Military Health System

(Final Calendar Year (CY) payment amounts for 60-day episodes and 30-day periods of care.)

Title XVIII of the Social Security Act, Section 1895(b)(3)(B), requires that HHA PPS rates provided to HHAs are updated annually. For CY 2020, the HHA PPS rate update includes implementation of the Patient-Driven Groupings Model (PDGM), a revised case-mix adjustment methodology for services beginning on or after January 1, 2020.

In order to calculate the CY 2020 national standardized 60-day episode payment for those 60-day episodes that start on or before December 31, 2019, and end on or after January 1, 2020--episodes that span into 2020--the CY 2019 estimated average payment per 60-day episode of $3,154.27 is adjusted by the wage-index budget neutrality factor, and the home health update factor, as reflected in Figure 12.C.2020-1.

In order to calculate the CY 2020 national standardized 30-day period for those 30-day periods of care that start on or after January 1, 2020, the CY 2019 budget neutral standard amount is adjusted by the wage-index budget neutrality factor, and the home health update factor, as shown in Figure 12.C.2020-2.

To calculate the CY 2020 national per-visit rates, the 2019 national per-visit rates are adjusted by a wage index budget neutrality factor and CY 2019 HH update factor. The final updated CY 2020 national per-visit rates per discipline are reflected in Figure 12.C.2020-3:

For CY 2020, as described in the December 2, 2013, Centers for Medicare and Medicaid Services (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, as is the current process.

Effective January 1, 2020, the NRS payment amounts apply to only those 60-day episodes that begin on or before December 31, 2019, but span the implementation of the PDGM and the 30-day unit of payment on January 1, 2020 (ending on February 28, 2020). Under the PDGM, NRS payments are included in the 30-day base payment rate. Payments for the NRS are computed by multiplying the relative weight for a particular severity level by the NRS conversion factor. For CY 2020, the 2019 NRS conversion factor was updated by the CY 2020 HH update factor. See Figure 12.C.2020-4.

The payment amounts, using the above computed CY 2020 NRS conversion factor ($55.01), for the various severity levels based upon the updated conversion factor are calculated in Figure 12.C.2020-5.

For CY 2020, the labor percent is 76.1%, and the non-labor percent is 23.9%.

Under the HHA PPS, outlier payments are made for episodes or periods of care 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 those 60-day episodes that span into CY 2020 will remain at 0.51. However, the FDL ration for 30-day periods of care in CY 2020 is 0.56.

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 shall 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 shall receive an outlier payment and the amount of payment for an episode of care.

HHAs shall collect OASIS data in order to participate in the TRICARE program. The current version of the OASIS data set is available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/OASIS-Data-Sets.html.

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:

The rural add-on payment percentages for visits and episodes ending during CY 2020 are listed below in Figure Figure 12.C.2020-7:

Effective for service dates on or after January 1, 2019, HHAs shall be required to enter the Federal Information Processing Standards (FIPS) state and county code where the beneficiary resides on each claim, and they shall continue to provide the Core Based Statistical Area (CBSA) codes on the claims. The contractors shall apply rural payment rates based upon 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-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/Center/Provider-Type/Home-Health-Agency-HHA-Center.