July 14, 2021 | Jessica Zeff

6 min read

Current CMS Home Health Proposed Rules: Where It Stands

At the end of June, CMS released the 2022 Home Health Prospective Payment System (PPS) Proposed Rule.  Here we touch on the top headlines with a version for those in a hurry and those who wish to know more!  Note: These are proposed rules – which means CMS is looking for feedback on the proposals.  The deadline for submitting feedback on this proposed rule is 08/27/2021.

In a Nutshell

CMS is proposing to accelerate the shift from paying for Medicare home health services based on volume to a system that pays for value and quality by proposing a nationwide expansion of the Home Health Value-Based Purchasing (HHVBP) Model. Home health providers may receive an estimated increase of $310 million in reimbursement, a 1.7% increase. There are also proposals and routine updates to the Medicare Home Health Prospective Payment System (HH PPS) and the home infusion therapy services payment rates for CY 2022.  Permanent changes to the Conditions of Participation (CoP) that were implemented during the PHE are proposed as well.

A Further Look

Payment and Policy Updates

CMS is proposing to recalibrate the PDGM case-mix weights, functional levels, and comorbidity adjustment subgroups but will maintain the low utilization payment adjustment (LUPA) thresholds from CY 2021 for CY 2022. 

CMS is also proposing updates to the following:

  • Home health wage index
  • CY 20-22 national
  • Standardized 30-day period payments amounts
  • CY 2022 national per-visit payment amounts
    • 1.8% change
    • Fixed Dollar Loss (FDL) Ratio to 0.41 for CY 2022

Patient-Driven Groupings Model (PDGM)

No changes to PDGM are proposed for 2022.  Home Health Resource Groupings are proposed to continue with the same 432 case-mix groups as 2021. 

CMS also notes they will continue to monitor and analyze section GG items.  Changes to the use of GG will be addressed in future rulemaking.

Medicare Coverage of Home Infusion Therapy

  • Proposed payment adjustments
  • Proposed updates to geographic adjustment factors (GAFs) used for wage adjustment
  • Proposal to maintain the percentages finalized for the initial and subsequent visit policy

Conditions of Participation

Supervision of Home Health Aides

Some of the home health aide supervision waivers that were issued during the PHE are to be made permanent.  CMS is also proposing HHAs be allowed to use audio/video communications for supervision, on occasion, but this form of supervision cannot exceed two virtual supervisory assessments per HHA in a 60-day period.

A supervisory assessment by the HH Supervisor must be completed either onsite or through audio/visual communications every 14 days. 

CMS is proposing to maintain the requirement that a registered nurse must make a visit in person every 60 days but is proposing to remove the requirement that the RN directly observe the aide in person.  

Occupational Therapy

As part of the Consolidated Appropriations Act of 2021 that was signed on December 27, 2020, occupational therapists were allowed to open home health therapy cases during the COVID-19 PHE, and CMS is proposing to make this change permanent.

CMS proposes to update the Conditions of Participation to allow occupational therapists to complete the initial and comprehensive assessments required to open Medicare home health therapy cases for Medicare beneficiaries under the home health benefit when:

  1. Skilled nursing is not included in the initial plan of care; and
  2. Either physical therapy or speech-language pathology is included in the original plan of care.

To support the above change, CMS proposes to create a LUPA add-on factor for CY 2022 for occupational therapy that will be the same as physical therapy until more accurate data can be gathered and analyzed.  The proposed LUPA add-on factor is 1.6700 for occupational therapy.

Home Health Value-Based Purchasing (HHVBP) Program

HHVBP Program expansion

The current HHVBP model requires only nine states to participate.  The model has demonstrated an improvement in quality scores of 4.6% and an average cost savings of $141 million annually for Medicare.  CMS is proposing to end the existing program one year early for the original nine states, and to expand the program to all 50 states, the District of Columbia, and the territories, beginning with the performance year 2022.  All HHAs certified prior to 1/1/2021 would be required to participate. 

A payment adjustment of 5% based on quality performance is proposed for 2024 which corresponds to the performance year 2022.  Additionally, if finalized, CY 2020 data would not be used to make payment adjustments for CY 2022 for the original model states.

Measure Changes

Initially, CMS is proposing to continue to use the initial measure set for the expanded Home Health Value-Based Program and consider other measures with future rulemaking.  The set includes claims-based, OASIS-based and HHCAHPS survey-based measures.

CMS is also considering aligning the HHVBP Program measures with the HH QRP program.   The Acute Care Hospitalization During the First 60 Days of Home Health (ACH) Measure and the Emergency Department Use Without Hospitalization During the First 60 days of Home Health (ED Use) measure are included in the measure set for CY 2022.  Feedback is requested on including these measures for CY 2020 in the HHVBP Program as the HH QRP is considering removing these measures in CY 2023.

Home Health Quality Reporting Program (HH QRP)

Measure Changes

There are a total of 20 measures currently included in the CY 2022 HH QRP.

Due to measure performance being so high, CMS is proposing to remove the Drug Education on All Medications Provided to Patient/Caregiver Measure for CY 2023.  This measure corresponds to M2016 on the OASIS.  CMS believes that the Improvement in Management of Oral Medications (OASIS item M2020) measure better addresses medication management.

CMS proposes to replace the Acute Care Hospitalization During the First 60 Days of Home Health (ACH) Measure and the Emergency Department Use Without Hospitalization During the First 60 days of Home Health (ED Use) measure with the Home Health Within-Stay Potentially Preventable Hospitalization (PPH) measure beginning CY 2023.  The PPH measure is claims-based.

OASIS-E

With updates to the HH QRP, CMS is proposing to implement data collection for the Transfer of Health (TOH) measures.  The measures are the Transfer of Health Information to Provider-Post Acute care and the transfer of Health Information to Patient-PAC measure as well as six categories of standardized patient assessment data elements.  This would require the use of the OASIS-E for data collection beginning 1/1/2023.  Updating to this version was previously delayed until two years after the year in which the PHE ends.  CMS feels that practitioners are equipped to move forward sooner.  If this proposal is finalized, the OASIS-E will be available in early 2022.

Survey and Enforcement Requirements for Hospice Programs

CMS is proposing enhancements to the hospice program survey process:

  • Requiring the use of multidisciplinary survey teams
  • Prohibiting surveyor conflicts of interest
  • Expanding CMS-based surveyor training to accrediting organizations (AOs)
  • Requiring AOs with CMS-approved hospice programs to begin use of the Form CMS-2567
  • Establishes a hospice program complaints hotline
  • Creates a Special Focus Program (SFP) for poor-performing hospice programs and the authority to impose penalties

Rule Timeframe:

Released: 6/28/2021
Comment period ends: 8/27/2021
Final Rules anticipated: 10/1/2021
Final Rules effective: 1/1/2022

References and Resources:

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