{"data":{"id":"us/42-cfr-484.240","jurisdiction":"us","citation":"42 CFR 484.240","heading":"Outlier payments.","body":"(a) For episodes beginning on or before December 31, 2019, an HHA receives an outlier payment for an episode whose estimated costs exceeds a threshold amount for each case-mix group. The outlier threshold for each case-mix group is the episode payment amount for that group, or the PEP adjustment amount for the episode, plus a fixed dollar loss amount that is the same for all case-mix groups.\n(b) For periods beginning on or after January 1, 2020, an HHA receives an outlier payment for a 30-day period whose estimated cost exceeds a threshold amount for each case-mix group. The outlier threshold for each case-mix group is the 30-day payment amount for that group, or the partial payment adjustment amount for the 30-day period, plus a fixed dollar loss amount that is the same for all case-mix groups.\n(c) The outlier payment is a proportion of the amount of imputed cost beyond the threshold.\n(d) CMS imputes the cost for each claim by multiplying the national per-15 minute unit amount of each discipline by the number of 15 minute units in the discipline and computing the total imputed cost for all disciplines.","path":["Title 42—Public Health","CHAPTER IV—CENTERS FOR MEDICARE \u0026 MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES","SUBCHAPTER G—STANDARDS AND CERTIFICATION","PART 484—HOME HEALTH SERVICES","Subpart E—Prospective Payment System for Home Health Agencies"],"source_url":"https://www.ecfr.gov/api/versioner/v1/full/2026-08-25/title-42.xml","current_through":"2026-08-25","vintage":"","retrieved_at":"2026-08-27T02:26:11Z","sha256":"2927a8d09d4c8d2aaa1e3fb19b5831a1873e7ac834f8f4efb2693257119caec5","source_id":"us-cfr","stale":true,"prev":"us/42-cfr-484.235","next":"us/42-cfr-484.245"},"notice":"GroundRules: Original legal text. Not legal advice."}