patients, improving beneficiary access to these services.”
This final rule is scheduled to be published in the Federal Register on November 8, 2019, and will be effective on January 1, 2020. Public comments regarding the coverage of additional drugs under the home infusion benefit for CY 2021 are due by 5 p.m. on December 30, 2019.
*Special thanks to Hayley White, Law Clerk and District of Columbia Bar license pending, for her assistance in preparing this post.