This regulation governs outlier payment calculations for Home Health Agencies (HHAs) under Medicare, specifying how additional payments are triggered when estimated episode or 30-day period costs exceed case-mix group thresholds. It applies to episodes beginning on or before December 31, 2019, and periods beginning on or after January 1, 2020, with outlier payments calculated as a proportion of imputed costs beyond the threshold. This is a Medicare reimbursement rule for home health services and does not govern any behavioral health, IDD, ABA, or foster care facility type.
View official source§ 484.240 Outlier payments. (a) For episodes beginning on or before December 31, 2019, an HHA receives an outlier payment for an episode whose estimated costs exceeds a threshold amount for each case-mix group. 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 imputed cost beyond the threshold. (d) CMS imputes the cost for each 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. [83 FR 56630, Nov. 13, 2018]