More Than Half of All Home Health Agencies Have Treated COVID-19 Patients

The U.S. Centers for Medicare & Medicaid Services (CMS) officially closed its public comment window for the 2021 proposed home health payment rule on Monday.

Unlike the past couple of years, the latest proposed payment rule included relatively minor changes and rate adjustments for the year ahead. In light of the mild proposal, CMS only received 161 comments from home health stakeholders.

When initially releasing its proposal, agency officials suggested that CMS did want to make any drastic overhauls due to the ongoing transition to the Patient-Driven Groupings Model (PDGM) and the disruption caused by the COVID-19 virus.


The 2021 proposed payment rule included increasing Medicare payments to home health agencies by 2.6%, a bump worth an estimated $540 million. Comparatively, the 2020 proposed rule included an increase of 1.3%.

The proposed rule also made certain telehealth requirements granted during the public health emergency permanent, such as the face-to-face requirement for home health. It also created new Medicare enrollment policies for qualified home infusion therapy suppliers and updated the home infusion payment rates.

The National Association for Home Care & Hospice (NAHC) was among the group of 161 commenters that made its feelings known. While CMS has yet to publicly release all of the comments, the Washington, D.C.-based advocacy organization shared a copy of its comments with Home Health Care News.


In its comments to CMS, NAHC first addressed the payment systems in place for home health agencies — and why they are, at times, inadequate for an industry dealing with COVID-19 head on. Specifically, NAHC urged CMS to establish a process that would modify home health agency payment systems and rates during a public health emergency.

More than half of all home health agencies have now treated COVID-19-positive patients in 2020, according to NAHC data. And while the hospitals and skilled nursing facilities (SNFs) have seen adjustments made to their payment models and amounts, home health agencies have not.

“Instead, the COVID-19 patients have had to be fit into a payment model that had no such comparable patients in its foundational database,” NAHC wrote in its comments to CMS.

The comments were listed in a letter signed by NAHC President William A. Dombi, along with Mary C. Carr, vice president of regulatory affairs. Katie Wehri, the director of regulatory affairs, also signed.

CMS left home health agencies out of similar relief elsewhere. Hospitals, for instance, can now provide reimbursable virtual care for patients inside their home. Home health agencies are still unable to do so.

“CMS should develop a model for claims reporting and payment for home health visits provided by telecommunication,” NAHC wrote. 

NAHC also asked for clarification on audio-only technology and believes it should be included in the permitted telecommunication technologies umbrella moving forward.

PPE costs

Allowing providers to be reimbursed for telehealth visits in place of in-person visits would reduce person-to-person contact, which would also decrease the amount of PPE each agency would need — a pain point for providers since COVID-19 hit the U.S.

PPE, on average, was costing each agency $11.50 per visit and increased 30-day costs by over $100 — approximately 5% of base payment rates, according to NAHC.

That 5% mark is troublesome because the Provider Relief Fund, which derived from the CARES Act, only covered 2%, on average.

“If CMS had included a process for mid-year adjustments for unexpected cost increases, stabilization of home health care access would be more readily achievable,” NAHC wrote.

NAHC recommends that CMS include a PPE cost add-on to the 2020 payment episodic and per-visit payment rates.

Moving forward with PDGM

The rate of Low Utilization Payment Adjustments (LUPAs) in 2020 is likely to be far different from what CMS originally expected.

“While the available data to date obviously does not represent a full year of experiences under PDGM, it is equally obvious that the existing data shows a massive increase in LUPA episodes in clear contrast to the decline assumed by CMS,” NAHC pointed out.

Data suggests LUPA rates are 2 to 3 times what was expected out of agencies in 2020, according to NAHC.

Still, overall, NAHC agrees with CMS’s decision to stand pat on PDGM and its continued application in home health, despite the pandemic.

At this point, it is too hard to know whether the payment model is working as planned, given the effects of the COVID-19 crisis and it still being a relatively new model.

NAHC did have one particular recommended change to PDGM, however.

“One exception is that CMS should restore the use of symptom codes as a patient diagnosis. Practitioners continue to use these codes in patient referrals and care planning for home health patients,” NAHC wrote. “Given that other reimbursement systems in Medicare accept these codes, CMS should incorporate these codes into the existing model with later refinements where needed.”

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