During the Public Health Emergency, the Centers for Medicare & Medicaid Services (CMS) instituted the Hospital Without Walls initiative, known in North Carolina as the Acute Hospital Care at Home (HAH) program. Acute HAH was made available temporarily during the early COVID-19 surge as a Medicaid tool to provide relief to hospitals with limited bed capacity. This coverage ended on March 31, 2021.
The Department underwent an extensive evaluation of that program to inform future coverage through an External Quality Review Organization (EQRO). The findings from that study will be released publicly and show mixed results compared to other studies of Hospital at Home programs since the inception of this model.
There are several factors that result in a more positive outcome with Hospital at Home programs, including a key tenet of successful implementation is the capacity building time required for a hospital to establish the best practices that lead to the best outcomes. The hospitals under the current CMS waiver have been working on their programs since the program evaluation completed March 31, 2021, and have provided assurances that their outcomes are equal to that or better than other HAH evaluations nationally.
After extensive discussions with CMS, NC health systems, NC Medicaid Standard Plans, and other State Medicaid programs, NC Medicaid will cover Acute HAH under the existing DRG methodology from Nov. 1, 2023, until Dec. 31, 2024, when the CMS Medicare Waiver flexibility is scheduled to end.
After that time, if CMS continues to allow this model of care, NC Medicaid anticipates that the reimbursement methodology may shift to a percent of DRG and ultimately into a bundled care value-based care methodology in line with other departmental initiatives to drive population health through shared accountability to outcomes. Future reimbursement details will emerge, and continued coverage past December 2024 will be determined based on a combination of factors including:
- Long term approval by CMS to continue the model after Dec. 31, 2024, and
- Analysis of admissions to Acute Hospital at Home from November of 2023 through October of 2024 and positive findings on the resultant outcomes for Medicaid members.
Effective Nov. 1, 2023, to bill for Acute HAH, providers should bill DRG claims using revenue code 0161 for room and board and occurrence span code 82.
The information in this bulletin applies to both NC Medicaid Direct and NC Medicaid Managed Care.
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