Community Health Plan of Washington Medicare Advantage Plans Community Health Plan of Washington Medicare Advantage Plans

CMS PDGM Payment Methodology

The Centers for Medicare and Medicaid Services (CMS) use the Patient-Driven Groupings Model (PDGM) payment methodology to reimburse home health agencies that provide home health services to Medicare beneficiaries under Medicare fee-for-service. As a reminder, PDGM has been in effect since January 1, 2020. CHPW is updating this bulletin to ensure new providers or billers are aware of this methodology.

Highlights of the PDGM include:

  • An increased reliance on clinical characteristics and other patient information helps ensure “meaningful payment categories” for home health periods of care.
  • The home health unit of payment has a 30-day period of care.
  • The 30-day periods are 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 are updated routinely.
  • Therapy service thresholds were eliminated.
  • Therapy assistants are allowed to provide maintenance therapy.

CHPW follows the CMS Medicare methodology; therefore, all such services for CHPW Medicare Advantage members should be billed according to the 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].


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