September 12-13, 2002 Public Meeting on Home Health Care and Medical
Devices
Presentation: Medicare Home Health Benefit, Kathleen Walch |
|
Home Health Eligibility
- Must meet all 4 qualifying criteria
- (1) Skilled Need
- You must need:
- intermittent skilled nursing (other than solely venipuncture) or
- physical therapy or
- speech language pathology or
- continue to need occupational therapy
- (2) You are homebound
- normal inability to leave
- leaving takes a considerable & taxing effort
- absences are for an infrequent or short duration or to receive health
care treatment
- BIPA 2000-Can attend State certified/licensed or accredited day
care program and religious services
- (3) You are under the plan of care established & periodically reviewed
by a physician
- (4) You receive the services from a Medicare participating HHA
Home Health Coverage
- Part-time or intermittent skilled nursing
- Part-time or intermittent home health aide
- Physical therapy
- speech-language pathology
- occupational therapy
- medical social services
- medical supplies
- durable medical equipment
- injectible osteoporosis drug
The Home Health Prospective Payment System (PPS)
- Laws Governing PPS:
- Balanced Budget Act of 1997 (BBA)
- Omnibus Consolidated and Emergency Supplemental Appropriations Act for
FY 1999
- Balanced Budget Refinement Act of 1999
- Proposed rule published October 28, 1999
- Final rule published July 3, 2000
- October 1, 2000 effective date for all home health agencies (HHAs)
What is included in the PPS Unit of Payment?
- Covered home health services paid on a reasonable cost basis as of the date
of enactment of the BBA
- Six Disciplines
- skilled nursing
- home health aide
- physical therapy
- speech-language pathology
- occupational therapy
- medical social services
- Non-Routine Medical Supplies
What is not included in the PPS unit of payment?
- Durable Medical Equipment
- Osteoporosis Drug
What is the unit of payment under PPS?
- 60 Day Episode Payment
- Continuous recertification for eligible beneficiaries
- Split Percentage Payment
- BBA Eliminates PIP -cash flow/pay& chase
- 60/40 First Episodes
- 50/50 Subsequent Episodes
- HHAs submit requests for anticipated payment (RAP) for initial percentage
payment
- HHAs submit claims for final percentage payment
What are the adjustments to the PPS unit of payment?
- CASE MIX
- Abt Case Mix Research Study
- 80 Case Mix Groups (80 Home Health Resource Groups-HRGs)
- 23 OASIS items
- Geographic Differences in Wages
- Latest pre-floor & pre-reclassified hospital wage index
- Based on site of service of the beneficiary
- Annual Updates for Inflation Required by Law
When can I restart the 60 day episode clock during an existing episode?
- Two Intervening Events Trigger a New 60 Day Episode Clock:
- Beneficiary Elected Transfer
- Discharge & Return to Same HHA
- The original 60 day episode payment will be closed out with a “Partial
Episode Payment Adjustment” (PEP Adjustment)
- PEP Adjustment to original 60 day episode is based on billable visit dates
as a proportion of 60
Significant Change in Condition Payment Adjustment (SCIC Adjustment)
- SCIC Adjustment occurs when:
- a beneficiary experiences a significant change in condition during the
60 day episode not envisioned in the original plan of care.
- a beneficiary’s significant change in condition requires a change
in case mix level & new physician orders reflecting change in course
of treatment.
SCIC Adjustment Calculation
- Both Parts of the SCIC Adjustment are calculated using the span of time
the patient was at the case mix level prior to and after the significant change
- SCIC adjustment does not restart the 60 day episode clock
- SCIC occurs within a given 60 day episode
- SCIC adjustment reflects proportional payments during a given episode both
before and after the significant change in condition
Low Utilization Payment Adjustment (LUPA)
- Reduces 60 Day Episode Payment for Minimal Service Delivery
- Four or fewer visit threshold
- Wage adjusted average per visit amounts per discipline
Outlier Payments
- Optional in Law
- Capped at 5% of total outlays
- Cost Outlier Payments
- No need for long stay outlier payments- continuous recertifications for
eligible beneficiaries
Consolidated Billing
- HHAs must furnish all covered home health services (EXCEPT DME) while patient
is under the POC directly or under arrangement and bill Medicare directly
- HHAs will no longer be able to unbundle covered home health services (EXCEPT
DME) under the home health
- POC to an outside supplier.
- Balanced Budget Refinement Act of 1999 removed DME from consolidated billing
Updated 10/25/2002
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