Following the September 26 introduction in the House of “The Hospice Care Accountability, Reform, and Enforcement (CARE) Act of 2024,” LeadingAge explains the bill’s provisions, and offers an analysis of changes from draft to introduction. We also highlight areas where LeadingAge’s feedback influenced the evolution. Read more here.

The Centers for Medicare & Medicaid Services (CMS) announced on September 5 they will expand prepayment review in four states: California, Nevada, Arizona, and Texas. This announcement is an expansion of the existing new provider Provisional Period of Enhanced Oversight (PPEO) to include other providers as well. Learn more about this update here.

LeadingAge President and CEO Katie Smith Sloan sent a letter to the editor of the Guardian U.S.  regarding the paper’s column on Last Week with John Oliver August 18 show. Oliver dedicated the majority of that episode to a discussion of bad actors and fraudulent behaviors at for-profit providers, which The Guardian US recapped. Though the issues discussed by Oliver are not new, Sloan noted that Oliver “failed viewers by not referencing the hard work underway now and over the past two years by many policymakers and advocacy organizations – including the one I lead, which represents nonprofit providers – on a wide range of potential reforms, including Congressman Earl Blumenauer’s draft Hospice Care, Accountability, Reform and Enforcement (CARE) Act of 2024.” Read our full response here.

The CMS Innovation Center released of the Calendar Year (CY) 2024 Technical and Operational Guidance on the Conclusion of the Value-Based Insurance Design (VBID) Model Hospice Benefit Component. This guidance is being issued to ensure that all obligations of impacted organizations may be met in a timely and reasonable manner so that hospice beneficiaries in the Hospice Benefit Component maintain a coordinated, seamless care experience. The guidance covers CMS’s requirements and expectations for the remainder of the Hospice Benefit Component’s operations through Calendar Year (CY) 2024 along with requirements and expectations for operations on and after January 1, 2025.

In a letter to the four hospice associations on July 10, CMS shared they are working on concerns raised during provider meetings with the Center for Program Integrity (CPI) this February. Specifically, CPI stated they are looking into including explanatory language in denial letters, the long length of stay reviews, and the need for audit education. CPI also shared they are close to releasing a request for information on the PEPPER program which will resume by the end of the year.

In June, the Centers for Medicare and Medicaid Services (CMS) released an updated fact sheet for the provisional period of enhanced oversight (PPEO) for new hospice providers in four states. This new fact sheet clarifies that new hospices include “those reactivating after being in a deactivated status.” In July 2023, CMS placed newly enrolling hospices located in Arizona, California, Nevada, and Texas under a PPEO based on reports of hospice, waste, fraud, and abuse with the goal of reducing these issues and bringing new hospices into compliance. The period of enhanced oversight can be for 30 days to one year and can include medical review such as prepayment review.

The Hospice CARE Act of 2024 discussion draft was released on June 13. LeadingAge provides an overview and detailed summaries of the draft provisions, as well as questions for members to share feedback as we prepare LeadingAge comments on the draft.

Read the full article and access the members-only detailed provision summaries.

Representatives Earl Blumenauer (D-OR) and Beth Van Duyne (R-TX) coordinated a letter to CMS Administrator Chiquita Brooks LaSure on continued concerns around hospice program integrity. The letter outlines examples of fraud in the hospice benefit and asks CMS to answer a number of questions about actions taken to date.

For example, the letter queries about the results of the provisional period of enhanced oversight that was implemented for new providers in California, Nevada, Texas and Arizona in July 2023. CMS also highlighted 6,700 completed surveys on hospice programs in 2023 to check authenticity, but only took action against 28 hospices.

LeadingAge has been engaged with both Congress and CMS, and submitted 34 recommendations on improving program integrity. The questions in the letter are, in part, asking for follow up on some of those recommendations. We applaud Blumenauer and Van Duyne on their continued leadership in this space and thank the other 32 members who signed on!

The Government Accountability Office (GAO) issued a report required by the Consolidated Appropriations Act (CAA) of 2021, found that the Centers for Medicare and Medicaid Services (CMS) has fully implemented five, and partially implemented three, of the eight provisions related to hospice oversight.

The three partially implemented provisions include: requirements for public reporting of the results of hospice surveys conducted by state survey agencies (SA) and accrediting organizations (AO) on the CMS website in a manner that is prominent, easily accessible, searchable, and readily understood; requirements for states to measure and reduce inconsistency in survey results among all surveyors; and a provision requiring CMS to develop and implement a range of enforcement tools.

Last week, CMS issued updated guidance in Chapter 10 of the State Operations Manual, outlining for surveyors what remedies can be applied to non-compliant hospices. GAO also found that about 15% of hospices that had at least one standard survey in each three-year reporting cycle between 2017 and 2022 were cited with serious quality deficiencies, and most were cited with multiple such deficiencies. However, only 18 hospices were terminated between 2017 and 2022. Additionally, the report highlighted a backlog of survey administration with about 10% of hospices overdue for a survey as of May 2023. Over one-quarter of the overdue hospices had not had a standard survey in at least five years.

LeadingAge had the opportunity to speak with GAO twice regarding their report and echoed many of the findings. Among GAO’s recommendations to CMS, which mostly focused on finalizing the implementation of the remaining three provisions of the CAA, GAO recommended CMS instruct SAs and AOs to prioritize the completion of standard surveys for hospices that are overdue for a survey based on potential risk factors, which could include the amount of time overdue or evidence of past quality issues. CMS did not concur with this recommendation, stating that AOs are up to date and for the limited number of states with backlogs, CMS is working with them individually to address performance.

On May 3, the Center for Clinical Standards and Quality at CMS issued a memo revising the State Operations Manual (SOM) Chapter 10 to update informal dispute resolution process and enforcement procedures for hospice and home health agencies. These procedures were last updated for home health in 2014 when an IDR and alternative sanction process was added for home health. In CY2022 home health final rule, CMS finalized enforcement remedies for hospice. The informal dispute resolution process for hospice agencies was finalized in the CY2024 home health rule.

The Centers for Medicare and Medicaid Services (CMS) is proposing in the FY2025 Hospice Wage Index to implement a revised CAHPS Hospice Survey beginning with January 2025 decedents. A 2021 CAHPS Hospice Survey mode experiment found that these changes to the survey instrument and administration protocols increased response rates. If the provisions are finalized, data collection using the revised survey will begin in April 2025.

The revised survey is shorter and simpler than the current survey and includes new questions on topics suggested by stakeholders, including two questions that will be used to calculate a new Care Preferences measure. A draft copy of the proposed survey is available here.

The proposed FY 2025 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements was released on the Federal Register public inspection site on March 28 and is scheduled for publication in the Federal Register on April 4.

LeadingAge brings you a detailed review here, and will also be reviewing the HOPE tool materials in detail and seeking feedback from members.

On March 20, Department of Health and Human Services (HHS) Secretary Xavier Becerra testified in front of the House Committee on Ways and Means on the President’s Fiscal Year 2025 Budget Request to Congress. Reps. Beth Van Duyne (R-TX) and Michelle Steel (R-CA) focused their questions on issues related to hospice program integrity. They asked Sec. Becerra about ongoing hospice certifications in California and other hot spots.

LeadingAge has been engaging with both Congress and CMS on issues of hospice fraud over the past year and half and we were pleased to see Reps. Steel and Van Duyne continue to pressure HHS to ensure access to quality hospice care.

As we work to ensure hospice program integrity, LeadingAge’s advocacy with the Centers for Medicare and Medicaid Services (CMS) and members of Congress continues. Following January 2024 meetings with CMS and members of Congress, LeadingAge, in collaboration with the National Association for Home Care & Hospice (NAHC), the National Hospice and Palliative Care Organization (NHPCO), and the National Partnership for Healthcare and Hospice Innovation (NPHI), on March 12 released findings of a hospice provider survey. Those findings underscore the need for CMS and Congress to act to improve the auditing and adjudication process of Medicare hospice benefit claims, and give policymakers important on-the-ground examples of shortcomings in the audit process.

Katie Smith Sloan, president and CEO of LeadingAge, said in a press release: “We’re moving in the right direction. Not only have nearly half of the 34 recommendations presented in early 2023 to improve oversight of the benefit been implemented, CMS, in our recent conversations, has demonstrated a willingness to consider, holistically, which pieces of oversight need to be strengthened and which need to be redirected. These survey findings, which underscore what’s not working currently, are the next step in that work. To ensure hospice beneficiaries are served by high-quality providers, the current oversight system must be reformed and enforcement focused to uncover genuine instances of fraud, waste, and abuse. We look forward to continuing our work with CMS and Congress to ensure an equitable and effective enforcement system that preserves access to nonprofit, mission-driven hospice care.”

The Centers for Medicare and Medicaid Services (CMS) announced the end of the Value Based Insurance Design (VBID) Hospice Benefit Component as of December 31, 2024. CMS stated the decision came “after careful consideration of recent feedback about the increasing operational challenges of the Hospice Benefit Component and limited and decreasing participation among Medicare Advantage Organizations that may impact a thorough evaluation…”

CMS further clarifies this decision “does not indicate whether the test has met its goals,” and the agency plans to continue evaluation of the component separately. CMS will not accept Requests for Application for the CY2025 Hospice Benefit Component of the VBID Model released late last year. More information will be released later in 2024 to support beneficiaries currently enrolled in the program to maintain seamless care.

As more information becomes available on the decision, LeadingAge will update members.

As the Centers for Medicare and Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI) explore the  hospice Value-Based Insurance Design Model (VBID), LeadingAge has taken advocacy action on two fronts.

In our February 14 response to CMMI’s Request for Information (RFI) for the VBID, LeadingAge strongly advised CMMI to exert extreme caution regarding closed networks for hospice providers and strongly opposed any change to current prior authorization restrictions for the VBID Hospice Benefit Component.

Read more details in the full LeadingAge article.

CMMI has announced that comments on the Value Based Insurance Design Model (VBID) request for information (RFI) are now due on February 16—two additional weeks from the original January 31 deadline.

In December 2023, CMMI released the RFI regarding implementation of networks and formulating an approach to network adequacy in the hospice benefit component of the VBID. After reviewing the questions and consulting with members, LeadingAge and other national partners requested that CMMI extend the deadline for comments to allow for more robust consideration of their questions.

The RFI and other components of the 2025 Request for Applications can be found here. Please email Katy Barnett (kbarnett@leadingage.org) with any thoughts or questions about the RFI.

LeadingAge and our partner national hospice associations conducted a survey to assess the burden of audits across our memberships and to gather data to share with the Centers for Medicare & Medicaid Services (CMS). See the key findings and access the full report in the LeadingAge article here.

After LeadingAge and our industry partners went through tremendous efforts to educate CMS on the reality of implementing the proposed Special Focus Program (SFP) as proposed in the CY2024 Home Health Rule, CMS has decided to move forward with what was initially proposed.

• CMS is finalizing the inclusion of CAHPS Hospice Survey data in the SFP algorithm as proposed, which includes using four CAHPS Hospice Survey measures to create the Hospice CAHPS Index, standardizing the CAHPS Index, double weighting the CAHPS Index in the algorithm, and using two versions of the algorithm to address missing CAHPS Hospice Survey data.
• CMS is finalizing without modification the inclusion of the HCI score, the standardization of the HCI score, and how missing HCI scores are handled in the SFP algorithm, specifically by replacing a hospice’s missing score with zero after standardization which is equivalent to replacing it with the average value.
• CMS is finalizing the inclusion of unscaled Condition Level Deficiencies and unscaled substantiated complaints from three consecutive years of data, the standardization of both inputs, and replacing a hospice’s missing CLDs or substantiated complaints with zero after standardization which is equivalent to replacing it with the average value in the SFP algorithm as proposed.

Additionally, CMS plans to select the poorest performing hospices, from the 10% selectee list based on the finalized SFP algorithm score, in sequential value. This selection process will not include hospices already in the SFP or on a correction track. The industry had asked for a preview period in advance of implementing the SFP algorithm, however CMS believes further delay would likely impact patient and family health and safety. CMS added, hospices are aware of their status for each element used in the algorithm and had opportunities to preview these elements prior to the use in the algorithm. Read a joint statement from the hospice industry associations.

The Centers for Medicare and Medicaid Services (CMS) released the 2023 Hospice Information Gathering Report from Abt Associates, which supports further hospice quality development efforts by reviewing available resources each year. This is the fifth report since 2019.

Literature from 2023 suggests that hospice quality still has room for improvement, specifically in the areas of symptom management, medication deprescribing, and hospice patients with dementia. Of interest to non-profit providers, hospice services provided by non-profit hospices, or hospices in states where hospice growth is regulated, were associated with better quality outcomes. Reviewers found few studies on novel quality measures or treatment approaches. The only studies identified in the report were for the Healthy Days at Home measure study and studies associating physical activity with improved symptoms.

The Center for Medicare and Medicaid Innovation (CMMI) released its yearly evaluation of the Value Based Insurance Design (VBID) demonstration including an at-a-glance review of the hospice benefit component. More than 1,168 hospices provided care to at least one hospice-eligible VBID beneficiary, a substantial increase from 596 hospices in 2021. Of those hospices, only 22% were in network hospices—but that’s a 6% increase since 2021. In 2022, almost half of VBID beneficiaries receiving hospice care chose in-network hospices, up from 37% in 2021. Additional key findings on the hospice benefit include:

• Indications that participation in hospice benefit is growing, but uptake of palliative care, transitional care coordination, and hospice supplemental benefits continued to be low in 2022.
• Hospices and new insurers reported substantial implementation challenges, but insurers with more than one year of experience with VBID reported fewer challenges, suggesting that implementation is becoming easier over time.
• The proportion of beneficiaries receiving care from in-network hospices grew from 2021 to 2022.
• Participation in the Hospice Benefit component was not associated with changes in hospice enrollment in 2021.
• Participation in the Hospice Benefit component was associated with reductions in combined MAPD bids in 2021 and 2022 and reductions in combined MAPD premiums in 2021.

LeadingAge staff met with the Government Accountability Office (GAO) on October 19 to discuss the implementation of the hospice survey changes authorized by the Consolidated Appropriations Act, 2021. This is the second conversation LeadingAge had with GAO regarding changes to survey expectations for state and accrediting organization surveyors, a new hospice Special Focus Program, and general information on barriers to hospices serving Medicare beneficiaries.

In this follow up from the May 2023 meeting, LeadingAge staff shared concerns with the proposed algorithm for the hospice Special Focus Program published in the CY2024 Home Health Proposed Rule. LeadingAge staff reiterated support for the HOSPICE Act and its provisions, but noted that the implementation is critical for success as excessive regulations and oversight can lead hospices to close or consolidate, hurting general access to services. LeadingAge asked to stay in touch with GAO as they move forward and the final proposal for the Special Focus Program is released in the final Home Health Rule.

In an October 4, 2023 letter, four members of Congress echoed LeadingAge’s concerns about the implementation of Special Focus Program (SFP) proposed by CMS. Writing to CMS Administrator Chiquita Brooks-LaSure and White House Office of Management and Budget Director Shalanda Young, the House members wrote that the SFP would not adequately identify poor performing hospices who are “truly struggling with performance” if implemented with the current algorithm. LeadingAge supported the HOSPICE Act, which resulted in creation of the SFP, and notes that it was implemented specifically to identify poor hospice performers, not as a fraud prevention program.

LeadingAge, along with our national association partners, met with the White House Domestic Policy Council (DPC) on September 18 to discuss our concerns with the proposed implementation of the hospice special focus program. We discussed our support for the program but discussed flaws in the Centers for Medicare & Medicaid (CMS) proposed algorithm that we had outlined in our comment letter. DPC staff asked a number of good questions that showed understanding of the issues we were raising and asked to see our comments in follow up.

Following up on LeadingAge’s August 11 letter on hospice audits to the Centers for Medicare and Medicaid Services’ (CMS) Center for Program Integrity, and the need to more effectively target hospice oversight, LeadingAge and other national organizations met with the Centers for Medicare and Medicaid Services (CMS) on September 8 to further discuss these important issues.

In a blog posted on August 22, Dara Corrigan, the Centers for Medicare & Medicaid Services (CMS) deputy administrator and director of the Center for Program Integrity, and Dora Hughes, CMS chief medical officer, Innovation Center, summarized benefit integrity issues that have come up related to Medicare hospice services and the actions CMS has and will take. As of mid-August, they identified 400 hospices that are being considered for potential administrative action, suggesting some will be able to demonstrate compliance by submitting a valid provider address, while those unable to do so “may be deactivated or revoked.”

Continuing its advocacy efforts aiming to improve targeting of hospice program initiatives, LeadingAge, the association of nonprofit providers of aging services including providers of hospice care, joins four other hospice-focused trade organizations in applauding the Centers for Medicare and Medicaid Services’ (CMS) reform work and urging additional action to ensure the success of the agency’s audit focus by appropriately targeting oversight efforts. In a letter to CMS’ Center for Program Integrity (CPI), the organizations described fundamental, long-standing problems that must be addressed including audit focus areas, the overpayment recovery and recoveries adjudication processes, and auditor consistency and education.

The Centers for Medicare & Medicaid Services (CMS) is nearing the end of a nationwide site visit project to determine whether hospices are operational at the address listed in the Provider Enrollment, Chain, and Ownership System (PECOS), as 93.5% of all locations are complete. Upon the completion of the project, CMS will provide results on the number of providers visited and the enforcement actions taken.

In response to the concerns regarding individuals entering hospice not being eligible for hospice care, the Centers for Medicare & Medicaid Services (CMS) is piloting a 90-day post-claim medical review process. Learn more in this LeadingAge article.

LeadingAge, three other hospice organizations, and Congressman Earl Blumenauer (D-OR) met with the Centers for Medicare & Medicaid Services (CMS) in a follow-up to our 34 hospice program integrity recommendations. The meeting was with leading officials from the Center for Program Integrity and the Center for Clinical Standards and Quality.

As required in the Consolidated Appropriations Act of 2021 (CAA 2021), the CY2024 Home Health Proposed Rule would implement a Special Focus Program (SFP) for poor performing hospices as well as an Informal Dispute Resolution process.

The CY2024 Home Health Proposed Rule included a number of actions related to hospice, including an outline of expectations for the Special Focus Program. In addition to the introduction of the Special Focus Program for hospices, the Centers for Medicare and Medicaid Services (CMS) include a number of other integrity actions. This article reviews those actions in more detail and how they will impact hospice providers.

Representatives Van Duyne (R-TX) and Blumenauer (D-OR) led a bipartisan letter to Department of Health and Human Inspector General Christi Grimm. The letter asked for a briefing on the OIG’s current and planned response to the proliferation of fraudulent hospices in the western United States. LeadingAge is supportive of the Congress’ continued pursuit of answers regarding these hospices and continue to advocate that Centers for Medicare & Medicaid Services implement our 34 recommendations.

The Consolidated Appropriations Act 2021 requires surveys and statements of deficiencies by state agencies and accrediting organizations, as well as enforcement actions taken as a result of these surveys, to be publicly reported prominently on the Centers for Medicare & Medicaid Services (CMS) website. Reports must be posted in a manner that is easily accessible, searchable, and presented in a readily understandable format. The surveys and deficiency reports can be found here, and the hospice data is complete through September 2022.

As part of the Consolidated Appropriations Act of 2021, the Department of Health and Human Services was authorized to develop a Special Focus Program (SFP) for hospice agencies which aims to address issues that place hospice beneficiaries at risk. Last fall, CMS convened a Technical Expert Panel (TEP) to provide feedback to inform the development of the SFP. CMS stated in the FY2024 Hospice Wage Index proposed rule, that regulatory proposals to implement the SFP would be in the CY2024 Home Health Proposed Rule. A new report summarizes the TEP conversations and feedback.

On March 28, HHS Secretary Xavier Becerra appeared before the House Ways and Means Committee to discuss the President’s FY24 budget proposal. Top aging services issues were discussed, such as the 3-Day Hospital Stay Requirement, Nursing Home Mandatory Staffing Ratios, and Home and Community Based Services (HCBS). Both Rep. Earl Blumenauer (D-OR) and Rep. Beth Van Duyne (R-TX) brought up hospice program integrity and pressed the Secretary to crack down on “shadow” or “ghost” hospices, and pledged bipartisan Congressional support to do so. This aligns with LeadingAge’s work on hospice program integrity.

Statement from Katie Smith Sloan, president and CEO, LeadingAge, the association of nonprofit providers of aging services, including hospice, on hospice benefit reform proposals submitted to Congressional leadership: LeadingAge Submits Hospice Benefit Reform Proposals.

In response to a request from a member of Congress, LeadingAge submitted ideas in a memo around reforms and improvements to the hospice benefit.

The four national hospice provider organizations: LeadingAge, the National Association for Home Care & Hospice (NAHC), the National Hospice and Palliative Care Organization (NHPCO), and the National Partnership for Healthcare and Hospice Innovation (NPHI), provided the Centers for Medicare and Medicaid Services (CMS) and key Congressional stakeholders with recommended legislative and regulatory changes to strengthen hospice program integrity.

LeadingAge President and CEO Katie Smith Sloan responds to The New Yorker article, “How Hospice Became a For-Profit Hustle.”

On December 8th, 2020, the Helping Our Senior Population in Comfort Environments Act or HOSPICE Act (H.R. 5821) passed out of the House as part of the Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act (H.R. 2477). We continue to work with the Senate to advocate for some key changes.