Medicare Home Health Prospective Payment System

Transcription

1 Medicare Home Health Prospective Payment System Payment Rule Summary PROPOSED CY 2017 Overview and Resources On July 5, 2016, the Centers for Medicare and Medicaid Services (CMS) published its proposed calendar year (CY) 2017 payment rule for the Medicare Home Health Prospective Payment System (HH PPS). The proposed rule includes updates of the Medicare fee-for-service (FFS) HH PPS payment rates based on regulatory changes, put forward by CMS and legislative changes previously adopted by the US Congress. Among the proposed regulatory updates and policy changes are: Implementation of the last year of a 4-year phase-in for rebasing adjustments to the HH PPS payment rates mandated by the Affordable Care Act (ACA) of 2010; Implementation of the second year of the 3 year reduction to the national, standardized, 60-day episode payment rates of 0.97 percent to recoup overpayments for nominal case-mix growth between CY 2012 and CY 2014; Updates to the Home Health Resource Group (HHRG) weights; Changes to the methodology used to calculate outlier payments; Changes in payment for Negative Pressure Wound Therapy (NPWT) performed using a disposable device for patients under a home health plan of care; Changes to the home health value-based purchasing (HHVBP) model with payment adjustments beginning January 1, 2018, applicable to Home Health Agencies (HHAs) in selected states; Changes to the home health quality reporting program requirements. A copy of the Federal Register (FR) with this proposed rule and other resources related to the HH PPS are available on the CMS website at Payment/HomeHealthPPS/Home-Health-Prospective-Payment-System-Regulations-and-Notices.html. An online version of the FR with this proposed rule is available at A brief summary of the proposed rule is provided below. Program changes adopted by CMS would be effective for services provided on or after January 1, 2017 unless otherwise noted. Comments on all aspects of the proposed rule are due to CMS by Friday, August 26 and can be submitted electronically at by using the website s search feature to search for file code 1648-P. HH PPS Payment Rates FR pages The tables below show the proposed CY 2017 conversion factor compared to the final CY 2016 conversion factor and the components of the update factor: 1 P age

2 Final CY 2016 Proposed CY 2017 Percent Change 60-Day Episode Rate $2, $2, % Proposed CY 2017 Update Factor Component Value Marketbasket (MB) Update +2.8% Affordable Care Act (ACA)-Mandated Productivity MB Reduction -0.5 percentage points Negative Rebasing Adjustment -$80.95 (-2.68%) Nominal Case-Mix Growth Reduction -0.97% Case-Mix Budget Neutrality Adjustment 0.62% Wage Index Budget Neutrality -0.10% Overall Proposed Rate Update -0.96% National Per-Visit Amounts HH PPS payments for episodes with 4 visits or less are paid on a per visit basis. CMS uses national per-visit amounts by service discipline to pay for these Low-Utilization Payment Adjustment (LUPA) episodes. The national per-visit amounts are also used for outlier calculations. The proposed CY 2017 per-visit amounts include a rebasing increase of 3.5% of the CY 2010 national per-visit payment amounts, an update factor increase of 2.3%, and an adjustment for wage index budget neutrality. Per-Visit Amounts Final Proposed Percent Proposed CY 2017 CY 2016 CY 2017 Change With LUPA Add-On * Home Health Aide $60.87 $64.09 N/A Medical Social Services $ $ N/A Occupational Therapy $ $ N/A +5.3% Physical Therapy (PT) $ $ $ ( adj.) Skilled Nursing (SN) $ $ $ ( adj.) Speech Language Pathology (SLP) $ $ $ ( adj.) * For SN, PT, or SLP visits in LUPA episodes that occur as the only episode or an initial episode in a sequence of adjacent episodes, CMS will continue the use of the LUPA add-on factors established in the CY 2014 final rule. Non-routine Medical Supply (NRS) Conversion Factor In CY 2008, CMS carved out the NRS component from the 60-day episode rate and established a separate national NRS conversion factor with 6 severity group weights to provide more adequate reimbursement for episodes with a high utilization of NRS. The proposed CY 2017 NRS conversion factor includes a rebasing reduction -2.82% and an update factor increase of 2.3%. Final CY 2016 Proposed CY 2017 Percent Change NRS Conversion Factor $52.71 $ % 2 P age

3 Severity Level Points (Scoring) Relative Weight (no change from prior years) CY 2017 Proposed Payment Amount $ to $ to $ to $ to $ $ Effect of Sequestration FR page reference not available All lines of Medicare payments authorized by Congress and currently in effect through federal fiscal year (FFY) 2025 are subject to a 2.0% sequester reduction. Sequester will continue unless/until Congress intervenes. Sequester adjustments are not applied to payment rates; they are a reduction to the Medicare claim payment after determining co-insurance, any applicable deductibles, and any applicable Medicare secondary adjustments. Wage Index and Labor-Related Share FR pages CMS is proposing to maintain the labor-related share at % for CY The labor-related portion of the HH payment rate is adjusted for differences in area wage levels using a wage index. CMS is not making any major changes to the calculation of Medicare HH wage indexes. As has been the case in prior years, CMS is proposing to use the most recent inpatient hospital wage index, the FFY 2017 pre-rural floor and prereclassified hospital wage index, to adjust payment rates under the HH PPS for CY A complete list of the proposed wage indexes for payment in CY 2017 is available on the CMS Web site at Prospective-Payment-System-Regulations-and-Notices-Items/CMS F.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending Payment Add-On for Rural HH Agencies FR pages The ACA, by amending the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), mandated a 3.0% increase to the payments for HH PPS episodes and visits provided in rural areas between April 1, 2010 and January 1, The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) amended the MMA again, extending the 3.0% increase to payments for HH PPS episodes and visits in rural areas for another 2 years. The 3.0% rural add-on now applies to payments for episodes and visits ending on or after April 1, 2010, and before January 1, This 3.0% add-on is not subject to budget neutrality and is applied to the 60-day episode rate, the national pervisit amounts, LUPA add-on payments, and the NRS conversion factor. Proposed CY Day Episode Rate Multiply by the 3 percent Rural Add-on Proposed Rural CY Day Episode Rate Rural Add-On Payment $2, X 1.03 $3, P age

4 Reductions Due To Nominal-Case-Mix Growth FR pages Previously, CMS accounted for nominal case-mix growth through HHRG weight reductions, implemented from 2008 through 2013, in order to better align payment with real changes in patient severity. In CY 2015 there was no nominal case-mix growth. CMS finalized a total reduction of 2.88%, implemented and distributed evenly over a 3 year period. This means that in CY 2016 there was a 0.97% reduction to the national, standardized 60- day episode payment rate. There will be one in both CY 2017 and CY 2018 as well. This reduction accounts for nominal-case mix growth from CY 2012 to CY CMS goal is to have Medicare pay more accurately for the delivery of home health service and this reduction will remain separate from the CY 2014 rebasing adjustments. HHRG Update FR pages The HH PPS program uses a 153-category case-mix classification called Home Health Resource Groups (HHRGs). Patients clinical severity level, functional severity level, and service utilization are extracted from the Outcome and Assessment Information Set (OASIS) instrument and used to assign HHRGs. Each HHRG has an associated case-mix weight which is used in calculating the payment for an episode. According to CMS, the HHRG weights were designed to maintain an average case-mix of about 1.0 for the nation. In the CY 2015 HH PPS final rule, CMS implemented a recalibration of case-mix weights to occur each year using the most current data available. This annual recalibration guarantees that the case-mix weights will reflect the current status of home health resource use and changes in utilization. For CY 2017, CMS is recalibrating the HH PPS case-mix weights using cost and utilization data from CY Overall the impact of the change is negative; therefore, CMS is proposing to increase the 60-day episode rate by 1.62% in order to maintain budget neutrality for the HH PPS program. Outlier Payments FR pages Outlier payments are intended to mitigate the risk of caring for extremely high-cost cases. An outlier payment is provided whenever a HHA s cost for an episode of care exceeds a fixed-loss threshold (the HH PPS payment amount for the episode plus a fixed dollar loss [FDL] amount). The cost for an episode of care is currently calculated using the number of visits in the episode multiplied by a wage index-adjusted national per-visit amount. CMS is concerned that the current methodology for calculating the cost for an episode of care may create financial disincentive for providers to treat medically complex beneficiaries who require longer visits. CMS is proposing to instead calculate the cost of an episode of care using a cost-per-unit calculation. The costper-unit calculation takes into account visit length, which the current calculation does not. CMS is also proposing a cap on the amount of time per day that would be counted toward the estimation of an episode s costs for outlier calculation purposes in the new methodology. They are proposing this cap to be 8 hours or 32 units per day (1 unit = 15 minutes). The FDL ratio is multiplied by the wage index-adjusted 60-day episode payment rate then added to the HH PPS payment amount for that episode. If the calculated cost exceeds the threshold, the HHA receives an additional outlier payment equal to 80% of the calculated excess costs over the fixed-loss threshold. Each HHA s outlier payments are capped at 10% of total PPS payments. By law, a limit of 2.5% of total HH PPS payments are set aside for outliers. Under the proposed methodology, which would use a cost per unit rather 4 P age

5 than a cost per visit when calculating episode costs, CMS is proposing to increase the FDL ratio from 0.45 in CY 2016 to 0.56 in CY Negative Pressure Wound Therapy (NPWT) Payments FR pages NPWT is a medical procedure in which a vacuum dressing is used to enhance and promote healing in acute, chronic, and burn wounds. The therapy involves using a sealed wound dressing attached to a pump to create a negative pressure environment in the wound. This conventional NPWT system is classified as durable medical equipment (DME). However, NPWT can also be performed with a single-use disposable system that consists of a non-wound therapy. These disposable systems consist of a small pump, which eliminates the need for a bulky canister. HH PPS includes payment for all covered home health services. However, the national, standardized 60-day episode payment amount does not include costs for DME. Therefore, DME is currently paid outside of the HH PPS. Medical supplies, both routine and non-routine, however are included in the definition of home health services and are included in the national, standardized 60-day episode amount. A disposable NPWT system would be considered a non-routine supply for home health. The Consolidated Appropriations Act of 2016 requires a separate payment, based on the Outpatient Prospective Payment System (OPPS) amount, to a HHA for an applicable disposable device when furnished on or after January 1, 2017, to an individual who receives home health services for which payment is made under the Medicare home health benefit. CMS is proposing that for instances where the sole purpose for a HHA visit is to furnish NPWT using a disposable device, Medicare will not pay for the visit under the HH PPS. Instead, they propose that the HHA must bill these visits separately under the type of bill 34x under the appropriate HCPCS code (97607 or 97608). This bill is used for patients not under a HH plan of care, Part B medical and other health services, and osteoporosis injection. If NPWT using a disposable device is performed during the course of an otherwise covered HHA visit, CMS proposes that the HHA must not include the time spent furnishing NPWT in their visit charge of in the length of time reported for the visit on the HH PPS claim. This will be paid separately based on the OPPS amount. In order for a beneficiary to receive NPWT using a disposable device under the home health benefit, a physician must certify that the Medicare beneficiary meets the following criteria: Is confined to the home; Needs skilled nursing care on an intermittent basis or physical therapy or speech language pathology; or Has a continuing need for occupational therapy; Is under the care of a physician; Receive services under a plan of care established and reviewed by a physician; and Has had a face-to-face encounter related to the primary reason for home health care with a physician or allowed Non-Physician Practitioner within a required timeframe. Additionally, care must be deemed as reasonable and necessary based on information reflected in the home health plan of care. Update on Research and Analysis of Home Health Groupings Model FR pages The Secretary of Health and Human Services conducted a study on home health agency costs involved with providing ongoing access to low-income Medicare beneficiaries or beneficiaries in medically underserved areas 5 P age

6 in treating beneficiaries with high levels of severity of illness. This study included an analysis of methods to potentially revise the HH PPS. In the CY 2016 proposed rule, CMS provided information on the initial research and analysis to address the study findings. In the CY 2017 proposed rule, CMS provided an update to this research and analysis on the Home Health Groupings Model (HHGM). The HHGM groups home health episodes by primary diagnosis based on what home health interventions would be required during the episode of care. The HHGM also incorporates information from claims data to further group the episodes for payment. Each episode is categorized into different sub-groups, where an episode is placed into 1 of the categories within each sub-group: Sub-Group Timing Referral Source Clinical Grouping Functional/Cognitive Level Comorbidity Adjustment Categories Within Sub-Group Early or late Community, acute, or post-acute admission source Musculoskeletal rehab, neuro/stroke rehab, wounds, MMTA, behavioral, or complex Low, medium, or high First, second, or third (tier based on secondary diagnoses) In total there would be 324 possible payment groupings an episode can be grouped. Unlike the current payment model, the HHGM does not rely on the number of therapy visits performed to influence payment. The HHGM address marginal differences across beneficiary characteristics that the current model does not provide. Also, the HHGM aligns with how clinicians generally identify the types of patients they see in home health. Update Future Plans To Group HH PPS Claims Centrally FR pages In the CY 2011 HH PPS proposed rule, CMS stated possible plans to group HH PPS claims centrally during claim processing potentially using the treatment authorization field to group the HH PPS claims and received many comments in support of this initiative. However, in conducting further analysis CMS determined that the use of the treatment authorization field was not a viable option and the information that CMS planned to report in this field was not permitted by the Health insurance Portability Accountability ACT (HIPAA). In the CY 2017 proposed rule, CMS is soliciting comments on a different process whereby all the information necessary to group HH PPS claims occurs centrally during claims processing. This would consist of embedding the HH PPS Grouper within the claims processing system to mitigate a provider s vulnerability and improve payment accuracy. Mandatory HH VBP Model Demonstration Project FR pages Background: CMS implemented an ACA mandated HHVBP demonstration model for certain Medicare-certified HHAs, starting January 1, 2016 and concluding December 31, The Medicare-certified HHAs required to participate are from 9 randomly selected states, each from 1 of 9 regional groupings determined by CMS. The demonstration program resembles the VBP Program for inpatient acute care hospitals. Finalized in the CY 2016 rule, random states were selected through grouping states by geographic proximity to one another and accounting for certain evaluation characteristics. The 9 states are Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee. 6 P age

7 Medicare-certified HHAs that are included in the HHVBP model would be required to compete for payment adjustments to their current PPS reimbursements based on their quality performance. A competing Medicarecertified HHA is defined as an agency having a current Medicare certification that is being reimbursed by CMS for home health care delivered in the boundaries of any of the randomly selected states to participate. The HHVBP model compares a competing HHA s performance on quality measures against the performance of other competing HHAs within the same state and size cohort, either the smaller-volume cohort or the largervolume cohort. The larger-volume cohort is made up of HHAs that participate in HHCAHPS while the smallervolume cohort is made up of HHAs that are exempt from participation in HHCAHPS (less than 60 eligible unique HHCAHPS patients annually). CMS determined in the CY 2016 final rule that payment adjustments for each year of the model would be calculated based on a comparison of how well each of the competing Medicare-certified HHAs performed during each 1 year performance period, beginning in CY 2016, compared to the baseline year CY 2015, as well as performance of their peers. The contribution amount is equal to the maximum payment adjustment. The payment adjustments will be applied in CY Payment Period Performance Period Aggregate HHVBP Payment Adjustment CY 2018 January 1, 2016 December 31, % max CY 2019 January 1, 2017 December 31, % max CY 2020 January 1, 2018 December 31, % max CY 2021 January 1, 2019 December 31, % max CY 2022 January 1, 2020 December 31, % max The goals of the HHVBP model are to improve the overall quality of home health care and deliver it to the Medicare population in a more efficient manner. The HHVBP demonstration program recognizes both the achievement of high quality standards and the improvement in quality performance. HH agencies in the selected states will be subject to upward and downward payment adjustments based on performance on the measures chosen. The HHVBP model will adjust Medicare HHA payments over the course of the model by up to 8% depending on the applicable performance year and the degree of quality performance demonstrated by each competing Medicare-certified HHA. The HHVBP program will be budget neutral by state. Similar to the Hospital VBP program, this is redistributive and all HHAs in the mandated state will contribute to the VBP pool; some will then get their contribution back, and some may get less. Quality Measures FR pages In the CY 2016 rule, CMS finalized the initial set of measures for the first performance year of the HHVBP demonstration to include 6 process measures, 10 outcome measures, 5 HHCAHPS, and 3 New Measures. CMS is proposing to remove 4 of the measures (3 process, 1 outcome) due to the fact that they need further consideration before inclusion in the HHVBP model measure set. These measures are: Care Management: Types and Sources of Assistance; Prior Functioning ADL/IADL; Influenza Vaccine Data Collection Period; Reason Pneumococcal Vaccine Not Received. 7 P age

8 The quality measures that would remain in the HHVBP measure set include: Measure NQS Domain Measure Title Type Data Source Outcome Improvement in Ambulation-Locomotion (NQF0167) OASIS (M1860) Clinical Quality of Care Communication & Care Coordination Efficiency & Cost Reduction Patient Safety Population/Co mmunity Health Patient & Caregiver Centered Experience Outcome Improvement in Bed Transferring (NQF0175) OASIS (M1850) Outcome Improvement in Bathing (NQF0174) OASIS (M1830) Outcome Improvement in Dyspnea OASIS (M1400) Process Drug Education on All Medications Provided to Patient/Caregiver during all Episodes of Care OASIS (M2015) Outcome Discharged to Community OASIS (M2420) Outcome Outcome Outcome Outcome Process Process Acute Care Hospitalization: Unplanned Hospitalization during first 60 days of Home Health (NQF0171); Emergency Department Use Without Hospitalization (NQF0173) Improvement in Pain Interfering with Activity (NQF0177) Improvement in Management of Oral Medications (NQF0176) Influenza Immunization Received for Current Flu Season (NQF0522) Pneumococcal Polysaccharide Vaccine Ever Received (NQF0525) CCW (Claims) CCW (Claims) OASIS (M1242) OASIS (M2020) OASIS (M1046) OASIS (M1051) Outcome Willingness to recommend the agency HHCAHPS Outcome Communications between Providers and Patients HHCAHPS Outcome Care of Patients HHCAHPS Outcome Specific Care Issues HHCAHPS Outcome Overall Rating of Home Health Care HHCAHPS The New Measures are: Measure NQS Domain Type Population/ Community Health Communication & Care Coordination Process Process Process Measure Title Influenza Vaccination Coverage for Home Health Care Personnel (NQF0431) Herpes Zoster (Shingles) Vaccination Received by HHA Patients Advance Care Plan (NQF0326) Data Source Proposed to be reported by HHAs through Webbased portal beginning October 2016 for PY1 and April 2017 for PY2 (annually thereafter) Reported by HHAs through Web-based portal beginning no later than October 7, P age

9 In the CY 2016 final rule CMS finalized that HHAs will be required to begin reporting data on each of the 3 New Measures no later than October 7, 2016 for the period July 2016 through September 2016 and quarterly thereafter. CMS is proposing to require annual, rather than quarterly reporting for the Influenza Vaccination Coverage for Home Health Personnel with the first annual submission in April 2017 for the second performance year and annually in April thereafter. This submission would be for the reporting period October 1, 2016 March 31, 2017 to coincide with flu season. For performance year 1, the HHA would report on this measure in October 2016 and January CMS is also proposing to increase the timeframe for submitting New Measures from 7 calendar days to 15 calendar days following the end of the reporting period to account for holidays and weekends. Inclusion/Exclusion Criteria FR pages Although every HHA in a selected state must participate in the HHVBP model, each HHA may not receive a payment adjustment every period due to an inadequate number of episodes of care to generate sufficient quality measure data. The minimum threshold for a HHA to receive a score on a given measure is 20 home health episodes of care per year for HHAs that have been certified for at least 6-months. In order to receive a payment adjustment the HHA must meet this threshold in at least 5 of the Clinical Quality of Care, Care Coordination and Efficiency, and Person and Caregiver-Centered Experience measures. Otherwise a payment adjustment will not be made for that particular HHA. If the HHA has greater volume during later performance years, the HHA will be subject to future payment adjustment. The HHA will still receive quality reports on any measures for which they have 20 episodes of care. When there are fewer than 8 HHAs in the smaller-volume cohort in a state to compete in a fair manner and mitigate outliers, these specific HHAs would be included in the state s larger-volume cohort without being measured on Home Health Consumer Assessment of Healthcare Providers and Systems Survey (HHCAHPS). This is for purposes of calculating the total performance score and payment adjustment for those HHAs. Scoring FR pages Background: The quality measures are aligned with 6 National Quality Strategy (NQS) domains. For the HHVBP, CMS is grouping these NQS domains into 4 classifications in order to correctly calculate payment adjustments based on the other measures. Measure distribution from the 6 NQS domains into the 4 classifications has not yet been determined. However, measures within each classification will be weighted the same for the purposes of payment adjustments. The model also includes the HHCAHPS for the competing Medicare-certified HHAs. HHAs are scored on their quality of care based on performance compared to both the performance of HHAs in the same size cohort and also their own past performance. Points are aggregated on individual measures across the 4 classifications to calculate the Total Performance Scores (TPS). 9 P age

10 Classification Clinical Quality of Care Care Coordination and Efficiency Person- and Caregiver- Centered Experience Possible Points 0-10 points Measure Weight for each Classification 30% 30% 30% New Measures 10% As for the new measures, HHAs will receive 10 points for each new measure they report and 0 points for each they do not. In total, the new measures will account for 10% of the TPS regardless of the number of measures applied to a HHA in the other 3 classifications. This is different than proposed in that HHAs were to instead receive 10 points if they reported all of the new measures and 0 points if they did not. TPS and payment adjustments would be calculated based on an HHA s CMS Certification Number (CCN) and would be based only on services provided to beneficiaries in the selected 9 states. However, HHAs that provide services in a state that had a reciprocal agreement with the HHA s home state would have those services included in the TPS. A reciprocal agreement is when a HHA has an agreement to provide services across state lines. CMS will calculate a score for achievement and another score for improvement. The higher of the 2 scores is used as the TPS for each measure. Achievement: [9 x ( Improvement: [10 x ( ) + 0.5] ) - 0.5] In the CY 2016 final rule CMS finalized that the achievement threshold and benchmark will be calculated separately for each selected state and each HHA cohort size. Therefore, CMS would have individual benchmarks and achievement thresholds for both larger-volume and smaller-volume cohorts of HHAs. However, CMS is concerned that because some smaller-volume cohorts are so small, these cohorts could be required to meet performance standards that are greater than the level of performance that HHAs in the larger-volume cohorts would be required to achieve. Therefore, CMS is proposing to calculate the benchmarks and achievement thresholds at the state level rather than at the cohort level for all model years, beginning with CY The thresholds and benchmarks will be defined in each state based on a CY 2015 baseline period. Achievement threshold Benchmark Median of HHA s performance on each measure Mean of top decile of HHA s performance on each measure Duration Baseline Period CMS will use a linear exchange function (LEF) to calculate HHA payment adjustments. The LEF translates a HHAs TPS into a percentage of the value-based payment adjustment earned by each HHA under the HHVBP model. The intercept of LEF will be zero percent, meaning HHAs that are average in relationship to other HHAs in their cohort would receive no payment adjustment. 10 P age

11 In the CY 2016 final rule, CMS set the slope for CY 2016 so that the estimated aggregate value-based payment adjustments for CY 2016 are equal to 3 percent of the total amount of episode payments made to all HHAs by Medicare in each individual state s larger- and smaller-volume cohorts for CY Instead, CMS is proposing to no longer calculate an individual slope for larger- and smaller-volume cohorts but only at the state level. Reporting/Review, Correction and Appeals Process FR pages A quarterly report, Interim Performance Report, will be provided to each Medicare certified HHA containing information on their performance during the quarter: Report First Release Releases Thereafter Final Release Quarterly July 2016 October, January, and April April 2021 An Annual TPS and Payment Adjustment Report will be released once a year in August containing payment adjustment percentages, an explanation of when the adjustment will be applied, and how the adjustment was calculated. This report will be specific to each HHA and accessible only to that HHA. A final annual report will then be publicly available that will provide home health industry stakeholders with information about their home health services quality of care. The first quarterly performance report in July 2016 will not account for any of the new measures. CMS is proposing an appeals process titled Appeals Process for Home Health Value-Based Purchasing Model that will codify the recalculation request process and the proposed reconsideration request process. The first level of the appeals process would be the recalculation process, as stated in the CY 2016 final rule. The proposed reconsideration process for the annual report would only be available when an HHA has first submitted a recalculation request for that report. The annual report will be released again in November with any changes made due to recalculation requests. In the CY 2016 final rule, CMS stated that HHAs will have a 30-day period to review and correct information after quarterly reports and annual reports are released. CMS is proposing to change the submission window to 15 calendar days rather than 30 calendar days in order for recalculations of the July quarterly reports to be completed prior to the posting of the August annual reports. CMS is proposing that reconsideration requests be available only for the annual report and must be submitted within 15 calendar days of release as well. A list of instructions on how to submit an appeal is available on the FR page CMS is also considering public reporting for the HHVBP Model beginning no earlier than CY 2019 to allow analysis of at least 8 quarters of performance data for the model and the opportunity to compare how those results align with other publicly reported quality data. A report on the development/design of a VBP program for HH providers (as mandated by the ACA) is available on the CMS website at Payment/HomeHealthPPS/downloads/stage-2-NPRM.PDF. Updates to the HH Quality Reporting Program (HH QRP) FR pages CMS collects quality data from HHAs on process, outcomes, and patient experience of care. HHAs that do not successfully participate in the HH QRP are subject to a 2.0 percentage point reduction to the marketbasket update for the applicable year. 11 P age

12 All of the process and most outcomes measures required under the HH QRP are derived from the OASIS assessment instrument. Medicare Conditions of Participation (CoPs) require all HH providers that participate in Medicare and Medicaid to collect and report OASIS data to CMS. In addition, HH providers must collect patient experience of care data using the HHCAHPS survey; CMS also calculates 2 HH QRP outcomes measures based on HH claims data that do not require additional reporting. CMS is proposing that, similar to the Hospital IQR, when they initially adopt a measure for the HH QRP for a payment determination, that measure will be automatically retained for all subsequent payment determinations unless it is proposed to be removed or replaced. In the CY 2015 final rule, CMS established a new pay-for-reporting performance standard to be phased in over 3 years for the submission of OASIS quality data. HHAs must meet a minimum reporting threshold, titled Quality Assessment Only (QAO), for OASIS data in order to avoid a 2% marketbasket reduction. In the CY 2016 final rule CMS implemented an increase in the minimum reporting threshold over the next 3 years: # QAO = ( ) *100 # # Performance Period QAO Minimum Reporting Threshold July 1, 2015 June 30, % July 1, 2016 June 30, % July 1, 2017 June 30, % CMS is proposing to adopt 3 measures to meet the Resource Use and Other Measures domain in CY 2018: Total Estimated Medicare Spending Per Beneficiary Post Acute Care Home Health Quality Reporting Program; Discharge to Community Post Acute Care Home Health Quality Reporting Program; Potentially Preventable 30-Day Post-Discharge Readmission Measure for Post-Acute Care Home Health Quality Reporting Program; and Additionally, CMS is proposing to adopt 1 measure to meet the Medication Reconciliation domain in CY 2018: Drug Regimen Review Conducted with Follow-Up for Identified Issues Post Acute Care Home Health Quality Reporting Program. CMS is also proposing to remove 28 measures from the Home Health Quality Initiative (HHQI) that were either topped out and/or determined to be of limited clinical and quality improvement value. Separately, there are 6 process measures that CMS is proposing to remove from the HH QRP beginning with the CY 2018 payment determination because they are also topped out : Pain Assessment Conducted; Pain Interventions Implemented during All Episodes of Care; Pressure Ulcer Risk Assessment Conducted; Pressure Ulcer Prevention in Plan of Care; Pressure Ulcer Prevention Implemented during All Episodes of Care; and Heart Failure Symptoms Addressed during All Episodes of Care. Furthermore, CMS is considering 8 quality measures for future years: Transfer of health information and care preferences when an individual transitions; 12 P age

13 Application of NQF #0674 Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay); Application of NQF #2631 Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function; Application of NQF #2633 Change in Self-Care Score for Medical Rehabilitation Patients; Application of NQF #2634 Change in Mobility Score for Medical Rehabilitation Patients; Application of NQF #2635 Discharge Self-Care Score for Medical Rehabilitation Patients Application of NQF # 2636 Discharge Mobility Score for Medical Rehabilitation Patients; and Application of NQF #0680 Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay). Home Health Care CAHPS Survey (HHCAHPS) FR pages In the CY 2016 HH PPS final rule, CMS stated that the home health quality measures reporting requirements include the HHCAHPS survey for the CY 2017 and CY 2018 Annual Payment Update (APU) periods. CMS requires monthly HHCAHPS data collection and reporting all 4 quarters of each year. CMS requires that all HHAs with fewer than 60 HHCAHPS-eligible unduplicated or unique patients in the previous year collection period are exempt from the HHCAHPS data collection and submission requirements. Also, if an HHA receives Medicare certification after the collection period, CMS automatically exempts them from the survey. Collection periods are below: APU Period Collection Period CY 2017 April 2015 March 2016 CY 2018 April 2016 March 2017 CY 2019 April 2017 March 2018 CY 2020 April 2018 March 2019 #### 13 P age