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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

CMS Releases FY2017 Hospice Wage Index, Payment Rule and Quality Reporting Requirements

Heavy Focus on Quality after FY2016 Payment Changes
April 22, 2016 09:49 AM

The Centers for Medicare & Medicaid Services (CMS) has issued Medicare Program; FY2017 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements (CMS-1652-P), the proposed payment and policy rule for the Medicare hospice benefit for fiscal year (FY) 2017.  The rule will be printed in the Feder​al Register on April 28, 2016, and the formal comment period ends on June 20, 2016.  Since the FY2016 rule contained significant payment refinements and other payment-related policy changes, the rule (as anticipated) focuses more heavily on hospice quality issues.  However, the rule does contain some useful information on CMS’ continuing efforts to monitor trends in hospice utilization and practice patterns that are worthy of note, some of which we have summarized below.

Trends in Hospice Utilization.  Hospice spending in FY2015 was estimated at $15.5 billion, and the Office of the Actuary estimates growth rates to continue to increase by approximately 7% annually (in the FY2016 rule, the Actuary had estimated future growth at 8% annually).  Diagnosis patterns have also changed, with the top 10 diagnoses for FY2015 listed as:

  1. Alzheimer’s disease
  2. Congestive Heart Failure, unspecified
  3. Lung Cancer
  4. COPD
  5. Senile Degeneration of the Brain
  6. Parkinson’s disease
  7. Heart disease, unspecified
  8. CVA/Stroke
  9. Cerebral Atherosclerosis
  10. Breast Cancer

A significant number of hospice claims in FY2014 (49%) still reported only a single diagnosis; preliminary analysis of hospice claims for FY2015 show that 37% of hospice claims contain a single diagnosis, with 63% submitting at least two diagnoses and 46% including at least three.

Pre-hospice Spending.  CMS conducted analysis of FY2014 data and found that daily pre-hospice spending for patients with Alzheimer’s disease, non-Alzheimer’s dementia or Parkinson’s (about 20% of patients) was $64.87 per day in the 180 days prior to admission to hospice, and in the 30 days prior to hospice election, the median Medicare spending for these patients was $96.99.  Both of these amounts are less than the hospice routine home care (RHC) rate.  For cancer patients, the 180day “prior” figure was $143.48 and the 30-day prior figure was $293.64.  The average length of stay for the Alzheimer’s, non-Alzheimer’s and Parkinson’s patients was 119 days compared to 47 days for patients with a cancer diagnosis.  CMS notes that analyzing pre-hospice spending was an initial step in determining whether patients require different resource needs prior to hospice based on the principal diagnosis on the hospice claim. 

Non-hospice Spending.  Based on continuing study of spending outside of hospice, CMS has found that over the CY2012 to FY2014 time period, non-hospice Part A and Part B spending during hospice elections has declined 15.4% (from $710.1 million in CY2012 to $600.8 million in FY2014).  For the same time period Part D spending also declined, although by a smaller percentage ($334.9 million in CY2012 and $291.6 million in FY2014).  Based on analysis, CMS remains concerned that common palliative and other disease-specific drugs for hospice beneficiaries are being covered and paid for under Part D.  As a result, Medicare could be “paying twice” for drugs for hospice patients.

Live Discharge Rates.  CMS continues to examine live discharge rates with an interest in better understanding characteristics of hospices with a tendency toward higher rates. CMS has found an “incremental” decrease in average annual rates of live discharge between 2006 and 2014 (live discharge rates averaged 20.4% in 2006 but rose to 21+% in the following 3 years; by 2014 average live discharge rates dropped to 17.4%).  CMS found that hospices with higher live discharge rates provided fewer visits per week, as well as fewer skilled visits.  CMS also found a relationship between high live discharge hospices and spending outside of hospice, as well as longer lifetime lengths of stay.  CMS is continuing to improve on its oversight in this area and may, in the future, consider additional regulatory proposals.

Visits in the Final Days of Life.  CMS continues to examine visits in the final days of life with an eye toward its impact on the quality and appropriateness of care provided to dying patients and their families.  CMS is attempting to address concerns in this area by introducing a pair of quality measures related to “Hospice Visits when Death is Imminent” which is discussed in greater detail in the Hospice Quality Reporting Program (HQRP) section of this article.  CMS is also hopeful that implementation of the Service Intensity Add-on (SIA) will have an impact in this area. 

Monitoring the Impacts of Hospice Payment Reform.  CMS intends to monitor the impact of hospice payment reform changes and general hospice trends to help guide future policy changes.  These areas are expected to include diagnosis reporting, lengths of stay, live discharge patterns in relationship to provision of services and the aggregate Cap, non-hospice spending, trends in live discharge at and around day 61 of care, and readmissions after a 60-day lapse following live discharge.  As part of the rule CMS also provides a lengthy list of payment reform metrics that its contractor Acumen LLC will monitor at the individual provider level and in the aggregate relative to the RHC payment changes that were implemented in January 2016.  Data from these ongoing analyses will be used for program integrity efforts and potentially for future payment system changes.  CMS also references the hospice PEPPER report and its usefulness for monitoring vulnerabilities and areas for improvement. 

Proposed FY2017 Hospice Wage Index.  For FY2016, hospices used a blended wage index as a transitional phase to the 2010 core-based statistical area (CBSA) values.  Beginning with FY2017 (October 1, 2016), the wage index for all hospice payments will be fully based on the new OMB CBSA delineations.  A link to the proposed wage index applicable for FY 2017 is available on the CMS Web site herein the SPOTLIGHT section. The proposed wage index applicable for FY 2017 will not be published in the Federal Register; itwill be effective October 1, 2016 through September 30, 2017.

Proposed Hospice Payment Update Percentage.  The hospice payment update percentage is based on the hospital inpatient market basket index, which for FY2017 CMS has estimated at 2.8 percent.  The market basket value, however, must be reduced to reflect Affordable Care Act-mandated reductions for a “productivity” adjustment (estimated at 0.5 percentage points) and an additional reduction of 0.3 percentage point.  It should be noted that the hospital market basket index and the MFP are subject to change, so the final hospice payment update percentage which will be published in late July or early August could be somewhat different from the current estimated net update of 2.0 percent.  Additionally, these figures do not reflect the 2% sequester.

The labor/non-labor portion of the hospice payment rates are as follow:




Routine Home Care



Continuous Home Care



General Inpatient Care



Inpatient Respite Care




Proposed FY2017 Payment Rates.   CMS indicates in the proposed rule that it will continue to make the SIA payments available for RN and Social Worker visits provided under RHC during the last seven days of life budget neutral through an annual determination of a SIA budget neutrality factor (SBNF), which will then be applied to RHC rates.  For FY2017, the SBNF applicable to RHC rates for days 1 through 60 is calculated at 1.0001, while the SBNF applicable to the RHC rate for days 61 and beyond has been calculated to be 0.9999. 

For FY 2017, CMS is proposing to apply a wage index standardization factor to the FY 2017 hospice payment rates in order to ensure overall budget neutrality when updating the hospice wage index with more recent hospital wage data. Wage index standardization factors are applied in other payment settings such as under home health Prospective Payment System (PPS), IRF PPS, and SNF PPS. Applying a wage index standardization factor to hospice payments would eliminate the aggregate effect of annual variations in hospital wage data. To calculate the wage index standardization factor, CMS simulated total payments using the FY2017 hospice wage index and compared it its simulation of total payments using the FY 2016 hospice wage index. By dividing payments for each level of care using the FY 2017 wage index by payments for each level of care using the FY 2016 wage index, CMS obtained a wage index standardization factor for each level of care (RHC days 1-60, RHC days 61+, CHC, IRC, and GIP).

Following are the base payment rates that CMS is proposing for FY2017:



FY2016 Payment Rates


Proposed Wage Index Standardization Factor (SBNF)

FY2017 Proposed Hospice Payment Update Percentage

FY2017 Proposed Payment Rates


Routine Home Care (days 1- 60)


X 1.0001

X 0.9990

X 1.020



Routine Home Care (days 61+)


X 0.9999

X 0.9995

X 1.020



Continuous Home Care


Full rate = 24 hours of care


$40.16=FY2017 hourly rate



X 1.0000

X 1.020



Inpatient Respite Care



X 1.0000

X 1.020



General Inpatient Care



X 0.9996

X 1.020



Hospice providers should note that the above values, again, are subject to change in the final rule.  They must also be modified by appropriate wage index values and will be subject to the sequester when claims are paid.  Service Intensity Add-on (SIA) payments will be made at the Continuous Home Care rate, currently estimated at $40.16 per hour.  Finally, hospices that fail to meet the applicable quality reporting requirements for FY2017 will have payments subject to a 2 percentage point reduction.

Hospice Aggregate Cap.  As required by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), for accounting years that end after September 30, 2016, and before October 1, 2015, the hospice Aggregate Cap is updated by the hospice payment update percentage (rather than using the consumer price index for urban consumers -- CPI-U -- as has historically been the case).  Consequently, the 2016 Cap (the Cap year for which runs from November 1, 2015, through October 31, 2016) will be $27,820.75, and the 2017 Cap will be $28,377.17.

Hospice providers are reminded that as part of the FY2016 hospice payment rule, CMS determined it appropriate to transition the Cap year to the federal fiscal year.   Following is a table outlining the changes:



Patient-by-patient (Proportional)























Much of the proposed rule deals with the hospice quality reporting program. 

CMS is proposing

  • Two new hospice quality reporting program (HQRP) measures:
    1. Hospice Visits When Death is Imminent- assessing hospice staff visits to patients and caregivers in the last week of life; and
    2. Hospice and Palliative Care Composite Process Measure- assessing the percentage of hospice patients who received care processes consistent with existing guidelines
  • To codify at §418.312 that if the National Quality Forum (NQF) makes only non-substantive changes to specifications for HQRP measures in the NQF’s re-endorsement process CMS would continue to utilize the measure in its new endorsed status. 
  • That hospices that received their CCN after January 1, 2017, are exempt from the FY 2019 APU Hospice CAHPS® requirements due to newness. This exemption will be determined by CMS. The exemption is for 1 year only.
  • That hospices that received their CCN after January 1, 2018, are exempted from the FY 2020 APU Hospice CAHPS® requirements due to newness. This exemption will be determined by CMS. The exemption is for 1 year only.

In addition to these proposals, CMS is considering a hospice patient assessment instrument as a new data collection mechanism, is not proposing to remove any of the HQRP measures at this time, and plans to publicly report all seven HIS measures on a CMS Hospice Compare Web site.  The CMS Hospice Compare Web site is on target to be implemented in spring/summer 2017.

Two New Proposed Measures:  Collection of the two new proposed measures would impact payments in FY2019.  The measures were included on CMS' List of Measures under Consideration (MUC list) for 2015 but have not yet been approved by the National Quality Forum (NQF). 

The Hospice Visits When Death is Imminent Measure Pair addresses whether a hospice patient and their caregivers’ needs were addressed by the hospice staff during the last days of life. This measure is specified as a set of two measures as follows:

  • Measure 1--assesses the percentage of patients receiving at least 1 visit from registered nurses, physicians, nurse practitioners, or physician assistants in the last 3 days of life and addresses case management and clinical care.
  • Measure 2-- assesses the percentage of patients receiving at least 2 visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses, or hospice aides in the last 7 days of life and gives providers the flexibility to provide individualized care that is in line with the patient, family, and caregiver’s preferences and goals for care and contributing to the overall well-being of the individual and others important in their life

CMS believes collecting information about hospice staff visits for measuring quality of care, in addition to the requirement of reporting visits from some disciplines on hospice claims, will encourage hospices to visit patients and caregivers and provide services that will address their care needs and improve quality of life during the patients’ last days of life.  CMS cited the fact that clinician visits to patients at the end of life are associated with improved outcomes such as decreased risk of hospitalization, emergency room visits, and hospital death, and decreased distress for caregivers and higher satisfaction with care.  CMS also cited data that were part of previous Hospice Technical Reports completed by Abt Associates relative to the number of visits in the last days of life from skilled hospice disciplines.  The 2014 Abt Medicare Hospice Payment Reform Report indicated that 28.9 percent of Routine Home Care hospice patients did not receive a skilled visit on the last day of life.  

No current HQRP measures address care beyond the hospice initial and comprehensive assessment period, nor do any current HQRP measures relate to the assessment of hospice staff visits to patients and caregivers in the last week of life.

Data for the paired measure would be collected via the existing Hospice Item Set (HIS).  CMS proposed that four new items be added to the HIS-Discharge record to collect the necessary data elements for the measure. The expectation is that data collection for this quality measure via the four new HIS items would begin no earlier than April 1, 2017 (providers would begin collecting data for the measure for patient admissions and discharges occurring after April 1, 2017).  

CMS submitted a request for approval to the Office of Management and Budget (OMB) for the Hospice Item Set version 2.00.0 that incorporates the four new HIS items. While not yet available, the new HIS data items that would collect this measure data will be available for public viewing at: -and -Guidance/Legislation/PaperworkReductionActof1995/PRA -Listing.html

For the second measuredata on a total of seven individual care processes will be captured, which include the six NQF-endorsed quality measures and one modified NQF-endorsed quality measure currently part of the HIS. This measure calculates the percentage of patients who received all care processes at admission.  These individual component measures address care processes around hospice admission that are clinically recommended or required in the hospice Conditions of Participation. To calculate this measure, the individual component of the composite measure are assessed separately for each patient and then aggregated into one score for each hospice.

CMS indicates that a composite measure serves to ensure all hospice patients receive a comprehensive assessment for both physical and psychosocial needs at admission. Collecting information about the total number of care processes conducted for each patient will incentivize hospices to conduct all desirable care processes for each patient and provide services that will address their care needs and improve quality during the time he/she is receiving hospice care.

Additionally, creating a composite quality measure for comprehensive assessment at admission will provide consumers and providers with a single measure regarding the overall quality and completeness of assessment of patient needs at hospice admission, which can then be used to meaningfully and easily compare quality across hospice providers and increase transparency.

Analyses conducted by the CMS measure development contractor, RTI International, show that hospice performance scores on the current seven HIS measures are high (a score of 90 percent or higher); however, these analyses also revealed that, on average, only 68.1 percent of patient stays in a hospice had documentation that all of these desirable care processes were done at admission. 

CMS recently submitted the CAHPS® Hospice Survey (experience of care) measure (NQF #2651) to be considered for endorsement under the NQF Palliative and End-of-Life Care Project 2015-2016.  The CAHPS®-based quality measures submitted to NQF include patient and caregiver experience of care outcome measures. CMS plans to propose these measures as part of the HQRP measure set in future rulemaking cycles.

Comprehensive Patient Assessment Instrument.CMS is considering developing a new data collection mechanism for use by hospices. This new data collection mechanism would be a hospice patient assessment instrument, which would serve two primary objectives concordant with the Affordable Care Act legislation: (1) to provide the quality data necessary for HQRP requirements and the current function of the HIS; and (2) provide additional clinical data that could inform future payment refinements.  For future payment refinements, a hospice patient assessment tool would allow more detailed clinical information -- beyond the patient diagnosis and comorbidities that are currently reported on hospice claims -- to be gathered.  Detailed patient characteristics are necessary to determine whether a case mix payment system could be achieved. A hospice patient assessment tool would allow information on symptom burden, functional status, and patient, family, and caregiver preferences to be captured, all of which will inform future payment refinements according to CMS. 

CMS also views a comprehensive patient assessment instrument as a potential enhancement of the current HIS data collection instrument to be more in line with other post-acute care settings. Also, a hospice patient assessment tool that provides clinical data that is used for both payment and quality purposes would align the hospice benefit with other care settings that use similar approaches, such as nursing homes, inpatient rehabilitation facilities, and home health agencies.

For quality data collection, a hospice patient assessment instrument would allow for collection of data concurrent with the provision of care instead of retrospective data collection. CMS stated that because of the concurrent collection it believes a hospice patient assessment tool would allow for more robust data collection that could inform development of new quality measures that are meaningful to hospice patients, their families and caregivers, and other stakeholders.

CMS envisions the hospice patient assessment tool itself as an expanded HIS. It would include current HIS items, as well as additional clinical items that could be used for payment refinement purposes or to develop new quality measures. The hospice patient assessment tool would not replace existing requirements set forth in the Medicare Hospice CoPs (such as the initial nursing and comprehensive assessment), but would be designed to complement data that are collected as part of normal clinical care. If such a patient assessment were adopted, the new data collection effort would replace the current HIS, but would not replace other HQRP data collection efforts (Hospice CAHPS® survey), nor would it replace regular submission of claims data.

The patient assessment data would be collected upon a patient’s admission to and discharge from any Medicare-certified hospice provider; additional interim data collection efforts are also possible.

In the development of such a hospice patient assessment tool, CMS will continue to receive stakeholder input from the Medicare Payment Advisory Commission (MedPAC) and ongoing input from the provider community, Medicare beneficiaries, and technical experts. Through the comment period for this proposed rule, CMS is soliciting comments on a potential hospice patient assessment tool that would collect both quality, clinical, and other data with the ability to be used to inform future payment refinement efforts.

Public Reporting and Hospice Compare Site:  Based on the efforts necessary to build the infrastructure for public reporting, CMS anticipates that public reporting of the eligible HIS quality measures on the CMS Compare Web site for hospice agencies will begin sometime in the spring/summer of CY 2017.  CMS is prepared to share HQRP information such as hospice demographic data and general information about hospice data publicly on the website in CY2016.

CMS has determined that all seven HIS measures are eligible for public reporting. Therefore, CMS plans to publicly report all seven HIS measures on a CMS Compare Web site for hospice agencies. Individual scores for each of the seven HIS measure scores would be reported. Current reportability analysis indicates that a minimum denominator size of 20 based on 12 rolling months of data would be sufficient for public reporting of all HIS quality measures. Under this methodology, hospices with a quality measure denominator size of smaller than 20 patient stays would not have the quality measure score publicly displayed since a quality measure score on the basis of small denominator size may not be reliable.

Consistent with many other CMS CAHPS® surveys that are publicly reported on CMS Web sites, 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, in order to help patients, family, friends, and caregivers choose the right hospice program.

CMS is currently developing the infrastructure for the public reporting, and will provide hospices an opportunity to review their quality measure data prior to publicly reporting the information through the use of “preview reports” in the CASPER system.  Under this process, providers would have the opportunity to review and correct data they submit on all measures that are derived from the HIS.  CMS also plans to make additional provider-level feedback reports available in CASPER, which are separate from public reporting and will be for provider viewing only, for the purposes of internal provider quality improvement. As is common in other quality reporting programs, quality reports would contain feedback on facility-level performance on quality metrics, as well as benchmarks and thresholds.

A Hospice Compare Web site is currently under development.  It will provide valuable information regarding the quality of care provided by Medicare-certified hospice agencies throughout the nation. Consumers would be able to search for all Medicare approved hospice providers that serve their city or zip code (which would include the quality measures and CAHPS® Hospice Survey results) and then find the agencies offering the types of services they need, along with provider quality information. Like other CMS Compare Web sites, the Hospice Compare Web site will, in time, feature a star rating system of 1 to 5 stars for each hospice. Hospices will have prepublication access to their own agency’s quality data, which enables each agency to know how it is performing before public posting of data on the Hospice Compare Web site. CMS will announce the timeline for development and implementation of the star rating system in future rulemaking.

In previous rulemaking CMS indicated it would post a list of hospices compliant with the HQRP reporting requirements. This is part of efforts to make healthcare more transparent, affordable, and accountable.  CMS is prepared to post hospice data on a public data set, the Web site, and directory located at This site includes the official datasets used on the Compare Web sites provided by CMS.  In an effort to move toward public reporting of hospice data, CMS will initially post demographic data of hospice agencies that have been registered with Medicare. This list will include addresses, phone numbers, and services provided for each agency. The timeline for posting hospice demographic data on a public dataset is scheduled for sometime late spring/summer CY 2016.

HQRP Measures and Timely Reporting Thresholds:  CMS is not proposing to remove any of the current HQRP measures at this time.

Quality measures selected for the HQRP must be endorsed by the NQF unless they meet the statutory criteria for exception under section 1814(i)(5)(D)(ii) of the Act.  CMS proposes to codify that if measures currently used in the HQRP undergo non-substantive changes in the specifications as part of their NQF re-endorsement process, CMS would subsequently utilize the measure with the new endorsed status in the HQRP without going through new notice-and-comment rulemaking.

Through NQF's measure maintenance process, NQF-endorsed measures are sometimes updated to incorporate changes that do not substantially change the nature of the measure. Examples of such changes could be updated diagnosis or procedure codes, or changes to exclusions to a particular patient/consumer population or definitions. CMS believes these types of maintenance changes are distinct from more substantive changes to measures. Additionally, since the NQF endorsement and measure maintenance process is one that ensures transparency, public input, and discussion among representatives across the healthcare enterprise, CMS believes that the NQF measure endorsement and maintenance process itself is transparent, scientifically rigorous, and provides opportunity for public input.

If NQF-endorsed specifications change and CMS does not adopt those changes, it would propose the measure as an application (that is, with CMS modifications). An application of an NQF-endorsed quality measure is utilized in instances when CMS has identified a need to use a NQF-endorsed measure in a QRP, but needs to use it with one or more modifications to the quality measure’s specifications.   There is currently one modified NQF measure on the HIS.

CMS may modify one or more of the following aspects of a NQF-endorsed measure: (1) numerator; (2) denominator; (3) setting; (4) look-back period; (5) calculation period; (6) risk adjustment; and (7) revisions to data elements used to collect the data the data required for the measure. CMS will continue to use rulemaking to adopt substantive updates made by the NQF to the endorsed measures adopted for the HQRP.

Beginning in CY2016, hospices need to meet a timeliness threshold for HQRP reporting in order to avoid a 2% payment penalty.  The timeliness threshold is currently set at 70% and will jump to 80% for the FY 2019 APU determination and to 90% for the FY 2020 APU determination and subsequent years.The threshold corresponds with the overall amount of HIS records received from each provider that fall within the established 30-day submission timeframes.  CMS is working on expanding this functionality of CASPER reports to include a timeliness compliance threshold report that providers could run to determine their preliminary compliance with the timeliness compliance requirement. These reports are expected to be available by late spring/early summer of 2016.

To meet participation requirements for the FY 2019 APU, hospices must collect CAHPS® Hospice Survey data on an ongoing monthly basis from January 2017 through December 2017 (inclusive). Data submission deadlines for the 2019 APU can be found in the table below. The data must be submitted by the deadlines listed in the table by the hospice’s authorized approved CMS vendor.  If the vendor does not submit the data the hospice is held responsible.


Sample months (month of death) 1

Quarterly data submission deadlines 2

FY2018 APU

January – March 2016 (Q1)

August 10, 2016

April – June 2016 (Q2)

November 9, 2016

July – September 2016 (Q3)

February 8, 2017

October – December 2016 (Q4)

May 10. 2017

FY2019 APU

January – March 2017 (Q1)

August 9, 2017

April – June 2017 (Q2)

November 8, 2017

July – September 2017 (Q3)

February 14, 2019

October – December 2017 (Q4)

May 9, 2019

FY2020 APU

January – March 2018 (Q1)

August 8, 2018

April – June 2018 (Q2)

November 14, 2018

July – September 2018 (Q3)

February 13, 2019

October – December 2018 (Q4)

May 8. 2019

1 Data collection for each sample month initiates 2 months following the month of patient death (for example, in April for deaths occurring in January)

2 Data submission deadlines are the second Wednesday of the submission months, which are August, November, February, and May.


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® Hospice Survey data collection and reporting requirements for the FY 2019 payment determination.  To qualify, hospices must submit an exemption request form. This form will be available in first quarter 2017 on the CAHPS® Hospice Survey Web site

Hospices that want to claim the size exemption are required to submit to CMS their total unique patient count for the period of January 1, 2016 through December 31, 2016. The due date for submitting the exemption request form for the FY 2019 APU is August 10, 2017.

CMS proposes that hospices that received their CCN after January 1, 2017, are exempted from the FY 2019 APU Hospice CAHPS® requirements due to newness. This exemption will be determined by CMS. The exemption is for 1 year only.  Likewise, CMS proposes the same for hospices that receive their CCN after January 1, 2018 (exempted from the FY 2020 Hospice CAHPS® requirements due to newness.)

Medicare Care Choices Model (MCCM) CMS reiterated information about the MCCM.  This 5 year model is being tested to encourage greater and earlier use of the Medicare and Medicaid hospice benefit to determine whether it can improve the quality of life and care received by Medicare beneficiaries, increase beneficiary, family, and caregiver satisfaction, and reduce Medicare or Medicaid expenditures. The Model includes over 130 hospices from 39 states projected to serve 100,000 beneficiaries by 2020. The Model implementation is broken down into two phases with the first phase beginning already in 2016 and the second phase beginning in 2018, with a 2020 end date for admissions into the MCCM.

CMS is accepting comments on all of its proposals as well as the burden estimate for the proposed changes.  The burden estimate can be found in Section IV of the proposed rule.  NAHC is compiling comments.  For inclusion in NAHC comments, please submit your feedback to tmf@nahc.orgor Katie@nahc.orgby June 10, 2016.




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