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PDGM Action Plan

Last month, the Centers for Medicare & Medicaid Services (CMS) issued its proposed rule for 2019 home health payment rates and policy changes, which includes significant harmful provisions that will impact your organization, staff, and the patients you serve.

Between now and when the Patient-Driven Groupings Model (PDGM) goes into effect on January 1, 2020, there are multiple ways that all home health industry professionals can take action to affect what PDGM will look like and how it will impact your business.

Please review the following PDGM Action Plan and make your voice heard as many ways as possible starting now.

Our industry’s collective advocacy efforts have undeniably made a difference in the past, including putting a stop to the Pre-Claim Review Demonstration and scrapping the Home Health Groupings Model thanks to more than 1,200 comments submitted to CMS last year. There is strength in numbers, so the more CMS and lawmakers hear from home health professionals like you, the better our chances are at reducing the devastation that PDGM in its proposed form can cause.

For more information, please send inquiries to Kyle Simon, Director of Government Affairs and Communications, at ksimon@homecarefla.org.


PDGM OMG: The Problem Areas

The most concerning provisions within the proposed rule are:

  • Reducing the Medicare base rate by 8.01% next year under the PDGM, which amounts to $1.298 billion nationwide next year alone, and approximately $162,000 for every Florida home health agency on average. CMS proposes the reduction to account for anticipated changes in provider behavior that are unrelated to changes in patients served or services delivered that increase payments. This “behavioral adjustment” reduction is more than the 6.42% reduction that CMS initially proposed, and the reduction would start before any actual behavioral changes occur.
  • Starting in 2021, a Notice of Admission (NOA) must be submitted within five days of the start of care. For every day late, CMS plans to reduce base-rate reimbursements for the unit of care. (Keep in mind this proposed requirement would coincide with the Review Choice Demonstration, which will most likely go into effect in Florida sometime next year!)

The Solution: Pass S.433/H.R.2573

Over the next month, Congress is in recess and back in the states, which presents a pivotal opportunity for home health industry professionals to engage with lawmakers about a key legislative priority – the Home Health Payment Innovation Act (S.433/H.R.2573).

This legislation prohibits CMS's ability to adjust payment based on "behavioral assumptions" as opposed to observed evidence of behavioral changes, thus rescinding the proposed 8.01% adjustment.

We cannot afford to miss this timely and critical opportunity to share our message with lawmakers. The time to act is now.

This month and throughout the rest of this year we critically need all home health industry professionals to contact Florida's congressional delegation and convey that we need their support by cosponsoring S.433/H.R.2573. So far, just four of Florida's 29-member congressional delegation have cosponsored the bill:

  • Rep. Vern Buchanan (R-Longboat Key)
  • Rep. Alcee Hastings (D-Miramar)
  • Rep. Daniel Webster (R-Winter Garden)
  • Rep. Val Demings (D-Orlando)

Talking Points for Advocacy Outreach

  • The Bipartisan Budget Act of 2018 requires Medicare to develop a new payment model for the home health benefit in 2020. Under the BBA, the transition to the new payment model must be budget neutral. In response to BBA, CMS plans to implement a payment model called the Patient-Driven Groupings Model (PDGM).
  • The BBA includes a provision that gives CMS the authority to make rate reductions based on “behavioral assumptions” of how providers will systemically change their coding to maximize reimbursement under the new payment model.
  • Using this authority, CMS’ 2020 proposed rule published two weeks ago calls for an 8.01% cut to rates for next year, which amounts to $1.298 billion nationwide next year alone, and approximately $162,000 for every Florida home health agency on average.
  • The Home Health Payment Innovation Act (S.433/H.R.2573), would remove CMS’ authority to make such cuts without any data or evidence.
  • Florida cosponsors to date:
    • Rep. Vern Buchanan (R-Longboat Key)
    • Rep. Daniel Webster (R-Winter Garden)
    • Rep. Alcee Hastings (D-Miramar)
    • Rep. Val Demings (D-Orlando)

The Plan: 6 Ways to Make Your Voice Heard Now

The following action items are the six most effective ways that every home health professional can take action now and make your voice heard to gain additional cosponsors on S.433/H.R.2573.

#1 – Meet With Your U.S. Representative

Contact your U.S. representatives’ district office and set up an in-person meeting during August recess. Click here to find your lawmakers' local office contact information. (Enter your home address, select your federal representative, and click on the office location nearest to you for the local phone number.)

#2 – Call Your Members of Congress in D.C.

Contact the Washington, D.C. offices of Senator Marco Rubio, Senator Rick Scott, and your U.S. representative and ask them to cosponsor S.433/H.R.2357. Phone numbers are listed below. Lawmakers who have already cosponsored the bill are marked as COSPONSOR. Similarly, key lawmakers who serve on committees with jurisdiction over Medicare issues are marked as TARGET.

District Member of Congress D.C. Phone Number
Statewide Senator Marco Rubio (R) (202) 224-3041
Statewide Senator Rick Scott (R) (202) 224-5274
1 Rep. Matt Gaetz (R) (202) 225-4136
2 Rep. Neal Dunn (R) (202) 225-5235
3 Rep. Ted Yoho (R) (202) 225-5744
4 Rep. John Rutherford (R) (202) 225-2501
5 Rep. Al Lawson (D) (202) 225-0123
6 Rep. Michael Waltz (R) (202) 225-2706
7 Rep. Stephanie Murphy (D) TARGET (202) 225-4035
8 Rep. Bill Posey (R) (202) 225-3671
9 Rep. Darren Soto (D) TARGET (202) 225-9889
10 Rep. Val Demings (D) COSPONSOR
11 Rep. Daniel Webster (R) COSPONSOR
12 Rep. Gus Bilirakis (R) TARGET (202) 225-5755
13 Rep. Charlie Crist (D) TARGET (202) 225-5961
14  Rep. Kathy Castor (D) TARGET (202) 225-3376
15 Rep. Ross Spano (R) (202) 225-1252
16 Rep. Vern Buchanan (R) COSPONSOR
17 Rep. Greg Steube (R) (202) 225-5792
18 Rep. Brian Mast (R) (202) 225-3026
19 Rep. Francis Rooney (R) (202) 225-2536
20 Rep. Alcee Hastings (D) COSPONSOR
21 Rep. Lois Frankel (D) (202) 225-9890
22 Rep. Ted Deutch (D) (202) 225-3001
23 Rep. Debbie Wasserman Schultz (D) (202) 225-7931
24 Rep. Frederica Wilson (D) (202) 225-4506
25 Rep. Mario Diaz-Balart (R) (202) 225-4211
26 Rep. Debbie Mucarsel-Powell (D) (202) 225-2778
27 Rep. Donna Shalala (D) (202) 225-3931

#3 – Email Your Members of Congress

Email Senator Rubio, Senator Scott, and your representative through HCAF's Legislative Action Center. In just a few clicks you can ask for their support for S.433/H.R.2357, and also spread the word on social media…it's that simple!

#4 – Attend a Public Event With Members of Congress

Find an in-person town hall event with your representative using the Town Hall Project tool. If your representative is hosting an event, please attend and ask them to support S.433/H.R.2357.

#5 – Advocate in D.C. Next Month

Join home health industry advocates next month in Washington, D.C. for The Council of State Home Care Associations’ Third Annual Public Policy Summit and Advocacy Day!

On September 9, participate in a full-day summit featuring speakers including Hillary Loeffler, Director of the CMS' Division of Home Health & Hospice, a Medicare Advantage industry leader, a CMS Medicaid official, and the Chief Medical Officer of CareCentrix, among others.

On September 10, home health professionals will be on Capitol Hill meeting with members of Congress to convey the critical need to pass S.433/H.R.2357. The Council's fee to attend is $250, and the group rate for lodging at the Public Policy Summit venue (Fairmont Hotel) has been negotiated at $289 per night.

More details can be found here, but registration must be submitted through The Council's website. We need your voice and as many Florida Medicare home health providers in attendance to share industry priorities with policy makers in-person before it's too late!

#6 – Submit Comments to CMS by September 9

Click here to submit comments to CMS in response to the 2020 proposed rule by 5:00 p.m. ET on Monday, September 9, 2019.

HCAF and other industry organizations will provide more thorough comments on other problematic areas of the proposed rule. As previously stated, there is strength in numbers, so the more business-focused comments from providers – both large and small – are critical to giving CMS a full and clear picture of how devastating PDGM will be should it be implemented as proposed. Last year, more than 1,200 comments were submitted in response to the now-scrapped Home Health Groupings Model. This figure was by far the most comments submitted from our industry in response to any proposed policy in recent memory. Let's put a dent in that number with as many of Florida's more than 900 Medicare-certified agencies submitting comments by the deadline.

In addition to the most concerning provisions of the proposed rule that are explained above, you may also refer to our PDGM Resources webpage, as well as CMS’s agency-level impact analysis to determine the financial impact on your agency (i.e., compare your agency’s current profit margin with what it is estimated to be after PDGM goes into effect, and provide insight into how that change will affect your business and staff.)


Additional Resources

National Association for Home Care & Hospice Advocacy Toolkit

The Partnership for Quality Home Healthcare Congressional August Recess Toolkit

HCAF PDGM Resources

Home Health Payment Innovation Act Fact Sheet

Home Health Payment Innovation Act Bill Analysis

CMS 2020 Proposed Rule Fact Sheet

CMS 2020 Proposed Rule Analysis

Dobson DaVanzo & Associates Issue Update: Prospective Behavioral Assumptions Create Challenges and Intensify Uncertainties in PDGM Implementation

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