The 2025 Home Health Prospective Payment System (HH PPS) proposed rule introduces several significant clinical updates aimed at enhancing care quality, improving patient outcomes and streamlining processes for providers.
To help organizations understand the clinical updates outlined in the proposed rule, Axxess Senior Vice President of Clinical Services Arlene Maxim, RN, HCS-C, hosted a webinar discussing these changes and sharing tips for success.
“Most of these updates [that are] clinical are probably going to take place in 2027,” Maxim said. “When we get the final rule, we’ll have more information about that.”
Home Health Quality Reporting Program Updates
The proposed rule outlines four new assessment items and one modified item projected to take effect in 2027:
- One living situation item (R0310)
- One utilities item (R0330)
- Two food items (R0320)
- Modified transportation item (R0340)
Each of these items falls into the social determinants of health (SDOH) category, meaning social workers are equipped to address them in initial and comprehensive assessments, Maxim says.
“If a nurse or a therapist finds out that a patient doesn’t have a place to call home [or] they are worried about losing their home, probably they’re not going to be able to do a whole lot about it,” Maxim said. “They’re going to check a box and go on with their day. The social worker is going to be able to bring in community services. They are likely going to be able to get results from these patients that perhaps the other disciplines would not take the time to get.”
CMS is also proposing removal of the suspension of all-payer OASIS data collection.
“What they’re saying here is that all of the OASIS items that you’re collecting for Medicare, Medicaid and other required folks right now, they’re going to require this for [all payers]. … So, if this happens, … all-payer data collection is really going to give them a better picture of what we do in the home.”
Maxim says all-payer data collection may take effect more quickly than the other quality reporting changes.
Home Health Conditions of Payment (CoPs) Updates
CMS is proposing adding a new standard to the home health Conditions of Payment (CoPs) that would require organizations to develop, implement and maintain a patient acceptance to service policy that is applied consistently to each prospective patient referred for home healthcare.
“This all came about because we are not seeing patients as quickly as we need to,” Maxim said. “We’re not meeting that 48-hour time frame.”
The policy must address, at a minimum, the following criteria related to the organization’s capacity to provide patient care:
- The anticipated needs of the referred prospective patient
- The organization’s caseload and case-mix
- The organization’s staffing levels
- The skills and competencies of the organization’s staff
“You need to be really careful about this,” Maxim said. “This is one of those policies that … will need to be written, or if you have something already, it’s going to probably have to be updated. Be very, very careful on how you write it. Don’t get so specific in this that you’re going to be caught because if you have something with a high degree of specificity, the surveyors are likely going to find deficiencies in what you’re doing. … If you don’t have generalizations in some areas, you might be caught in a trap for survey.”
CMS is also proposing adding a new standard that would require organizations to make information about their services and service limitations available to the public. They are requesting public comments on factors that influence patient referral and intake processes, and whether rehabilitative therapists should be permitted to conduct the initial and comprehensive assessment for cases that have both therapy and nursing services ordered as part of the plan of care.
“I would encourage you to be writing to [CMS] on this request for information,” Maxim said. “This is going to be important information for CMS to collect, and it’s going to determine policy in the future.”
Health Equity Adjustor in Value-Based Purchasing
CMS is proposing a health equity adjustor in value-based purchasing, meaning data collected on health equity would be used to address disparities in healthcare by potentially increasing payments for home health services provided to underserved populations.
“Some of the information we are collecting, as far as health equity is concerned, will be used to make adjustments in value-based purchasing in the future,” Maxim said. “Underserved communities are going to be looked at very, very closely and probably be added to value-based purchasing in an adjustment of some sort.”
Medicare Provider Enrollment Updates
CMS is proposing adding providers and suppliers that are reactivating their Medicare billing privileges to the categories of new providers and suppliers subject to additional oversight.
“They’re talking about additional oversight for [new] providers and [those] reactivating [their] billing privileges,” Maxim said. “For many years, almost anybody could get into the Medicare program. So, now they’re talking about scrutinizing who’s going to be a provider, a supplier, and if they’ve had their billing privileges stopped, whether or not they can have them reactivated. … So, there’s going to be certain criteria and there’s going to be oversight. They’re looking at a provisional period of enhanced oversight [for] 30 days to one year for new providers and suppliers. I believe that’s going to happen.”
Maxim advises start-up organizations to seek consultancy to help navigate this enhanced scrutiny.
“I know that some folks start up on a wing and a prayer,” Maxim said. “They don’t get the consultants that they need. I would highly encourage anybody who’s going to start up to get somebody [who’s] a consultant in there [who] knows what they’re doing … – somebody with an objective opinion.”
To watch the full webinar on clinical updates outlined in the 2025 proposed rule, click here.
Axxess Home Health, a cloud-based home health software, includes clinical guidance and innovative tools designed to help organizations thrive under regulatory challenges.
