Home Health Services

Basis and scope.

This provision defines the statutory basis and regulatory scope for Home Health Agency participation in the Medicare program.

Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients.

Home health agencies must comply with all applicable laws, maintain required licensure, and ensure laboratory services meet federal standards.

Condition of participation: Emergency preparedness.

Home health agencies must develop and maintain an emergency preparedness program that includes a risk assessment, communication plan, and training and testing requirements.

Condition of participation: Organization and administration of services.

Home health agencies must maintain a governing body, clinical management oversight, and institutional planning to ensure the effective administration of patient care services.

Condition of participation: Clinical records.

Home health agencies must maintain accurate, authenticated, and protected clinical records for all patients, including specific content requirements and retention schedules.

Condition of participation: Personnel qualifications.

HHA staff are required to meet the following standards:

Definitions.

As used in subparts A, B, and C, of this part—

Basis and scope.

This provision defines the legal basis and regulatory scope for the prospective payment system applicable to home health agencies.

Definitions.

This provision provides definitions for terms used in the home health prospective payment system subpart.

Basis of payment.

This provision establishes the prospective payment system for home health agencies, detailing payment units, adjustments, medical review, and mandatory data submission requirements for claims processing.

Initial establishment of the calculation of the national, standardized prospective payment rates.

This provision outlines the methodology for calculating the initial unadjusted national prospective payment rates for home health episodes, including cost determination, utilization, and market basket adjustments.

Calculation of the case-mix and wage area adjusted prospective payment rates.

This provision details the adjustments applied to national standardized prospective payment rates to account for patient case-mix and geographic wage variations.

Annual update of the unadjusted national, standardized prospective payment rates.

This provision establishes the annual update process for home health prospective payment rates, including adjustments based on quality data submission and market basket indices.

Low-utilization payment adjustments.

This provision defines the payment methodology for home health episodes or periods that fall below a specific visit threshold, resulting in a per-visit payment adjustment.

Partial payment adjustments.

This provision outlines the partial payment adjustment methodology for home health episodes or periods interrupted by intervening events such as transfers or discharges.

Outlier payments.

This provision describes the criteria and calculation for outlier payments for home health episodes or periods where estimated costs exceed established thresholds.

Requirements under the Home Health Quality Reporting Program (HH QRP).

This provision establishes the mandatory data submission requirements, quality measure reporting, and reconsideration processes for home health agencies participating in the Home Health Quality Reporting Program.

OASIS data.

This provision mandates that home health agencies submit OASIS data to CMS to support the administration of home health payment rate methodologies.

Limitation on review.

This provision specifies that home health agencies are not entitled to judicial or administrative review regarding the establishment of payment units, rates, and adjustment factors.

Additional payment.

This provision authorizes additional payments to home health agencies for the costs associated with providing requested patient records to Quality Improvement Organizations.

Basis and scope of subpart.

This provision outlines the statutory authority for the subpart governing innovative payment and service delivery models in home health care.

Definitions.

This provision defines key terms used in the subpart regarding the Home Health Value-Based Purchasing Model.

Applicability of the Home Health Value-Based Purchasing (HHVBP) Model.

This provision identifies the Medicare-certified home health agencies in selected states that are required to participate in the Home Health Value-Based Purchasing Model.

Data reporting for measures and evaluation and the public reporting of model data under the Home Health Value-Based Purchasing (HHVBP) Model.

This provision mandates that competing home health agencies report quality measures and evaluation data to CMS as required for the Home Health Value-Based Purchasing Model.

Calculation of the Total Performance Score.

This provision outlines the methodology for calculating the Total Performance Score for home health agencies under the HHVBP model.

Payments for home health services under Home Health Value-Based Purchasing (HHVBP) Model.

This provision establishes the basis for determining payment adjustments for home health agencies based on their Total Performance Score.

Process for determining and applying the value-based payment adjustment under the Home Health Value-Based Purchasing (HHVBP) Model.

This provision details the calculation methodology for applying value-based payment adjustments to home health agency claims.

Appeals process for the Home Health Value-Based Purchasing (HHVBP) Model.

This provision outlines the procedures for home health agencies to request recalculation or reconsideration of performance scores and payment adjustments.

Basis and scope of this subpart.

This provision identifies the statutory authority and scope for the HHVBP model regulations.

Definitions.

This provision defines key terms used within the HHVBP model subpart.

Applicability of the Expanded Home Health Value-Based Purchasing (HHVBP) Model.

This provision specifies the applicability of the HHVBP model to Medicare-certified home health agencies.

Data reporting for measures and evaluation and the public reporting of model data under the expanded Home Health Value-Based Purchasing (HHVBP) Model.

This provision mandates data submission requirements for quality measures and survey data under the HHVBP model.

HHVBP Measure removal factors.

CMS may remove a quality measure from the expanded Home Health Value-Based Purchasing Model based on specific criteria such as performance saturation, lack of clinical alignment, or feasibility.

Calculation of the Total Performance Score.

This provision outlines the methodology for calculating a home health agency's Total Performance Score based on achievement and improvement points across various measure categories.

Payments for home health services under the Expanded Home Health Value-Based Purchasing (HHVBP) Model.

CMS determines payment adjustments for home health agencies based on their Total Performance Score using a linear exchange function.

Process for determining and applying the value-based payment adjustment under the Expanded Home Health Value-Based Purchasing (HHVBP) Model.

This provision details the calculation of the value-based payment adjustment amount and the percentage applied to home health prospective payment claims.

Appeals process for the Expanded Home Health Value-Based Purchasing (HHVBP) Model.

This provision establishes the procedures for home health agencies to request recalculation and reconsideration of their performance scores and payment adjustments.

Condition of participation: Release of patient identifiable OASIS information.

Home health agencies must ensure the confidentiality of patient identifiable information in clinical records, including OASIS data, and are prohibited from releasing it to the public.

Condition of participation: Reporting OASIS information.

Home health agencies are required to electronically encode and transmit accurate OASIS assessment data to CMS using specified secure electronic formats.

Condition of participation: Patient rights.

This regulation establishes comprehensive patient rights for home health agencies, including requirements for notice of rights, complaint investigations, transfer and discharge policies, and accessibility standards.

Condition of participation: Comprehensive assessment of patients.

Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment.

Condition of participation: Discharge planning.

Home health agencies must implement an effective discharge planning process that includes sharing quality and resource use data with post-acute care providers and ensuring the safe transition of clinical information.

Condition of participation: Care planning, coordination of services, and quality of care.

Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence.

Condition of participation: Quality assessment and performance improvement (QAPI).

Home health agencies must develop and maintain a data-driven QAPI program that involves all services and is overseen by the governing body to improve patient outcomes and safety.

Condition of participation: Infection prevention and control.

Home health agencies must maintain a coordinated, agency-wide infection control program that includes surveillance, identification, prevention, and education for staff and patients.

Condition of participation: Skilled professional services.

Home health agencies must ensure skilled professional services are provided by qualified staff who participate in interdisciplinary assessment, care planning, and coordination of care.

Condition of participation: Home health aide services.

This regulation establishes the requirements for home health aide services, including personnel qualifications, training and competency evaluation programs, in-service training, instructor qualifications, eligible organizations, aide assignments, and supervision standards.