Tag: PPS

CMS Releases 2026 Home Health PPS Final Rule

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a final rule updating the home health (HH) prospective payment system (PPS) for calendar year (CY) 2026.

Highlights of the rule include:

  • An updated 30-day episode payment rate of $2,038.22, comprised of a net 2.4% market basket update, a 3.6% reduction due to budget neutrality requirements of the Patient-Driven Groupings Model (PDGM) and other budget neutrality adjustments. The 2026 rate is down 0.1% from the current $2,057.35. Providers who fail to submit quality data are subject to an additional two percentage point reduction.
  • A fixed-dollar loss ratio of 0.37, up from 0.35, with the CMS maintaining the existing 0.8 loss-sharing ratio.
  • Recalibrated PDGM case mix weights based on CY 2024 data; updated low-utilization payment adjustment thresholds, updated functional impairment levels and comorbidity adjustment subgroups.
  • Modifying the face-to-face encounter restriction to allow physicians and non-physician practitioners to perform the face-to-face encounter, regardless of whether they are the certifying physician or previously cared for the patient.
  • Updating the HH quality reporting program (QRP) to remove the measure that assesses the percentage of patients receiving COVID-19 vaccinations and the corresponding outcome and assessment information set data element. The CMS is also removing four patient assessment data elements related to social drivers of health from the HH QRP. These measures include one living situation item, two food items and one utilities item.
  • 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.
  • Adopting several new and revised provider enrollment provisions that the CMS believes will help reduce improper Medicare payments and protect beneficiaries.

The MHA will provide members with an updated impact analysis in the next several weeks. Members with questions should contact Vickie Kunz at the MHA.

MHA Monday Report July 14, 2025

Member News, Monday Report

Medical Debt Legislation Introduced, Maternal and Behavioral Health Bills Clear Senate

Legislation addressing medical debt was introduced in the Michigan State Senate June 26. The bipartisan three-bill package, Senate Bills 449, 450 and 451, codify the existence of hospital financial assistance programs, create new …

MHA Service Corporation Highlights Security Technology Solutions and Action Plan Priorities

The MHA Service Corporation board held its final meeting of the 2024-2025 program year focused on supporting the MHA Strategic Action Plan priorities of protecting access, workforce support, strengthening cybercrime and cybersecurity policy, mental …

CMS Releases Home Health PPS Proposed Rule

The Centers for Medicare and Medicaid Services (CMS) recently released a proposed rule updating the home health prospective payment system (PPS) for calendar year 2026. Highlights of the proposed rule include: A 6% …

Deadline Approaching to Qualify for MDHHS Maternal Health Quality Payments

Birthing hospitals pursuing the 2025 Michigan Department of Health and Human Services (MDHHS) Maternal Health Quality Payments must meet all requirements by July 31 to receive payments. Eligibility requirements include full participation in the Michigan …

Free Substance Use Disorder Technical Assistance Available

The Michigan Opioid Partnership is offering free, tailored technical assistance to help Michigan hospitals and healthcare providers improve care for patients with substance use disorders, whether they are implementing new protocols or strengthening existing …

Virtual Maternal Health Quality Improvement Courses Available

The Michigan Alliance for Innovation on Maternal Health (MI AIM) is offering virtual modules to support maternal health quality improvement efforts. All obstetric team members at MI AIM participating birthing hospitals are encouraged to complete …

MHA Shares State Impacts and Insights at Regional 340B Roundtable

MHA staff attended the Regional 340B Roundtable July 8 in Florence, IN to join colleagues from the Indiana Hospital Association, Ohio Hospital Association, Kentucky Hospital Association and endorsed business partner, SunRx, to share best practices for successful 340B administration and …

MHA Releases Executive Summary of Final LARA Rules for Osteopathic Medicine and Surgery

The MHA recently released an executive summary regarding administrative rules finalized by the Michigan Department of Licensing and Regulatory Affairs (LARA), updating licensing and practice standards for osteopathic medicine and surgery in Michigan. The rules, …

MHA Rounds image of Brian PetersMHA CEO Report — A Year of Progress and Purpose

With another program year behind us, the MHA Annual Meeting served as a powerful reminder of our shared mission to advance the health and well-being of Michigan’s patients and communities. Despite an evolving political landscape, we’ve made meaningful progress and are moving …

Keckley Report

Special Edition: Lessons from the ACA applicable to the Big Beautiful Bill

“One Big Beautiful Bill Act (OBBBA) passed both houses of Congress by the thinnest of margins and was signed into law by President Trump last Thursday. It is the most significant legislation for U.S. healthcare since the Patient Protection and Affordable Care Act (ACA) signed into law by President Obama March 23, 2010. …

It’s too soon to know what the results will be for OBBBA. Many fear it will cause irreparable damage to the safety net—public health programs, rural and safety net hospitals, nursing homes and others that serve lower-income and disabled populations. Some see it as a necessary reset asserting waste, fraud and abuse in healthcare has been allowed to fester, harming those in bona-fide need and keeping resources in healthcare better used elsewhere.

What’s known for sure is that opinions about the OBBBA will change as it’s implemented over the next four years. How states address work requirements and implementation will be central to its success.  And executive orders, administrative actions, court decisions and market conditions will alter its trajectory—especially economic conditions at home.”

Paul Keckley, July 6, 2025

New to KnowNews to Know

MHA Endorsed Business Partner CorroHealth, is hosting the webinar Price Transparency in 2025: What’s Required, What’s Coming, What to do Now, for MHA members from 2 to 3 p.m. ET July 16.

MHA in the News

The MHA received media coverage during the weeks of June 30 and July 7 on Medicaid cuts included in the federal budget reconciliation bill. MHA CEO Brian Peters and MHA Executive Vice President Laura Appel …

CMS Releases Home Health PPS Proposed Rule

Member News

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.

Recording and Materials Available from Medicare Quality Based Program Webinars

Member News

The MHA recently partnered with DataGen to host two webinars focused on the three Medicare fee-for-service (FFS) quality-based programs. These programs, mandated by the Affordable Care Act of 2010, can reduce hospital inpatient FFS payments by up to 6% based on performance.

The Medicare value-based purchasing (VBP) program is funded by a 2% contribution from inpatient operating payments of eligible prospective payment system hospitals with these funds, totaling approximately $1.7 billion, redistributed among hospitals nationally. Each hospital’s total performance score is determined based on four program domains, comprised of various measures. Materials and the recording of the June 11 webinar are available.

The second webinar, focusing on the Hospital Readmissions Reduction Program (RRP) and Hospital-Acquired Conditions (HAC) Reduction Programs, was also held. The RRP evaluates Medicare FFS patients with six medical conditions and penalizes hospitals for exceeding expected readmission rates. The HAC program evaluates performance on six measures and penalizes hospitals in the worst performing quartile compared to all other eligible hospitals nationally. For these two programs, hospitals can remain whole or be subject to payment penalties of up to 3% for the RRP and 1% for the HAC program, with all penalties benefiting the Centers for Medicare & Medicaid Services. Materials and the recording from the June 17 webinar are also available.

The MHA recently provided prospective payment system hospitals with the latest VBP and HAC program estimates through the hospital association reporting portal.

Members with questions should contact Vickie Kunz at the MHA.

2025 Medicare Fee-for-Service Home Health Proposed Rule Released

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule to update the home health (HH) prospective payment system (PPS) for calendar year (CY) 2025. The rule includes updates to the Medicare fee-for-service HH PPS payment rates based on changes by the CMS and those previously adopted by Congress.

Highlights of the proposed rule, which takes effect Jan. 1, 2025, include:

  • A negative 4% adjustment to base payment rates to achieve budget neutrality following the transition to the Patient-driven Groupings Model (PDGM).
  • A 30-day standard payment rate of $2,008.12 ,down 1.5% from the current $2,038.13, for HH agencies that submit the required quality data.
  • Updating core-based statistical areas for wage index purposes, consistent with recent fiscal year 2025 proposed rules.
  • Recalibrating the PDGM case-mix weights, low utilization payment adjustment thresholds, functional levels and comorbidity adjustment subgroups.
  • Revising the fixed dollar loss ratio from 0.27 to 0.38, reducing outlier payments.
  • Requiring HH agencies to report four new patient assessment items in the HH agency Outcome and Assessment Information Set under the social determinants of health category, beginning CY 2027.
  • Adding a new standard within the Medicare Conditions of Participation requiring HH agencies to develop, implement and maintain a patient acceptance to service policy that is applied consistently to each prospective patient referred for HH care.
  • Requiring long-term care facilities to report respiratory illness data as part of their infection prevention and control programs. The CMS proposes that facilities would electronically report weekly data on COVID-19, influenza and RSV in a standardized format through the National Healthcare Safety Network.
  • Requesting information on:
    • HH quality reporting program measure concepts under consideration for future years.
    • Future performance measure concepts for the expanded HH value-based purchasing model.
    • Rehabilitative therapists conducting the initial and comprehensive assessment.
    • Plan of care development and scope of services HH patient receive.

Members are encouraged to review the proposed rule and contact Vickie Kunz by Aug. 19 regarding issues. Comments are due to the CMS Aug. 26, 2024, and can be submitted electronically. The MHA will provide an estimated impact analysis in the near future.

Members with questions should contact Vickie Kunz at the MHA.

CMS Releases FY 2025 LTCH PPS Proposed Rule

Member News

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule to update the Medicare fee-for-service (FFS) long-term care hospital (LTCH) prospective payment system (PPS) for fiscal year 2025.

Specifically, the rule proposes:

  • Increasing the standard LTCH PPS rate by a net 2.4% from $48,117 to $49,263 for LTCHs that meet the CMS quality program reporting (QPR) requirements. LTCHs that fail to meet these requirements are subject to a two percentage point reduction to the annual update.
  • Rebasing the market basket from 2017 to 2022 base year.
  • Increasing the high-cost outlier (HCO) threshold by 52% for standard LTCH cases from the current $59,873 to $90,921 to achieve the target of paying roughly 8% of aggregate LTCH payments as HCO payments. This increase will result in a decrease in the number of cases qualifying for an outlier payment.
  • Continuing to pay cases at the site neutral rate if they fail to meet LTCH criteria.
  • Updating the cost outlier threshold for site-neutral cases to the inpatient PPS threshold proposed at $49,237, up from $42,750.
  • Revising core based statistical areas as a result of the new Office of Management and Budget labor market delineations based on the 2020 Decennial Census.
  • Updating the LTCH QRP to require reporting of four new items to the LTCH Continuity Assessment Record and Evaluation (CARE) Data Set, (LCDC) social determinant of health category.
  • Modifying the Transportation assessment item.
  • Seeking responses on two requests for information:
    • Quality measure concepts for future years.
    • Future LTCH Star rating.

The MHA continues to review the proposed rule and will provide LTCHs with an estimated impact analysis in the next few weeks. The MHA encourages hospitals to review the rule and submit comments to the CMS by June 10 and to notify Vickie Kunz regarding issues identified by May 28.

Members with questions should contact Vickie Kunz at the MHA.