CMS Issues Display Copy of Updates to Home Health Agency PPS Rules

On October 31, the Centers for Medicare and Medicaid Services (“CMS”) released the display copy of the CY 2019 Home Health Prospective Payment System Rate Update and CY 2020 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model (“Final Rule”), which included other updates of interest to home health agency providers. The Final Rule will be published in the Federal Register on November 13, 2018 and will be effective on January 1, 2019, except for specific provisions related to the new value-based purchasing model and the new home infusion therapy services benefit. CMS believes the provisions of the Final Rule will strengthen and modernize the home health prospective payment system by “focus[ing] on patient needs and not on the volume of care,” according to CMS Administrator, Seema Verma.

Among the provisions of the Final Rule that may be of interest to home health agencies (“HHAs”) are the following:

New Case-Mix Payment System

  • Beginning on or after January 1, 2020, HHAs will be paid under a new payment model, the Patient-Driven Groupings Model (“PDGM”), which relies more on patient clinical characteristics and other patient information (such as diagnosis, functional level, comorbid conditions, and admission source, community or institutional) to place patients into meaningful payment categories and eliminates the current therapy service thresholds now used to case-mix adjust payments under the current HHA PPS methodology.
  • The PDGM methodology will also change in the unit of payment from 60-day episodes of care as units of payment to 30-day periods of care for home health services.
  • The Final Rule further describes the methodology for assignments to payment classifications, calculation of the cost of care, and other aspects of payment under the PDGM.

Access to Remote Patient Monitoring Technology

  • Under the Final Rule, HHAs will be permitted to report the costs of remote patient monitoring as allowable administrative costs for Medicare cost reporting purposes. CMS believes the use of this technology can promote greater patient independence and empowerment and encourage patients to share data with caregivers and providers, thereby augmenting the care planning process and resulting in more effective care.
  • The Final Rules define “remote patient monitoring” for purposes of the Medicare home health benefit as “the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient or caregiver or both to the home health agency.”
  • CMS added the following language to the regulations to ensure a more complete description of remote patient monitoring services, while also ensuring that such services cannot be reported as a visit without the provision of another skilled service: Visits to a beneficiary’s home for the sole purpose of supplying, connecting, and/or training the patient on the remote patient monitoring equipment, without the provision of another skilled service are not separately billable. These services do constitute services included in the expense of providing remote patient monitoring allowed as administrative costs.
  • CMS is amending the regulations at 42 C.F.R. § 409.46 to include the costs of remote patient monitoring as an allowable administrative cost (i.e., an operating expense), if remote patient monitoring is used by the HHA to augment the care planning process.

Home Infusion Therapy Services Benefit

  • Section 5012 of the 21st Century Cures Act established a new Medicare home infusion therapy benefit, which covers the professional services, including nursing services furnished under a plan of care, patient training and education (that is not otherwise covered under the DME benefit), remote monitoring, and monitoring services for the provision of home infusion therapy and home infusion drugs furnished by a qualified home infusion therapy supplier. A “qualified home infusion therapy supplier” includes pharmacies, physicians, or other providers of services or suppliers licensed by the state in which supplies or services are furnished.
    • Note that pharmacy services associated with preparing and dispensing home infusion therapy drugs are covered under the Medicare Part B DME benefit and are not part of the new home infusion therapy services benefit.
  • The Final rule establishes standards and requirements governing the provision of home infusion therapy services.
    • Qualified home infusion therapy suppliers must obtain accreditation from approved accrediting organizations.
    • CMS is adding new 42 CFR Part 486, subpart I, to incorporate the home infusion therapy supplier requirements. Home infusion therapy suppliers must, among other things:
      • Ensure that all patients must be under the care of an applicable provider (defined as a physician, a nurse provider, and a physician assistant) and have a plan of care established by the physician that prescribes the type, amount, and duration of home infusion therapy services that are furnished. The plan of care would also include the specific medication, the prescribed dosage and frequency as well as the professional services to be utilized for treatment, as well as care and services to meet patient-specific needs. The supplier must ensure that the plan of care is periodically reviewed by the physician.
      • Ensure that professional services are available on a 7-day-a-week, 24-hour-a-day basis in order to ensure that patients have access to expert clinical knowledge and advice in the event of an urgent or emergent infusion-related situation.
      • Provide patient training and education
      • Provide remote monitoring (for example, through follow-up telephone or other electronic communication, based on patient preference of communication) and monitoring services for the provision of home infusion therapy services and home infusion drugs furnished by the supplier, including direct monitoring during in-home patient visits.
    • CMS is seeking comments on its interpretation of certain aspects of the home infusion benefit.
    • The Final Rule implements the temporary transitional payments for home infusion therapy services for calendar years 2019 and 2020, until the new permanent home infusion therapy services benefits begins on January 1, 2021. CMS will consider additional comments as it works on developing the payment model for the permanent home infusion therapy services benefit.

Reduction of Unnecessary Reporting Requirements for Certifying Physicians

  • Under the Final Rule, certifying physicians will not have to estimate how much longer home health services will be needed when recertifying the need for continued HHA services.

CMS has also issued a Fact Sheet on these and other provisions of the Final Rule.  Please feel free to contact any member of the Health Law Department should you have any questions or need additional information on any of the provisions of the Final Rule.

This News Alert has been prepared for informational purposes only and should not be construed as, and does not constitute, legal advice on any specific matter. For more information, please see the disclaimer.