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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

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

Health 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

NAHC Summary: CMS Finalizes FY2016 Hospice Payment Rule

August 3, 2015 03:45 PM

Late Friday, July 31, the Centers for Medicare & Medicaid Services (CMS) released the final hospice payment rule for fiscal year 2016 (FY2016); the final rule is available here: The rule is scheduled for publication in the Federal Register on August 6, 2015. Final hospice wage index tables are not included in the publication but are available online at: This summary by the National Association for Home Care & Hospice (NAHC) is an expanded version of the synopsis provided to NAHC members via its member listservs late Friday, July 31.

The overall impact of the final rule is an estimated net increase in federal Medicare payments to hospices of $160 million; hospice base payments under Medicare will increase an average of 1.1 percent over FY2015 (this amount takes both the projected market basket update of 1.6 percent and changes to the wage index into account). In April CMS projected the net market basket update to be 1.8 percent, but since that time has adjusted the calculations for both the hospital market basket update calculation and the productivity adjustment. Following is a table containing the initial and final market basket calculations:




Hospital market basket

2.7 percent

2.4 percent

Productivity adjustment



Add’l ACA reduction



Net market basket

1.8 percent

1.6 percent*

*wage index changes further reduce the impact on payment rates by 0.5 percentage points

Medicaid hospice rates, which vary slightly from the Medicare rates, will be released by CMS at some time in the near future.

A key element of the proposed FY2016 payment rule released in late April was the planned October 1, 2015, implementation of a two-tiered system for payment of Routine Home Care (RHC)—a higher base rate for days 1 through 60 of an episode of care, and a lower base rate for days 61 and subsequent days in the episode. CMS also proposed a Service Intensity Add-on (SIA) to the RHC rates that would be permitted for up to four hours per day during the last seven days of life when the patient receives RN and/or social work visits. As proposed the SIA would NOT be applicable when the patient resides in a nursing facility (NF) or skilled nursing facility (SNF). Additional NAHC analysis of the proposed FY2016 hospice payment rule is available here.

When the payment changes were proposed, NAHC expressed particular concern that the planned SIA—designed to help cover the higher costs associated with care needs in the last seven days of life while a patient is on RHC—would not be provided for patients residing in nursing facilities. Based on input from NAHC and others, CMS has revised the SIA policy to allow for the adjustment regardless of the location where the patient resides. NAHC President Val J. Halamandaris commented, “While we continue to review the finer details of the rule, we applaud steps CMS has taken to modify the SIA policy so that it applies to all patients. We believe that to do otherwise would deny patients equal access to care based on their place of residence.”

Halamandaris continued, “We also strongly support CMS’ decision to delay implementation of the new two-tiered RHC payment rates until January 1, 2016; this is essential to ensuring that CMS, its administrative contractors, state Medicaid programs, hospices, and vendors are fully prepared for these changes.”

NAHC submitted comments to CMS on a wide range of issues addressed in the proposed rule; for additional coverage, please go here.

Following is a summary of the final FY2016 hospice payment rule:


PAYMENT FOR ROUTINE HOME CARE: As anticipated, CMS is finalizing the proposal to establish a two-tiered payment system for RHC, with an effective date of January 1, 2016. This delay in implementation from October 1, 2015 to January 1, 2016 will allow for state Medicaid agencies to make the necessary systems and software changes. Between October 1, 2015 and December 31, 2015, hospices will continue to be paid a single FY2016 RHC per diem payment amount ($161.89). Effective January 1, 2016, a higher RHC rate for days 1 through 60 of a hospice episode of care ($186.84) and a lower RHC rate for days 61 and beyond ($146.83) of a hospice episode of care will replace the single RHC per diem payment rate (the RHC per diem rates are listed in the table below). An episode of care for hospice RHC payment purposes is a hospice election period or series of election periods separated by no more than a 60-day gap in hospice care. For hospice patients who are discharged and readmitted to hospice within 60 days of that discharge, a patient’s prior hospice days would continue to follow the patient and count toward his or her patient days for the new hospice election. CMS will not count the days between hospice elections as hospice days. CMS will calculate the patient’s episode day count based on the total number of days the patient has been receiving hospice care separated by no more than a 60 day gap in hospice care, regardless of level of care or whether those days were billable or not. The patient’s episode day count will include hospice days that occurred prior to January 1, 2016.

In order to determine the date of service in an episode when a patient is admitted to hospice care, CMS advises that hospices access this information through the HIPAA Eligibility Transaction System (HETS); to ensure that all hospice episodes available in the HETS system are returned, hospices should request a date 12 months PRIOR to the date of the request.

For billing purposes, when a RHC rate changes during a period that is shown as a single line item on a claim, the line item should NOT be split (if split, the claim will be returned to provider). Medicare systems will combine the high and low RHC rates for the applicable days in the total payment for the RHC line item.

CMS provided the following additional comments related to the new payment system:

  • CMS believes it is not appropriate to reset all hospice episodes back to day 1 on January 1, 2016; nor does CMS believe allowing existing patients to continue on service at the single RHC rate is appropriate.
  • Hospices will not be required to change how they bill for RHC days to comply with the payment changes; CMS’ claims processing system will be responsible for the count of days and will pay the appropriate rate accordingly.
  • CMS believes its systems are prepared for an October 1, 2015, start, and that hospices will be required to make minimal changes. However, in order to allow state Medicaid programs to adapt, it is delaying the start of the two-tiered payment rates until January 1, 2016.
  • CMS indicates that CMS and the MACs will take steps to educate and train hospice providers and others on the policy changes and associated systems changes to ensure preparedness for the January 1, 2016 start.
  • When a patient transfers hospices and there is no gap in care, the transfer day will only be counted as 1 day.

SERVICE INTENSITY ADD-ON: CMS is finalizing the SIA proposal as proposed; however, CMS will include episodes in SNF/NF as eligible for the SIA payment. CMS is finalizing the SIA proposal with an effective date of January 1, 2016 in order to coordinate implementation of the hospice payment reforms, including the finalization of the new RHC rates discussed above. Finally, CMS will also finalize its proposal to continue to make the SIA payments budget neutral through an annual determination of the SIA budget neutrality factor (SBNF), which will then be applied to the RHC payment rates. The SBNF for the SIA payments will be calculated for each FY using the most current and complete fiscal year utilization data available at the time of rulemaking.

CMS notes that it did not include spiritual care counseling in the SIA because Medicare explicitly precludes payment for bereavement and other counseling as separate services. CMS has also indicated that in the future it will reevaluate whether inclusion of LPN services as part of the SIA is warranted. In cases where care by a RN and social worker is provided concurrently in the last seven days of life, both are counted separately for purposes of the SIA payment. Both new and existing hospice elections will be eligible for the SIA, and no additional documentation will be required in order to receive the SIA payment.  The SIA budget neutrality factor will be applied annually using the most current and complete fiscal year utilization data available at the time of rulemaking.

  • CMS also notes that the SIA rates were established using hospice claims data. Once new cost report data is available CMS will analyze costs by level of care.


FY2016 Proposed and Final Hospice Payment Rates*


Labor portion

Non-labor portion

Proposed FY2016 Rate

Final FY2016 Rate

651 -- Routine Home Care (10/1 - 12/31/15)







651/Routine Home Care days 1 - 60 (eff. 1/1/2016)






$ 188.20



651/Routine Home Care days 61+ (eff. 1/1/2016






$ 147.34



652 -- Continuous Home Care





$ 946.65 ($39.44/hr.)

$944.79 ($39.37/hr.)

655 -- Inpatient Respite






$ 167.78



656 -- General Inpatient Care









​ *hospices failing to meet quality reporting requirements will be paid 98% of these values; these rates are not wage-adjusted

WAGE INDEX: CMS is implementing the hospice wage index with a 1-year transition period as proposed, meaning the counties impacted will receive 50 percent of the rate from the current CBSA and 50 percent from the new OMB CBSA delineations for FY 2016 effective October 1, 2015. Due to the way the transitional index is calculated, some CBSAs and statewide rural areas may have more than one transition wage index value but each county will have only one transition wage index. In such cases, the CBSA number may not be used on the claim. Instead, a transitional wage index number must be used -- these are five digits in length and begin with “50”. In FY2017 hospices will cease using the transitional wage index number.

The wage index rates for FY2016 reflect the full phase-out of the Budget Neutrality Adjustment Factor (BNAF), along with annual changes to the wage index values; the combined impact of these changes and the transitional CBSA policy have an overall impact of MINUS 0.5 percentage points on overall payment rates.  

CMS also provided the following information in its response to payment-related comments as part of the final rule:

  • CMS plans to monitor the impact of the two-tiered RHC payment system, including trends in discharges and revocations, and propose future refinements if necessary. CMS reminds hospices that patients may only be discharged due to the patient moving out of the service area, for cause when the patient or others living in the home are disruptive, or if the hospice determines the patient is no longer terminally ill. Program integrity efforts are being considered to address fraud and abuse in this area.
  • CMS believes that the higher RHC rate in conjunction with the proposed SIA payment will mitigate some of the financial concerns associated with very short stay patients.
  • While CMS is not eliminating the sequential billing requirements at this time they will consider whether it is appropriate at some time in the future.
  • In cases where a hospice exceeds its GIP cap, CMS will reduce the GIP rate to the tier 2 hospice payment rate (rate for days 61 and after).
  • CMS estimates that the payment changes will increase payments for hospices that are below the aggregate cap by 0.14 percent and decrease payments for over-cap hospices by 5.40 percent.
  • Relative to reporting of all diagnoses on claims, CMS commented that “once several years of additional data are available for analysis, we will determine whether additional changes to the hospice payment system are needed in the future, including analysis to determine whether a case-mix system for hospice payments would be an appropriate, viable option.”
  • CMS will release the contractor’s 2015 Technical Report later this year (although CMS indicated that the technical report does not contain payment reform analysis); all analysis in support of hospice payment reform can be found in section III.B of the final rule.
  • The IMPACT Act enacted technical changes to the ACA language requiring CMS to conduct medical review of hospices with a high proportion of long-stay patients. In the rule, CMS indicates that it is engaged in “cross-agency collaboration” to meet the intent of the IMPACT Act to increase monitoring and oversight of hospice providers.
  • Relative to admission of patients who do not meet hospice eligibility criteria, CMS commented that it expects to analyze additional claims and cost report data reported by hospices to determine whether additional regulatory proposals to reform and strengthen the Medicare hospice benefit are warranted.


AGGREGATE CAP CALCULATION: The final rule implements changes mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), in which the aggregate cap for accounting years that end after September 30, 2016 and before October 1, 2025, will be updated by the hospice payment update percentage rather than using the consumer price index for urban consumers (CPI-U). Specifically, the 2016 cap year, starting on November 1, 2015 and ending on October 31, 2016, will be updated by the FY 2016 hospice update percentage for hospice care. This will continue through any cap year ending before October 1, 2025 (that is, through cap year 2025). The hospice payment update percentage has risen at a slower pace than the CPI-U. Therefore, it is anticipated that the result of this change is more hospices going over the allowed aggregate cap and by a greater amount than in the past.

2015 Aggregate Cap Value (Nov. 1, 2014 - Oct. 31, 2015) -- $27,382.63

2016 Aggregate Cap Value (Nov. 1, 2015 - Oct. 31, 2016) -- $27,820.75

AGGREGATE AND INPATIENT CAP ACCOUNTING YEAR CHANGES: In addition, CMS is shifting the cap accounting year for both the inpatient cap and the hospice aggregate cap to align with the federal fiscal year, which runs from October 1 through September 30. By the 2018 cap year the patient count and accounting timeframes for both the inpatient and aggregate caps will be the federal fiscal year (starting October 1, 2017 and ending September 30, 2018). The 2017 cap year will be a transitional year relative to the shift in the cap year. For the transition year (cap year 2017), for the inpatient cap, CMS will calculate the percentage of all hospice days of care provided as either GIP or Respite from November 1, 2016 through September 30, 2017 (11 months). Relative to the aggregate cap, for hospices using the proportional method for aggregate cap determinations, CMS will count beneficiaries from November 1, 2016, to September 30, 2017. For hospices using the streamlined method for the aggregate cap, CMS will count beneficiaries from September 28, 2016 to September 30, 2017 (12 months and 3 days). For the 2017 cap year relative to all hospices (using either the proportional or streamlined aggregate cap method), CMS will count 11 months of payment (from November 1, 2016 to September 30, 2017).   Based on the FY2015 final rule, hospices are required to file a self- determined inpatient and aggregate cap determination five months after the end of the cap year. In accordance with this requirement, hospices must file their self-determined inpatient and aggregate cap determinations on or before March 31, 2017 for the 2016 cap year and on or before February 28, 2018 for the 2017 cap year.

Updates to the HQRP

CMS is finalizing the updates as laid out in the proposed rule. Those are:

  • Beginning with the FY 2018 payment determination, for the purpose of streamlining the rulemaking process, when CMS adopts measures for the HQRP beginning with a payment determination year, these measures are automatically adopted for all subsequent years’ payment determinations, unless CMS proposes to remove, suspend, or replace the measures.
  • Quality measures may be considered for removal by CMS if:
    • Measure performance among hospices is so high and unvarying that meaningful distinctions in improvements in performance can be no longer be made;
    • Performance or improvement on a measure does not result in better patient outcomes;
    • A measure does not align with current clinical guidelines or practice;
    • A more broadly applicable measure (across settings, populations, or conditions) for the particular topic is available;
    • A measure that is more proximal in time to desired patient outcomes for the particular topic is available;
    • A measure that is more strongly associated with desired patient outcomes for the particular topic is available; or
    • Collection or public reporting of a measure leads to negative unintended consequences.

For any such removal, the public will be given an opportunity to comment through the annual rulemaking process. However, if there is reason to believe continued collection of a measure raises potential safety concerns, CMS will take immediate action to remove the measure from the HQRP and will not wait for the annual rulemaking cycle. The measures will be promptly removed and CMS will immediately notify hospices and the public of such a decision through the usual HQRP communication channels, including listening sessions, memos, email notification, and Web postings. In such instances, the removal of a measure will be formally announced in the next annual rulemaking cycle.

  • CMS did not propose to remove any measures for the FY 2017 reporting cycle. However, in the proposed rule CMS did identify priority areas for future measure enhancement and development and invited comment regarding these.
    • Patient reported pain outcome measure that incorporates patient and/or proxy report regarding pain management;
    • Claims-based measures focused on care practice patterns including skilled visits in the last days of life, burdensome transitions of care for patients in and out of the hospice benefit, and rates of live discharges from hospice;
    • Responsiveness of hospice to patient and family care needs;
    • Hospice team communication and care coordination

CMS indicated these measure concepts are under development, and details regarding measure definitions, data sources, data collection approaches, and timeline for implementation will be communicated in future rulemaking. In this final rule, CMS summarized the comments received on the priority areas and responded to some of those comments. Overall, commenters were supportive of all priority areas except the claims-based measures. CMS commented that it will conduct continued quantitative and qualitative analysis to determine correlation between these measure concepts (claims-based measures) and quality of care. CMS agrees that establishing a relationship between a measure concept and quality of care is a vital consideration in the measure development process, and reiterates its intent to adopt measures that have been endorsed by NQF if at all possible.

  • New providers will be required to begin reporting quality data under for the HQRP beginning on the date they receive their CCN Notification Letter from CMS.  This will begin with the FY 2018 payment determination and for each subsequent payment determination. Currently, new hospices that receive their CCN Notification Letter from CMS on or after November 1st of the preceding year are excluded from any payment penalty for quality reporting purposes for the following fiscal year and would begin reporting their quality data on January 1 of the next calendar year. CMS clarified in this final rule that providers are required to begin reporting data on the date that they receive their CCN notification letter. For example, if a provider receives its CCN notification letter on November 5, the provider would need to begin submitting its HIS data for all admissions occur on November 5 and later. Since the hospice did not received its letter until after November 1 it would not be subject to any payment penalties for the relevant fiscal year.
  • Hospices must submit all HIS records within 30 days of the Event Date (admission or discharge) as proposed
  • CMS is implementing the proposed timeliness threshold requirement beginning with all HIS admission and discharge records that occur on or after January 1, 2016, in accordance with the following schedule.
    • Beginning on or after January 1, 2016 to December 31, 2016, hospices must submit at least 70 percent of all required HIS records within the 30 day submission timeframe for the year or be subject to a 2 percentage point reduction to their market basket update for FY 2018.
    • Beginning on or after January 1, 2017 to December 31, 2017, hospices must score at least 80 percent for all HIS records received within the 30 day submission timeframe for the year or be subject to a 2 percentage point reduction to their market basket update for FY 2019.
    • Beginning on or after January 1, 2018 to December 31, 2018, hospices must score at least 90 percent for all HIS records received within the 30 day submission timeframe for the year or be subject to a 2 percentage point reduction to their market basket update for FY 2020.
  • Codifies the HQRP Submission Extension and Exemption Requirements at §418.312.
  • To meet participation requirements for the FY 2019 APU, hospices must collect data on an ongoing monthly basis from January 2017 through December 2017 (inclusive). Data submission deadlines for the 2019 APU will be announced in future rulemaking.
  • Hospices that have fewer than 50 survey-eligible decedents/caregivers in the period from January 1, 2016 through December 31, 2016 are exempt from CAHPS®
  • CMS will add CASPER as an additional communication mechanism for disseminating notifications of noncompliance, as well as publish a list of compliant hospices on the HQRP Web site.

Diagnosis codes on claims

CMS clarifies that hospices must report all diagnoses of the beneficiary on the hospice claim as a part of the ongoing data collection efforts for possible future hospice refinements. CMS believes that reporting of all diagnoses on the hospice claim aligns with current coding guidelines as well as admission requirements for hospice certifications. The purpose of collecting this data, which is required in every other healthcare setting as per coding guidelines, is to have adequate data on hospice patient characteristics. This data will help to inform thoughtful, appropriate, and clinically relevant policy for future rulemaking. In order to consider any future refinements, such as a case mix system which utilizes diagnosis information as a few commenters suggested, it is imperative that detailed patient characteristics are available to determine whether a case mix payment system could be achieved.

NAHC will continue to analyze the final rule and provide updates and commentary as appropriate, as well as continue to work to secure additional detail that will help stakeholders as the industry transitions to the new payment system.




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