Reimbursement changes for Home Health Agencies (HHA)

February 6, 2023 - Update

To align with the Medicare Claims Processing Manual (CPM), Home Health Agencies (HHA) must submit a Notice of Admission (NOA) for periods of care with dates of service on or after January 1, 2022.

Effective February 6, 2023, Humana Military will no longer accept Requests for Anticipated Payment (RAP). Providers who previously submitted RAPs and received reimbursement are not required to take further action.

TRICARE Reimbursement Manual Chapter 12, Section 9

Home Health Agency (HHA) reimbursement FAQs

June 15, 2022 - Update

Humana Military will accept the Notice of Admission (NOA) and Requests for Anticipated Payment (RAP), pending guidance from the Defense Health Agency (DHA). Until then, you will see Requests for Anticipated Payment (RAP) information on the Explanation of Benefits (EOB).

March 4, 2022 - Update

Humana Military is awaiting the Defense Health Agency’s direction to adopt the Centers for Medicare and Medicaid Services (CMS) policy change for Calendar Year (CY) 2022. Until it has been received, we will continue to follow current guidance as written in the TRICARE Reimbursement Manual Chapter 12, Section 9

Requests for Anticipated Payment (RAP) for CY 2021 and the implementation of a new one-time Notice of Admission (NOA) process start in CY 2022.

May 26, 2021

Retroactive to January 1, 2021, TRICARE has implemented the following changes.

National Operating Standard Cost as a Share of Total Costs (NOSCASTC)

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.

Split percentage payments and Requests for Anticipated Payment (RAP)

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.

Low Utilization Payment Adjustment (LUPA)

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.

See the TRICARE Reimbursement Manual, Chapter 12, Section 9 for more information.