Home Health Proposed Rule Results in $810M Decrease in Payments

WASHINGTON, D.C. (June 21, 2022)—The annual proposed rule for Medicare home health services includes an estimated 4.2% or $810 million decrease in aggregate payments, said the Centers for Medicare and Medicaid Services (CMS) in its fact sheet on the rule. The rule would apply to calendar year 2023. 

This decrease reflects the effects of: the proposed 2.9% home health payment update percentage ($560 million increase); an estimated 6.9% decrease that reflects the effects of the proposed prospective permanent behavioral assumption adjustment of -7.69% ($1.33 billion decrease); and an estimated 0.2% decrease that reflects the effects of a proposed update to the fixed-dollar loss ratio (FDL) used in determining outlier payments ($40 million decrease).  

Overall, the rule presents serious concerns for the home health community as it includes significant proposed rate reductions to account for the change in the payment model in 2020, the National Association for Home Care & Hospice (NAHC) said. Medicare law requires CMS to make permanent and temporary adjustments intended to ensure that the transition to the Patient Driven Groupings Model (PDGM) is budget neutral in comparison to expected Medicare spending on the 2019 payment model. 

“We are extremely disappointed in the CMS proposed rule issued today. The stability of home health care is at risk because of CMS proposing the application of a fatally flawed methodology for assessing whether the PDGM payment model led to budget neutral spending in 2020 and later years,” stated William A. Dombi, president of NAHC. “That has been made clear to CMS in the 2021 rulemaking and in multiple discussions since. With significantly rising costs for staff, transportation, and more, home health agencies across the country cannot withstand the impact of the proposed rate cut. Reliable analyses proves that PDGM underpaid home health agencies. We will be taking all steps to protect the home health benefit as this proposed rule advances and have fully prepared for congressional action and more.” 

“Considering that access to home-based care has become increasingly important to the health and safety of American seniors, it is very troubling that CMS would propose such steep rate cuts for next year and potentially even deeper cuts in the future,“ said Joanne Cunningham, CEO of the Partnership for Quality Home Healthcare. “If implemented as proposed, this payment adjustment will jeopardize the stability of this vital sector and risk seniors’ access to Medicare home health services.”

“What we see in the proposed rule is the equivalent of a declaration of war against home health agencies and the 3 million plus patients they serve. To believe this will have no impact on patients is to live in a bubble,” Dombi stated.

The rule also contains:

• A net 2.9% inflation update (3.3% market basket index – 0.4% productivity adjustment)—This is a strikingly low inflation update given that current inflation is at a 20-year high, nearing double digits.
• A 7.69% budget neutrality adjustment allegedly related to provider behavior changes triggered by PDGM
• An alleged $2 billion overpayment in 2020 and 2021. CMS proposed withholding any adjustment at this time to reconcile the alleged overpayment.
• Recalibration of the 432 case mix weights—Recalibration has been done annually to account for changes in case-specific resource and cost changes.
• Modification of the LUPA thresholds Institution of a 5% cap on negative changes in the area-specific wage index.

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HHS Announces Historic, First-in-the-Nation Program that Seeks to Expand Coverage to Nearly 10,000 Coloradans

New “Colorado Option” will lower premiums and ensure greater access to health care for more residents, advancing health equity in the state.

[Last week], the U.S. Department of Health and Human Services (HHS) announced approval of Colorado’s Section 1332 State Innovation Waiver amendment request to create the “Colorado Option,” a state-specific health coverage plan that increases health coverage enrollment and lowers health care costs, making insurance more affordable and accessible for nearly 10,000 Coloradans starting in 2023. It is designed to reduce racial and ethnic health disparities by providing new coverage options for Coloradans, reflecting the Biden-Harris Administration’s commitment to advancing health equity. 

“We are thrilled to partner with Colorado in our shared commitment to lowering health care costs and ensuring greater access to quality, affordable care,” said HHS Secretary Xavier Becerra. “The Colorado Option will help thousands more families sign up for health coverage. I applaud Governor Jared Polis and encourage all states to pursue innovative ways to ensure health care is within reach for their residents.”

Section 1332 of the Affordable Care Act (ACA) allows states to apply for State Innovation Waivers to pursue innovative strategies for providing residents with access to high-quality, affordable coverage. Colorado is the first in the nation to adopt this waiver to introduce a new and more affordable state-based health insurance option, and leverage federal savings to support state subsidies to improve affordability and coverage initiatives. Colorado projects that approximately 32,000 Coloradans will gain health insurance under the amended waiver by 2027, which would be an increase of approximately 15% in the individual market.

This 1332 waiver amendment implements the Colorado Option, which lowers premiums and health care costs while making it easier for consumers to compare their coverage options and select the best plan that fits their needs. Starting in 2023, the Colorado Option will be available to all Coloradans who enroll in health insurance plans on the individual market (i.e., not through an employer) and small employers with less than 100 employees. Colorado Option plans will lower health insurance premiums for individuals, families, and small businesses by up to 15% by 2025.

The Colorado Option will operate in tandem with Colorado’s existing section 1332 waiver, a state-based reinsurance program, which is authorized to continue under the amended waiver. The amended waiver is expected to lower premiums by an average of approximately $132 per person per month (or 22%). This is even further than the state’s reinsurance waiver program alone, which has already resulted in statewide average premium reductions of approximately 20% since its implementation in 2020.

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Find more information about the Colorado Option here: Colorado Option website. 

View a fact sheet for additional information here: https://www.cms.gov/newsroom/fact-sheets/colorado-state-innovation-waiver-0

CDC Authorizes COVID Vaccines for Children Ages 6 Months+

The Centers for Disease Control and Prevention (CDC) issued recommendations for vaccinating children 5 years of age and younger against COVID-19. The recommendation clears the way for the nearly 241,000 Utah children in this age group who are now eligible to get vaccinated.

Additionally, the U.S. Food and Drug Administration (FDA) has authorized both the Pfizer and Moderna mRNA vaccines for use with all ages (6 months and older) eligible for COVID-19 vaccinations. Previously, only the Pfizer vaccine was available for children younger than 18. 

Vaccines for this youngest age group will begin to arrive in Utah the week of June 20th. The first batch of doses is expected early in the week and another batch of doses is expected later in the week. According to the Utah Department of Health and Human Services (DHHS), providers have already ordered 32,300 doses of the vaccines. 

Providers such as local health departments, select pharmacies, and doctor’s offices will begin offering vaccinations to the youngest Utahns over the next several days to weeks. “We encourage parents to reach out to their child’s healthcare provider if they have questions about the COVID-19 vaccines and to find out when they can get their children vaccinated. Please be patient with vaccine providers over the next couple of weeks as they receive vaccines and prepare to administer them to our youngest children,” said Dr. Leisha Nolen, a pediatrician and the state epidemiologist at the DHHS.

A list of vaccine providers is available on the state’s coronavirus webpage. Vaccines will not be available for this youngest age group at all locations right away. Parents can visit vaccines.gov to verify which providers have younger pediatric vaccines available or call their child’s doctor’s office or local health department for information on scheduling a vaccination.  

Vaccine dosage is based on the brand of the vaccine and a person’s age the day they receive the vaccine, not weight. Depending on the type of vaccine given, children younger than 5 may need 2 or 3 doses. 

• Pfizer vaccine: Children ages 6 months through 4 years of age will need 3 doses to complete their primary vaccine series. The 2nd dose should be given 21 days after the 1st dose and then a 3rd dose 2 months after the 2nd dose.
• Moderna vaccine: Children ages 6 months through 5 years of age will need 2 doses to complete their primary vaccine series. The 2nd dose should be given at least 28 days after the 1st dose. 

For more information visit https://coronavirus.utah.gov/vaccine/ or call the COVID-19 hotline at 1-800-456-7707.

'Part of a New Normal': Covid Reinfections are Here to Stay

NBC News | By Akshay Syal, M.D. and Sara G. Miller

In 2020, Covid reinfections were considered rare.

In 2021, breakthrough infections in vaccinated individuals could occur, but again, the risk was low.

In 2022, that's no longer the case for either. As more immune-dodging coronavirus variants emerge, reinfections and breakthrough infections appear increasingly normal. 

The United States isn't currently tracking Covid reinfections. However, U.K. researchers have found that the risk of reinfection was eight times higher during the omicron wave than it was in last year's delta wave. 

“I would not be surprised if we see people get infected more than once per year,” Dr. Anthony Fauci, chief medical adviser to President Joe Biden, said in an interview with NBC News last week, though he added that he feels optimistic that it will eventually settle into becoming just a seasonal occurrence, like the flu. (Fauci, who has received two vaccine boosters, himself tested positive for Covid on Wednesday, saying he has mild symptoms.)

Of course, just because reinfections are possible, doesn’t mean people should give up on all efforts to prevent them; staying up-to-date on vaccinations and wearing masks indoors in places with high transmission still work to lower risk.

Here’s what we know so far about reinfections.

Can I be Reinfected if I’ve Already Had Covid, or Been Vaccinated or Boosted? 

To put it bluntly, yes. Experts are in agreement that reinfections are possible, even in people who have already been infected or those who are up-to-date on their vaccines.

“Reinfections, unfortunately, are not unusual for coronavirus,” said Akiko Iwasaki, a professor of immunobiology at Yale University. “It’s just the nature of this virus infection.”

The coronavirus that causes Covid is not unique — other types of coronaviruses that cause common colds can also reinfect, Fauci said. But those reinfections may occur every two or three years, because those viruses don’t change very much. 

That’s not the case for SARS-CoV-2, and particularly the rapidly evolving omicron subvariants, which are good at evading existing immunity. Combine that with the fact that people’s immunity naturally wanes over time, Iwasaki said, and “it’s not that surprising to see a lot of reinfections now.”

That’s especially true for people who were infected with the original omicron variant, dubbed BA.1, in the winter. The BA.4 and BA.5 subvariants — currently gaining a foothold in the U.S. — are quite different from BA.1, so “it’s no guarantee” that having a past omicron infection will protect you from subsequent subvariants, she said.

How Many Times Can I be Reinfected? 

It’s impossible to put an exact number on how many times a person can be reinfected, experts say.

With a high level of Covid currently spreading in the U.S., any of us have a good chance of being exposed to someone who is contagious — and becoming reinfected.

Whether a person is reinfected depends on the strength of the immune response when the person was exposed, as well as whether he or she has been recently vaccinated, said Dr. Julie McElrath, director of the vaccine and infectious disease division at the Fred Hutchinson Cancer Center in Seattle. Multiple exposures to the virus — which may not necessarily lead to symptoms — could have a silver lining, McElrath said.

Each time a person is exposed, the immune response matures and improves.

“We should consider reinfection as part of the new normal,” she said. “The hope is that with these multiple exposures continually improving antibody response will occur.”

Read Full Article for answers to the following questions:

• How long does Covid immunity last after infection?
• If reinfected, will symptoms be milder or worse?
• Are certain people more vulnerable to reinfection?
• Am I more likely to develop long Covid if I get reinfected?