WASHINGTON, D.C. (September 17, 2019)—The National Association for Home Care & Hospice (NAHC) submitted comments on the 2020 home health prospective payment system rate update proposed rule.

The proposed rule was issued on July 11, and includes a number of provisions, most notably, the Patient Driven Groupings Model (PDGM) that begins in 2020, changes to the home health quality reporting program and updates to the home infusion therapy supplier requirements. In addition, the Centers for Medicare & Medicaid Services (CMS) requested input from stakeholders on its proposal to collect the Outcome and Assessment Information Set (OASIS) on all patients regardless of payer. Comments were submitted on September 9.

Following are NAHCs specific comments:


  • NAHC strongly recommends that CMS closely monitor changes in practice that can be correlated with the impact of the admission source and the elimination of therapy as a case mix determinant.
  • CMS should withdraw the proposed behavior adjustment. Any replacement should be based on the most relevant and reliable historical data that ties previous behavior changes to facts similar to the change risks in PDGM.
  • CMS should consider the impact of any behavior adjustment applied to the first-year rates in PDGM to ensure that the transition to the new payment model fully limits the risk of disruptions in full access to the Medicare home health benefit. In doing so, CMS should apply any adjustment in a flexible manner to secure both continued access to care and budget neutrality under PDGM by 2029.
  • CMS must comply with the Regulatory Flexibility Act and the Small Business Regulatory Enforcement Fairness Act. To do so, CMS must consider the alternative to the behavior adjustment of relying on its oversight capabilities and powers to address any unwarranted changes in behavior rather than apply the proposed adjustments in an untargeted manner. CMS should factor into any assumptions an offsetting consideration as to what it can achieve through targeted oversight to prevent upcoding or unnecessary utilization increases. Oversight can significantly reduce any level of change from the current assumption that 100% of all claims will be upcoded. If CMS oversight can reduce such by 50%, the adjustment would be significantly less.
  • CMS must acknowledge that its proposed rate reduction based on assumed behavior changes sanctions and encourages the behavior changes through the adjustment. CMS must clearly state, as it did with inpatient hospital services, that any reasonable upcoding is expected and accepted as compliant behavior.
  • CMS should recalculate its assumptions to recognize that its behavior change assumptions can actually trigger change. Reducing or eliminating the proposed adjustment should reduce or elimination the assumed behavior changes.
  • CMS should make available all specifications of the PDGM pricer module as soon as possible to allow these stakeholders the opportunity to prepare for PDGM on a timely basis. In addition, CMS should establish an efficient accelerated payment program to protect HHAs from third-party implementation problems that could jeopardize continued operations
  • CMS should withdraw its proposed modification and termination of the RAP model. Should CMS intend to proceed with its proposal, CMS should delay its application an additional 12 months to allow HHAs sufficient time to adjust cash management. In addition, CMS should fully explore targeted approaches to managing the integrity of RAPs.

Notice of Admission (NOA)

CMS should Require only what is necessary to begin home health services in order to   submit the NOA, to include:

  • A verbal order to begin care that is signed and dated by the registered nurse or qualified therapist (as defined in § 484.115) responsible for furnishing or supervising the ordered service in the plan of care signed by the clinician,
  • Conduct the SOC visit, or
  • Allow a least 14 days for the agency to submit the NOA before any penalty is imposed.
  • Provide an explicit exception to the timely submission requirement for the NOA when the CWF is not updated timely to show MA enrollment status.

Home Health Quality Reporting Program

  • CMS should issue a draft of the assessment tool no later than six months prior to the implementation date to allow for staff training and other necessary preparations required for agency implementation.
  • Use the authority permitted by the IMPACT Act to waive the Paperwork Reduction Act (PRA) requirements related to modification of the assessment tools for providers subject to the IMPACT Act. Waiving the PRA may expedite CMS’s ability to issue a final version of the revised OASIS instrument in a timely manner.
  • Refrain from issuing any revisions to the OASIS instrument for at least five years after the 2021 implementation of the proposed changes.

Home Infusion Therapy Supplier

  • CMS should work with Congress to promote legislation that would enable beneficiaries to continue to receive the professional services associated with Part B home infusion drugs under the home health benefit. A legislated change should either limit the home infusion therapy supplier benefit to beneficiaries not eligible for the home health benefit, or provide beneficiaries with a choice of receiving the benefit from a home infusion therapy supplier or a home health agency under a home health plan of care.
  • If the fragmentation of home infusion therapy and home health services is continued, CMS should revise the regulations to permit beneficiaries to meet the qualifying skilled services condition under the home health benefit to be met through any skilled nursing services provide through the home infusion therapy supplier. Further, CMS should waive any copayment or coinsurance for any services provided under the home infusion benefit that would not be subject to such if those services could previously have been provided under the home health benefit.

OASIS Collection on All Patients

  • CMS should not require the OASIS data set be collected on all patients served by the agency regardless of payer. In the event that CMS decides to collect OASIS data on all patients, CMS must modify its Home Health Compare and Star ratings system to reflect the impact of that increased patient population on outcomes. Just as patients with different diagnoses or functional status can have different outcomes, patients of non-Medicare payers can be affected by the payer’s scope of benefits, benefit administration, and care management.

Read NAHC’s full comments here.