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.