[Code of Federal Regulations]

[Title 42, Volume 3]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR484.240]



[Page 593]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 484_HOME HEALTH SERVICES--Table of Contents

 

      Subpart E_Prospective Payment System for Home Health Agencies

 

Sec. 484.240  Methodology used for the calculation of the outlier payment.



    (a) CMS makes an outlier payment for an episode whose estimated cost 

exceeds a threshold amount for each case-mix group.

    (b) The outlier threshold for each case-mix group is the episode 

payment amount for that group, the PEP adjustment amount for the episode 

or the total significant change in condition adjustment amount for the 

episode 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 estimated 

cost beyond the threshold.

    (d) CMS imputes the cost for each episode by multiplying the 

national per-visit amount of each discipline by the number of visits in 

the discipline and computing the total imputed cost for all disciplines.

    (e) The fixed dollar loss amount and the loss sharing proportion are 

chosen so that the estimated total outlier payment is no more than 5 

percent of total payment under home health PPS.