HOME HEALTH · PDGM SCENARIO SIMULATOR

PDGM Scenario Simulator

Model how clinical grouping, admission source, timing, functional impairment, comorbidity coding, and visit utilization move the home-health 30-day period payment, LUPA risk, and episode margin — live as you change inputs. Built for administrators, DONs, clinical managers, coders, and finance teams, not just billing.

EstimatorCMS-based

Data statusEstimator

Status: Estimator
Data year / effective: CY2026
Last reviewed: June 2026
Last updated: June 2026
Primary source: CMS Home Health PPS Final Rule, CY2026
Known exclusions: Wage-index / CBSA adjustment varies
LUPA, PEP, and outlier policy may apply
Sequestration and MAC edits not applied

Estimate only — wage index, sequestration, and payer/MAC edits are not applied. Validate against CMS and your MAC before billing.

Patient & Episode

30-Day Period

Year (base rate)

Payer (methodology)

Admission Source

Timing (period in sequence)

Clinical Grouping (from primary dx)

Wage Index (CBSA)

Rural Add-On Applyrural county

Functional & Comorbidity

Case-Mix

Functional Impairment Level

Comorbidity Adjustment

Advanced — OASIS functional scoring (0–6 each)

Grooming

Dressing — upper

Dressing — lower

Bathing

Toilet transfer

Ambulation

Use OASIS-derived leveloverride the buttons above

Visit Utilization

Planned Visits

Skilled Nursing

Physical Therapy

Occupational Therapy

Speech (SLP)

Home Health Aide

Medical Social Work

Total visits13

Visit Pattern (scheduling)

Financial Assumptions

Cost Model

Simple modesingle average cost per visit

SN / visit

PT / visit

OT / visit

SLP / visit

HHA / visit

MSW / visit

Mileage / visit

Supply estimate

Administrative Overhead (%)

Estimated Reimbursement

CY2026

LUPA Risk

Per-Visit Threshold

Margin & Efficiency

Estimate

Reimbursement Breakdown

Case-Mix Build

Optimization Insights

Live