November 19, 2024

Speech-language pathologists (SLPs) working for home health agencies (HHAs) will see changes to Medicare regulations in 2025. These changes-which come after the Centers for Medicare & Medicaid Services (CMS) issued a final rule on November 1, 2024-will take effect starting January 1, 2025.

There are six update areas SLPs should know about:

• Payment
• Administrative mandates
• Conditions of participation
• Therapy and nursing services
• Social determinants of health
• Home health value-based purchasing program.

Payment

CMS will update payments to HHAs by 0.5% in 2025. This increase is in spite of a 1.975% negative payment adjustment applied because the industry continues to experience payments above federally mandated budget neutrality requirements due to the transition to the patient-driven groupings model. As a result, payments to the home health industry will increase by $85 million in 2025 as compared to 2024.

The national per-visit payment amount for speech-language pathology is $205.22 as compared to physical therapy ($188.79) and occupational therapy ($190.08).

CMS also updated the low-utilization payment adjustments (LUPA) for nursing, physical therapy, and speech-language pathology services using more recent claims data.

Administrative Mandates

ASHA members continue to share concerns about predictive analytic models and administrative mandates that dictate plans of care and undermine the clinical judgment of SLPs. For example, some mandates restrict patients to a minimal number of speech-language pathology home health visits before they're discharged from an SLP's caseload. In response to our efforts to amplify these concerns with Medicare staff, CMS states in the final rule:

"These comments mirror comments we responded to in last year's HH PPS final rule discussing the potential for the functional impairment levels to create an incentive for HHAs to hand-pick patients based on their predicted case mix grouping. We again emphasize that the plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. It is improper for an HHA to influence a practitioner on what should be included in the plan of care based on the HHA's own financial constraints and staffing abilities. As stated in the CY 2024 HH PPS final rule (88 FR 77699), we expect the provision of services be made to best meet the patient's care needs and in accordance with the home health CoPs at § 484.60, and that it is not proper for HHAs to under-supply care or services or reduce the number of visits in response to payment, as this would be a violation of the CoPs."

ASHA will continue to work with CMS to highlight our members' concerns about inappropriate administrative mandates and to identify solutions to ensure that clinicians can develop plans of care based on clinical need.

Conditions of Participation (CoPs)

ASHA supported several updates to the Medicare CoPs for HHAs to ensure the industry is only accepting patients it has the capacity for. We're pleased to see these finalized.

Specifically, CMS is finalizing a new standard that requires HHAs to develop, implement, and maintain, through an annual review, a patient acceptance-to-service policy that is applied consistently to each prospective patient referred for home health care. The policy must address, at a minimum, the following criteria related to the HHA's capacity to provide patient care: the anticipated needs of the referred prospective patient, the HHA's caseload and case mix, the HHA's staffing levels, and the skills and competencies of the HHA staff.

CMS is also finalizing a standard that HHAs must make available to the public accurate information regarding the services offered by the HHA and any service limitations related to types of specialty services, service duration, or service frequency. Initially, CMS required this information be updated only annually. But in response to concerns raised by ASHA and other stakeholders, CMS updated the proposal to require HHAs to review this information as frequently as the services are changed, but at least annually.

Therapists Opening Home Health Cases for Patients Needing Therapy and Nursing Services

In the proposed rule, Medicare included a request for information (RFI) about the feasibility of allowing SLPs and physical therapists to open home health cases for patients that need both nursing and therapy services. While the requirements were relaxed during the COVID-19 public health emergency, under "normal" circumstances, only a nurse can open such cases. ASHA responded to the RFI by noting that, with the appropriate training and support of the agency and consideration of the patient's clinical presentation, an SLP could be qualified to open such cases. However, based on feedback from members, we raised concerns that some HHAs could inappropriately use therapists to open cases and increase caseload inappropriately. We stressed the importance of guardrails, such as the finalized acceptance-to-service CoP, to prevent abuse of these flexibilities.

CMS did not address the feedback it received in the final rule. ASHA will follow up with Medicare staff to determine if it is considering future rulemaking on this issue.

Home Health Quality Reporting Program: Social Determinants of Health (SDOH)

Medicare will require HHAs to collect four new items and one modified item associated with SDOH using the Outcome and Assessment Information Set (OASIS) beginning in 2027. These same items were finalized for other post-acute care settings earlier this year, including inpatient rehabilitation and skilled nursing facilities. The items finalized for collection are:

• Living Situation item: "What is your living situation today?" The proposed response options are: (1) I have a steady place to live; (2) I have a place to live today, but I am worried about losing it in the future; (3) I do not have a steady place to live; (4) Patient unable to respond; and (5) Patient declines to respond.
• Food items: "Within the past 12 months, you worried that your food will run out before you got money to buy more." And "Within the past 12 months, the food you bought just didn't last and you didn't have money to get more." We propose the same response options for both items: (1) Often true; (2) Sometimes true; (3) Never true; (4) Patient unable to respond; and (5) Patient declines to respond.
• Utilities item: "In the past 12 months, has the electric, gas, oil, or water company threatened to shut off services in your home?" The proposed response options are: (1) Yes; (2) No; (3) Already shut off; (4) Patient unable to respond; and (5) Patient declines to respond.
• Transportation item: This has been modified to read "In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living?" The two response options are: "(1) Yes"; and "(2) No."

SLPs may report SDOH data via the OASIS when performing a start-of-care assessment. They could also review such data when creating their SLP plan of care. ASHA supports the reporting of SDOH as they help policymakers, including payers, better understand the resources required to appropriately care for patients. We have developed resources for our members to help them engage in effective SDOH reporting.

Home Health Value-Based Purchasing (HHVBP) Program

Request for Information (RFI) on Future Performance Measure Concepts for the Expanded HHVBP Model

CMS stated that comments (including those related to function measures that complement the existing cross-setting Discharge [DC] Function measure) will be reviewed with stakeholders and the HHVBP Technical Expert Panel that provides input on changes to the HHVBP applicable measure set. ASHA advocated for the assessment of holistic functions that adequately capture the outcomes required for safety and independence, including communication, cognition, and swallowing. We remain committed to ensuring CMS includes concepts of function that relate to speech-language pathology services.

Health Equity

CMS affirmed its commitment to health equity but did not propose or finalize any changes. Input was collected from home health stakeholders that will be considered in future rulemaking.

Resources

• CY 2025 Home Health Prospective Payment System Final Rule Fact Sheet
• ASHA Comments to CMS Regarding the CY 2025 Home Health Prospective Payment System [PDF]
• Medicare Home Health Prospective Payment System: The Patient Driven Groupings Model

Questions?

Please contact ASHA's health care and education policy team at [email protected].