[Code of Federal Regulations]
[Title 42, Volume 3, Parts 430 to end]
[Revised as of October 1, 2000]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR484.240]

[Page 503]
 
                         TITLE 42--PUBLIC HEALTH
 
                         CHAPTER IV--HEALTH CARE
                        FINANCING ADMINISTRATION,
                        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) HCFA 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) HCFA 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.