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How Prepared Is Your Agency for 2021 Changes?

Tiffany Karlin

October 29, 2020

Currently, Medicare makes a split-percentage payment for most 30-day periods of care.  The first payment is made in response to a RAP submitted at the beginning of care, and the second payment is made in response to a final claim submitted at the end of the 30-day period of care. Added together, the first and second payments equal one-hundred percent of the permissible payment for the 30-day period.

The Risk Adjusting Processing System (RAP) is also an instrument used to establish the beneficiary’s primary HHA in the Common Working File (CWF). This allows the claims processing system to reject claims from providers or suppliers, other than the primary HHA.

In the CY 2019 HH PPS final rule, The Centers for Medicare & Medicaid Services (CMS) finalized that HHAs certified for participation in Medicare effective on or after January 1, 2019 (newly enrolled), will not receive split-percentage payments beginning in CY 2020. The HHAs were still required to submit a RAP at the beginning of a period of care, as well as every 30 days thereafter. No payment was associated with RAP submission.

In the CY 2020 HH PPS final rule, the CMS finalized HHAs that were certified for participation in Medicare with effective dates prior to January 1, 2019 (existing HHAs), would continue to receive split-percentage payments upon implementation of the Patient-Driven Groupings Model (PDGM). The change to a 30-day unit of payment would occur in CY 2020, but the up-front payment would be decreased from 60/50 to 20/80.

Starting in CY 2021, the split-percentage payment would be lowered to zero percent for all HHAs. However, all HHAs would still be required to submit a RAP at the beginning of each 30-day period of care. Since no payment will be associated with the submission of the RAP in CY 2021, the elements of when an HHA can submit a RAP will change to the following:

  • The HHA will need to have an appropriate physician’s written or verbal order that sets out the services required for the initial visit has been received and documented
  • The initial visit within the 60-day certification period will have to have been made and the individual admitted to HHA.

The information needed for submission of the RAP in CY 2021 will mirror the one-time Notice of Admission (NOA) process that begins in CY 2022.

In instances where the plan of care dictates multiple 30-day periods of care will be required to effectively treat the beneficiary, HHAs will be allowed to submit RAPs for both the first and second 30-day periods of care (for a 60-day certification) at the same time to help further reduce provider administrative burden.

 There will be a monetary penalty for RAPS that are not filed and accepted for processing within 5 days of the beginning date of the 30-day period. There will be a daily rate, based on the claim value as a proportion of 30 days, which will be deducted from the final claim payment for every day up until the date that the RAP is accepted.

Example: (30-DAY PAYMENT PERIOD of January 15, 2021 – February 14, 2021)

RAP accepted at MAC on 02/01/21 –

  • Claim value $4,500
  • When the final amount is paid the agency will receive the following payment:
    • ($4,500 divided by 30) + $150.00 per day
    • $150.00 x 17 days (days until RAP accepted) = $2,550.00
    • $4,500 – $2,550.00 = $1,950.00

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