Retroactive to January 1, 2021, TRICARE has implemented the following changes.
The NOSCASTC for calculating the cost-outlier threshold for Calendar Year (CY) 2021 is .926. The cost-outlier uses a cost-per-unit rather than cost-per-visit approach with a limit of 32 units or eight hours per day.
HHAs certified for participation in Medicare on or after January 1, 2019, will no longer submit split-percentage or RAP payments. HHAs that are certified for participation in Medicare effective on or after January 1, 2019, will still be required to submit a “no pay” RAP at the beginning of care to establish the home health period of care, as well as every 30 days thereafter upon implementation of the Patient Driven Groupings Model (PDGM). Because the level of care can change during the 30-day period of care, the Health Insurance Prospective Payment System (HIPPS) codes will determine the final payment amount.
For periods of care beginning on or after January 1, 2020, if an HHA provides fewer than the threshold of visits specified for the period’s Home Health Resource Group (HHRG), they will be paid a per-visit payment instead of a payment for a 30-day period of care. This payment adjustment is called a LUPA. Under PDGM each of the 432 case-mix groups has a visit threshold ranging from two to six visits to determine whether the period of care meets the LUPA threshold.
Under PDGM, if the LUPA threshold is met, the 30-day period of care is reimbursed at the full 30-day national, standardized payment amount. For periods of care that do not meet the LUPA threshold, reimbursement shall be at the appropriate CY per-visit payment amount.Payment of LUPA episodes
See the TRICARE Reimbursement Manual, Chapter 12, Section 9 for more information.