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.