Information and resources on Medicare payment and policies in the home health setting. If you have questions about this information, contact firstname.lastname@example.org.
News and Updates
Patient-Driven Groupings Model
July 2, 2018: the Centers for Medicare and Medicaid Services (CMS) issued its proposed rule for calendar year 2019, which includes a new case-mix methodology for home health payments that would begin in 2020. The new case-mix system, termed the Patient-Driven Groupings Model (PDGM), would rely more heavily on patient characteristics and other information to better align payments with patients’ needs. Under the proposed PDGM, as mandated by the Bipartisan Budget Act of 2018, the unit of payment would switch from 60-day episodes of care to 30-day periods and remove therapy visit thresholds as a determinant of payment. The PDGM would base case-mix adjustment solely on patient characteristics—including diagnosis, functional level, comorbidities, and admission source—to place patients into clinically meaningful payment categories.
Additional Resources on the PDGM:
Review Choice Demonstration
September 26, 2018: CMS followed up on its May 31 announcement by proposing to begin the Review Choice Demonstration on December 10, 2018, in Illinois. (No further information was given on the other 4 states originally named in the announcement.) CMS will continue to post additional information on its Review Choice Demonstration for Home Health Services webpage.
May 31, 2018: CMS issued a notice indicating its intention to re-launch a home health agency (HHA) pre-claim review demonstration project it had shelved in 2017. Now called the Review Choice Demonstration for Home Health Services, the revised demonstration will begin no earlier than October 1, 2018, in 5 states.
The original program had drawn criticism that it created significant administrative burdens and reduced access to care. The revised Review Choice Demonstration will give HHAs in the demonstration states 3 options: pre-claim review of all claims, postpayment review of all claims, or minimal postpayment review with a 25% payment reduction for all home health services. The demonstration initially will apply to HHA providers in Florida, Illinois, North Carolina, Ohio, and Texas, with the option to expand after 5 years to other states in the Medicare Administrative Contractor Jurisdiction M (Palmetto).
In regards to a new home health payment system, within the Bipartisan Budget Act of 2018, Congress instructed CMS to develop and implement a new case-mix methodology for the home health prospective payment system by January 1, 2020. Similar to the previously proposed but withdrawn Home Health Groupings Model (HHGM), payment will be based on a 30-day unit of service; additionally, therapy visits will be eliminated as a payment factor. APTA expects CMS to release more details about the model in spring 2019.
Additional Resources on the Review Choice Demonstration: