(Final
payment amounts per 60-day episodes ending on or after January 1,
2019, and before January 1, 2020 - Continuing Calendar Year (CY)
update.)
Home
Health Agency Prospective Payment System (HHA PPS) - Determination
of Standard HHA PPS amounts
Section
1895(b)(3)(B) of the Act, as amended by section 5201 of the Deficit
Reduction Act (DRA), requires for CY 2019 that the standard prospective
payment amount be increased by a factor equal to the applicable
Home Health (HH) market basket update for HHAs.
National
60-Day Episode Payment Amounts - CY 2019
In
order to calculate the CY 2019 national standardized 60-day episode,
the CY 2018 estimated average payment per 60-day episode of $3,039.64
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.2019-1.
Figure 12.C.2019-1 CY 2019 National Standardized
60-Day Episode Payment Amounts
CY 2018
National Standardized 60-Day Episode Payment
|
Wage Index
Budget Neutrality Factor
|
Case-Mix
Weights Budget Neutrality Factor
|
CY 2018
HH Payment Update Percentage
|
CY 2019
National, Standardized
60-Day Episode Payment
|
$3,039.64
|
x 0.9985
|
x 1.0169
|
x 1.022
|
= $3,154.27
|
National
Per-Visit Amounts Used to Pay Low Utilization Payment Adjustments
(LUPAs) and Compute Costs of Outlier - CY 2019
To
calculate the CY 2018 national per-visit rates, the 2018 national
per-visit rates are adjusted by a wage index budget neutrality factor
and CY 2019 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.2019-2:
Figure 12.C.2019-2 CY 2019 National Per-Visit
Payment Amounts For HHAs
HH Discipline
Type
|
CY 2018
Per-Visit Payment
|
Wage Index Budget
Neutrality Factor
|
CY 2019
HH Payment Update Percentage
|
CY 2019
Per-Visit Payments
|
HH Aide
|
$64.94
|
x 0.9996
|
x 1.022
|
$66.34
|
Medical Social
Services (MSS)
|
229.86
|
x 0.9996
|
x 1.022
|
234.82
|
Occupational
Therapy (OT)
|
157.83
|
x 0.9996
|
x 1.022
|
161.24
|
Physical Therapy
(PT)
|
156.76
|
x 0.9996
|
x 1.022
|
160.14
|
Skilled Nursing
(SN)
|
143.40
|
x 0.9996
|
x 1.022
|
146.50
|
Speech-Language
Pathology (SLP)
|
170.38
|
x 0.9996
|
x 1.022
|
174.06
|
Payment
of LUPA Episodes
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 $270.31 ($146.50 multiplied by 1.8451), subject to area wage
adjustment.
NRS
Conversion Factor Update
Payments
for the NRS are computed by multiplying the relative weight for
a particular severity level by the NRS conversion factor. For CY
2019, the 2018 NRS conversion factor was updated by the CY 2019
HH market basket. See
Figure 12.C.2019-3.
Figure 12.C.2019-3 CY 2019 NRS
Conversion Factor
CY 2018
NRS Conversion Factor
|
CY 2019
HH Payment
Update Percentage
|
CY 2019
NRS Conversion Factor
|
$53.03
|
x 1.022
|
= $54.20
|
The
payment amounts, using the above computed CY 2019 NRS conversion
factor ($54.20), for the various severity levels based on the updated
conversion factor are calculated in
Figure 12.C.2019-4.
Figure 12.C.2019-4 CY 2019 Relative
Weights For The Six-Severity NRS System
Severity
Level
|
Points
(Scoring)
|
Relative
Weight
|
CY 2018
NRS Payment Amounts
|
1
|
0
|
0.2698
|
$14.62
|
2
|
1 to 14
|
0.9742
|
52.80
|
3
|
15 to 27
|
2.6712
|
144.78
|
4
|
28 to 48
|
3.9686
|
215.10
|
5
|
49 to 98
|
6.1198
|
331.69
|
6
|
99+
|
10.5254
|
570.48
|
Labor
And Non-Labor Percentages
For
CY 2019, the labor percent is 76.1%, and the non-labor percent is
23.9%.
Outlier
Payments
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 2019 is 0.51. 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.
Figure 12.C.2019-5 CY 2019 Cost-Per-Unit Payment
Rates For The Calculation Of Outlier Payments
Visit
Type
|
CY 2019
National Per-Visit Payment Rates
|
Average
Minutes-per-visit
|
Cost-per-unit
(1 unit = 15 minutes)
|
HH aide
|
$66.34
|
63.0
|
$15.80
|
MSS
|
234.82
|
56.5
|
62.34
|
OT
|
161.24
|
47.1
|
51.35
|
PT
|
160.14
|
46.6
|
51.55
|
SN
|
146.50
|
44.8
|
49.05
|
SLP
|
174.06
|
48.1
|
54.28
|
Outcome
and Assessment Information Set (OASIS)
HHAs
must collect OASIS data in order to participate in the TRICARE program.
Temporary
Rural Add-On Payment for the HHA PPS
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. Section 50208(a)(1)(D) of the Bipartisan
Budget Act (BBA) amended section 421 of the MMA to provide rural
add-on payments for episodes and visits ending on or after January
1, 2019, and before January 1, 2023. Unlike previous years, where
a 3% rural add-on was applied to all rural areas, the new rural
add-on extension for CYs 2019 through 2022 provides varying add-on amounts
depending on the rural county (or equivalent areas) and assigning
rural counties to one of three categories:
• High
utilization category -- rural counties and equivalent areas in highest
quartile of all counties and equivalent areas based on number of
Medicare home health episodes furnished per 100 Medicare beneficiaries
excluding counties or equivalent areas with 10 or fewer episodes
during 2015;
• Low population
density category -- rural counties and equivalent areas with a population density
of six individuals or less per square mile of land area and that
are not included in the high utilization category; or
• All
other rural counties and equivalent areas.
The
rural add-on payment percentages for visits and episodes ending
during CY 2019 are listed below in Figure
Figure 12.C.2019-6:
Figure 12.C.2019-6 CY 2019 Rural Add-On Percentages
By Category
Category
|
CY 2019
|
High Utilization
|
1.5%
|
Low Population
Density
|
4%
|
All Other
|
3%
|
Effective for service dates on or
after January 1, 2019, HHAs will be required to enter the Federal Information
Processing Standards (FIPS) state and county code where the beneficiary
resides on each claim, and they will continue to provide the CBSA
codes on the claims. The contractors shall apply rural payment rates
based on whether the FIPS state and county code is in the list of
codes associated with one of three categories of rural counties.
Claims shall be returned for correction when the FIPS code is missing
or invalid. The county-based rural add-on shall be 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.
For
rural county or equivalent area names, their FIPS state and county
codes, and their designation into one of the three rural add-on
categories, refer to the CMS website at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Home-Health-Prospective-Payment-System-Regulations-and-Notices-Items/CMS-1689-P.html.