Proposed Rule: Calendar Year 2025 Home Health Prospective Payment System (HH PPS)

The proposed Calendar Year (CY) 2025 Home Health Prospective Payment System (HH PPS) Rate Update; HH Quality Reporting Program Requirements; HH Value-Based Purchasing Expanded Model Requirements; Home Intravenous Immune Globulin (IVIG) Items and Services Rate Update; and Other Medicare Policies proposed rule (CMS-1803-P) was posted on the Federal Register Public Inspection desk on 6/2/2024. The comment period is 60 days from the publish date in the Federal Register. Instructions for submitting comments are included at the beginning of the rule.  Providers are strongly encouraged to review the rule in its entirety and submit comments to CMS. The process to submit comments is outlined at the beginning of the rule.

Here are the highlights of the proposed rule. 

Payment adjustment information:

CMS states the proposed actions in this rule would help improve patient care and protect the Medicare program’s sustainability for future generations. 

CMS proposes an adjustment to the CY 2025 home health payment rate of -4.067%. This adjustment accounts for differences between assumed behavior changes and actual behavior changes on estimated aggregate expenditures due to the CY 2020 implementation of the PDGM and the change to a 30-day unit of payment.
- CMS proposes a permanent adjustment to the base payment rate under the HH PPS to rebalance the Patient-Driven Groupings Model (PDGM) and make it budget-neutral.
  - Each of the 432 payment groups under the PDGM has an associated case-mix weight and LUPA threshold. CMS’ policy is to annually recalibrate the case-mix weights and LUPA thresholds using the most complete utilization data available at the time of rulemaking. In this proposed rule, CMS is proposing to recalibrate the case-mix weights — including the functional levels and comorbidity adjustment subgroups — and LUPA thresholds using CY 2023 data, to more accurately pay for the types of patients HHAs are serving.

CMS proposes to:
- update the fixed dollar loss (FDL) for outlier payments;
- update the low utilization payment adjustment (LUPA) thresholds, functional impairment levels, and comorbidity adjustment subgroups for CY 2025; establish a home health occupational therapy (OT) LUPA add-on factor; and update other LUPA add-on factors.

This rule includes a proposed rate update for the CY 2025 intravenous immune globulin (IVIG) items and services’ payment under the IVIG benefit. The updated home intravenous immune globulin items and services payment rate will be posted in the Billing and Rates section of the CMS’ Home Infusion Therapy (HIT) webpage (found at https://www.cms.gov/medicare/payment/fee-for-service-providers/home-infusion-therapy/billing-and-rates) once this rate is finalized.
It discusses how the CY 2025 payment rate update for the negative pressure wound therapy disposable device (dNPWT) will be applied.
This rule proposes to update the home health wage index and adopt the new labor market delineations from the July 21, 2023, OMB Bulletin No. 23-01 based on data collected from the 2020 Decennial Census. The July 21, 2023, OMB Bulletin No. 23-01 contains several significant changes. For example, there are new CBSAs, urban counties that have become rural, rural counties that have become urban, and existing CBSAs that have been split. We note that existing home health PPS regulations limit one-year wage index decreases to 5%, which will help mitigate the impact of CBSA changes on payment.

Patient-Driven Groupings Model (PDGM)

CMS includes analysis on home health utilization, as well as analysis determining the difference between assumed versus actual behavior change on estimated aggregate expenditures for home health payments as result of the change in the unit of payment to 30 days and the implementation of the Patient Driven Groupings Model (PDGM) case-mix adjustment methodology.

CMS proposes a crosswalk for mapping the Outcome and Assessment Information Set-D (OASIS-D) data elements to the equivalent OASIS-E data elements for use in the methodology to analyze the difference between assumed versus actual behavior change on estimated aggregate expenditures and proposes a permanent prospective behavior adjustment to the CY 2025 home health payment rate.
CMS proposes to recalibrate the PDGM case-mix weights and to update the low-utilization payment adjustment (LUPA) thresholds, functional impairment levels, and comorbidity adjustment subgroups.

Home Health CoP Changes

CMS proposes the following changes to § 484.105:

add a new standard at § 484.105(i) that would require HHAs to develop, implement, and maintain an acceptance to service policy that is applied consistently to each prospective patient referred for home health care. We propose to require that the policy be reviewed annually and address, at minimum, the following criteria related to the HHA’s capacity to provide patient care: the anticipated needs of the referred prospective patient, the HHA’s caseload and case mix, the HHA’s staffing levels, and the skills and competencies of the HHA staff.
at § 484.105(i)(1)(i) through (iv), HHAs would be required to include information regarding the HHA’s caseload and case mix (that is, the volume and complexity of the patients currently receiving care from the HHA), anticipated needs of the referred prospective patient, the HHA’s current staffing levels, and the skills and competencies of the HHA staff.
at § 484.105(i)(2), that HHAs make public accurate information regarding the services offered by the HHA and any limitations related to the types of specialty services, service duration, or service frequency, and that HHAs review that information annually or as necessary.

CMS requests public comment on these proposals:

they request comments on alternative ways to address the delay of home health care initiation, barriers for patients with complex needs to find and access HHAs, and other opportunities to improve transparency regarding home health patient acceptance policies to better inform referral sources.
They also request public comment regarding other ways to improve the referral process for referral sources, patients, and HHAs.

Crosswalk for Mapping OASIS-D Data Elements to The Equivalent OASIS-E Data Elements

The Outcome and Assessment Information Set (OASIS)-D was the home health assessment instrument used under the prior 153-group system and the first three years (CYs 2020-2022) of the current PDGM; however, the Office of Management and Budget (OMB) approved an updated version of the OASIS instrument, OASIS-E, on November 30, 2022, effective January 1, 2023 (OMB-control number 0938-1279). To accurately determine payments under the 153-group system, we use the October 2019 3M Home Health Grouper (v8219) to assign a Health Insurance Prospective Payment System (HIPPS) code to each simulated 60-day episode of care. This older version of the Home Health Grouper requires responses from OASIS-D. Therefore, to continue with the repricing methodology, CMS will need to impute responses for the three items from OASIS-D that have changed in the OASIS-E. Additionally, 13 items on the OASIS-E are no longer required to be asked at a follow-up visit. For these items, we can use the most recent SOC/ROC to determine a response, which would not require imputation. We are proposing a methodology to address this issue by mapping the OASIS-E items in this proposed rule.

Requests for Information (RFI)

1. RFI Regarding Rehabilitative Therapists Conducting the Initial and Comprehensive Assessment

CMS seeks public comments regarding whether CMS should shift its longstanding policy and permit all classes of rehabilitative therapists (PTs, SLPs, and OTs) to conduct the initial assessment and comprehensive assessment for cases that have both therapy and nursing services ordered as part of the plan of care. We ask the public for data, detailed analysis, academic studies, or any other information to support their comments that provide a direct link to patient health and safety. Specifically, we solicit comments regarding the following:
- What types of mentorships, preceptorship, or training do these disciplines have qualifying them to conduct the initial assessment and comprehensive assessment?
- How do HHAs currently assign staff to conduct the initial assessment and comprehensive assessment? Do HHAs implement specific skill and competency requirements?
Do the education requirements for entry-level rehabilitative therapists provide them with the skills to perform both the initial assessment and comprehensive assessment? Is this consistent across all the therapy disciplines? How does this compare with entry-level education for nursing staff?
What, if any, potential education or skills gaps may exist for rehabilitative therapists in conducting the initial assessment and comprehensive assessment?
What challenges did HHAs and therapists who conducted these assessments under the PHE waiver experience that may have impacted the quality of these assessments?
For the HHAs and therapists that conducted the initial assessment and comprehensive assessment under the PHE waiver, what were the benefits, and were there any unintended consequences of this on patient health and safety?
What challenges, barriers, or other factors, such as workforce shortages, particularly in rural areas, impact rehabilitative therapists and nurses in meeting the needs of patients at the start of care and early in the plan of care?

2. Plan of Care Development and Scope of Services Home Health Patients Receive

CMS seeks public comments on factors that influence the services HHAs provide, the referral process, limitations on patients being able to obtain HHA services, such as rural location and availability of staff, plan of care development, and the HHA’s communication with patients’ ordering physicians and allowed practitioners. We ask the public for data, detailed analysis, academic studies, or any other information to support their comments that provide a direct link to patient health and safety. Specifically, we solicit comments regarding the following questions:

What factors influence an HHA’s decision on what services to offer as part of its business model and how often do HHAs change the service mix?
What are the common reasons for an HHA to not accept a referral?
How do physicians and allowed practitioners use their role in establishing and reviewing the plan of care to ensure patients are receiving the right mix, duration, and frequency of services to meet the measurable outcomes and goals identified by the HHA and the patient?
To what extent do physicians rely on HHA clinician evaluations and reports in establishing the mix of services, service frequency, and service duration included in the plan of care?
What are the patient and caregiver experiences in receiving nursing, aide, and therapy services when under the care of a home health agency?
What additional evidence is available regarding negative outcomes or adverse events that may be attributable to the mix, duration, and service frequency provided by HHAs, including, but not limited to, avoidable hospitalizations?
In what ways can referring providers and HHAs improve the referral process?
What other factors may influence the provision of services that impact the timeliness of services and service initiation?
What additional areas should CMS consider addressing HHA patient health and safety concerns?

Long-term Care (LTC) Requirements for Acute Respiratory Illness Reporting

CMS proposes replacing the current COVID-19 reporting standards for LTC facilities that sunset in December 2024 with a new standard that will address a broader range of acute respiratory illnesses.
- This new standard would require that, beginning on January 1, 2025, facilities electronically report information about COVID-19, influenza, and respiratory syncytial virus (RSV) to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). CMS proposes that the data elements for which reporting would be required include facility census; resident vaccination status for COVID-19, influenza, and RSV; confirmed resident cases of COVID-19, influenza, and RSV (overall and by vaccination status); and hospitalized residents with confirmed cases of COVID-19, influenza, and RSV (overall and by vaccination status).
CMS proposes that in the event of a declared — or significantly likely — national public health emergency (PHE) for an acute respiratory illness, there may be additional categories or reporting required, such as: reporting data up to a daily frequency and additional or modified data elements relevant to the PHE — including but not limited to relevant confirmed infections, supply inventory shortages, and additional demographic factors.

CMS is seeking comment on ways the reporting burden can be minimized while still providing adequate data; whether we should expand the proposed requirements for what is collected and how often, both during and outside a declared — or significantly likely — PHE; the value of these data in protecting the health and safety of residents in LTC facilities both during and outside of a PHE; system readiness and capacity to collect and report these data; and whether race, ethnicity, or other demographic information, such as socioeconomic factors or disability status, should be included in the requirements for ongoing reporting beginning on January 1, 2025.

Medicare Provider Enrollment

CMS is proposing to add providers and suppliers that are reactivating their Medicare billing privileges to the categories of new providers and suppliers subject to additional oversight.
- CMS may impose a provisional period of enhanced oversight (PPEO) for 30 days to one year for new providers and suppliers. The goal of a PPEO is to reduce and prevent fraud, waste, and abuse.  
- During a PPEO, CMS may, among other things, conduct prepayment medical review and cap payments.
- Currently, CMS can apply a PPEO to new providers or suppliers, which are defined as providers or suppliers that are: (1) newly enrolling; (2) undergoing a change of ownership under 42 CFR § 489.18; and/or (3) undergoing a 100% change of ownership via a change of information. 
This proposal would add reactivating providers and suppliers as another category of new providers and suppliers subject to a PPEO.

Home Health Quality Reporting Program (QRP)

HH VBP Model

There are no proposed changes to the expanded HHVBP Model for CY 2025.

Assessment data elements

CMS proposes to collect four additional items as standardized patient assessment data elements and replace one item collected as a standardized patient assessment data element beginning with the CY 2027 HH QRP. The net effect of these proposals is an increase of four data elements at the start of care time point and a net increase in burden. The four assessment items proposed for collection are:

(1) Living Situation

(2) Food Runs Out

(3) Food Doesn’t Last

(4) Utilities

CMS proposes replacing the current Access to Transportation item with a revised Transportation (Access to Transportation) item beginning with the CY 2027 HH QRP.
CMS proposes an update to the removal of the suspension of OASIS all-payer data collection to change all-payer data collection beginning with the start of care OASIS data collection timepoint instead of discharge timepoint.

Future Approaches to Health Equity in the Expanded HHVBP Model

CMS has been exploring several potential approaches for integrating health equity concepts into the expanded HHVBP Model. Considerations for evaluating these approaches include the following:

Effectiveness: Does the approach further the model test? What would its impact on underserved communities be?
Feasibility: How long would it take to implement the approach? Are the necessary data currently being collected? How many HHAs would be included?
Reliability: Does the approach allow for reliable measurement of health equity within HHAs?
Alignment: Is this approach aligned with other Medicare quality and VBP Programs?

They are also exploring other health equity measures that would more directly focus on certain disparities. These could be structured in several different ways:

Measure(s) for particular underserved communities: Performance on one or more measures for specific underserved communities (for example, based on DES).
Measure(s) based on within-provider differences in performance for underserved communities (for example, based on DES): This type of measure could be based on a single outcome or multiple outcomes (that is, a composite measure).
Measure(s) based on the worst performing group: Calculate performance scores for multiple patient groups and set the measure performance equal to the score for the worst performing group.

CMS is committed to and working towards the establishment of an HHVBP HEA that rewards HHAs that provide high-quality care to underserved communities. They state they will continue to explore the addition of other measures, using other proxies for identifying the underserved and possibly adjusting the scoring mechanism to be more effective at addressing the issue.

CMS stated in the CY 2024 HH PPS final rule (88 FR 77790), they will gather at least 2 years of performance data, and study the effects of the expanded Model on health equity outcomes before incorporating any potential changes to the expanded Model regarding health equity.

Review the proposed rule on the Federal Register Public Inspection desk – https://public-inspection.federalregister.gov/2024-14254.pdf

It is anticipated that this proposed rule will be posted in the Federal Register on July 3^rd or 5^th.

For further information, see the CMS summary of the hospice proposed rule – https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-home-health-prospective-payment-system-proposed-rule-fact-sheet-cms-1803-p

Questions about the content of this rule? Contact CHAP