Proposed Rule Summary. Medicare Home Health Prospective Payment System Program Year: CY2019

Proposed Rule Summary Medicare Home Health Prospective Payment System Program Year: CY2019 July 2018

TABLE OF CONTENTS Overview and Resources... 2 HHPPS Payment Rates... 2 National Per Visit Amounts... 3 n-routine Medical Supply Conversion Factor... 3 Revising and Rebasing of the Home Health Market Basket... 4 Wage Index and Labor-Related Share... 4 Payment Add-On for Rural Home Health Agencies... 4 Reductions Due To minal Case Mix Growth... 5 Home Health Resource Group Update... 5 Outlier Payments... 6 Home Infusion Therapy Services... 6 Certifying and Recertifying Patient Eligibility... 7 Remote Patient Monitoring... 8 Implementation of the Patient-Driven Groupings Model... 8 Mandatory Home Health Value-Based Purchasing Model Demonstration Project... 11 Quality Measures... 12 Scoring... 13 Reporting/Review, Correction and Appeals Process... 14 Updates to the Home Health Quality Reporting Program... 14 CMS Request For Information (RFI)... 16 If you have any questions about this summary, contact Kathy Reep, FHA Vice President/Financial Services, by email at kathyr@fha.org or by phone at (407) 841-6230.

OVERVIEW AND RESOURCES On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) published its proposed calendar year (CY) 2019 payment rule for the Medicare home health prospective payment system (HHPPS). The proposed rule includes updates of the Medicare fee-for-service (FFS) HHPPS payment rates based on regulatory changes set forward by CMS and legislative changes previously adopted by the U.S. Congress. Among the proposed regulatory updates and policy changes are: Updates to the Home Health Resource Group (HHRG) weights for CY2019; Change in the home health unit of payment from 60 days to 30 days for CY2020; Revising and rebasing of the home health market basket; Changes to rural-add on payments for CYs 2019 through 2022; Implementation of payment for home infusion therapy services; Changes to the home health value-based purchasing (HHVBP) model, 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 with this proposed rule and other resources related to the HHPPS are 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.html. An online version of the proposed rule Federal Register is available at https://federalregister.gov/a/2018-14443. A summary of the proposed rule is provided below. Program changes adopted by CMS would be effective for services provided on or after January 1, 2019, unless otherwise noted. Comments on all aspects of the proposed rule are due to CMS by Friday, August 31, 2018, and can be submitted electronically at http://www.regulations.gov by using the Web site s search feature to search for file code 1689-P. HHPPS PAYMENT RATES Federal Register pages 32345-32347, 32360-32373 The tables below show the proposed CY2019 conversion factor compared to the final CY2018 conversion factor and the components of the update factor: Final CY2018 Proposed CY2019 Percent Change 60-Day Episode Rate $3,039.64 $3,151.22 +3.67 2 P a g e

Proposed CY2019 Update Factor Component Value (Percent) Market Basket Update +2.8 PPACA-Mandated Productivity Market Basket Reduction -0.7 percentage points Case Mix Budget Neutrality Adjustment +1.63 Wage Index Budget Neutrality -0.09 Overall Final Rate Update +3.67 National Per Visit Amounts HHPPS payments for episodes with four visits or less are paid on a per visit basis. CMS uses national per visit amounts by service discipline to pay for these -Utilization Payment Adjustment (LUPA) episodes. The national per visit amounts are also used for outlier calculations. The proposed CY2019 per visit amounts include an update factor increase of 2.1 percent and an adjustment for wage index budget neutrality. Per Visit Amounts Final Proposed Percent Proposed CY2019 CY2018 CY2019 Change With LUPA Add-On * Home Health Aide $64.94 $66.30 N/A Medical Social Services $229.86 $234.69 N/A Occupational Therapy $157.83 $161.14 N/A +2.1 Physical Therapy (PT) $156.76 $160.05 $267.28 (1.6700 adj.) Skilled Nursing (SN) $143.40 $146.41 $270.14 (1.8451 adj.) Speech Language Pathology (SLP) $170.38 $173.96 $282.96 (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 is proposing to continue the use of the LUPA add-on factors established in the CY2014 final rule. n-routine Medical Supply Conversion Factor In CY2008, CMS carved out the n-routine Medical Supply (NRS) component from the 60- day episode rate and established a separate national NRS conversion factor with six severity group weights to provide more adequate reimbursement for episodes with a high utilization of NRS. The proposed CY2019 NRS conversion factor has an update factor increase of 2.1 percent. Final CY2018 Proposed CY2019 Percent Change NRS Conversion Factor $53.03 $54.14 +2.1 Points Relative Weight Proposed CY2019 Severity Level (Scoring) (no change from prior years) Payment Amount 1 0 0.2698 $14.61 2 1 to 14 0.9742 $52.74 3 15 to 27 2.6712 $144.62 4 28 to 48 3.9686 $214.86 5 49 to 98 6.1198 $331.33 6 99+ 10.5254 $569.85 3 P a g e

REVISING AND REBASING OF THE HOME HEALTH MARKET BASKET Federal Register pages 32361-32368 CMS is proposing to revise and rebase the home health market basket for fiscal year (FY) 2019 from a base year of 2010 to 2016. The 2016-based home health market basket would eliminate the cost category Postage and include these expenses in the All Other Services cost weight due to its small weight. The forecasted growth rate for CY2019 for the proposed 2016-based home health market basket is the same as the growth rate estimated using the 2010-based home health market basket. WAGE INDEX AND LABOR-RELATED SHARE Federal Register pages 32347-32369 CMS is proposing to decrease the labor-related share from 78.535 percent for CY2018 to 76.1 percent for CY2019 in order to reflect the 2016-based home health market basket. The labor-related portion of the home health 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 home health wage indexes. As has been the case in prior years, CMS is proposing to use the most recent inpatient hospital wage index, the FY2019 pre-rural floor and pre-reclassified hospital wage index, to adjust payment rates under the HHPPS for CY2019. A complete list of the proposed wage indexes for payment in CY2019 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-1689-p.html?dlpage=1&dlentries=10&dlsort=2&dlsortdir=descending. PAYMENT ADD-ON FOR RURAL HOME HEALTH AGENCIES Federal Register pages 32373-32375 The Patient Protection and Affordable Care Act of 2010 (PPACA), by amending the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), mandated a 3.0 percent increase to the payments for HHPPS 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 percent increase to payments for HHPPS episodes and visits in rural areas for episodes and visits ending before January 1, 2018. The Bipartisan Budget Act of 2018 amended the MMA once more to extend the 3.0 percent rural-add on for episodes and visits ending before January 1, 2019. CMS is proposing rural add-on payments for episodes and visits ending during CYs 2019 through 2022 as required by the Bipartisan Budget Act of 2018. The proposal includes varying add-on amounts depending on the rural county (or equivalent area) by classifying each into one of three distinct categories: home health utilization category rural counties and equivalent areas in highest quartile of all counties and equivalent areas based on number of Medicare home health episodes furnished per 100 Medicare beneficiaries excluding counties or equivalent areas with 10 or fewer episodes during 2015; 4 P a g e

population density category rural counties and equivalent areas with a population density of six individuals or less per square mile of land area and that are not included in the high utilization category; or All other rural counties and equivalent areas. Categorization of counties (using FIPS county codes) for the proposed rural add-on can be found at: https://www.cms.gov/medicare/medicare-fee-for-service- Payment/HomeHealthPPS/Downloads/CY2019-CY2022-Rural-Add-On-Payments-Analysis-and- Designations.zip The proposed add-on percentages for CY2019 through CY2022 are as follows: Category CY2019 (Percent) CY2020 (Percent) CY2021 (Percent) CY2022 (Percent) utilization 1.5 0.5 0.0 0.0 population density 4.0 3.0 2.0 1.0 All other 3.0 2.0 1.0 0.0 REDUCTIONS DUE TO NOMINAL CASE MIX GROWTH Federal Register pages 32346-32347 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 CY2016 final rule, CMS finalized a total reduction of 2.88 percent to account for nominal case mix growth from CY2012 to CY2014, to be implemented and distributed evenly over a three-year period. CY2018 was the last year of the three-year phase-in of the 0.97 percent reduction and, therefore, there will be no reduction in CY2019. HOME HEALTH RESOURCE GROUP UPDATE Federal Register pages 32353-32360 The HHPPS 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 () 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. CMS recalibrates the case mix weights 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 CY2019, CMS is proposing to recalibrate the HHPPS case mix weights using cost and utilization data from CY2017. Overall the impact of the change is negative; therefore, CMS is increasing the 60-day episode rate by 1.63 percent in order to maintain budget neutrality for the HHPPS program. The proposed CY2019 case mix payment weights can be found on Federal Register pages 32358-32360. 5 P a g e

OUTLIER PAYMENTS Federal Register pages 32375-32380 Outlier payments are intended to mitigate the risk of caring for extremely high-cost cases. An outlier payment is provided whenever an HHA s cost for an episode of care exceeds a fixed-loss threshold (the HHPPS payment amount for the episode plus a fixed dollar loss [FDL] amount). Currently there is a cap of eight 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 status. The discipline of care with the lowest associated cost per unit is discounted first in the calculation of episode cost, in order to cap the estimation of an episode s cost at eight hours of care per day. The FDL amount is a FDL ratio multiplied by the wage index-adjusted 60-day episode payment. This is added to the HHPPS payment amount for that episode. If the calculated cost exceeds the threshold, the HHA receives an additional outlier payment equal to 80 percent of the calculated excess costs over the fixed-loss threshold. Each HHA s outlier payments are capped at 10 percent of total PPS payments. By law, a limit of 2.5 percent of total HHPPS payments are set aside for outliers. CMS is proposing to decrease the FDL ratio from 0.55 to 0.51 in CY2019. HOME INFUSION THERAPY SERVICES Federal Register pages 32347-32348, 32446-32469 The Medicare Part B home infusion therapy benefit was established by the 21st Century Cures Act to cover professional services including nursing services furnished in accordance with the plan of care, patient training and education, remote monitoring, and monitoring services for the provision of home infusion therapy and home infusion drugs furnished by a qualified home infusion therapy supplier. Home infusion therapy involves the intravenous or subcutaneous administration of drugs or biologicals to an individual at home. The Act requires CMS to implement a payment system under which a single payment is made to a home infusion therapy supplier for items and services, beginning January 1, 2021. CMS is proposing a transitional payment for CYs 2019 and 2020 as required by the Bipartisan Budget Act of 2018 in which payment for home infusion therapy is only for the day on which the nurse is in the patient s home when an infusion drug is being administered. Payment amounts during the transition period would be equal to the amounts determined under the Physician Fee Schedule, using three payment categories. The transitional payment would only apply to existing Medicare qualified home infusion suppliers. In addition, CMS is proposing health and safety standards for home infusion therapy including an accreditation and oversight process for home infusion therapy suppliers. Specifically, CMS is requiring that home infusion therapy suppliers select a CMS-approved accredited organization (AO) and undergo an accreditation review process to demonstrate that the home infusion therapy program meets the accreditation organization s standards in three areas: 6 P a g e

Ensuring all patients have a plan of care established and updated by a physician that sets out the care and prescribed infusion therapy necessary to meet the patient-specific needs; Having procedures to ensure that remote monitoring services associated with administering infusion drugs in a patient s home are provided; and Having procedures to ensure patients receive education and training on the effective use of medications and equipment in the home. Six AOs currently provide accreditation to home infusion therapy suppliers. However, CMS is proposing a separate process for approval by Medicare for accreditation. The proposed process and criteria can be found on Federal Register pages 32450-32464. The current six AOs are: The Joint Commission; Accreditation Commission for Health Care; Compliance Team; Community Health Accreditation Partner; Healthcare Quality Association on Accreditation; and National Association of Boards of Pharmacy Proposed HCPCS codes for transition home infusion drugs are listed on Federal Register page 32465. CMS is soliciting comments on proposals related to the full implementation of payment of home infusion therapy services for CY2021 and future years. Specifically, CMS is soliciting comments on: Requiring two separate claim submissions to account for all components of home infusion therapy; Submitting claims to both DME MACs and the A/B MACs for processing; and Additional suggestions as to how qualified home health infusion therapy suppliers should bill and be paid for services. CERTIFYING AND RECERTIFYING PATIENT ELIGIBILITY Federal Register pages 32423-32425 Currently CMS requires documentation in the certification of physician s medical records and/or the acute/post-acute care facility s medical records to be used as the basis for certification of home health eligibility. Specifically, the documentation must substantiate the patient s need for skilled services and homebound status, as well as contain actual clinical notes for the face-to-face encounter visit that demonstrates that the encounter occurred within the required timeframe, was related to the primary reason the patient requires home health services, and was performed by an allowed provider type. CMS is proposing that, beginning January 1, 2019, in addition to using the documentation in the medical record of the certifying physician or of the acute/post-acute care facility, the Secretary may use documentation in the medical record of the HHA as supporting material that the criteria was met. However, this information must be verified by other medical record entries in the certifying physician s and/or the acute/post-acute care facility s medical record for the patient. 7 P a g e

Due to public comments in the FY2018 proposed rule, CMS is also proposing to eliminate the requirement that the certifying physician estimate how much longer skilled services will be required at each home health recertification to reduce regulatory burden. REMOTE PATIENT MONITORING Federal Register pages 32425-32426 CMS is proposing to define remote patient monitoring under the Medicare home health benefit as the collection of physiologic data digitally stored and/or transmitted by the patient and/or caregiver to the HHA. The cost of remote patient monitoring is not separately billable under the HHPPS and may not be used as a substitute for in-person home health services but can be used to augment the care planning process as appropriate. CMS believes the expenses of remote patient monitoring must be reported on the cost report as allowable administrative costs that are factored into costs per visit. IMPLEMENTATION OF THE PATIENT-DRIVEN GROUPINGS MODEL Federal Register pages 32380-32423 In the CY2018 proposed rule, CMS proposed the Home Health Groupings Model (HHGM), a major recalibration of the HHPPS including a change in the unit of payment from 60 days to 30 days implemented in a non-budget neutral manner. CMS did not finalize the HHGM in order for CMS to have more time to consider public comments. As required by the Bipartisan Budget Act of 2018, in the CY2019 proposed rule CMS is again proposing to implement case mix methodology refinements and a change in the unit of payment from a 60-day episode of care to a 30-day period of care, implemented in a budget neutral manner, and effective January 1, 2020. 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. Since the proposed case mix methodology refinements represent a more patient-driven approach to payment, CMS is renaming it the Patient-Driven Groupings Model (PDGM). The PDGM groups periods of care in a manner consistent with how clinicians differentiate between patients and the primary reason for needing home health care. The model also eliminates the use of therapy thresholds in the case mix adjustment for determining payment, removing the financial incentive to overprovide therapy in order to receive higher payment. Case mix adjustment for home health payment would be based solely on patient characteristics, specifically relying more heavily on clinical characteristics and other patient information to place patients into 216 clinically meaningful payment categories. In order to construct case mix weights, the costs of providing care need to be determined. For the current case mix weights, CMS uses Wage Weighted Minutes of Care, which uses data from the Bureau of Labor Statistics (BLS). For the PDGM, 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 that 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. 8 P a g e

Similar to the current model, 30-day periods under the PDGM would be classified as early or late depending on when they occur within a sequence of 30-day periods. Under the current model, the first two 60-day episodes of a sequence of adjacent 60-day episodes are considered early, while the third and subsequent are considered late. In the PDGM, the first 30-day period is classified as early and all subsequent periods are late. CMS is proposing that a 30-day period cannot be considered early unless there was a gap of more than 60 days between the end of a prior period and the beginning of the next. The current comprehensive assessment would still be completed within five days of the start of care date and completed no less frequently than during the last five days of every 60 days beginning with the start of care date. In addition, the plan of care would still be reviewed and revised by the HHA and the physician responsible for the home health plan of care no less frequently than once every 60 days, beginning with the start of care date. Under the PDGM, each period would also be classified into one of two admission source categories depending on what health care setting was utilized in the 14 days prior to home health: Admission Source Category Community Institutional 30-Day Period Classification acute or post-acute care stay occurred in the 14 days prior to the start of the 30-day period of care Acute or post-acute care stay occurred in the prior 14 days to the start of the 30-day period PDGM would then group 30-day periods into one of six clinical groups based on principal diagnosis reported on the claim: Musculoskeletal Rehabilitation; Neuro/Stroke Rehabilitation; Wounds Post-Op Wound Aftercare and Skin/n-Surgical Wound Care; Complex Nursing Interventions; Behavioral Health Care (including Substance Use Disorder); or Medical Management, Teaching and Assessment (MMTA). Each 30-day period would then be placed into one of three functional levels with roughly 33 percent of periods within each clinical group to each functional level. Criteria for assignment to each of the three functional levels may differ across each clinical group. Afterwards, a comorbidity adjustment may be made depending on a patient s secondary diagnosis. The 30-day period may receive a no, low, or a high comorbidity adjustment. CMS is proposing that the LUPA threshold would be the 10 th percentile value of visits under the PDGM for each payment group (minimum threshold of at least two for each group). 9 P a g e

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/Stroke Rehab, Wounds, Complex Nursing Interventions, Musculoskeletal (MS) Rehab, or Behavioral Health MMTA, Neuro/Stroke Rehab, Wounds, Complex Nursing Interventions, MS Rehab, or Behavioral Health MMTA, Neuro/Stroke Rehab, Wounds, Complex Nursing Interventions, MS Rehab, or Behavioral Health MMTA, Neuro/Stroke Rehab, Wounds, Complex Nursing Interventions, MS Rehab, or Behavioral Health Functional Level Medium Medium Medium Medium Comorbidity Adjustment? PDGM Classification In the PDGM, the LUPA add-on policy, the partial episode payment adjustment policy, and the methodology used to calculate payments for high-cost outliers would remain unchanged except for occurring on a 30-day basis rather than a 60-day basis. CMS is also proposing to update the HHPPS Grouper software once a year on January 1, rather than the current twice a year on October 1 and January 1 in an effort to reduce provider burden. In the CY2018 proposed rule, CMS discussed the current split percentage payment approach to the 60-day episode and if it is still needed for HHAs if the unit of payment changes from 60-day episodes to 30-day periods of care. The current split payment approach is as follows: 10 P a g e

First Episode Amount Paid Beginning of Episode: Request for Anticipated Payment 60 percent of the anticipated final claim (RAP) End of Episode Remaining 40 percent For all subsequent episodes for beneficiaries who receive continuous home health care, the episodes are paid at a 50/50 percentage payment split. In the CY2019 proposed rule, CMS is proposing not to allow newly-enrolled HHAs (certified for participation in Medicare on or after January 1, 2019) to receive RAP payments beginning CY2020 and, therefore, not participate in split percentage payments. However, CMS is proposing that existing HHAs would continue to receive split percentage payments upon implementation of the PDPM. CMS is soliciting comments on ways to completely phase-out the split percentage payment approach in future years. MANDATORY HOME HEALTH VALUE-BASED PURCHASING MODEL DEMONSTRATION PROJECT Federal Register pages 32426-32439 Background: CMS implemented a PPACA-mandated Home Health Value-based Purchasing (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 nine 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. Payment adjustments for each year of the model are calculated based on a comparison of how well each of the competing Medicare-certified HHAs performed during each one year performance period, beginning in CY2016, compared to the baseline year CY2015, as well as performance of their peers. The contribution amount is equal to the maximum payment adjustment. CY2018 is the first year that payment adjustments were applied. Payment Period Performance Period Aggregate HHVBP Payment Adjustment (Percent) CY2018 January 1, 2016 December 31, 2016 3 max CY2019 January 1, 2017 December 31, 2017 5 max CY2020 January 1, 2018 December 31, 2018 6 max CY2021 January 1, 2019 December 31, 2019 7 max CY2022 January 1, 2020 December 31, 2020 8 max The HHVBP program is budget neutral by state. Similar to the hospital VBP program, this is redistributive and all HHAs in the mandated state contribute to the VBP pool; some will then get their contribution back or even more than what they contributed, and some lose money to the program. 11 P a g e

Quality Measures Federal Register pages 32426-32431 The current quality measures in Performance Year 4 (CY2019) of the HHVBP measure set include: NQS Domain Clinical Quality of Care Measure Type Outcome Outcome Outcome Measure Title Improvement in Ambulation-Locomotion (NQF0167) (proposal to remove for Performance Year 4) Improvement in Bed Transferring (NQF0175) (proposal to remove for Performance Year 4) Improvement in Bathing (NQF0174) (proposal to remove for Performance Year 4) Data Source (M1860) (M1850) (M1830) Outcome Improvement in Dyspnea (M1400) Communication & Care Coordination Efficiency & Cost Reduction Patient Safety Population/ Community Health Patient & Caregiver Centered Experience Outcome Discharged to Community (M2420) Process Outcome Outcome Outcome Outcome Process Process Process Process Advance Care Plan (NQF0326) 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) (proposal to remove for Performance Year 4) Pneumococcal Polysaccharide Vaccine Ever Received (NQF0525) (proposal to remove for Performance Year 4) Influenza Vaccination Coverage for Home Health Care Personnel (NQF0431) Herpes Zoster (Shingles) Vaccination Received by HHA Patients Reported by HHAs through Web-based portal CCW (Claims) CCW (Claims) (M1242) (M2020) (M1046) (M1051) Reported by HHAs through Web-based portal Reported by HHAs through Web-based portal 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 CMS is proposing to remove the Influenza Immunization Received for Current Flu Season and Pneumococcal Polysaccharide Vaccine Ever Received for Performance Year 4 (CY2019) of the program. 12 P a g e

CMS is also proposing to replace Improvement in Ambulation-Locomotion, Improvement in Bed Transferring, and Improvement in Bathing with two proposed composite measures on total normalized composite change in self-care and mobility for Performance Year 4 (CY2019). Each of the two measures would have a maximum score of 15 points, so that 30 points would still be available in total for activities of daily living (ADL) related measures. Scoring Federal Register pages 32431-32438 CMS calculates the benchmarks and achievement thresholds at the state level for all model years. 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 The Linear Exchange Function is calculated at the state level. In the CY2016 final rule, CMS finalized weighting measures within each measure category the same for purposes of payment adjustment. In order to better support improvement in claimsbased measures CMS is proposing that beginning Performance Year 4, measures will be weighted as follows: Measure Category Percentage of Total Points Total Points -based measures 35 Claims-based measures 35 90 HHCAHPS 30 New measures 100 10 Weights would be adjusted under this proposal for HHAs that are missing entire measure categories. CMS is also proposing that the weight of the Acute Care Hospitalization: Unplanned Hospitalization during first 60 days of home health claims-based measure be increased so that it has three times the weight of the Emergency Department Use without Hospitalization claimsbased measure. CMS is also proposing to reduce the maximum amount of improvements points a HHA could earn from 10 points to 9 points for all measures except for, if finalized, the two normalized composite change in self-care and mobility measures beginning Performance Year 4. The improvement point formula would be: HHA Performance Score HHA Baseline Period Score Improvement: [9 x ( ) - 0.5] Benchmark HHA Baseline Period Score 13 P a g e

Reporting/Review, Correction and Appeals Process Federal Register pages 32438-32439 HHAs have a 15-day period to review and correct information after quarterly reports and annual reports are released. Reconsideration requests are available only for the annual report and must be submitted within 15 calendar days of release as well. CMS is soliciting further public comment on what information, specifically from the CY2017 Annual Total Performance Score and Payment Adjustment Reports and subsequent annual reports, should be made publicly available. UPDATES TO THE HOME HEALTH QUALITY REPORTING PROGRAM Federal Register pages 32439-32446 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 market basket update for the applicable year. CMS is considering options to improve health disparities among patient groups within and across hospitals by increasing transparency of disparities through quality measures and quality programs. Also, CMS is proposing an additional factor to consider when evaluating measures for removal from the HH QRP program measure set: the costs associated with a measure outweigh the benefit of its continued use in the program. Summary Table of Measure Currently Adopted for the CY2020 Home Health Quality Reporting Program Measures Data Source Improvement in Ambulation/Locomotion (NQF #0167) Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674) Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631). Improvement in Bathing (NQF #0174) Improvement in Bed Transferring (NQF #0175) Depression Assessment Conducted Diabetic Foot Care and Patient/Caregiver Education Implemented during All Episodes of Care (NQF #0519) Drug Regimen Review Conducted With Follow-Up for Identified Issues- Post Acute Care (PAC) HH QRP Drug Education on All Medications Provided to Patient/Caregiver during All Episodes of Care Improvement in Dyspnea Multifactor Fall Risk Assessment Conducted For All Patients Who Can Ambulate (NQF #0537) Influenza Immunization Received for Current Flu Season (NQF #0522) Improvement in Management of Oral Medications (NQF #0176) Improvement in Pain Interfering with Activity (NQF #0177) 14 P a g e

Pneumococcal Polysaccharide Vaccine Ever Received Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678), removed as of January 1, 2019 Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury measure, effective January 1, 2019 Improvement in Status of Surgical Wounds (NQF #0178) Timely Initiation Of Care (NQF #0526) Acute Care Hospitalization During the First 60 Days of HH (NQF #0171) Discharge to Community-Post Acute Care (PAC) Home Health (HH) Quality Reporting Program (QRP) Emergency Department Use without Hospitalization During the First 60 Days of HH (NQF #0173) Emergency Department Use without Hospital Readmission During the First 30 Days of HH (NQF #2505) Total Estimated Medicare Spending Per Beneficiary (MSPB)-Post Acute Care (PAC) HH QRP Potentially Preventable 30-Day Post-Discharge Readmission Measure for HH Quality Reporting Program Rehospitalization During the First 30 Days of HH (NQF #2380) How well did the home health team communicate with patients How do patients rate the overall care from the home health agency How often the home health team gave care in a professional way Did the home health team discuss medicines, pain, and home safety with patients Will patients recommend the home health agency to friends and family Claims-based Claims-based Claims-based Claims-based Claims-based Claims-based Claims-based HHCAHPS HHCAHPS HHCAHPS HHCAHPS HHCAHPS CMS is proposing to remove the following measures from the CY2021 HH QRP: Depression Assessment Conducted; Diabetic Foot Care and Patient/Caregiver Education Implemented during All Episodes of Care; Multifactor Fall Risk Assessment Conducted For All Patients Who Can Ambulate; Pneumococcal Polysaccharide Vaccine Ever Received; Improvement in the Status of Surgical Wounds; Emergency Department Use without Hospital Readmission during the First 30 Days of HH; and Removal of the Rehospitalization during the First 30 Days of HH. A pay-for-reporting performance standard is currently being phased-in over three years for the submission of quality data. HHAs must meet a minimum reporting threshold, titled Quality Assessment Only (QAO), for data in order to avoid a two percent market basket reduction: # of Quality Assessments Reported QAO = ( # of Quality Assessments Reported + # of nquality Assessments Reported ) *100 Calendar Year Performance Period QAO Minimum Reporting Threshold (Percent) 2017 July 1, 2015 June 30, 2016 70 15 P a g e

2018 July 1, 2016 June 30, 2017 80 2019 July 1, 2017 June 30, 2018 90 CMS is proposing to remove 38 data elements from the current items, effective January 1, 2020. Lastly, CMS is proposing to increase the number of years of data used to calculate the MSPB- PAC HH QRP measure for purposes of display from one year to two years. CMS REQUEST FOR INFORMATION (RFI) Federal Register pages 32471-32474 With this proposed rule, CMS is issuing an RFI on Promoting Interoperability and Electronic Healthcare Information Exchange through Possible Revisions to the CMS Patient Health and Safety Requirements for Hospitals and Other Medicare- and Medicaid-Participating Providers and Suppliers. This RFI is to solicit feedback on positive solutions to better achieve interoperability in the sharing of health care data between providers. CMS is also issuing an RFI on Price Transparency: Improving Beneficiary Access to Home Health Agency Charge Information. This RFI is to solicit feedback on ways to improve the accessibility and usability of current charge information, specifically to help providers and suppliers engage in consumer-friendly communication of charges to help patients understand what their potential financial liability might be. Submissions will be considered in developing future regulatory proposals or sub-regulatory guidance. 16 P a g e