PDGM New Payment Methodology - Community Health Plan of Washington - Medicare Advantage

PDGM New Payment Methodology

Beginning January 1, 2020, the Centers for Medicare and Medicaid Services (CMS) will begin using a new payment methodology, Patient-Driven Groupings Model (PDGM). PDGM will be used to reimburse home health agencies that provide home health services to Medicare beneficiaries under Medicare fee-for-service.

Highlights of the PDGM include:

  • Payments to home health agencies are expected to increase by 1.3% ($250 million total).
  • An increased reliance on clinical characteristics and other patient information will result in “meaningful payment categories” for home health periods of care.
  • The home health unit of payment will change from a 60-day episode of care to a 30-day period of care.
  • The 30-day periods will be assigned to one of 432 case-mix groups based on specific variables including (but not limited to) admission source, functional impairment level, etc.
  • Home infusion therapy payment rates will be updated routinely.
  • The use of therapy service thresholds will be eliminated.
  • Therapy assistants will be allowed to provide maintenance therapy.

CHPW will follow the new CMS Medicare methodology. Effective for home health services beginning on or after January 1, 2020, all such services for CHPW Medicare Advantage members should be billed according to the new PDGM.

Please refer to the following CMS resources for an overview of the PDGM:


If you have questions about the information in this bulletin, please email [email protected].


Nurse Advice Line
Doctors in an emergency room with patient,What kind of care do you need? Not every medical issue needs emergency care. If you have a medical issue that doesn’t seem to be life-threatening, but you’re not sure what to do, you can call our Nurse Advice Line for help. They can help you decide if you should see a primary or urgent care doctor. The Nurse Advice Line is free and available 24/7 for members at 1-866-418-2920 (TTY Relay: 7-1-1).



Sales Team

Get real answers
from real people

Phone: 1-800-944-1247
Email: [email protected]