1.0 PURPOSE
1.1 As a result
of Section 705 of National Defense Authorization Act (NDAA) for
Fiscal Year (FY) 2017, which authorizes the Defense Health Agency
(DHA) to adopt value-based incentive programs conducted by the Centers
for Medicare and Medicaid Services (CMS) or any other Federal, State,
or commercial health care programs, the DHA issued a notice in the
Federal Register on September 25, 2019, to adopt Medicare’s HHVBP
model as a demonstration under the TRICARE program.
1.2 The purpose
of this demonstration is to improve the quality and delivery of
home healthcare, and incentivize those Home Health Agencies (HHAs)
that provide higher quality, more efficient care, as well as evaluate
the administrative feasibility of adopting HHVBP adjustments under
the TRICARE program. It is expected that TRICARE’s adoption of the
HHVBP model will strengthen the impact of the incentives included
within the model by adding TRICARE’s market share to Medicare’s.
2.0 BACKGROUND
2.1 As finalized
in the Medicare Calendar Year (CY) 2016 Home Health Prospective
Payment System (HH PPS) final rule (80 FR 68624), CMS began testing
the HHVBP Model in January 2016. This program outlined goals to:
1) incentivize better quality care with greater efficiency; 2) study
potential quality and efficiency measure for use in the HH setting;
and 3) enhance the public reporting process. It is expected that
tying quality to payment through a system of Value-Based Purchasing
(VBP) for all Medicare-certified Home Health Agencies (HHAs) providing
services in the states of Arizona, Florida, Iowa, Maryland, Massachusetts,
Nebraska, North Carolina, Tennessee, and Washington will improve
the beneficiaries’ experience and outcomes.
2.2 In Medicare’s HHVBP model,
CMS determines a payment adjustment up to the maximum percentage,
upward or downward, based upon the HHA Total Performance Score (TPS).
The distribution of payment adjustments under this HHVBP Model are
based upon quality performance, as measured by both achievement
and improvement, across a set of quality measures constructed to minimize
the burden as much as possible and improve care. The degree of the
payment adjustment is dependent upon the level of quality achieved
or improved from the base year, with the highest upward performance
adjustment going to competing HHAs with the highest overall level
of performance based upon either achievement or improvement in quality.
2.3 A payment
adjustment report is provided once a year to each of the HHAs by
CMS. The annual report from CMS provides the HHA’s payment adjustment
percentage and explains how the adjustment was determined relative
to its performance scores. This is the document that HHAs in the selected
states shall be required to submit to TRICARE contractors prior
to the beginning of each CY, upon adoption of the HHVBP by TRICARE.
For additional information on quality measures and methodologies
used for calculating the HHVBP payment adjustment factor, refer
to the CMS Innovation Center website at
https://innovation.cms.gov/initiatives/home-health-value-based-purchasing-model.
2.4 Due to the complexity of the
multiple reporting systems and methodology used in the calculation
of TPSs and final payment adjustment factors, DHA’s approach to
mirroring these HHVBP adjustment factors is to require each HHA
to submit their current payment adjustment report to the TRICARE
contractor. See
paragraph 2.3. Failure to submit the required
payment adjustment report shall result in full application of the
negative adjustment factor for the CY, as described in
paragraph 4.1.2.
3.0 Applicability
3.1 Participation
in the demonstration is mandatory for all TRICARE-authorized HHAs
(network and non-network) that are Medicare-certified and provide
services in Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska,
North Carolina, Tennessee, and Washington. This demonstration is
applicable to the East and West Regional Managed Care Support Contracts
(MCSCs), and does not apply to the Uniformed Services Family Health
Plan (USFHP), TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC),
or any other contracts.
3.2 The demonstration is effective January 1, 2020,
and will run through December 31, 2022. However, if Medicare decides
to terminate early or expand the demonstration beyond December 31, 2022,
TRICARE will follow suit as well as adopt future modifications made
to the HHVBP model by Medicare, as practicable.
4.0 POLICY
4.1 Reimbursement
4.1.1 The HHVBP
payment adjustment shall apply to all TRICARE HHA PPS claims, which
includes the Patient-Driven Groupings Model (PDGM) (see TRICARE
Reimbursement Manual (TRM),
Chapter 12), based
upon the location where services were rendered, and contractors
shall use the same adjustment factor calculated by Medicare for
each HHA. An annual TPS and Payment Adjustment Report is released by
Medicare which contains payment adjustment percentages, an explanation
of when the adjustment will be applied, and how the adjustment was
calculated. This report is specific to each HHA and accessible only
to that HHA.
4.1.2 Since DHA will not have access
to the TPS and Payment Adjustment Report, each HHA shall provide
a current copy of this report to TRICARE contractors every calendar
year, and contractors shall adjust claim payments in accordance
with this report. The HHA is responsible for ensuring that the appropriate
TRICARE contractor who is responsible for processing the beneficiary’s
claim has a current copy of the TPS and Payment Adjustment Report.
4.1.3 Providers shall have 90 days
to submit their TPS to the contractor after publication of this policy.
During this time contractors shall continue to process claims with
a TPS adjustment factor of 1.0. At the end of the 90 days, or upon
receipt of the TPS, the contractor shall reprocess all claims with
a “Through” date ending on or after January 1, 2020, with the TPS
factor (if received) or the full negative adjustment of 6% (if not
received).
4.1.4 For claims received 90 days after publication
of this policy, failure to submit the required payment adjustment
documentation with the claim or prior to the first claim submission
shall result in full application of the negative adjustment factor
as follows:
• Six
percent (6%) for episodes or periods of care ending on or after
January 1, 2020, and before January 1, 2021;
• Seven percent (7%)
for periods of care ending on or after January 1, 2021, and before January
1, 2022; and
• Eight
percent (8%) for periods of care ending on or after January 1, 2022,
and before January 1, 2023.
Reconsideration
requests shall be considered, if the provider submits the TPS Report
within 90 days from the date of the initial remittance advice listing
the claim as paid. Claims that are reprocessed under
paragraph 4.2,
the reconsideration request shall be considered, if the TPS Report
is received within 90 days of the new remittance advice.
4.1.5 The HHA
PPS payment amount that is due to an HHA on each claim, shall be
increased or decreased by the applicable HHVBP payment adjustment
percentage, after all other payment adjustments are applied. The
claim payment amount that is made to an HHA by the TRICARE contractor,
shall include the HHVBP incentive amount (negative or positive)
that was calculated for that HHA PPS claim. Therefore, any negative
incentives, if applicable, shall not be withheld from future claim payments,
except for reprocessed claims described in
paragraph 4.2.
4.1.6 Revisions have been made to
the HH Pricer program to accept the necessary adjustment factor
to apply the appropriate adjustment percentage and to capture the
adjusted amount on the claim record. The HHVBP adjustment amount
shall be placed on the claim as a value code QV amount, which
may be a positive or a negative amount.
4.1.7 All normal home health benefits
and conditions for coverage requirements as outlined in TRM,
Chapter 12 and other TRICARE manuals shall
continue to apply. This also includes those requirements related
to (not an all-inclusive list):
• Beneficiary cost-share
amounts
• Assessment
process
• Prior
authorization
• Claims and billing
submission
• Medical
review requirements
• Consolidated billing
• Primary provider
status
4.2 Special Processing Code (SPC)
4.2.1 The contractor shall for all
HHVBP claims, submit a non-underwritten TRICARE Encounter Data (TED)
records citing SPC HH “Home Health Value-Based Purchasing”.
Since this demonstration shall be implemented in the contractors’
systems after January 1, 2020, contractors shall search for previously
processed HHA PPS claims with “Through” dates ending on or after
January 1, 2020, that are eligible for the HHVBP payment adjustment
(positive or negative) and adjust those claims and TED records to
reflect SPC HH and the new payment amount. If any of
the previously submitted claims were submitted as underwritten claims,
the contractor shall cancel the underwritten TED record (returning the
underwritten funds to the contract) and submit the new TED record
as non-underwritten citing SPC HH.
4.2.2 Providers shall have 90 days
to submit their TPS to the contractor after publication of this policy.
At the end of the 90 days, or upon receipt of the TPS, the contractor
shall reprocess these claims with the TPS (if received) or the full
negative adjustment of 6% (if not received).
4.3 Contractor
Responsibilities
4.3.1 The contractor shall educate HHVBP participating
providers regarding the goals, terms, and conditions of the initiative.
4.3.2 The contractor
shall continually monitor access to care for participating providers according
to existing TRICARE requirements. The contractor shall contact DHA
within five calendar days if it is determined that HHVBP participation
is adversely impacting access to care.
5.0 Evaluation
And Reports
5.1 Evaluation
5.1.1 This demonstration project
will assist the Department of Defense (DoD) in evaluating the feasibility
of incorporating the HHVBP model in the TRICARE program. The hypothesis
is that payments that are linked to quality outcomes will:
• Be
administratively feasible, meaning that the demonstration is successfully implemented
and administered within a reasonable margin of the DHA’s estimate
of this demonstration;
• Improve the quality
of care delivered over time; and
• Be cost-neutral or
result in modest long-term cost savings.
5.1.2 Success is defined as:
• Implementation
and ongoing maintenance costs do not exceed 2% of the annual TRICARE
total spent on home health care in the HHVBP demonstration states,
and a high percentage of TRICARE HHAs provide their TPS scores.
• Measurable improvements
in HHA quality of care measures for HHA patients in HHVBP states
as compared to non-HHVBP states as reported in the Medicare HHVBP
evaluation reports.
• The average acuity-adjusted
home health cost per TRICARE beneficiary or episode in the HHVBP
states increases at a slower rate or at the same rate compared to
the same measure in the non-HHVBP states.
5.2 Quarterly Reports
5.2.1 The contractor shall submit
the first quarterly reports and subsequent quarterly reports through
the DHA e-Commerce Extranet, in accordance with
Chapter 14, Section 1.
5.2.2 The contractor shall provide
quarterly written reports to DHA. Details for reporting are identified
in DD Form 1423, Contract Data Requirements List (CDRL), located
in Section J of the applicable contract. The quarterly written reports
summarize all of the following:
• Total dollar amount
of HHVBP incentives paid to providers;
• Total dollar amount
of HHVBP incentives paid to providers by State (based upon where HH
services were furnished);
• Total number of claims
paid under the demonstration;
• Total number of unique
beneficiaries receiving HH services under the HHVBP model;
• Total number of new
TPS reports received from HHAs;
• Summary of any access
to care issues; and
• Summary of any provider
feedback (positive or negative) received, specifically related to
the demonstration.
5.2.3 These quarterly
written reports shall be provided to DHA within 15 calendar days
after the end of the reporting period. Reporting periods are every
April 1, July 1, October 1, and January 1. The report shall be based
upon claims that were completed during the prior three months. For
example, the report that is due in October, shall provide information
on claims completed and issues reported during the months of July,
August, and September.
5.2.4 In addition to the written reports, contractors
shall also provide quarterly claims data on each claim that was
paid under the HHVBP model. These reports shall be provided to DHA
within 15 calendar days after the end of the reporting period. Reporting
periods are every April 1, July 1, October 1, and January 1, and
is separate from the written report. The report shall be based upon
claims completed during the prior three months, as described in
paragraph 5.2.3.
Details for reporting are identified in DD Form 1423, CDRL, located
in Section J of the applicable contract.
5.3 Annual Reports
5.3.1 The contractor shall submit
the first annual written report and subsequent annual written reports
through the DHA e-Commerce Extranet, in accordance with
Chapter 14, Section 1. Details for reporting
are identified in DD Form 1423, CDRL, located in Section J of the
applicable contract.
5.3.2 The contractor shall provide annual written
reports to DHA that summarize the following:
• Total dollar amount
of HHVBP incentives paid to providers by State (based upon where HH
services were furnished);
• Total number of claims
paid under the demonstration;
• Total number of unique
beneficiaries receiving HH services under the HHVBP model;
• Total number of new
TPS reports received from HHAs;
• Summary of any access
to care issues;
• Summary
of any provider feedback (positive or negative) received, specifically
related to the demonstration;
• Analysis in emergency
department utilization for beneficiaries who received HH services
in HHVBP states; and
• Analysis in spending
and utilization of HH services in the nine states.
5.3.3 These annual written reports
shall be provided to DHA within 20 calendar days after the end of
the calendar year, and is in addition to the quarterly reports.
The report shall be based upon claims completed during the prior
year. For example, the annual report that is due in January 2021, shall
provide an analysis and summary of all HHVBP claims completed during
CY 2020.
6.0 Exclusions
6.1 Any claims where home health
services are furnished outside of the nine selected states listed in
paragraph 3.1.
6.2 Any Medicare-certified HHA
that provides services in the nine selected states, and has a CMS exemption
letter stating that the HHA is exempt from participating in the
Medicare HHVBP Model.
6.3 Any claims for TRICARE beneficiaries with Other
Health Insurance (OHI), where TRICARE is not the primary payer.
6.4 Beneficiaries enrolled in
TRICARE For Life (TFL).
6.5 Beneficiaries who have dual eligibility under
both TRICARE and Medicare and whose claims are not processed under
the East or West Regional MCSC.
6.6 Beneficiaries enrolled in
the TRICARE Overseas Program (TOP).
6.7 Beneficiaries enrolled in
the Continued Health Care Benefit Program (CHCBP).
7.0 Effective
Date
The HHVBP Model is effective January
1, 2020.