§ 484.240 - Outlier payments.

§ 484.240 Methodology used for the calculation of the outlier payment.

Cross Reference

Link to an amendment published at 83 FR 56630, Nov. 13, 2018.

(a) CMS makes an

Outlier payments.

(a) For episodes beginning on or before December 31, 2019, an HHA receives an outlier payment for an episode whose estimated cost costs exceeds a threshold amount for each case-mix group.

(b)

The outlier threshold for each case-mix group is the episode payment amount for that group, or the PEP adjustment amount for the episode, plus a fixed dollar loss amount that is the same for all case-mix groups.

(b) For periods beginning on or after January 1, 2020, an HHA receives an outlier payment for a 30-day period whose estimated cost exceeds a threshold amount for each case-mix group. The outlier threshold for each case-mix group is the 30-day payment amount for that group, or the partial payment adjustment amount for the 30-day period, plus a fixed dollar loss amount that is the same for all case-mix groups.

(c) The outlier payment is a proportion of the amount of estimated imputed cost beyond the threshold.

(d) CMS imputes the cost for each episode claim by multiplying the national per-15 minute unit amount of each discipline by the number of 15 minute units in the discipline and computing the total imputed cost for all disciplines.

(e) The fixed dollar loss amount and the loss sharing proportion are chosen so that the estimated total outlier payment is no more than 2.5 percent of total payment under home health PPS.

(f) The total amount of outlier payments to a specific home health agency for a year may not exceed an amount equal to 10 percent of the total payments to the specific agency under home health PPS for the year.

[65 FR 41212, July 3, 2000, as amended at 72 FR 69879, Aug. 29, 2007; 80 FR 68717, Nov. 5, 2015; 81 FR 76796, Nov. 3, 2016[83 FR 56630, Nov. 13, 2018]