The Centers for Medicare and Medicaid Services (CMS) recently released a proposed rule updating the home health (HH) prospective payment system (PPS) for calendar year (CY) 2026.
Highlights of the proposed rule include:
- A 6% rate cut from the current $2,057.35 to $1,933.61 after the net 2.4% market basket update, an 8.3% cut due to budget neutrality requirements of the Patient-Driven Groupings Model (PDGM) and a 0.5% decrease related to outlier payments and other adjustments. Providers who fail to submit quality data are subject to an additional 2% point reduction.
- A higher fixed-dollar loss ratio of 0.46, up from 0.35, expected to decrease outlier payments by 0.5% of total payments. The CMS proposes to maintain the existing 0.8 loss-sharing ratio.
- Recalibration of relative weights for the PDGM using CY 2024 data.
- Removing the face-to-face encounter restriction. Currently the CMS allows nonphysician practitioners to perform the required face-to-face encounter regardless of whether they were the certifying practitioner or previously cared for the patient. However, if a physician performed the face-to-face encounter, they were required to be the certifying physician or have previously cared for the patient. The CMS proposes to remove this restriction, allowing physicians to perform the face-to-face encounter regardless of whether they are the certifying physician or previously cared for the patient.
- Removing the measure that assesses the percentage of patients receiving COVID-19 vaccinations from the HH quality reporting program (QRP). The proposal also requests information on changing the data submission deadline for HH QRP data, advancing digital quality measures and new measure concepts for the HH QRP.
- Adding four new measures to the HH value-based purchasing program—Medicare Spending per Beneficiary and three measures assessing patient functional improvement in dressing and bathing.
- New and revised provider enrollment provisions to reduce improper payments, including retroactive revocation of a provider’s Medicare enrollment such as if the beneficiary attest that the provider did not provide the service that was claimed. The CMS also proposed to deactivate an enrolled physician or practitioner’s billing privileges if they have not ordered or certified services for 12 consecutive months.
- The CMS is collecting feedback on Executive Order 14192, “Unleashing Prosperity Through Deregulation”.
The MHA will provide members with an estimated impact analysis in the next several weeks and encourages members to contact Vickie Kunz regarding issues identified by Aug. 22. The CMS will accept comments on the HH proposed rule until Sept. 2. Members with questions should contact Vickie Kunz at the MHA.