Billing & Revenue Reference
CY2026 Home Health PPS Rates & Per-Visit Costs
The Centers for Medicare & Medicaid Services (CMS) 2026 Home Health Prospective Payment System (PPS) establishes per-visit costs, OASIS/HIPPS case-mix adjustments, wage indices by state, and high-cost outlier thresholds. This reference guide breaks down the 2026 rates for agency revenue forecasting, EMR billing validation, and compliance audits.
CY2026 Home Health PPS Overview
The CY2026 Home Health PPS rate base is $3,112.86 per 60-day episode, increasing 2.85% from CY2025 ($3,027.00). The PPS model distributes this rate across six disciplines (RN, PT, OT, SLP, HHA, MSW) based on per-visit cost assumptions, adjusted by case-mix (OASIS/HIPPS), geographic wage index, and outlier thresholds.
Key 2026 Figures
- Base rate: $3,112.86 per 60-day episode
- Per-visit avg: ~$97–$105 (varies by discipline)
- HCO threshold: $38,180 (unchanged from 2025)
- Payment adjustment: Wage index × case-mix multiplier × PAM
Per-Discipline Cost Assumptions
CMS's PPS model assumes the following average per-visit costs for each discipline within a 60-day episode. Agencies' actual costs vary by geography, case mix (OASIS/HIPPS), and operational efficiency.
| Discipline | CMS Per-Visit | Notes |
|---|---|---|
| Skilled Nursing (RN) | ~$155–$175 | Highest cost; assessment, wound care, medication management |
| Physical Therapy (PT) | ~$105–$130 | Rehabilitation-focused; case-mix adjusted (HIPPS) |
| Occupational Therapy (OT) | ~$95–$115 | Functional & adaptive living; HIPPS-adjusted |
| Speech-Language Pathology (SLP) | ~$100–$120 | Swallow & communication; lower volume than PT/OT |
| Home Health Aide (HHA) | ~$65–$85 | Custodial care; 60%–80% of RN; volume-dependent |
| Medical Social Work (MSW) | ~$90–$110 | Psychosocial support; lower visit frequency per episode |
Source: CMS Home Health PPS Final Rule cost assumptions (Federal Register, November 2025).
Example: 60-Day Mixed-Discipline Episode
Assume a typical mixed-discipline episode in Houston, TX (wage index 0.95):
6 RN visits @ $165
10 PT visits @ $118
8 OT visits @ $105
3 SLP visits @ $110
15 HHA visits @ $75
1 MSW visit @ $100
Subtotal per-visit costs: $4,565
CMS 60-day episode rate (2026): $3,112.86
Implied margin (PPS model): –$1,452 (cost-based; margin via case-mix lift + outliers)
OASIS/HIPPS Case-Mix Adjustment
The final episode rate is not flat. It adjusts based on the patient's OASIS assessment and resulting Home Health Resource Groups (HHRGs) score:
| Case-Mix Category | HIPPS Code Example | Adjusted Rate Range |
|---|---|---|
| Low acuity | 1AA0A | ~$2,100–$2,400 |
| Mid-range | 2CD5E | ~$3,100–$3,500 |
| High acuity | 6XX5U | ~$4,800–$5,200 |
The HIPPS score is derived from OASIS data: ADL/IADL dependencies, medication complexity, acute conditions, behavioral health, and ED use. Incomplete or inaccurate OASIS assessment directly reduces payment. Each missing M-item can shift the case-mix multiplier from 1.15 to 0.85, costing agencies thousands per episode.
State Wage Index Variation (Sample CY2026)
The wage index accounts for regional labor-cost differences. Below is a sample of CY2026 values:
| Region / MSA | Wage Index | Implied $/Episode |
|---|---|---|
| San Francisco, CA | 1.24 | $3,859 |
| Houston, TX | 0.95 | $2,955 |
| Chicago, IL | 1.09 | $3,393 |
| New York City, NY | 1.18 | $3,673 |
| Rural Iowa | 0.78 | $2,426 |
Billing & Compliance: OASIS Accuracy Is Revenue
Accurate OASIS = accurate payment. Common billing denials stem from OASIS errors:
- M0080 (primary diagnosis): Must match home health certification; missing or mismatched → claim held
- M0100 (care type): Routine vs. acute designation drives case-mix; errors downgrade episode payment
- Face-to-face timing: Must occur within 48 hours of first visit; violation → entire episode voided
- HIPPS derivation: Missing M1610–M1625 (ADL scores) → case-mix multiplier cannot calculate
- EVV reconciliation: Timestamps must align between EVV system and visit documentation; gaps trigger audits
OASIS Validation Checklist
- ☐ Face-to-face timing: Completed within 48 hours of first skilled visit
- ☐ Primary diagnosis (M0080): Matches certification reason & ICD-10 code
- ☐ HIPPS derivation: All mandatory M-items completed
- ☐ No missing M-items: Every required assessment field populated
- ☐ Episode type: Correctly marked as new 60-day or resumption
- ☐ EVV reconciliation: Visit timestamps match documentation
- ☐ Billing codes: CPT codes match visit type (e.g., 97001 PT eval)
- ☐ Outlier documentation: High-cost episodes ($38K+) have supporting clinical detail
Revenue Forecasting: RN Productivity and Episode Value
Home health agencies often achieve margin through case-mix concentration (higher acuity episodes) and aide leverage (more HHA visits per RN-managed case).
Example: RN FTE in Houston (wage index 0.95, mixed case-mix avg HIPPS 1.2)
Average episode value: $3,113 × 0.95 × 1.2 = $3,559 per episode
RN productivity: 6 episodes per year (each ~60 days; 2–3 in parallel)
Annual RN revenue: 6 episodes × $3,559 = $21,354 (gross)
RN labor cost (salary + benefits): varies by market — use your own payroll figure; this reference does not publish one.
Direct contribution: Margin from case-mix lift + HHA leverage + outliers
What Copergrine Charges an Agency
Everything above is what CMS pays. What Copergrine charges is a separate question with a separate unit: Home Health is licensed by the Medicare number (CCN), not by clinician headcount. From $490 per Medicare number (CCN) per month for your first 6 months at 1–15 patients, stepped by active patient census; from $690 per month thereafter. Unlimited clinicians and staff — headcount is not a price input. One unit per CMS Certification Number. A multi-branch agency operating under several CCNs licenses one unit per CCN. An agency still working through certification licenses one unit keyed on its NPI. See the full band table.
Data Source & Attribution
This reference is compiled from the CMS Home Health Prospective Payment System Final Rule (CMS-1818-F), published in the Federal Register, November 2025. All rates, wage indices, and calculations are public CMS data.
For the full regulatory text, case studies, and the complete wage-index table, visit cms.gov/homehealth.