Health Care Law Blog

CMS Proposed Rule Affecting Home Health Agencies

The Centers for Medicare & Medicaid Services ("CMS") recently announced proposed changes to the Medicare home health prospective payment system (“PPS”) for the 2015 calendar year. CMS is proposing to tighten eligibility requirements for home health services and set a minimum requirement on Home Health Agencies ("HHAs") to prove their effectiveness, as well as revise how much CMS will pay for certain services. These proposed changes are expected to reduce Medicare payments to HHAs by $58 million next year alone, a reduction of .30 percent.

To qualify for the Medicare home health benefit, a beneficiary must be under the care of a physician, have a need for skilled nursing care, physical therapy, speech-language pathology, or continued need for occupational therapy. Further, the beneficiary must be homebound and receive home health services from a Medicare approved agency.

The proposed changes include the following:

Face-to-Face Encounters

The Affordable Care Act requires a certifying physician or other allowed provider to have a face-to-face encounter with the beneficiary before certifying the beneficiary's eligibility for home health services. The current regulations require a documented narrative explaining why the findings of the encounter support the patient’s need for skilled home services.

The rule proposes three changes to the face-to-face requirements:

1. Eliminate the narrative requirement entirely. The physician will still have to certify that the encounter occurred and document the date as part of a beneficiary’s certification of eligibility, but will not need to provide the extensive narrative currently mandated.

2. For the purpose of medical review, only records from the patient's certifying physician or discharging facility will be considered to determine initial eligibility.

3. A physician claim for certification or re-certification of eligibility will be considered a non-covered service if the claim was non-covered because the patient was ineligible for the home health benefit.

The rule further clarifies that the face-to-face requirement only applies to initial certifications and not re-certification.

Rate-Setting Changes

CMS proposes a number of changes affecting rate-setting. These include a change to the home health PPS wage index. In February of 2013, the Office of Management and Budget (“OMB”) issued a bulletin making changes to the Metropolitan Statistical Areas, Micropolitan Statistical Areas, and Combined Statistical Areas. CMS is proposing changing the wage index based on these changes and definitions. The changes would use a blended wage index for a one-year transition. The blended wage index would use 50 percent of the calendar year 2015 wage index using the current OMB delineations and 50 percent of the calendar year 2015 wage index using the new OMB delineations.

Home Health Quality Reporting Program

HHAs are required to submit Outcome and Assessment Information Set (“OASIS”) assessments as a condition for payment and quality measurement purposes. Those that do not submit quality measurement information will see a two percent decrease in their annual payment update.

The proposed rule will establish a minimum threshold for OASIS assessments that must be submitted by each HHA. The initial threshold in calendar year 2015 would be 70 percent of all patients receiving care during the reporting period. The threshold would then increase by 10 percent each year, with a maximum of 90 percent by calendar year 2017.

Speech Language Pathologists

Further, CMS is proposing changes to the conditions for speech pathologists to participate in home health services, starting with the qualifications to be considered a qualified speech language pathologist.

To qualify, an individual must meet one of the following requirements:

1. Has a masters' or doctoral degree in speech language pathology, and is licensed as a speech language pathologist by the state where they furnish services, or

2. Has successfully completed 350 hours of supervised clinical practicum (or is in the process of completing these hours), at least nine months of supervised full-time speech-language pathology experience, and has successfully completed a national examination approved by the Secretary.

The qualifications are designed to greater align with those delineated in the Social Security Act and replace the current more stringent requirements by providing deference to State licensing requirements.

Value-Based Purchasing Model

CMS is seeking comments on a potential value-based purchasing model for HHAs in certain states that it is considering testing, beginning in 2016. CMS has already implemented such a program with Hospitals, where the payments hospitals receive are directly related to the quality of care provided. CMS wants to know if a similar incentive based program could lead to a greater quality of care for home health beneficiaries.

Comment Period

HHAs should take note of the proposed changes and be prepared to adapt their policies and procedures, as the changes would affect funding. Also, any provider that wishes to comment on the proposed rule should be mindful that the comment period ends September 2, 2014. If you have any questions, please contact Jennifer Van Regenmorter.

Categories: Health Care Reform, Medicare/Medicaid