CMS Proposed Payment Changes for Medicare Home Health Services

Table of Content

• Medicare Advantage Home Health Spells Shortened Relative to traditional Medicare between 2011 and 2016
• Illness Severity Among Medicare Home Health Users During the Pandemic
• Mär 2010 - Daylight Saving Time Started
• CMS & HHS Websites
• Average Cost Of Health Benefits Per Employee
• Home Health Spell Lengths Fell in Most Medicare Advantage Plan Types between 2011 and 2016

Under HH PPS, HHAs are paid prospectively for 60-day episodes of care. Based on an assessment from the patient’s OASIS data, HHAs are paid at different rates for different patients, depending on their care needs, and based upon their clinical severity, their level of function, and their usage of HHA services. This rule proposes ways to improve the comprehensiveness of the case-mix model and thus improve the accuracy of Medicare’s payments.

Treatment codes may be inconsistently applied, in part, because home health care services are ill-defined. Further, the growing volume and intensity of home health care necessitates an evaluation of current medical review processes, including a reexamination of how cases are selected for review and a consideration of giving HHAs greater responsibility for utilization review. A home health episode was defined based on claims for 30-day episodes in the 2020 data. Analogous 30-day episodes were constructed for the 2019 home health episode claims to allow for comparison of claim counts across years, following the change from 60-day to 30-day home health episodes with the introduction of the Patient-Driven Groupings Model in 2020. In both 2011 and 2016, Medicare Advantage home health spells were shorter than traditional Medicare home health spells by 6.7 and 7.3 days, respectively after adjustment for beneficiary characteristics including primary diagnosis and functional status .

Medicare Advantage Home Health Spells Shortened Relative to traditional Medicare between 2011 and 2016

Though a relatively small change, this finding indicates a shift in home health use among this subpopulation during the pandemic. To decrease Medicare spending, the Medicare Payment Advisory Commission recommended a 5% reduction in payments to home health agencies for 2020. A Medicare-certified home health agency must deliver care or it will not be covered. To find a reputable agency in your area, Medicare offers a searchable database at Home Health Compare. Short, infrequent absences for nonmedical reasons (e.g., attending a family event) should not count against you either.

For example, the current Medicare payment systems might incorporate quality measures and payment structures that incentivize improved care coordination and patient and caregiver education. Between 2019 and 2020, a greater increase in severity of illness was observed among home health users admitted from acute or postacute facilities than chronically ill homebound users, an increase notably higher for Latinx/Hispanic beneficiaries. NoteIf you get services from a home health agency in Florida, Illinois, Massachusetts, Michigan, or Texas, you may be affected by a Medicare demonstration program. Under this demonstration, your home health agency, or you, may submit a request for pre-claim review of coverage for home health services to Medicare. This helps you and the home health agency know earlier in the process if Medicare is likely to cover the services. Medicare will review the information and cover the services if the services are medically necessary and meet Medicare requirements.

Illness Severity Among Medicare Home Health Users During the Pandemic

You may also have dollar or percentage limits, or maximums placed on the amount of benefits that you can receive. Maximums can apply to specific health benefits like eyeglasses or massage therapy sessions in a specified period typically a year, or during your lifetime. Some plans have a co-insurance feature in addition to the deductible. That means you have to pay a percentage, or co-insure, the medical expenses on top of your deductible. It could be 10 per cent of the eligible medical expense, or higher, and it may depend on the type of medical service required.

However, given that we hypothesize that Medicare Advantage spells are shorter than traditional Medicare spells, this bias would lead to more conservative estimates of differences between Medicare Advantage and traditional Medicare. These items do not required skilled nursing care, but skilled care or skilled therapy is needed in order to qualify for these limited non-skilled services. This is the primary reason why Medicare’s home health benefits are more difficult to qualify for as compared to the Medicaid Waiver home care benefit . CMS is also proposing to revise the way to account for non-routine medical supplies in the standardized 60-day episode payment rate. This rule proposes to pay for NRS based on 5 severity groups, similar to the proposed clinical case-mix model, to more accurately reflect home health agency costs for NRS.

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Administrative and operational changes to improve program efficiency and integrity are also being addressed through the Home Health Initiative. HCFA needs to improve its ability to ensure that the program pays for only those services that are medically reasonable and necessary and meet home health coverage requirements. Data collection, audit processes , and coordination of services for beneficiaries dually entitled to Medicare and Medicaid have been identified as areas for initial attention. Medicare Advantage plans cover the same home health care services that are covered by Medicare Part A and Part B. Supplementary health and dental insurance policies are contracts between you and an insurance company. You agree to pay a yearly or monthly fee called a premium, and the company agrees to pay the benefits which are covered under your policy.

It may be possible to extend that duration of coverage under special circumstances. Providers must be familiar with Medicare coverage for home care members. Bill Medicare when Medicare is liable for the service or, if not Medicare certified, refer the member to a Medicare-certified provider of the member’s choice. Notify members when Medicare is no longer the liable payer for home care services.

CHANGES IN HOME HEALTH CARE USE IN MEDICARE ADVANTAGE COMPARED TO TRADITIONAL MEDICARE, 2011-2016

Contact Us.For assistance obtaining or maintaining, Medicare-covered home health services, please contact the Center for Medicare Advocacy at To organize your search, build a home health agency checklist to help narrow your options. You may want to ask, for example, if the agency accepts Medicare payment or offers the specific services you need. You can use the checklist on the Medicare.gov website or create your own based on your personal health needs and budget. Medicare Advantage plans combine the benefits covered by Medicare Part A and Part B into one single plan sold by a private insurance company.

Find more about the waiver services and the Alternative Care program in HCBS Waiver Services and Elderly Waiver and Alternative Care Program sections of the MHCP Provider Manual. Request authorization within 20 business days of the date the member was notified that the case was opened. Public health organizations can convene, integrate, influence, and contribute to big changes. Beneficiaries can receive home health services to improve their condition, to maintain their current condition, or to slow or prevent further decline.

Our first outcome measure was the share of beneficiaries using home health during 2011 and 2016. We conducted analyses for any home health use and segmented by type of home health use based on the beneficiary's first spell during the calendar year. Our key explanatory variables included Medicare Advantage or traditional Medicare enrollment, Medicare Advantage contract type, Medicare Advantage cost-sharing, and Medicare Advantage prior authorization. Medicare Advantage contract types include health maintenance organizations , preferred provider organizations , employer-sponsored plans, and special needs plans .

In 2019, comorbidity levels were higher for chronically ill homebound beneficiaries than they were for those admitted from acute or postacute facilities, regardless of race. However, in 2020, the level of comorbidity was higher for Latinx/Hispanic and Asian American beneficiaries after acute and postacute stays than it was for chronically ill homebound beneficiaries — a result of the greater shift in patient acuity for these groups of patients. Given shifting home health care patient volumes and an increasing preference for home-based care, it is important to understand the changing characteristics of the Medicare home health care patient population. In this issue brief, we discuss changes in home health users’ characteristics between 2019 and 2020, including differences in race, gender, and overall health status. We also detail shifts in service use during 2020 that may reflect both the COVID-19 pandemic and change in the home health payment system. Finally, we examine caregiver availability to learn how needs may vary by home health users’ race, health status, and outcomes.

Prior work has shown that home health providers strategically provide therapy visits and recertify episodes in order to maximize payment under this system, which may not be the most efficient or clinically effective use of home health services. Medicare Advantage plans receive a monthly capitated rate from Medicare for each enrollee and thus have financial incentives to use home health care strategically and efficiently, and potentially to substitute home health for more intensive services. Moreover, Medicare Advantage plans have flexibility to define a network of HHAs, apply cost-sharing to home health benefits, and manage utilization of home health services. Little research has been conducted on the differences in home health utilization and length of home health spells between Medicare Advantage and traditional Medicare by admission type, however.

These include, but are not limited to, a change in health or level of care, service addition, change in physician, APRN, or PA orders, recent facility placement, or change in primary caregiver’s availability. Be under a plan of care that a doctor establishes and reviews regularly. That plan should note all services needed and how often, the provider, required supplies and the results your doctor anticipates.