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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Heath care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

CMS Issues Proposed Regulation for FY2015 Hospice Payment and Policy Changes

May 5, 2014 04:18 PM

On Friday, May 2, the Centers for Medicare & Medicaid Services (CMS) posted online Medicare Program; FY 2015 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements and Process and Appeals for Part D Payment for Drugs for Beneficiaries Enrolled in Hospice; the proposed regulation will be printed in the May 8, 2014, issue of the Federal Register.A final regulation, based on stakeholder input, will be published this summer. 

This rule provides an update on hospice payment reform analyses and solicits comments on “terminal illness” and “related conditions” definitions, and on a process and appeals for Part D payment for drugs, while beneficiaries are under a hospice election.  Also, this rule proposes timeframes for filing the notice of election and the notice of termination/revocation; adding the attending physician to the hospice election form; a requirement that hospices complete their hospice inpatient and aggregate cap determinations within 5 months after the cap year ends, and remit any overpayments; and provides updates for the hospice quality reporting program (HQRP).

Additionally, the proposed rule provides guidance on determining hospice eligibility, information on the delay in the implementation of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), and would further clarify how hospices are to report diagnoses on hospice claims. Finally, the rule proposes to make a technical regulatory text change. 

Comments must be submitted within 60 days of the proposed regulation’s display, which is estimated to be COB Monday, June 30, 2014.

While CMS did not propose a new hospice payment model, it does state:  “An initial step of hospice payment reform in this proposed rule is to clarify and enforce hospice payment policy, when necessary, in order to safeguard beneficiaries and the Medicare hospice benefit.” 

Throughout the proposed rule, CMS provides information on hospice behavior and trends that raise program integrity concerns; the impact of beneficiary access to quality end of life care; and the effect of hospice providers’ market driven goals rather than preserving the intent of the Medicare Hospice benefit.  The regulation clearly conveys the context within which CMS will be addressing payment and oversight issues related to hospice for the coming years. 

The following issues covered in the proposed rule are summarized below:

  • FY2015 Payment Update
  • Hospice Cap Calculation
  • Definitions of “Terminal Illness” and “Related Conditions”
  • HQRP

The National Association for Home Care & Hospice (NAHC) and its Hospice Association of America (HAA) will be soliciting comments from hospice provider members, beneficiaries, and other stakeholders on each topic. 

NAHC and HAA strongly encourages all hospices to thoroughly review the proposed regulation in its entirety and submit individual or organizational comments to CMS. 

NAHC staff is also developing a tabular format outlining the significant proposals and requests for comments in the regulation by topic that may be used as an organizational tool to collect and synthesize comments and examples by topic. NAHC also has a teleconference tentatively scheduled for Monday, May 12 during which it will outline the key issues covered in the regulation for member agencies.  Watch for additional information about the teleconference on the NAHC Member Listserv and in NAHC Report

PAYMENT REFORM:  Under the Affordable Care Act, CMS was required to revise the hospice payment model for routine home care (RHC) and implement those revisions no sooner than Oct. 1, 2013.  CMS began work with Abt Associates in 2010 to conduct research on potential changes to the hospice payment system; in April 2013, as part of the proposed rule for the FY2014 hospice wage index and payment rate update, CMS provided a status report on payment reform efforts that indicated it was considering numerous options, including imposition of a tiered payment system that provided higher payment at the beginning of hospice care and for days of care provided just prior to death.  CMS also indicated it was considering rebasing RHC rates (which could reduce RHC payments by 10 percent or more) and a reduction in payments for hospice care provided in nursing facilities (called a “site of service” adjustment).

As part of the proposed FY2015 payment rule, CMS indicates it does not propose making changes to the payment system at this time but instead indicates it is addressing issues related to the hospice “bundle” and appropriate delivery of services under hospice, summarizes more recent payment research that has been conducted, and has posted two reports authored by Abt (a technical reportand literature review) on its website. The Technical Report provides much data that leads to the identification of concerns regarding hospice provider behavior.  Some concerns are new, many others are not. 

The data cites certain types of hospices/small percentage of hospices as responsible for the majority of situations that are at the base of the concerns.  Furthermore, CMS references its interpretation of the Medicare hospice benefit at the time of its inception throughout its comments in the proposed rule.  CMS places a strong emphasis on hospices, in general, having incorrectly interpreted the Medicare hospice benefit, and specifically coverage of medications and other seemingly “unrelated” services and treatments.  Additionally, hospice care being provided in the “home” as being a basic tenet of the hospice philosophy is highlighted in the comments.  CMS states: “…we believe that a critical goal of the Medicare hospice payment system is to strengthen and safeguard the current scope of the Medicare hospice benefit. This will provide a solid foundation on which to reform the methodology used to pay for Medicare hospice services. Program integrity is being addressed immediately while we fully develop our data and research to address payment reform in the near future…Our expectation continues to be that hospices offer and provide comprehensive, virtually all-inclusive care, and in a better, more humane way, than is available in other healthcare settings. In order to preserve the Medicare hospice benefit and ensure that Medicare beneficiaries continue to have access to comprehensive, high-quality and appropriate end-of-life hospice care, we will continue to examine program vulnerabilities and implement appropriate safeguards in the Medicare hospice benefit, when appropriate.”

CMS indicates as part of the rule that it intends to use the additional data supplied by hospices on their claims for payment (required under Change Request 8358) and the revised hospice cost report (which should be publicly available at any time) to help guide its future decisions on payment reform.

CMS notes that the Office of the Actuary projects that hospice expenditures will continue to increase by approximately 8 percent annually.  CMS sees this trend as the result of an increase in the number of hospice beneficiaries and greater awareness of hospice, but also believes higher spending is in part attributable to an increase in the average lifetime length of stay (from 54 days in 2000 to 86 days in 2001, an increase of 59 percent).  Average hospice spending per beneficiary has increased between 2006 and 2013 from $9,833 to $11,458.  CMS also references changes in the diagnosis patterns and provides updated data on those trends.

Several areas of concern are highlighted in the regulation (based on claims data from Jan. 1, 2010 through Dec. 31, 2012):

Beneficiaries Dying Without Skilled Visits in the Last Days of Life: CMS and Abt found that 28.9 percent of hospice decedents receiving RHC did not receive a skilled visit on the day of their death; 14.4 percent of decedents did not receive skilled care in their last 2 days of life; and 6.2 percent of decedents did not receive skilled visits in their last 4 days of life. CMS is concerned those beneficiaries and their families are not receiving hospice care and support at the end of life.  Additionally, 10.3 percent of very short-stay decedents (5 days or less) did not receive skilled visits during their last 2 days of life and 15.9 percent of long stay beneficiaries (181 days or longer) did not receive visits in the last two days of life.  Newer hospices were more likely to have decedents with no skilled visits during the last 2 days of life.  Thirty-four hospices made no skilled visits during the last 2 days of life for any of their decedents.  CMS also found geographic differences relative to this trend.

General Inpatient Care (GIP), Continuous Home Care (CHC), and Inpatient Respite(IRC) – CMS found that 77.3 percent of beneficiaries had no GIP care in 2012, and 21.1 percent of hospices provided no GIP care to their beneficiaries.  This raises concerns that hospice patients do not have adequate access to appropriate levels of care for symptom management.  Over two-thirds of GIP days were provided in an inpatient hospice setting and those stays averaged the longest compared with other settings.  CMS also found considerable variation among hospices in delivery of CHC – 40 hospices delivered 46 percent of all CHC days and one hospice provided over one-quarter of all CHC days.  Only a small percentage of beneficiaries utilize IRC (3.4 percent in CY2012), but 26 hospices did not bill for any IRC.  Based on these trends, CMS is concerned that some providers may not be offering the full range of services required under the hospice Conditions of Participation (CoP) and will continue to monitor data in this area.  CMS will refer providers identified through their analysis to Survey and Certification, the Office of Financial Management, and to the Center for Program Integrity for further investigation.

Hospice Live Discharges– Between 2000 and 2012, the overall rate of live discharges increased from 13.2 to 18.1 percent, and 71 hospices had live discharges on 100 percent of their patients (the average length of stay for these hospices averaged 193 days).  These data have been referred to the Office of Financial Management and the Center for Program Integrity for follow-up.   Live discharge rates vary significantly by type and size of provider.  CMS also notes serious concern about patterns of election, revocation and reelection where a costly hospitalization occurred during the revocation.

Non-Hospice Spending for Hospice Beneficiaries During an Election– As the Medicare Payment Advisory Commission (MedPAC) has previously reported, CMS found that in CY2012, Medicare spent over $1 billion for care outside the hospice benefit for patients enrolled in hospice; $710 million of this amount was charged to Parts A and B for durable medical equipment (7 percent), inpatient care, (28.6 percent), outpatient Part B services (16.9 percent), other Part B services (37.4 percent), SNF care (5.7 percent), and home health care (4.5 percent).  CMS also found high use of emergency room and observation stays ($268.4 million for 8.8 percent of beneficiaries during CY2010 and CY2011) that were not included as part of hospice care.  Part D spending for drugs for hospice patients totaled $334.9 million; CMS notes that average spending for drugs based on hospice cost report data has trended downward in recent years, from an average of $20 per patient day in 2004 to $11 in 2012.  CMS notes that 56 percent of total non-hospice Medicare spending is attributable to 373 hospices and the average per beneficiary non-hospice spending for these hospices averaged $1,289.

FY2015 PAYMENT UPDATE: As is its normal practice, CMS will use the hospital market basket update as the basis for establishing the payment update for hospices in FY2015.  Following is a summary of the factors that go into calculating the estimated payment update:

Estimated hospital market basket update:  2.7 percent

Impact of ACA Reductions:   minus 0.7 percentage points

Impact of Wage Index Changes(6th year of BNAF phase out and wage index changes): minus 0.7 percentage points

NET UPDATE:  1.3 percent

PLEASE NOTE THAT THE ESTIMATED 1.3 PERCENT PAYMENT UPDATE DOES NOT INCLUDE THE IMPACT OF THE 2 PERCENT SEQUESTER.   In addition, since some of these values are estimates, they could change between the proposed and final rule which will be issued during the summer months.

Hospice Aggregate Cap for 2014:  $26,725.79

Hospice Wage Index:  For FY2015, CMS will use the pre-floor, pre-reclassified FY2014 hospital wage index for hospice and the values will be posted shortly on the CMS website at: (scroll down to WAGE INDEX FILES section on left side of screen); they are no longer published in the Federal Register

FY2015 Hospice Preliminary Medicare* Payment Rates Updated by the Proposed Hospice Payment Update Percentage (for hospices that successfully meet quality reporting requirements)



FY2014 Payment Rates

Multiply by the FY2015 proposed hospice payment update of 2.0 percent


(adjusted by wage index)/

Non-labor percentage

FY2015 Preliminary Payment Rate


Routine Home Care



68.71 percent/

31.29 percent



Continuous Home Care

Full Rate = 24 hours of care

$38.71 hourly rate



68.71 percent/

31.29 percent



Inpatient Respite Care



54.13 percent/

45.87 percent



General Inpatient Care



64.01 percent/

35.99 percent


*Medicaid rates differ slightly and will be issued by CMS in the near future.



Beginning with the 2014 cap year and subsequent cap years, CMS is proposing a regulatory change under which hospices would be required to calculate their own inpatient and aggregate cap determinations (using a pro-forma spreadsheet supplied by CMS) within 5 months of the end of the cap year (that is, by March 31) and remit any overpayments at that time. The MACs would then reconcile all payments at the final cap determination. If a provider fails to file its inpatient and aggregate cap determination 150 days after the end of the cap year, CMS proposes that payments to the provider would be suspended in whole or in part until the self-determined cap is filed with the Medicare contractor. The regulations at §418.308 and §405.371 would be amended to state that payments to a hospice would be suspended in whole or in part, for failure to file a self-determined inpatient and aggregate cap determination.

CMS SEEKS TO DEFINE “TERMINAL ILLNESS” AND “RELATED CONDITIONS” AND REQUESTS COMMENT ON THE PROPOSED DEFFINITIONS:  CMS notes that “since implementation of the Medicare hospice benefit, we have defined a ‘terminally ill’ individual to mean ‘that individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course.’  We have always interpreted ‘terminally ill’ to mean a time frame of life expectancy and expect that the individual’s whole condition plays a role in that prognosis.’  Additionally, CMS cites Section 1812(d)(2) of the Social Security Act and its provision that an individual, upon making an election to receive hospice coverage, would be deemed to have waived payments for certain other benefits except in “exceptional and unusual circumstances as the Secretary may provide.” CMS cites comments in response to previous years’ proposed rules about chronic, longstanding, preexisting conditions as playing a limited or no role in a patient’s terminal illness or related conditions, and should not be included in the bundle of services provided by hospice. CMS indicates that it believes these services are included in the hospice bundle, as hospice is unique in its comprehensive, holistic, and palliative philosophy and practice.  As part of the proposed rule, CMS has developed definitions of “terminal illness” and “related conditions” that it is seeking comment on.  While CMS does not anticipate proposing a regulatory change in this area at this time, it may consider codifying these definitions in future rulemaking.  Following are the definition CMS has developed:

DEFINITION/TERMINAL ILLNESS:  Abnormal and advancing physical, emotional, social and/or intellectual processes which diminish and/or impair the individual’s condition such that there is an unfavorable prognosis and no reasonable expectation of a cure; not limited to any one diagnosis or multiple diagnoses, but rather it can be the collective state of diseases and/or injuries affecting multiple facets of the whole person, are causing progressive impairment of body systems, and there is a prognosis of a life expectancy of six months or less.

DEFINITION/RELATED CONDITIONS:  Those conditions that result directly from terminal illness; and/or result from the treatment or medication management of terminal illness; and/or which interact or potentially interact with terminal illness; and/or which are contributory to the symptom burden of the terminally ill individual; and/or are conditions which are contributory to the prognosis that the individual has a life expectancy of 6 months or less.

GUIDANCE ON DETERMINING/DOCUMENTING ELIGIBILITY:  In the proposed rule CMS also provides guidance on determining and documenting eligibility. There are multiple resources available to the public to assist in making eligibility determinations, specifically from the MACs. CMS expects hospice providers to use the full range of tools available, including guidelines, comprehensive assessments, and the complete medical record, as necessary, to make responsible and thoughtful determinations regarding terminally ill eligibility.  Hospices are reminded that certifying physician should use their best clinical judgment in determining eligibility and the hospice medical director must consider at leas the following information per 418.25(b):

  • Diagnosis of the terminal condition of the patient.
  • Other health conditions, whether related or unrelated to the terminal condition.
  • Current clinically relevant information supporting all diagnoses.

This information must be in the record and it is the hospice’s responsibility to make certain that the physician's clinical judgment can be supported by clinical information and other documentation that provide a basis for the certification of 6 months or less if the illness runs its normal course.  Hospices should note that CMS points out that section 1869(a)(1) of the Act makes clear that the Secretary makes determinations concerning entitlement, coverage and payment of benefits under part A and part B of Medicare.  CMS goes on to state that it has the right to review clinical documentation that supports physician certifications emphasizing that this right has been established in the courts.

These comments serve as a warning to hospice providers that it is a hospice’s responsibility to make sure that the physician certifying the patient has the clinical information he/she needs to make a determination of hospice eligibility and to verify that the clinical record contains the clinical documentation supporting a patient’s eligibility.  Services must also be reasonable and necessary – there has always been a prohibition on Medicare paying for services that are not reasonable or necessary. 


CMS is proposing a regulatory change, effective October 1, 2014, that would require hospices to file the NOE with its MAC within 3 calendar days after the hospice effective date of election, regardless of how the NOE is filed (by direct data entry, or sent by mail or messenger). Medicare would not cover and pay for days of hospice care from the effective date of election to the date of filing of the NOE. CMS proposes that these days be considered the financial responsibility of the hospice; the hospice could not bill the beneficiary for them.  The regulations at §418.24(a) would be revised to require hospices to file a NOE within 3 calendar days after the effective date of election; the regulations at §418.26 and §418.28 would be revised to require filing of the Notice of Termination or Revocation (NOTR) within 3 calendar days after the effective date of a beneficiary’s discharge or revocation, if they have not already filed a final claim.


To ensure the attending physician of record is properly documented in the patient’s medical record, CMS proposes a regulatory change (effective October 1, 2014) under which the election statement must include the patient’s choice of attending physician. The proposed information identifying the attending physician should be recorded on the election statement in enough detail so that it is clear which physician or NP was designated as the attending physician. Hospices have the flexibility to include this information on their election statement in whatever format works best for them, provided the content requirements in §418.24(b) are met. The language on the election form should include an acknowledgement by the patient (or representative) that the designated attending physician was the patient’s (or representative’s) choice.

In addition, CMS also proposes that if a patient (or representative) wants to change his or her designated attending physician, he or she must follow a procedure similar to that which currently exists for changing the designated hospice. Specifically, the patient (or representative) must file a signed statement, with the hospice, that identifies the new attending physician in enough detail so that it is clear which physician or NP was designated as the new attending physician.

Additionally, CMS proposes that the statement include the date the change is to be effective, the date that the statement is signed, and the patient’s (or representative’s) signature, along with an acknowledgement that this change in the attending physician is the patient’s (or representative’s) choice. The effective date of the change in attending physician cannot be earlier than the date the statement is signed.

SOLICITATION OF COMMENTS ON COORDINATION OF BENEFITS PROCESS AND APPEALS FOR PART D PAYMENT FOR DRUGS WHILE BENEFICIARIES ARE UNDER A HOSPICE ELECTION:  CMS issued final guidance on March 10, 2014, laying out a process to be followed by Part D plans and hospice providers (effective May 1, 2014) to establish appropriate responsibility for drug coverage for patients with Part D plans that are on hospice care.  When the guidance was issued, CMS indicated that unless the processes outlined in the guidance are enacted through the rulemaking process, CMS cannot mandate that the Part D plans comply with guidance.  As part of the proposed hospice rule, CMS does not propose any changes at this time related to Part D coverage for drugs for hospice patients; however, CMS is seeking input on whether specific elements of the March 10 guidance should be codified so that they would be able to enforce the guidance.  Specifically, CMS is seeking input on:

  • Whether a regulatory change should be enacted that would require Part D sponsors to communicate and coordinate with Medicare hospices when:
    • The hospice furnished information regarding a beneficiary’s hospice election or plan of care (hospice could furnished information to the Part D sponsor at any time); and
    • The Part D coverage determination process is initiated (this communication/coordination process would begin when the beneficiary, the beneficiary’s appointed representative or the prescriber requests a coverage determination).
  • Requiring Part D sponsors to implement beneficiary-level hospice prior authorization and issue reject codes at point-of-sale for drugs for beneficiaries who have elected hospice (when a coverage determination is requested, Part D plans would be required to comply with 24-hour (expedited) and 72-hour (standard) response time frames); when a claim rejects at point of sale, the plan must provide a notice explaining the right to request a coverage determination from the plan.
  • Codifying the requirement that sponsors must conduct retrospective review of drugs covered by the Part D plan during a time that the patient was under hospice care.

CMS is also particularly interested in the experiences of Part D sponsors and hospices that successfully communicate with each other and how both parties ensured that the beneficiary did not experience any delay in drug coverage. While the solicitation of comments is focused on coordination between the hospice and Part D sponsor, the solicitation would apply broadly to any payer or non-hospice provider.

Perhaps the most troubling aspect of the Part D discussion in the regulation are examples provided by CMS that send a clear signal of CMS’ expectation relative to responsibility for drug coverage under the hospice benefit. CMS states:  “….several hospices have stated that pre-existing, chronic and/or controlled conditions are not related to the prognosis of the hospice beneficiary and should not be the responsibility of the hospice -- a concept which is contrary to the hospice philosophy of providing comprehensive coordinated care to patients at end of life….One hospice illustrated this issue with an example, a patient that was admitted with a primary terminal diagnosis of COPD…the patient also has diabetes which pre-dates the COPD; the patient uses corticosteroids to manage the COPD.  The diabetes is well managed with an oral hypoglycemic agent and the patient needs to continue the medication to manage the diabetes.  The hospice argues that since the diabetes is unrelated to the COPD, the oral hypoglycemic agent medication should not be covered by hospice.  However, increased glucose levels are a common manifestation of corticosteroid use.  While the hospice states that the admission to hospice is a result of COPD, treatment for the COPD has the potential to affect glucose levels, and hence the hypoglycemic agent would be covered by the hospice and not through Part D.”  CMS cautions hospices to use thoughtful clinical judgment when developing a plan of care (including in relationship to medication management).

HOSPICE DIAGNOSIS CODING/SYSTEM EDITS WILL ADDRESS MANIFESTATION CODES EFFECTIVE OCT. 1:  CMS reminds hospices that diagnosis coding on claims must adhere to ICD-9-CM coding conventions and guidelines regarding the selection of principal diagnosis and the reporting of additional diagnoses.  CMS expects hospices to report all diagnoses related to the terminal illness and related conditions to provide accurate beneficiary information.  CMS reminds hospices that “debility” and “adult failure to thrive” are not appropriate principal diagnoses, and that certain dementia diagnoses are also not appropriate.  CMS indicates that, effective for claims submitted on or after October 1, 2014, it will implement edits by way of the Medicare Code Editor (MCE) that detect and report diagnosis coding errors on hospice claims.  “Hospice claims containing inappropriate principal or secondary diagnosis codes, per ICD-9-CM coding conventions and guidelines, will be returned to the provider and will have to be corrected and resubmitted to be processed and paid. We will implement edits related to etiology /manifestation code pairs from the MCE; therefore, it is important for hospice providers to follow the ICD 9-CM Coding Guidelines.”  It is anticipated that use of any manifestation code as a principal diagnosis will be returned to provider as the result of this action by CMS; additional information will be issued by way of a Change Request later this summer.  CMS also reminds hospices that all diagnosis codes representing the principal diagnosis and related conditions should be included on claims; while the industry has made some progress in this regard during FY2013 indicated that 67 percent of hospice claims still included only a single diagnosis code.

HOSPICE QUALITY REPORTING PROGRAM/HQRP:  CMS’ paramount concern is development of a Hospice Quality Reporting Program (HQRP) that promotes the delivery of high quality healthcare services. Therefore, CMS is proposing to codify the HIS submission requirements at §418.312 in this proposed rule. 

Much of what CMS commented on in the proposed rule is already in force for hospices, i.e. the Secretary shall reduce the market basket update by 2 percentage points for any hospice that does not comply with the quality data submission requirements with respect to the appropriate payment year.  As is common in other quality reporting programs, CMS proposes to make accommodations for participation and payment determinations in the case of natural disaster or other extenuating circumstances.

Hospices will be implementing the Hospice Item Set (HIS) component of the HQRP on July 1, 2014. The HIS-Admission and HIS-Discharge records must be submitted electronically.  As stated by CMS before and reported previously by NAHC, CMS will make available submission software for the HIS to hospices at no cost. Hospices not having software compatible with CMS systems will be able to use this free software called H.E.A.R.T.  CMS will also provide reports to individual hospices on their performance on the measures calculated from data submitted via the HIS. The specifics of the reporting system and precisely when specific measures reports will be made available have not yet been determined.

CMS seeks to adopt measures for the HQRP that promote efficient and safer care.  It is not proposing any new measures for the HQRP at this time. Future development of the HQRP measures, according to CMS, should address existing measure gaps by focusing on two primary opportunities:

  • To expand measures already in use in other quality reporting programs that could apply to the HQRP and
  • To develop new measures if no suitable measures are ready for implementation or expansion.

CMS is particularly interested in outcome measures for symptom management, particularly pain. It is also interested in measures of patient reported outcomes and welcomes comments and input on future measure development.

CMS goes on to identify hospices that would be excluded from the quality reporting requirements for FY2016 payment determinations and future annual payment determinations.

In this proposed rule, a portion of the HQRP section is devoted to adoption of the CAHPS survey for hospices.  Participation in the Hospice CAHPS affects a provider’s FY2017 payment update.  There is an extensive discussion of the Hospice Experience of Care Survey (Hospice CAHPS) in the Hospice Wage Index FY 2014 final rule and to which CMS directs hospices for a description of the measurements involved and their relationship to the statutory requirement for hospice quality reporting (78 FR 48261-482-66). 

Field testing of the Hospice CAHPS was conducted by CMS in November and December 2013.  Thirty-three hospice programs from 29 hospice organizations participated in the field test, which was designed to assess survey administration procedures among hospices of varying size, geographic region, chain status, ownership, and urbanicity.  Respondents were primary caregivers of patients who died while receiving hospice care in the prior 2 to 5 months. In all, 1,136 respondents, representing the three main settings of hospice care (home, nursing home, and inpatient, including freestanding hospice inpatient unit, and acute care hospitals), completed the field test survey.  Field test survey data were analyzed to identify for removal survey questions which exhibited little variation between hospices or for which there was little room for hospice improvement. Field test survey data were further analyzed to identify composite measures of hospice performance, including:

  • Communication,
  • Care Coordination,
  • Getting Timely Care,
  • Treating Your Family Member with Respect,
  • Providing Emotional Support, and
  • Getting Help for Symptoms.

Please see Table 9, Hospice Experience of Care Survey Quality Measures and Their Items, on page 115 of the proposed rule for further details.

Caregivers will be presented with a set of standardized questions about their own experiences and the experiences of the patient in hospice care.  During national implementation of this survey, hospices are required to conduct the survey to meet the hospice quality reporting requirements, but individual caregivers will respond only if they voluntarily choose to do so. Hospices with fewer than 50 decedents during the prior calendar year are exempt from the CAHPS® Hospice Survey data collection and reporting requirements for payment determination. Hospices with 50 to 699 decedents in the prior year will be required to survey all cases.  This represents the overwhelming majority of the 3702 hospices.  For large hospices with 700 or more decedents in the prior year (n = 274 in 2012), a sample of 700 will be drawn under an equal-probability design.  For national implementation, CMS assumed an eligibility rate of 85% and a response rate of 50%, based on experience in the 2013 field test of the CAHPS® Hospice Survey instrument. 

Hospices will need to use a vendor for the Hospice CAHPS portion of the HQRP.  This vendor will be a business associate of the hospice so hospices should be sure to include the proper agreements and security for these types of vendors. As stated in previous publications, hospices will do a dry run of the survey with a vendor in Jan 2015.  A list of approved survey vendors will be available on the Hospice CAHPS webpage closer to this 2015 date.  Until then, hospices may want to view the list of approved survey vendors for home health at as it is expected that these same vendors will be submitting applications to be approved vendors for the hospice CAHPS survey.  However, it is not known if this will be the case as interested vendors will not be able to apply until summer 2014. 

To meet the HQRP requirements for the FY 2018 payment determination, hospices would collect survey data on a monthly basis for the months of January 1, 2016 through December 31, 2016 in order to qualify for the full APU. See Table 10, Data Submission Dates 2015-2016 for CAHPS® Hospice Survey, on page 118 of the proposed rule for further details.  CMS further proposes to codify the process for filing a request for reconsiderations of a CMS imposed reduction of 2 percentage points which can be found at §418.312.

CMS will publicly report hospice data when at least 12 months of data are available so that valid comparisons can be made across hospice providers in the United States, to help patients, family and friends choose a hospice program for themselves or their loved ones.   CMS had previously stated that public reporting could begin as early as FY2018.

As part of national implementation CMS will launch a web site intended as the primary information resource for hospices and vendors (  The web site is expected to launch in the summer of 2014.




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