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TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
Home Health Care (HHC)
Chapter 12
Addendum C (CY 2020)
Annual Home Health Agency Prospective Payment System (HHA PPS) Rate Updates - CY 2020
Revision:  C-46, March 26, 2020
(Final Calendar Year (CY) payment amounts for 60-day episodes and 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. For CY 2020, the HHA PPS rate update includes implementation of the Patient-Driven Groupings Model (PDGM), a revised case-mix adjustment methodology for services beginning on or after January 1, 2020.
National 60-Day Episode Payment Amounts - CY 2020
In order to calculate the CY 2020 national standardized 60-day episode payment for those 60-day episodes that start on or before December 31, 2019, and end on or after January 1, 2020--episodes that span into 2020--the CY 2019 estimated average payment per 60-day episode of $3,154.27 is adjusted by the wage-index budget neutrality factor, and the home health update factor, as reflected in Figure 12.C.2020-1.
Figure 12.C.2020-1  CY 2020 National Standardized 60-Day Episode Payment Amounts
CY 2019 National Standardized 60-Day Episode Payment
Wage Index Budget Neutrality Factor
CY 2020 HH Payment Update Percentage
CY 2020 National, Standardized 60-Day Episode Payment
$3,154.27
x 1.0060
x 1.015
= $3,220.79
National 30-Day Period Payment Amounts - CY 2020
In order to calculate the CY 2020 national standardized 30-day period for those 30-day periods of care that start on or after January 1, 2020, the CY 2019 budget neutral standard amount is adjusted by the wage-index budget neutrality factor, and the home health update factor, as shown in Figure 12.C.2020-2.
Figure 12.C.2020-2  CY 2020 National Standardized 30-Day Period Payment Amounts
CY 2019 30-Day Neutral Standard Amount
Wage Index Budget Neutrality Factor
CY 2020 HH Payment Update Percentage
CY 2020 National, Standardized 30-Day
$1,824.99
x 1.0063
x 1.015
= $1,864.03
National Per-Visit Amounts Used to Pay Low Utilization Payment Adjustments (LUPAs) and Compute Costs of Outlier - CY 2020
To calculate the CY 2020 national per-visit rates, the 2019 national per-visit rates are adjusted by a wage index budget neutrality factor and CY 2019 HH update factor. The final updated CY 2020 national per-visit rates per discipline are reflected in Figure 12.C.2020-3:
Figure 12.C.2020-3  CY 2020 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
$66.34
x 1.0066
x 1.015
$67.79
Medical Social Services (MSS)
234.82
x 1.0066
x 1.015
239.92
Occupational Therapy (OT)
161.24
x 1.0066
x 1.015
164.74
Physical Therapy (PT)
160.14
x 1.0066
x 1.015
163.61
Skilled Nursing (SN)
146.50
x 1.0066
x 1.015
149.68
Speech-Language Pathology (SLP)
174.06
x 1.0066
x 1.015
177.84
Payment of LUPA Episodes
For CY 2020, 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
Effective January 1, 2020, the NRS payment amounts apply to only those 60-day episodes that begin on or before December 31, 2019, but span the implementation of the PDGM and the 30-day unit of payment on January 1, 2020 (ending on February 28, 2020). Under the PDGM, NRS payments are included in the 30-day base payment rate. Payments for the NRS are computed by multiplying the relative weight for a particular severity level by the NRS conversion factor. For CY 2020, the 2019 NRS conversion factor was updated by the CY 2020 HH update factor. See Figure 12.C.2020-4.
Figure 12.C.2020-4  CY 2020 NRS Conversion Factor
CY 2019 NRS Conversion Factor
CY 2020 HH Payment Update Percentage
CY 2020 NRS Conversion Factor
$54.20
x 1.015
= $55.01
The payment amounts, using the above computed CY 2020 NRS conversion factor ($55.01), for the various severity levels based upon the updated conversion factor are calculated in Figure 12.C.2020-5.
Figure 12.C.2020-5  CY 2020 Relative Weights For The Six-Severity NRS System
Severity Level
Points (Scoring)
Relative Weight
CY 2018 NRS Payment Amounts
1
0
0.2698
$14.84
2
1 to 14
0.9742
53.59
3
15 to 27
2.6712
146.94
4
28 to 48
3.9686
218.31
5
49 to 98
6.1198
336.65
6
99+
10.5254
579.00
Labor And Non-Labor Percentages
For CY 2020, 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. The FDL ratio, which is used in calculating the FDL amount for those 60-day episodes that span into CY 2020 will remain at 0.51. However, the FDL ration for 30-day periods of care in CY 2020 is 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.2020-6  CY 2020 Cost-Per-Unit Payment Rates For The Calculation Of Outlier Payments
Visit Type
CY 2020 National Per-Visit Payment Rates
Average Minutes-per-visit
Cost-per-unit (1 unit = 15 minutes)
HH aide
$67.79
63.0
$16.14
MSS
239.92
56.5
63.70
OT
164.74
47.1
52.46
PT
163.61
46.6
52.66
SN
149.68
44.8
50.12
SLP
177.84
48.1
55.46
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 2020 are listed below in Figure Figure 12.C.2020-7:
Figure 12.C.2020-7  CY 2020 Rural Add-On Percentages By Category
Category
CY 2019
High Utilization
0.5%
Low Population Density
3%
All Other
2%
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 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-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.
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