(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 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.2021-1 Figure 12.C.2021-1 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.2021-1 Figure 12.C.2021-1 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.2021-1 Figure 12.C.2021-1 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.