(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.