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.