(Final Calendar Year (CY) 2021
payment amounts for 30-day periods of care.)
Home Health Agency Prospective
Payment System (HHA PPS) - Determination of Standard HHA PPS amounts
Title XVIII of the Social Security
Act, Section 1895(b)(3)(B), requires that HHA PPS rates provided
to HHAs are updated annually. The Act requires that standard prospective
payment amounts for CY 2021 be increased by a factor equal to the
applicable Home Health market basket for HHAs.
National 30-Day Episode
Payment Amounts - CY 2021
In order to calculate the CY
2020 national standardized 30-day episode payment for those 30-day episodes
that start on or after January 1, 2021, the CY 2020 budget neutral
standard amount is adjusted by the wage-index budget neutrality
factor, and the home health update factor, as reflected in
Figure 12.C.2021-1.
Figure 12.C.2021-1 CY 2021 National Standardized
30-Day Period Payment Amounts
CY 2020
30-Day Neutral Standard Amount
|
Wage Index Budget Neutrality
Factor
|
CY 2021
HH Payment Update Percentage
|
CY 2021
National, Standardized
30-Day
|
$1,864.03
|
x 1.9999
|
x 1.020
|
= $1,901.12
|
National Per-Visit Amounts
Used to Pay Low Utilization Payment Adjustments (LUPAs) and Compute
Costs of Outlier - CY 2021
To calculate the CY 2021 national
per-visit rates, the 2020 national per-visit rates are adjusted
by a wage index budget neutrality factor and CY 2020 HH update factor.
The final updated CY 2021 national per-visit rates per discipline
are reflected in
Figure 12.C.2021-2:
Figure 12.C.2021-2 CY 2021 National Per-Visit
Payment Amounts For HHAs
HH Discipline Type
|
CY 2019
Per-Visit Payment
|
Wage Index Budget
Neutrality Factor
|
CY 2020
Payment Update Percentage
|
CY 2020
Per-Visit Payments
|
HH Aide
|
$67.78
|
x 1.9997
|
x 1.020
|
$69.11
|
Medical Social Services (MSS)
|
239.92
|
x 1.9997
|
x 1.020
|
244.64
|
Occupational Therapy (OT)
|
164.74
|
x 1.9997
|
x 1.020
|
167.98
|
Physical Therapy (PT)
|
163.61
|
x 1.9997
|
x 1.020
|
166.83
|
Skilled Nursing (SN)
|
149.68
|
x 1.9997
|
x 1.020
|
152.63
|
Speech-Language Pathology (SLP)
|
177.84
|
x 1.9997
|
x 1.020
|
181.34
|
Payment of LUPA Episodes
For CY 2021, 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.
Non-Routine Supply (NRS)
Conversion Factor Update
Under the PDGM, NRS payments
are included in the 30-day base payment rate. Durable Medical Equipment
are paid separately, and they are not included in the not included
in the 30-day base payment rate.
Labor And Non-Labor Percentages
For CY 2021, 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 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. There
was no change to the FDL ratio for CY 2021. Therefore, the FDL ration
for 30-day periods of care in CY 2021 will remain at 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.
Figure 12.C.2021-3 CY 2021
Cost-Per-Unit Payment Rates For The Calculation Of Outlier Payments
Visit Type
|
CY 2021
National Per-Visit Payment Rates
|
Average
Minutes-per-visit
|
Cost-per-unit
(1 unit = 15 minutes)
|
HH aide
|
$69.11
|
63.0
|
$16.45
|
MSS
|
244.64
|
56.5
|
64.95
|
OT
|
167.98
|
47.1
|
53.50
|
PT
|
166.83
|
46.6
|
53.70
|
SN
|
152.63
|
44.8
|
51.10
|
SLP
|
181.34
|
48.1
|
56.55
|
Outcome and Assessment
Information Set (OASIS)
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.
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 upon 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 2021 are listed below in
Figure 12.C.2021-4:
Figure 12.C.2021-4 CY 2021 Rural Add-On Percentages
By Category
Category
|
CY 2011
|
High Utilization
|
0.0%
|
Low Population Density
|
2%
|
All Other
|
1%
|
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 30-day period rate, the national per-visit rates, the
LUPA add-on payment amount, and the n 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.
Home Health Wage Index
On September 14, 2018, the
Office of Management and Budget (OMB) issued OMB Bulletin No. 18-04, established
revisions to the delineation of Metropolitan Statistical Areas (MSAs),
Micropolitan Statistical Areas, and Combined Statistical Areas,
and guidance on uses of the delineation in these areas. These revisions
shall be adopted effective for claims with “Through” dates on or
after January 1, 2021, and shall include a one-year transition cap
of 5 percent for any decreases in wage index value from CY 2020 to
CY 2021.
For a complete list of new
CBSA designations as well as those wage indexes affected by the
5 percent cap, refer to the CMS website at
https://www.cms.gov/files/zip/cy-2021-hh-pps-wage-index.zip.
The OMB bulletin 18-04 is located at
https://whitehouse.gov/wp-content/uploads/2018/09/Bulletin-18-04.pdf.