Medicare Home Health Prospective Payment System

Medicare Home Health Prospective Payment System Payment Rule Summary PROPOSED CY 2018 Overview and Resources On July 28, 2017, the Centers for Medicare and Medicaid Services (CMS) published its proposed calendar year (CY) 2018 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, suggested 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 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; Changes in the unit of payment from 60-day episodes of care to 30-day episodes of care and case-mix calculations beginning January 1, 2019; Updates to the Home Health Resource Group (HHRG) weights; Expiration of the rural-add on for episodes and visits that end on or after January 1, 2018; 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; and 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 https://www.cms.gov/medicare/medicare-fee-for-service- Payment/HomeHealthPPS/Home-Health-Prospective-Payment-System-Regulations-and-tices.html. An online version of the Federal Register with this proposed rule is available at https://federalregister.gov/a/2017-15825. 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, 2018 unless otherwise noted. Comments on all aspects of the proposed rule are due to CMS by Monday, September 25, 2017 and can be submitted electronically at http://www.regulations.gov by using the website s search feature to search for file code 1672-P. HH PPS Payment Rates Federal Register pages 35288-35292 The Medicare Access and CHIP Reauthorization Act (MACRA) mandated the annual marketbasket update for FFY 2018, after applying the productivity adjustment, to be 1 percent. The tables below show the proposed CY 2018 conversion factor compared to the final CY 2017 conversion factor and the components of the update factor: 1 P age

Final CY 2017 Proposed CY 2018 Percent Change 60-Day Episode Rate $2,989.97 $3,038.43 +1.62% Proposed CY 2018 Update Factor Component Value Marketbasket (MB) Update +2.7% Affordable Care Act (ACA)-Mandated Productivity MB Reduction -0.5 percentage points MACRA Mandated 1.0% Marketbasket Update -1.17% minal Case-Mix Growth Reduction -0.97% Case-Mix Budget Neutrality Adjustment +1.59% Wage Index Budget Neutrality +0.01% Overall Proposed Rate Update +1.62% 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 2018 per-visit amounts include a rebasing increase of 3.5% of the CY 2010 national per-visit payment amounts, an update factor increase of 1.0%, and an adjustment for wage index budget neutrality. Per-Visit Amounts Final Proposed Percent Proposed CY 2018 CY 2017 CY 2018 Change With LUPA Add-On * Home Health Aide $64.23 $64.90 N/A Medical Social Services $227.36 $229.75 N/A Occupational Therapy $156.11 $157.75 N/A +1.01% Physical Therapy (PT) $155.05 $156.68 $261.66 (1.6700 adj.) Skilled Nursing (SN) $141.84 $143.33 $264.46 (1.8451 adj.) Speech Language Pathology (SLP) $168.52 $170.29 $276.99 (1.6266 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. n-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 2018 NRS conversion factor an update factor increase of 1.0%. Final CY 2017 Proposed CY 2018 Percent Change NRS Conversion Factor $52.50 $53.03 +1.01% 2 P age Severity Level Points Relative Weight CY 2018 Proposed (Scoring) (no change from prior years) Payment Amount 1 0 0.2698 $14.31 2 1 to 14 0.9742 $51.66 3 15 to 27 2.6712 $141.65

4 28 to 48 3.9686 $210.45 5 49 to 98 6.1198 $324.53 6 99+ 10.5254 $558.16 Wage Index and Labor-Related Share Federal Register pages 35288-35289 CMS is proposing to maintain the labor-related share at 78.535% for CY 2018. The labor-related portion of the HH payment rate is adjusted for differences in area wage levels using a wage index. CMS is not proposing 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 2018 pre-rural floor and prereclassified hospital wage index, to adjust payment rates under the HH PPS for CY 2018. A complete list of the proposed wage indexes for payment in CY 2018 is available on the CMS Web site at https://www.cms.gov/medicare/medicare-fee-for-service-payment/homehealthpps/home-health- Prospective-Payment-System-Regulations-and-tices-Items/CMS-1672- P.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending Payment Add-On for Rural HH Agencies Federal Register page 35292 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, 2016. 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 episodes and visits ending before January 1, 2018. Therefore, for episodes and visits that end on or after January 1, 2018, a rural add-on payment will not apply. Reductions Due To minal-case-mix Growth Federal Register pages 35272 and 35275 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 the CY 2016 final rule, CMS finalized a total reduction of 2.88% to account for nominal case-mix growth from CY 2012 to CY 2014, to be implemented and distributed evenly over a 3 year period. This distribution resulted in a 0.97% reduction to the national, standardized 60-day episode payment rate for each of the three years (CYs 2016-2018). CMS goal is to increase the accuracy of Medicare payments for the delivery of home health services and this reduction will remain separate from the CY 2014 rebasing adjustments. HHRG Update Federal Register pages 35282-35288 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 a national average case-mix of about 1.0. 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 3 P age

current status of home health resource use and changes in utilization. For CY 2018, CMS is proposing to recalibrate the HH PPS case-mix weights using cost and utilization data from CY 2016. Overall the impact of the change is negative; therefore, CMS is proposing to increase the 60-day episode rate by 1.59% in order to maintain budget neutrality for the HH PPS program. The proposed CY 2018 case-mix payment weights can be found on Federal Register pages 35286 35288. Outlier Payments Federal Register pages 35292-35294 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). In the CY 2017 final rule, CMS adopted a costper-unit calculation, rather than a cost-per-visit approach, in order to determine the cost of an episode. In the CY 2017 final rule CMS also implemented a cap of 8 hours or 32 units per day (1 unit = 15 minutes, summed across the six disciplines of care) on the amount of time per day that would be counted toward the estimation of an episode s costs for outlier. The discipline of care with the lowest associated cost per unit will be discounted first in the calculation of episode cost, in order to cap the estimation of an episode s cost at 8 hours of care per day. The FDL amount is calculated as a FDL ratio multiplied by the wage index-adjusted 60-day episode payment rate. This is 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. CMS is proposing to maintain the FDL ratio of 0.55 in CY 2018. Implementation of the Home Health Groupings Model (HHGM) Federal Register pages 35275 35282, 35294-35332 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 in treating beneficiaries with high levels of severity of illness. Findings in the report suggested that the current system may discourage HHAs from serving patients with clinically complex and/or poor controlled chronic conditions who do not need therapy services, but require skilled nursing care. This is because, under the current system, HHAs receive higher payments for providing more therapy visits once certain thresholds are reached, creating a financial incentive for therapy visits. CMS is proposing case-mix methodology refinements through the implementation of the HHGM for home health periods of care beginning on or after January 1, 2019. The HHGM uses two 30-day periods, rather than a single 60-day episode as episodes have more visits, on average, during the first 30 days compared to the last 30 days. Costs are much higher earlier in the episode and lesser later on. Therefore, dividing a single 60-day episode into two 30-day periods more accurately apportions payments based on resource use. This implementation would not be budget neutral. The HHGM also eliminates the use of the number of therapy visits provided to determine payment, and relies more heavily on clinical characteristics and other patient information (for example, diagnosis, functional level, comorbid conditions) to place patients into meaningful payment categories, rather than the current therapy driven system. In total, there are 144 different payment groups in the HHGM. 4 P age

In order to construct case-mix weights, the costs of providing care need to be determined. For the current casemix weights, CMS uses Wage Weighted Minutes of Care, which uses data from the Bureau of Labor Statistics (BLS). For the HHGM, CMS is proposing to use a Cost-Per-Minute plus n-routine Supplies (CPM + NRS) approach, which uses information from the Medicare Cost Report. This approach incorporates a wider variety of costs and are available for individual HHA providers, while the BLS costs are aggregated. It also allows the NRS to be incorporated into the case-mix system, rather than maintaining a separate payment system. Under the HHGM, CMS is proposing that each period would be classified into one of two admission source categories using newly-created occurrence codes: Admission Source Category 30-Day Period Classification acute or post-acute care stay occurred in the 14 days prior to the start Community of the 30-day period of care (no occurrence code present on claim) Acute or post-acute care stay occurred in the prior 14 days to the start of Institutional the 30-day period (occurrence code present on claim) Then, the HHGM would group 30-day periods into six clinical groups based on the principal diagnosis listed on the home health claim. Within each of the six clinical groups, each 30-day period would be placed into one of three functional levels with roughly 33 percent of periods in each level. Afterwards, a comorbidity adjustment would be made if any secondary diagnosis codes listed on the home health claim are included on a list of comorbidities that occurred in at least 0.1 percent of 30-day periods and are associated with increased average resource use. Admission Source and Timing Community Early (First 30-Day Period) Community Late (Subsequent 30- Day Periods) Institutional Early (First 30-Day Period) Institutional Late (Subsequent 30- Day Periods) Clinical Grouping (One of Six Groups From Principal Diagnosis) Medication Management, Teaching and Assessment (MMTA), Neuro Rehab, Wounds, Complex Nursing Interventions, Musculoskeletal (MS) Rehab, or Behavioral Health MMTA, Neuro Rehab, Wounds, Complex Nursing Interventions, MS Rehab, or Behavioral Health MMTA, Neuro Rehab, Wounds, Complex Nursing Interventions, MS Rehab, or Behavioral Health MMTA, Neuro Rehab, Wounds, Complex Nursing Interventions, MS Rehab, or Behavioral Health Functional Level Low Medium High Low Medium High Low Medium High Low Medium High Comorbidity Adjustment? HHRG classification Similar to the current HH PPS, CMS is proposing that 30-day periods are considered to be in the same sequence as long as no more than 60 days pass between the end of one period and the start of the next. Currently, if an HHA provides four visits or less in an episode, they will be paid at the LUPA amount. HHGM would still include LUPAs, but CMS is proposing to use a LUPA threshold equal to the 10 th percentile value of visits to create payment group specific LUPA thresholds, with a minimum threshold of at least 2 for each group. This proposed change is due to the proposed change in the unit of payment to 30-day periods from 60-day episodes. CMS is proposing to keep the LUPA add-on factors the same as the current payment system. 5 P age

The conditions for payment in the HHGM would remain the same for Medicare home health services including: The individual must be in need or needed intermittent skilled nursing care, or physical therapy or speech-language pathology services, and is confined to the home; A plan of care has been established and will be periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine; The individual was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine; and A face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician or allowed nonphysician practitioner. CMS is proposing to calculate the CY 2019 national, standardized 30-day payment amount using the HHGM by starting with the CY 2019 60-day episode payment amount, adding back in the CY 2019 NRS conversion factor amount, and then dividing the sum by two. For CY 2020 and subsequent years, CMS is proposing to calculate the 30-day payment amount by updating the amount from the immediate proceeding year by the home health payment update percentage. In the current HH PPS, there is a split percentage payment approach: First Episode Amount Paid Beginning of Episode: Request for Anticipated Payment (RAP) 60% of the anticipated final claim End of Episode Remaining 40% For all subsequent episodes for beneficiaries who receive continuous home health care, the episodes are paid at a 50/50 percentage payment split. CMS is not proposing a change to the split percentage payment approach in conjunction with the proposed HHGM, but is soliciting feedback on whether the split payment approach is still needed with the proposed HHGM due to the length of time HHAs currently take to submit the RAP, as well as ways to phase-out the approach in the future. This would also potentially eliminate the need for HHAs to submit a notice of admission within 5 days of the start of care to assure being established as the primary HHA for the beneficiary. Under the HHGM, CMS is also proposing to keep the partial episode payment adjustment and the payments for high-cost outliers the same as the current HH PPS methodologies. CMS is soliciting comment on whether they should implement the HHGM in a fully non-budget neutral manner beginning in CY 2019 or alternatively use a phased approach to implementation. The phased approach would apply a HHGM partial budget neutrality adjustment factor in CY 2019 that would reduce the estimated impact of the HHM from -4.3% to -2.2% in the initial year of implementation. The budget neutrality factor would not apply in CY 2020. Alternatively, the budget neutrality adjustment factor could be applied and then phased-out over a longer time period. Mandatory HH VBP Model Demonstration Project Federal Register pages 35332-35340 Background: CMS implemented an ACA mandated HHVBP demonstration model for certain Medicare-certified HHAs, starting January 1, 2016 and concluding December 31, 2022. The Medicare-certified HHAs required to participate are from 9 randomly selected states: Massachusetts, Maryland, rth Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee. The demonstration program resembles the VBP Program for inpatient acute care hospitals. 6 P age

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. CY 2018 is the first year that payment adjustments will be applied. Payment Period Performance Period Aggregate HHVBP Payment Adjustment CY 2018 January 1, 2016 December 31, 2016 3% max CY 2019 January 1, 2017 December 31, 2017 5% max CY 2020 January 1, 2018 December 31, 2018 6% max CY 2021 January 1, 2019 December 31, 2019 7% max CY 2022 January 1, 2020 December 31, 2020 8% max 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 or even more than what they contributed, and some may get less. Quality Measures Federal Register pages 35332-35340 CMS is proposing to remove the Drug Education on All Medications Provided to Patient/Caregiver during All Episodes of Care measure for performance year 3 of the program. The quality measures in performance year 1 of the HHVBP measure set include: NQS Domain Measure Type Measure Title Data Source Outcome Improvement in Ambulation-Locomotion (NQF0167) OASIS (M1860) Outcome Improvement in Bed Transferring (NQF0175) OASIS (M1850) Clinical Quality of Care Communication & Care Coordination Efficiency & Cost Reduction Outcome Improvement in Bathing (NQF0174) OASIS (M1830) Outcome Improvement in Dyspnea OASIS (M1400) Drug Education on All Medications Provided to Patient/Caregiver during all Episodes of Care (proposal to remove for performance year 3) OASIS (M2015) Outcome Discharged to Community OASIS (M2420) Outcome Outcome Acute Care Hospitalization: Unplanned Hospitalization during first 60 days of Home Health (NQF0171); Emergency Department Use Without Hospitalization (NQF0173) CCW (Claims) CCW (Claims) 7 P age

Patient Safety Population/Co mmunity Health Patient & Caregiver Centered Experience Outcome Improvement in Pain Interfering with Activity (NQF0177) OASIS (M1242) Outcome Improvement in Management of Oral Medications (NQF0176) OASIS (M2020) Influenza Immunization Received for Current Flu Season (NQF0522) OASIS (M1046) Pneumococcal Polysaccharide Vaccine Ever Received (NQF0525) 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 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 Reported by HHAs through Web-based 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, 2016 CMS is considered the inclusion of the following measures for future program years: Composite Total ADL/IADL Change Composite Functional Decline HHA Correctly Identifies Patient s Need for Mental or Behavioral Health Supervision Caregiver Can/Does Provide for Patient s Mental or Behavioral Health Supervision Need Inclusion/Exclusion Criteria Federal Register pages 35332 35334 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. Currently, 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. CMS is proposing to increase the minimum number of completed Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) surveys from 20 to 40 completed HHCAHPS surveys to better align the model with HHCAHPS policy for the Patient Survey Star Ratings on Home Health Compare, beginning with performance year one. 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 8 P age

a payment adjustment will not be made for that particular HHA. 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 to mitigate outliers, these specific HHAs would be included in the state s larger-volume cohort without being measured on HHCAHPS. This is for purposes of calculating the total performance score and payment adjustment for those HHAs. Scoring Federal Register page 35332 As finalized in the CY 2017 final rule, CMS will calculate the benchmarks and achievement thresholds at the state level for all model years, beginning with CY 2016. 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 In the CY 2017 final rule CMS finalized that they will calculate the Linear Exchange Function at the state level. Reporting/Review, Correction and Appeals Federal Register page 35332 In the CY 2017 final rule CMS finalized that HHAs will have a 15-day period to review and correct information after quarterly reports and annual reports are released. Reconsideration requests are only available only for the annual report and must be submitted within 15 calendar days of release as well. Updates to the HH Quality Reporting Program (HH QRP) Federal Register pages 35341-35376 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. CMS is considering methods to account for social risk factors in the SNF QRP such as income, education, race and ethnicity, employment, disability, community resources, and social support. CMS is seeking comment on how to incorporate social risk factors and which social risk factors should be incorporated. To comply with the IMPACT act, in order to enable access to longitudinal information and to facilitate coordinated care, CMS is proposing that HHAs begin reporting standardized patient assessment data with respect to five specified patient assessment categories required by law for the CY 2019 HH QRP, including: Functional status Cognitive function Special services, treatments, and interventions Medical conditions and comorbidities Impairments 9 P age

Other categories deemed necessary 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 3 years: # oooo QQQQQQQQQQQQQQ AAAAAAAAAAAAAAAAAAAAAA RRRRRRRRRRRRRRRR QAO = ( ) *100 # oooo QQQQQQQQQQQQQQ AAAAAAAAAAAAAAAAAAAAAA + # oooo NNNNNNNNNNNNNNNNNNNN AAAAAAAAAAAAAAAAAAAAAA Calendar Year Performance Period QAO Minimum Reporting Threshold 2017 July 1, 2015 June 30, 2016 70% 2018 July 1, 2016 June 30, 2017 80% 2019 July 1, 2017 June 30, 2018 90% CMS is proposing to apply these threshold requirements to the submission of standardized patient assessment data beginning with the CY 2019 HH QRP. CMS is also proposing to remove the current Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) measure and replace it with a modified version of the measure, Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury, for the FFY 2020 HH QRP. In addition, CMS is proposing to adopt two more measures for CY 2020: Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674); and Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631). Furthermore, CMS is considering 4 quality measures for future years: Application of Change in Self-Care Score for Medical Rehabilitation (NQF #2633); Application of Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634); Application of Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635); and Application of Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636). Beginning with the CY 2019 HH QRP, CMS is proposing a process for HHAs to request and for CMS to grant exceptions and extensions for the reporting requirements of the HH QRP for one or more quarters when there are certain extraordinary circumstances beyond control of the HHA. The HHA must request an exception or extension within 90 days of the date that the extraordinary circumstances occurred. CMS is also proposing that a HHA would receive a notification of noncompliance if CMS determines that the HHA did not submit data in accordance with the HH QRP reporting requirements for the applicable CY, beginning CY 2019. The HHA may then, within 30 days of receiving the notice, file a request for reconsideration if it believes that the finding of noncompliance is erroneous, has submitted a request for an extension or exception that has not yet been decided, or has been granted an extension or exception. Lastly, CMS is proposing that is a HHA had fewer than 20 eligible cases for a measure, the HHA s performance on that measure would not be publicly reported for that performance period. 10 P age

Home Health Care CAHPS Survey (HHCAHPS) Federal Register pages 35376-35378 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. CMS is proposing to continue their home health quality measures reporting requirements for the CY 2021 Annual Payment Update (APU) period. 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 CY 2021 April 2019 March 2020 All the requirements for the HHCAHPS survey and which home health patients are ineligible for the HHCAHPS survey are detailed at http://homehealthcahps.org. Request for Information on CMS Flexibilities and Efficiencies Federal Register page 35378 CMS is issuing a Request for Information on how Medicare can contribute to making the healthcare delivery system less bureaucratic and complex, and how they can reduce burden to clinicians, providers, and patients in a way that increases the quality of care and decreases costs. CMS suggest ideas for regulatory, subregulatory, policy, practice, and procedural changes to better accomplish these goals including: Payment system design; Elimination or streamlining of reporting; Monitoring and documentation requirements; Aligning Medicare requirements and processes with those from Medicaid and other payers; Operational flexibility; Feedback mechanisms and data sharing that would enhance patient care; Support of the physician-patient relationship in case delivery; and Facilitation of individual preferences. #### 11 P age