(Final Calendar Year (CY) 2023
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 2023 be increased by a factor equal to the
applicable Home Health (HH) market basket for HHAs.
National 30-Day Episode
Payment Amounts - CY 2023
In order to calculate the CY
2023 national standardized 30-day episode payment for those 30-day
episodes that start on or after January 1, 2023, the CY 2022 budget
neutral standard amount is adjusted by the permanent behavior adjustment
(BA) factor, wage-index budget neutrality factor, and the HH update
factor, as reflected in
Figure 12.C.2023-1.
Figure 12.C.2023-1 CY 2023 National Standardized
30-Day Period Payment Amounts
CY 2022
30-Day Neutral Standard Amount
|
Permanent BA Factor
|
Wage Index Budget Neutrality
Factor
|
Case-Mix Budget Neutrality
Factor
|
CY 2023
HH Payment Update Percentage
|
CY 2023
National, Standardized
30-Day
|
$2,031.64
|
0.96075
|
x 1.0001
|
x 0.9904
|
x 1.040
|
= $2,010.69
|
National Per-Visit Amounts
Used to Pay Low Utilization Payment Adjustments (LUPAs) and Compute
Costs of Outlier - CY 2023
To calculate the CY 2023 national
per-visit rates, the 2022 national per-visit rates are adjusted
by a wage index budget neutrality factor and CY 2023 HH update factor.
The final updated CY 2023 national per-visit rates per discipline
are reflected in
Figure 12.C.2023-2:
Figure 12.C.2023-2 CY 2023 National Per-Visit
Payment Amounts For HHAs
HH Discipline Type
|
CY 2022
Per-Visit Payment
|
Wage Index Budget
Neutrality Factor
|
CY 2023
Payment Update
|
CY 2023
Per-Visit Payments
|
HH Aide
|
$71.04
|
x 1.0007
|
x 1.040
|
$73.93
|
Medical Social Services (MSS)
|
251.48
|
x 1.0007
|
x 1.040
|
261.72
|
Occupational Therapy (OT)
|
172.67
|
x 1.0007
|
x 1.040
|
179.70
|
Physical Therapy (PT)
|
171.49
|
x 1.0007
|
x 1.040
|
178.47
|
Skilled Nursing (SN)
|
156.90
|
x 1.0007
|
x 1.040
|
163.29
|
Speech-Language Pathology (SLP)
|
186.41
|
x 1.0007
|
x 1.040
|
194.00
|
Payment of LUPA Episodes
For CY 2023, 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 SLP, the payment for the visit would be $303.21 ($186.41 multiplied
by 1.6266), subject to area wage adjustment, as is the current process.
Non-Routine Supply (NRS)
Conversion Factor Update
Under the Patient Driven Groupings
Model (PDGM), NRS payments are included in the 30-day base payment
rate. Durable Medical Equipment (DME) 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 2023, 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.
For CY 2023, the FDL ratio is calculated at 0.35.
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 HH 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.2023-3 CY 2023 Cost-Per-Unit Payment
Rates For The Calculation Of Outlier Payments
Visit Type
|
CY 2023 National Per-Visit
Payment Rates
|
Average Minutes-per-visit
|
Cost-per-unit (1 unit
= 15 minutes)
|
HH aide
|
$73.93
|
63.0
|
$17.60
|
MSS
|
261.72
|
56.5
|
69.48
|
OT
|
179.70
|
47.1
|
57.23
|
PT
|
178.47
|
46.6
|
57.45
|
SN
|
163.29
|
44.8
|
54.67
|
SLP
|
194.00
|
48.1
|
60.50
|
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 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 Medicare Prescription
Drug, Improvement, and Modernization Act (MMA) to provide rural
add-on payments for episodes and visits ending on or after January
1, 2019, and before January 1, 2023. However, Section 4137 of the
Consolidated Appropriations Act of 2023 extended the rural add-on
by providing an increase of 1% of the payment made for HH services
provided in the low utilization category for CY 2023. The new rural
add-on extension for CYs 2019 through 2023 provides varying add-on
amounts depending on the rural county (or equivalent areas) and
assigning rural counties to one of three categories listed below.
There is no change in the rural add-on percentage between CY 2022
and CY 2023.
• High utilization category --
rural counties and equivalent areas in highest quartile of all counties
and equivalent areas based upon number of Medicare HH 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 2023 are listed below in
Figure 12.C.2023-4:
Figure 12.C.2023-4 CY 2023 Rural Add-On Percentages
By Category
Category
|
CY 2023
|
High Utilization
|
0.0%
|
Low Population Density
|
1%
|
All Other
|
0.0%
|
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, and the LUPA add-on
payment amount 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.
HH 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% for any decreases in wage index value from CY 2020 to
CY 2021. For CY 2023, a permanent 5% cap on any decrease to a geographic
area’s wage index from its wage index in the prior year applies
regardless of the circumstances causing the decline.
For a complete list of new
CBSA designations as well as those wage indexes affected by the
5% 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.