Federal Home Health Updates
(Feb. 25, 2025) Please see the following updates from LeadingAge National on home health issues:
Join the New Home Health Value-Based Purchasing Workgroup. A new initiative from LeadingAge National’s Home Health Member Network offers education, resources, and up-to-date information to help providers succeed and excel in the current payment environment. Participate in the workgroup’s bimonthly meetings to benefit from insights delivered by payment and quality experts, data analysis from LeadingAge National staff, and knowledge sharing during peer-to-peer discussions and open dialogue. Join the group here.
CMS Announces New HCPCS Codes for Home Health. The Centers for Medicare and Medicaid Services (CMS) issued Change Request (CR) 13732, which makes revisions to Healthcare Common Procedure Coding System (HCPCS) codes used for home health consolidated billing in Calendar Year (CY) 2025. This annual update of HCPCS codes was delayed due to the communications freeze from the Trump administration. These changes formally went into effect Jan. 1, 2025. CMS updated the non-routine supply code list to:
- Add five new codes for disposable collection and storage bags for breast milk, enema tub, exsufflation belt, adhesive clip for skin, and pessary.
- Update three code descriptions related to gradient compression stockings and wrap.
CMS Posts Update to Telehealth Policy; Prepare for Reversion to Pre-COVID Rules on April 1st. CMS updated their telehealth coverage webpage to note that COVID-era waivers will remain in place through March 31st, including allowing the home to be an originating site, no geographic restrictions, utilizing audio-only services for some codes, and more flexibility in terms of what providers can provide telehealth services. The update notes that starting April 1, 2025, CMS policy reverts to pre-COVID rules. This webpage does not specifically mention the hospice face-to-face recertification, but LeadingAge National has spoken with CMS before previous extensions, and unless Congress acts, there is no wiggle room: the flexibility will end March 31st. This website update comes in advance of any congressional action on telehealth; Congress must act before March 31st to extend these waivers. While Congress can still act, LeadingAge National recommends that members make a plan for reversion to pre-COVID rules related to telehealth in the event that there is no extension of the current waivers. A link to a longer Frequently Asked Questions (FAQ) document on telehealth can be found here.
Former Medicare Staff Pen Plea for Further Prior Authorization Reforms. Former Deputy Administrator and Director of the Center for Medicare at CMS Meena Seshamani and former CMS Senior Policy Advisor on Medicare Advantage (MA) and Medicare Part D Molly Turco reflected in a Health Affairs article on the work they have done to clarify prior authorization practices in MA, and outlined that problems persist and further reforms are necessary. Much of what is laid out in the article aligns with issues LeadingAge National identified and communicated to the authors during their CMS tenure, such as prior authorizations are: “1) barriers to access for medically necessary care, 2) a huge administrative burden on the U.S. health care system, and 3) [having] negative market impacts.” These Medicare and MA experts argue there is “wide consensus for change” and encourage current policymakers to finalize the CY 2026 MA policy rule along with pursuing other bipartisan actions. The article includes some key takeaways:
- Initial appeals are overwhelmingly successful. When prior authorization denials are appealed, the plans overturn roughly 80 percent of their own denials.
- Paperwork, not medical necessity, is a frequent cause of denials. Plans often suggest insufficient documentation by the providers led to the denial, but the authors point out that means the services are being denied not because of medical necessity, but for paperwork reasons.
- Plans are increasing their spending on supplemental benefits versus core Medicare benefits. “The portion of the government payments to plans directed towards core Medicare Part A and Part B benefits has decreased.” Supplemental benefit spending by plans has nearly doubled in the past 10 years.
- MA plan audits suggest high-cost service should be prioritized for oversight. Providers and consumers feel appropriate post-acute care is being denied, while plans think they made the correct decision. Some plans have suggested other plans' non-compliance gives them a “financial edge.” The challenge is many plans have outsourced their prior authorization work to third parties. They believe new data collection efforts will give CMS a better view into whether certain services (e.g., skilled nursing facility services) are being denied more often by some plans than others.
LeadingAge National Webinar: Mismanaged Care: Navigating Medicare Advantage. Please note LeadingAge National's MA webinar on March 4th. Learn more here. Back by popular demand, and not to be missed.
Contact: Meg Everett, meverett@leadingageny.org, 518-867-8871