Military Health System

(Final payment amounts per 60-day episodes ending on or after January 1, 2016, and before January 1, 2017 - Continuing Calendar Year (CY) update.)

Section 1895(b)(3)(B) of the Act, as amended by section 5201 of the Deficit Reduction Act (DRA), requires for CY 2016 that the standard prospective payment amount be increased by a factor equal to the applicable Home Health (HH) market basket update for HHAs.

Beginning in CY 2014, as required by section 3131(a)(1) of the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS), in their Final Rule published December 2, 2013, rebased the national, standardized 60-day episode payment amount, the national per-visit rates, and the NRS conversion factor. The rebasing adjustments will continue through CY 2017. For CY 2016 the rebasing adjustment is $80.95

In order to calculate the CY 2016 national standardized 60-day episode, the CY 2015 estimated average payment per 60-day episode of $2,961.38 is adjusted by the wage-index budget neutrality factor, a case-mix weights budget neutrality factor, an adjustment for nominal case-mix growth, the rebasing adjustment, and the home health market basket update, as reflected in Figure 12.K-2016-1.

To calculate the CY 2016 national per-visit rates, the 2015 national per-visit rates are adjusted by a wage index budget neutrality factor, and are then increased by the rebasing adjustments described in the December 2, 2013, CMS Final Rule. Finally, the rates are updated by the CY 2016 HH market basket update. National per-visit rates are not subjected to the nominal increase in case-mix. The final updated CY 2016 national per-visit rates per discipline are reflected in Figure 12.K-2016-2:

For CY 2016, as described in the December 2, 2013, CMS Final Rule, the per-visit payment amount for the first SN, PT, and SLP visit in LUPA episodes that occur as the only episode or an initial episode in a sequence of adjacent episodes is multiplied by the LUPA add-on factors, which are: 1.8451 for SN; 1.6700 for PT; and 1.6266 for SLP

Payments for the NRS are computed by multiplying the relative weight for a particular severity level by the NRS conversion factor. For CY 2016, the 2015 NRS conversion factor was adjusted using the 2.82 rebasing adjustment factor, as described in the December 2, 2013, CMS Final Rule, and then updated by the CY 2016 HH market basket. See Figure 12.K-2016-3.

The payment amounts, using the above computed CY 2016 NRS conversion factor ($52.71), for the various severity levels based on the updated conversion factor are calculated in Figure 12.K-2016-4.

For CY 2016, the labor percent is 78.535%, and the non-labor percent is 21.465%.

Under the HHA PPS, outlier payments are made for episodes for which the estimated cost exceeds a threshold amount. The wage adjusted Fixed Dollar Loss (FDL) amount represents the amount of loss that an agency must bear before an episode becomes eligible for outlier payments. The FDL ratio, which is used in calculating the FDL amount, for CY 2016 is 0.45.

HHAs must collect OASIS data in order to participate in the TRICARE program. See Addendum G for the OASIS.

Section 421(a) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (Public Law 108-173, enacted on December 8, 2003, and as amended by Section 3131(c) of the Affordable Care Act) provides an increase of 3% of the payment amount otherwise made under Section 1895 of the Social Security Act for HH services furnished in a rural area (as defined in Section 1886(d)(2)(D) of the Social Security Act), for episodes and visits ending on or after April 1, 2010, and before January 1, 2018. The 3% rural add-on is applied to the national standardized 60-day episode rate, the national per-visit rates, the LUPA add-on payment amount, and the NRS conversion factor when HH services are provided in rural (non-Core Based Statistical Area (CBSA)) areas. The applicable case-mix and wage index adjustments are subsequently applied. Episodes that qualify for the 3% rural add-on will be identified by a CBSA code that begins with ‘999’.

In order to calculate the national standardized 60-day episode payment for beneficiaries residing in a rural area, the CY 2016 national standardized 60-day episode payment of $2,965.12 was increased by 3% to $3,054.07.

The CY 2016 national per-visit amounts were increased by 3% for beneficiaries who reside in rural areas. See Figure 12.K-2016-5.

The CY 2015 NRS Conversion Factor was multiplied by the 3% rural add-on to result in a NRS Conversion Factor of $54.29 for CY 2016.

The CY 2016 NRS payment amounts for services provided in rural areas are summarized in Figure 12.K-2016-6.