LUPA Threshold
The LUPA threshold is the minimum number of visits a home health agency must deliver in a 30-day payment period to receive the full case-mix payment under the Patient-Driven Groupings Model (PDGM). Thresholds vary by case-mix group, ranging from 2 to 6 visits, and periods that fall short are paid per visit as a Low Utilization Payment Adjustment (LUPA).
How thresholds are set
Unlike the old prospective payment system, which used a single threshold for every episode, PDGM sets a separate threshold for each case-mix group. CMS bases each group's threshold on historical visit patterns for that group, so groups whose patients typically receive more visits carry higher thresholds. The result is a range of 2 to 6 visits per 30-day period depending on the HIPPS group. Two patients on the same street with the same visit plan can face different thresholds because their clinical grouping, functional level, admission source, timing, or comorbidity tier differ.
Annual recalibration
Thresholds are recalibrated in the annual home health final rule alongside the case-mix weights. The CY2026 rule recalibrated them using CY2024 utilization data. This matters operationally: a visit plan that cleared the threshold for a given patient profile last year may sit exactly at or below the recalibrated threshold this year. Agencies should reload the new threshold table into their systems each January, re-check standing frequency templates against it, and brief schedulers and clinical managers on the groups where thresholds moved, because those are the periods where last year's habits quietly become this year's LUPAs.
What counts toward the threshold
Only billable, in-person visits by covered disciplines count: skilled nursing, physical therapy, occupational therapy, speech-language pathology, medical social work, and home health aide visits that appear on the claim. Telehealth and remote monitoring interactions do not count toward the threshold because they are not billable visits, even when they are clinically valuable and reported on the claim for tracking. Missed visits count for nothing, and a visit that slips past the period's end date counts toward the next period. This is why period-boundary awareness matters as much as total visit volume.
Operational tracking that works
Agencies that rarely take avoidable LUPAs make thresholds visible where scheduling decisions happen:
- Show each active period's threshold and current completed-visit count on scheduling and clinical dashboards
- Flag periods within one visit of threshold in the final week of the period
- Route missed-visit alerts to someone accountable for rescheduling inside the period
- Review every LUPA after the fact: clinically appropriate, or an operational miss?
The discipline cuts both ways. The threshold is a payment mechanic, not a care standard, and adding unneeded visits to clear it is a compliance risk.
Frequently asked questions
Are LUPA thresholds the same for both 30-day periods in a certification?
Not necessarily. Each period is grouped on its own, and the threshold belongs to the period's case-mix group. If timing, admission source, diagnoses, or functional level change the group between periods, the threshold can change too.
Where do I find the current thresholds?
CMS publishes the threshold for every case-mix group with the annual home health payment rule, and grouper software returns the applicable threshold when a period is grouped. EHR and billing systems typically load the updated table each calendar year.
Do telehealth visits count toward the LUPA threshold?
No. Only billable in-person visits count. Telehealth encounters are not separately billable visits in Medicare home health, so a period sustained mainly by virtual touchpoints can still fall below threshold.