42 U.S.C. § 1395fff : US Code - Section 1395FFF: Prospective payment for home health services

Search 42 U.S.C. § 1395fff : US Code - Section 1395FFF: Prospective payment for home health services

(a) In general
Notwithstanding section 1395x(v) of this title, the Secretary
shall provide, for portions of cost reporting periods occurring on
or after October 1, 2000, for payments for home health services in
accordance with a prospective payment system established by the
Secretary under this section.
(b) System of prospective payment for home health services
(1) In general
The Secretary shall establish under this subsection a
prospective payment system for payment for all costs of home
health services. Under the system under this subsection all
services covered and paid on a reasonable cost basis under the
medicare home health benefit as of August 5, 1997, including
medical supplies, shall be paid for on the basis of a prospective
payment amount determined under this subsection and applicable to
the services involved. In implementing the system, the Secretary
may provide for a transition (of not longer than 4 years) during
which a portion of such payment is based on agency-specific
costs, but only if such transition does not result in aggregate
payments under this subchapter that exceed the aggregate payments
that would be made if such a transition did not occur.
(2) Unit of payment
In defining a prospective payment amount under the system under
this subsection, the Secretary shall consider an appropriate unit
of service and the number, type, and duration of visits provided
within that unit, potential changes in the mix of services
provided within that unit and their cost, and a general system
design that provides for continued access to quality services.
(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) 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
The reduction described in this clause is a reduction by 15
percent in the cost limits and per beneficiary limits
described in section 1395x(v)(1)(L) of this title, as those
limits are in effect on September 30, 2000.
(B) Annual update
(i) In general
The standard prospective payment amount (or amounts) shall
be adjusted for fiscal year 2002 and for fiscal year 2003 and
for each subsequent year (beginning with 2004) in a
prospective manner specified by the Secretary by the home
health applicable increase percentage (as defined in clause
(ii)) applicable to the fiscal year or year involved.
(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 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 each of
2005 and 2006 the home health market basket percentage
increase minus 0.8 percentage points; or
(IV) 2007 and any subsequent year, the home health market
basket percentage increase.
(iii) Home health market basket percentage increase
For purposes of this subsection, the term "home health
market basket percentage increase" means, with respect to a
fiscal year or year, a percentage (estimated by the Secretary
before the beginning of the fiscal year or year) determined
and applied with respect to the mix of goods and services
included in home health services in the same manner as the
market basket percentage increase under section
1395ww(b)(3)(B)(iii) of this title is determined and applied
to the mix of goods and services comprising inpatient
hospital services for the fiscal year or year.
(iv) Adjustment for case mix changes
Insofar as the Secretary determines that the adjustments
under paragraph (4)(A)(i) for a previous fiscal year or year
(or estimates that such adjustments for a future fiscal year
or year) did (or are likely to) result in a change in
aggregate payments under this subsection during the fiscal
year or year that are a result of changes in the coding or
classification of different units of services that do not
reflect real changes in case mix, the Secretary may adjust
the standard prospective payment amount (or amounts) under
paragraph (3) for subsequent fiscal years or years so as to
eliminate the effect of such coding or classification
changes.
(C) Adjustment for outliers
The Secretary shall reduce the standard prospective payment
amount (or amounts) under this paragraph applicable to home
health services furnished during a period by such proportion as
will result in an aggregate reduction in payments for the
period equal to the aggregate increase in payments resulting
from the application of paragraph (5) (relating to outliers).
(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
The amount shall be adjusted by an appropriate case mix
adjustment factor (established under subparagraph (B)).
(ii) Area wage adjustment
The portion of such amount that the Secretary estimates to
be attributable to wages and wage-related costs shall be
adjusted for geographic differences in such costs by an area
wage adjustment factor (established under subparagraph (C))
for the area in which the services are furnished or such
other area as the Secretary may specify.
(B) Establishment of case mix adjustment factors
The Secretary shall establish appropriate case mix adjustment
factors for home health services in a manner that explains a
significant amount of the variation in cost among different
units of services.
(C) Establishment of area wage adjustment factors
The Secretary shall establish area wage adjustment factors
that reflect the relative level of wages and wage-related costs
applicable to the furnishing of home health services in a
geographic area compared to the national average applicable
level. Such factors may be the factors used by the Secretary
for purposes of section 1395ww(d)(3)(E) of this title.
(5) Outliers
The Secretary may provide for an addition or adjustment to the
payment amount otherwise made in the case of outliers because of
unusual variations in the type or amount of medically necessary
care. The total amount of the additional payments or payment
adjustments made under this paragraph with respect to a fiscal
year or year may not exceed 5 percent of the total payments
projected or estimated to be made based on the prospective
payment system under this subsection in that year.
(6) Proration of prospective payment amounts
If a beneficiary elects to transfer to, or receive services
from, another home health agency within the period covered by the
prospective payment amount, the payment shall be prorated between
the home health agencies involved.
(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 (provided under section
1395u(r) of this title) for the physician who prescribed the
services or made the certification described in section
1395f(a)(2) or 1395n(a)(2)(A) of this title; and
(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.
(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) of this section;
(2) the definition and application of payment units under
subsection (b)(2) of this section;
(3) the computation of initial standard prospective payment
amounts under subsection (b)(3)(A) of this section (including the
reduction described in clause (ii) of such subsection);
(4) the establishment of the adjustment for outliers under
subsection (b)(3)(C) of this section;
(5) the establishment of case mix and area wage adjustments
under subsection (b)(4) of this section; and
(6) the establishment of any adjustments for outliers under
subsection (b)(5) of this section.
(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
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) Physician certification
Nothing in this section shall be construed as waiving the
requirement for a physician certification under section
1395f(a)(2)(C) or 1395n(a)(2)(A) of this title for the payment
for home health services, whether or not furnished via a
telecommunications system.