Military Health System

(Final payment amounts per 60-day episodes ending on or after January 1, 2018, and before January 1, 2019 - 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 2018 that the standard prospective payment amount be increased by a factor equal to the applicable Home Health (HH) market basket update for HHAs.

In order to calculate the CY 2018 national standardized 60-day episode, the CY 2017 estimated average payment per 60-day episode of $2,989.97 is adjusted by the wage-index budget neutrality factor, a case-mix weights budget neutrality factor, an adjustment for nominal case-mix growth, and the home health market basket update, as reflected in Figure 12.C.2018-1.

To calculate the CY 2018 national per-visit rates, the 2017 national per-visit rates are adjusted by a wage index budget neutrality factor and CY 2018 HH market basket update. National per-visit rates are not subjected to the nominal increase in case-mix. The final updated CY 2018 national per-visit rates per discipline are reflected in Figure 12.C.2018-2:

For CY 2018, 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.

EXAMPLE: If the first skilled visit is SN, the payment for the visit would be $264.59 ($143.40 multiplied by 1.8451), subject to area wage adjustment.

Payments for the NRS are computed by multiplying the relative weight for a particular severity level by the NRS conversion factor. For CY 2018, the 2017 NRS conversion factor was updated by the CY 2018 HH market basket. See Figure 12.C.2018-3.

The payment amounts, using the above computed CY 2018 NRS conversion factor ($53.03), for the various severity levels based on the updated conversion factor are calculated in Figure 12.C.2018-4.

For CY 2018, 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 2018 is 0.55. The wage-adjusted FDL amount is added to the case-mix and wage-adjusted 60-day episode payment amount to determine the threshold amount that costs have to exceed before TRICARE would pay 80 percent (loss sharing ratio) of the additional estimated costs.

The methodology to calculate the outlier payment will utilize a cost-per-unit approach rather than a cost-per-visit approach. The national per-visit rates are converted into per 15 minute unit rates. The per-unit rate by discipline will be used along with the visit length data reported on the home health claim to calculate the estimated cost of an episode to determine whether the claim will receive an outlier payment and the amount of payment for an episode of care.

HHAs must collect OASIS data in order to participate in the TRICARE program.

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 50208 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, 2019. 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 2018 national standardized 60-day episode payment of $3,039.64 was increased by 3% to $3,130.83.

The CY 2018 national per-visit amounts were increased by 3% for beneficiaries who reside in rural areas. See Figure 12.C.2018-6.

The CY 2018 NRS Conversion Factor was multiplied by the 3% rural add-on to result in a NRS Conversion Factor of $54.62 for CY 2018.

The CY 2018 NRS payment amounts for services provided in rural areas are summarized in Figure 12.C.2018-7: