42 USC 1395fff - Prospective payment for home health services

U.S Code last checked for updates: Apr 27, 2024

§ 1395fff.

Prospective payment for home health services

(a)

In general

(b)

System of prospective payment for home health services

(1)

In general

(2)

Unit of payment

(A)

In general

(B)

30-day unit of service

(3)

Payment basis

(A)

Initial basis

(i)

In general

Under such system the Secretary shall provide for computation of a standard prospective payment amount (or amounts) as follows:

(I)

Such amount (or amounts) shall initially be based on the most current audited cost report data available to the Secretary and shall be computed in a manner so that the total amounts payable under the system for the 12-month period beginning on the date the Secretary implements the system shall be equal to the total amount that would have been made if the system had not been in effect and if section 1395x(v)(1)(L)(ix) of this title had not been enacted.

(II)

For the 12-month period beginning after the period described in subclause (I), such amount (or amounts) shall be equal to the amount (or amounts) determined under subclause (I), updated under subparagraph (B).

(III)

Subject to clause (iii), for periods beginning after the period described in subclause (II), such amount (or amounts) shall be equal to the amount (or amounts) that would have been determined under subclause (I) that would have been made for fiscal year 2001 if the system had not been in effect and if section 1395x(v)(1)(L)(ix) of this title had not been enacted but if the reduction in limits described in clause (ii) had been in effect, updated under subparagraph (B).

Each such amount shall be standardized in a manner that eliminates the effect of variations in relative case mix and area wage adjustments among different home health agencies in a budget neutral manner consistent with the case mix and wage level adjustments provided under paragraph (4)(A). Under the system, the Secretary may recognize regional differences or differences based upon whether or not the services or agency are in an urbanized area.

(ii)

Reduction

(iii)

Adjustment for 2014 and subsequent years

(I)

In general

(II)

Transition

(iv)

Budget neutrality for 2020

(B)

Annual update

(i)

In general

(ii)

Home health applicable increase percentage

For purposes of this subparagraph, the term “home health applicable increase percentage” means, with respect to—

(I)

each of fiscal years 2002 and 2003, the home health market basket percentage increase (as defined in clause (iii)) minus 1.1 percentage points;

(II)

for 1

 So in original. The word “for” probably should not appear.

the last calendar quarter of 2003 and the first calendar quarter of 2004, the home health market basket percentage increase;

(III)

the last 3 calendar quarters of 2004, and all of 2005 2

 So in original. Probably should be followed by a comma.

the home health market basket percentage increase minus 0.8 percentage points;

(IV)

2006, 0 percent; and

(V)

any subsequent year, subject to clauses (v) and (vi), the home health market basket percentage increase.

(iii)

Home health market basket percentage increase

(iv)

Adjustment for case mix changes

(v)

Adjustment if quality data not submitted

(I)

Adjustment

(II)

Submission of quality data

(III)

Public availability of data submitted

(IV)

Submission of additional data

(aa)

In general

(bb)

Standardized patient assessment data

(cc)

Submission

(V)

Non-duplication

(vi)

Adjustments

After determining the home health market basket percentage increase under clause (iii), and after application of clause (v), the Secretary shall reduce such percentage—

(I)

for 2015 and each subsequent year (except 2018 and 2020), by the productivity adjustment described in section 1395ww(b)(3)(B)(xi)(II) of this title; and

(II)

for each of 2011, 2012, and 2013, by 1 percentage point.

The application of this clause may result in the home health market basket percentage increase under clause (iii) being less than 0.0 for a year, and may result in payment rates under the system under this subsection for a year being less than such payment rates for the preceding year.

(C)

Adjustment for outliers

(D)

Behavior assumptions and adjustments

(i)

In general

(ii)

Permanent adjustments

(iii)

Temporary adjustments for retrospective behavior

(4)

Payment computation

(A)

In general

The payment amount for a unit of home health services shall be the applicable standard prospective payment amount adjusted as follows:

(i)

Case mix adjustment

(ii)

Area wage adjustment

(B)

Establishment of case mix adjustment factors

(i)

In general

(ii)

Treatment of therapy thresholds

(C)

Establishment of area wage adjustment factors

(5)

Outliers

(A)

In general

(B)

Program specific outlier cap

(6)

Proration of prospective payment amounts

(c)

Requirements for payment information

With respect to home health services furnished on or after October 1, 1998, no claim for such a service may be paid under this subchapter unless—

(1)

the claim has the unique identifier for the physician ² the nurse practitioner or clinical nurse specialist (as those terms are defined in section 1395x(aa)(5) of this title), or the physician assistant (as defined in section 1395x(aa)(5) of this title) who prescribed the services or made the certification described in section 1395f(a)(2) or 1395n(a)(2)(A) of this title;

(2)

in the case of a service visit described in paragraph (1), (2), (3), or (4) of section 1395x(m) of this title, the claim contains a code (or codes) specified by the Secretary that identifies the length of time of the service visit, as measured in 15 minute increments; and

(3)

in the case of home health services furnished on or after January 1, 2019, the claim contains the code for the county (or equivalent area) in which the home health service was furnished.

(d)

Limitation on review

There shall be no administrative or judicial review under section 1395ff of this title, 1395oo of this title, or otherwise of—

(1)

the establishment of a transition period under subsection (b)(1);

(2)

the definition and application of payment units under subsection (b)(2);

(3)

the computation of initial standard prospective payment amounts under subsection (b)(3)(A) (including the reduction described in clause (ii) of such subsection);

(4)

the establishment of the adjustment for outliers under subsection (b)(3)(C);

(5)

the establishment of case mix and area wage adjustments under subsection (b)(4); and

(6)

the establishment of any adjustments for outliers under subsection (b)(5).

(e)

Construction related to home health services

(1)

Telecommunications

Nothing in this section shall be construed as preventing a home health agency furnishing a home health unit of service for which payment is made under the prospective payment system established by this section for such units of service from furnishing services via a telecommunication system if such services—

(A)

do not substitute for in-person home health services ordered as part of a plan of care certified by a physician ² a nurse practitioner or clinical nurse specialist, or a physician assistant pursuant to section 1395f(a)(2)(C) or 1395n(a)(2)(A) of this title; and

(B)

are not considered a home health visit for purposes of eligibility or payment under this subchapter.

(2)

Rule of construction regarding requirement for certification

(Aug. 14, 1935, ch. 531, title XVIII, § 1895, as added Pub. L. 105–33, title IV, § 4603(a), Aug. 5, 1997,

cite as: 42 USC 1395fff