The current labor shares did not reflect this differential in utilization as the same labor share was used for both levels of care. developer tools pages. CMS issued a final rule, CMS-1629-F, which created two routine home care daily payment rates. [27] One commenter stated that with only those cost reports from providers that have a hospice inpatient unit being used to determine the GIP and inpatient respite labor costs, they are concerned because one of their two affiliated hospices does have an inpatient unit, and yet they sometimes refer patients to contracted facilities for these levels of care as well. For these reasons, we determined the best course of action would be to continue to publicly report the most recent 8 quarters of data, but exempting Q1 and Q2 2020. Given the exemptions provided due to COVID-19 PHE in the March 27, 2020 Guidance Memorandum,[45] 553, and, where applicable, section 1871 of the Act. This could also include guidance on any additional items, including standardized patient assessment and data elements that could be used to assess health equity in the care of hospice patients, for use in the HQRP. Hospice Rates for Providers that Have Submitted the Required Quality Data Federal Fiscal Year 2023 Effective Retroactive to October 1, 2022 County-level Hospice Rates for Providers that Have Submitted the Required Quality Data County Name County Number CBSA FFY 2022 Hospice Wage Index Continuous Home Care Inpatient Respite Care General Inpatient In addition to the Preview Report, we will also include claims-based measure scores in the Hospice Agency-Level QM Report in CASPER. The 'Wage Index' links contain the listing of Core Based Statistical Area (CBSA) codes and the corresponding wage index. Clustering methodology assigns cut points by minimizing differences within star categories and maximizing differences across star categories. Additionally, the regulations that govern hospice reimbursement do not provide a mechanism for allowing hospices to seek geographic reclassification or to utilize the rural floor provisions that exist for IPPS hospitals. 2) The SIApayment is in addition to the per diem RHC rate when all the following criteria are met: (a) The day is an RHC level of care day. The documents posted on this site are XML renditions of published Federal Chapter 12: Hospice Services. documents in the last year, by the Food Safety and Inspection Service Regarding the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey, CMS finalized a policy that hospices that receive their CMS Certification Number (CCN) after January 1, 2017 for the FY 2019 Annual Payment Update (APU) and January 1, 2018 for the FY 2020 APU will be exempted from the Hospice CAHPS requirements due to newness (81 FR 52182). as patients and their family caregivers also place value on physical symptom management and spiritual/psychosocial care as important factors at the end-of-life. In the original schedule (Table 20), the October 2020 refresh included Q4 2019 measure based on OASIS and HH CAHPS data and is the last refresh before Q1 2020 data are included. L. 105-33) amended section 1814(i)(1)(C)(ii)(VI) of the Act to establish updates to hospice rates for FYs 1998 through 2002. Thus, these exemptions or extensions can occur when a hospice encounters certain extraordinary circumstances. The HIS Comprehensive Assessment Measure captures whether multiple key care processes were delivered upon patients' admissions to hospice in one measure as described in the Table 6. PDF FY 2023 Medicaid Hospice Rates and State/County Rate Charts However, the prohibition does not pertain to the provision of an item or service for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, so long as the item or service is not furnished for the specific purpose of causing or accelerating death. Assuming an average reading speed of 250 words per minute, it would take approximately 2.4 hours for the staff to review half of it. We refer readers to the HQRP website at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Public-Reporting-HIS-Preview-Reports-and-Requests-for-CMS-Review-of-HIS-Data,, which we will revise to include further information on public reporting of claims as well as HIS data. The commenter stated that there are no regulations that require cost reports to be completed by an outside or otherwise qualified accounting firm, and many hospices are doing their own costs reports without complete understanding of how to allocate specific costs and which box is appropriate for particular costs. 14. Similarly, we proposed to clarify at 418.24(d)(5) that in the event that a beneficiary requests the addendum and the hospice furnishes the addendum within 3 or 5 days (depending upon when the request for the addendum was made), but the beneficiary dies, revokes, or is discharged prior to signing the addendum, a signature from the individual (or representative) is no longer required. Similarly, section 1871(b)(1) of the Act requires the Secretary to provide for notice of the proposed rule in the Federal Register and a period of not less than 60 days for public comment for rulemaking carrying out the administration of the insurance programs under title XVIII of the Act. (or the day of death); One day prior to death is calculated as A0270 minus 1, and two days prior to death is calculated as A0270 minus 2. For each hospice, we sum together all skilled nursing minutes provided on RHC days and divide by the sum of RHC days. This is an illustrative example for hospices to modify and develop their own forms that meet the content requirements at 418.24. Then, for each level of care separately, we proposed to further trim the sample of MCRs. As discussed in the FY 2016 Hospice Wage Index and Rate Update final rule (80 FR 47183), we implemented changes mandated by the IMPACT Act of 2014 (Pub. Section 1899B(g) of the Act requires that data and information regarding PAC provider performance on quality measures and resource use or other measures be made publicly available beginning not later than 2 years after the applicable specified application date. CMS is working to make the HQRP and CMSs other quality reporting programs more transparent to consumers and providers, enabling them to make better choices as well as promoting provider accountability around health equity. The wage index applicable for FY 2022 is available on our website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Wage-Index. Such comparative star ratings, as proposed by CMS, help consumers identify high and low performing hospices. on FederalRegister.gov They encouraged HHS to continue pursuing adoption of FHIR APIs for health IT vendors. (3) CMS may remove a quality measure from the Hospice QRP based on one or more of the following factors: (i) Measure performance among hospices is so high and unvarying that meaningful distinctions in improvements in performance can no longer be made. We will monitor HCI score trends to identify whether any regional or size-based variations suggest a need for measure revision. Final Decision: We are finalizing our proposal to use the CAR scenario for refreshes for January 2022 for OASIS-based measures and for refreshes from Start Printed Page 42598January 2022 through July 2024 for some claims-based measures. This revision to our labor share methodology results in upward revisions to the proposed labor shares for each of the levels of care (between 0.6 percentage point and 1.1 percentage point). The MAP conditionally supported the HCI for rulemaking contingent on NQF endorsement. They called for customer research on how the public would interpret the absence of star ratings as well as research on the extent to which the public understands how star ratings are calculated. This PDF is Under the Medicare hospice benefit, the election of hospice care is a patient choice and once a terminally ill patient elects to receive hospice care, a hospice interdisciplinary group is essential in the seamless provision of primarily home-based services. Registered Nurses Did Not Always Visit Medicare Beneficiaries Homes at Least Once Every 14 Days to Assess the Quality of Care and Services Provided by Hospice Aides. Hospices are only considered compliant if they meet the standards for HIS and CAHPS reporting, as codified in 418.312. The commenter also claimed that if it is based on no days being reported as contracted on Worksheet S-1, this assumption is also in error. Both the use of the pseudo-patient and targeted aide training align requirements between these two providers, home health and hospice, affording the opportunity for efficiency in implementation for many agencies that are Medicare certified to provide both services. In addition, national accreditation bodies with approved hospice accreditation programs are required to use the same survey form used by state and local survey agencies, which is currently the Form CMS-2567, on or after October 1, 2021. The individual measures show performance for only one process and do not demonstrate whether the hospice provides high-quality care overall, as an organization. Starting with FY 2013 (and in subsequent FYs), the market basket percentage update under the hospice payment system referenced in sections 1814(i)(1)(C)(ii)(VII) and 1814(i)(1)(C)(iii) of the Act are subject to annual reductions related to changes in economy-wide productivity, as specified in section 1814(i)(1)(C)(iv) of the Act. However, for rural Puerto Rico, we would not apply this methodology due to the distinct economic circumstances that exist there (for example, due to the close proximity to one another of almost all of Puerto Rico's various urban and non-urban areas, this methodology would produce a wage index for rural Puerto Rico that is higher than that in half of its urban areas); instead, we would continue to use the most recent wage index previously available for that area. Hospices that fail to meet quality reporting requirements receive a 2 percentage point reduction to the annual hospice payment update percentage increase for the year. We believe that using the most current OMB delineations provides a more accurate representation of geographic variation in wage levels and do not believe it would be appropriate to allow hospices to be assigned a higher CBSA designation or to allow 1-year limited increase in hospice wage index payments for hospices only in the Montgomery County Metropolitan Divisions. documents in the last year, 37 Journal of Pain and Symptom Management, 50, 548-552. doi: 10.1016/j.jpainsymman.2015.05.001. We would note that the freestanding hospice MCR data was used to rebase the hospice payment rates effective for FY 2020 (84 FR 38487 to 38496). Therefore, we proposed to clarify in regulation that the date furnished must be within the required timeframe (that is, 3 or 5 days of the beneficiary or representative request, depending on when such request was made), rather than the signature date. Accessible via: http://www.medpac.gov/docs/default-source/reports/Mar09_Ch06.pdf?sfvrsn=0. In September 2020, we launched Care Compare, a streamlined redesign of eight existing CMS healthcare compare tools available on Medicare.gov, including Hospice Compare. However, providers with substantially higher percent of live discharge than their peers could signal a potential concern with quality of care or program integrity. A more broadly applicable measure (across settings, populations, or conditions) for the particular topic is available; 5. For the proposal to remove the 7 HIS measures from the HQRP, we do not propose any changes to the requirement to submit the HIS admission assessment since we continue to collect the data for these 7 HIS measures in order to calculate the more broadly applicable NQF # 3235, the Hospice and Palliative Care Composite Process MeasureHIS-Comprehensive Assessment Measure at Admission. These specifications will now be contained in the revised HQRP QM User's Manual V4.00 located on the CMS HQRP Current measures web page. The proposed methodology for calculating the labor shares cited by the commenter of using Worksheet A-1 and A-2 column 7, lines 26 through 37 for total labor costs reflects only one component of the proposed calculation of the labor share. COVID-19 Affected Reporting (CAR) Scenario: We calculated OASIS-based measures using 3 quarters of HH QRP CY 2019 data to simulate using only Q3 2020, Q4 2020, and Q1 2021 data for public reporting. We also have a dedicated email account, HospiceAssessment@cms.hhs.gov, for comments about HOPE. Response: We thank commenters for their support of this proposal on public reporting for refreshes affected by the exceptions. 2020. Response: We are currently conducting an experiment to test a new version of the survey, including the web mode of administration which may have an impact on response rates and the number of survey completes. Comment: A few commenters stated that providers should be protected against substantial payment reductions due to dramatic reductions in wage index values from one year to the next. However, there are distributional effects of the FY 2022 hospice wage index. FY 2023 Final Medicaid State/County Rate Charts (XLS) for every county in every state with all levels of care, based on the national Medicaid rates in Table 1 below. In the FY 2017 Hospice Wage Index and Rate Update final rule (81 FR 52156), we initiated a policy of applying a wage index standardization factor to hospice payments to eliminate the aggregate effect of annual variations in hospital wage data. on Both the Hospice and PAC PUFs provide information on services provided to Medicare beneficiaries by hospice providers. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. We encourage hospices to keep the letter they receive providing them with their CMS Certification Number (CCN). The cap amount for FY 2022 is $31,297.61 (FY 2021 cap amount of $30,683.93 increased by 2.0 percent). Fewer hospices, 2,328 (46.2 percent), would have had 30+ completes if 4 quarters of data were used to calculate scores and 1,970 (39.1 percent) would have 30+ completes if 3 quarters were used to calculate scores. This periodicity of updates aligns with most claims-based measures across PAC settings. MedPAC. Response: We acknowledge and appreciate the commenters' concerns regarding labor costs and understand the challenges created by the PHE. (2020). In the FY 2019 Hospice Wage Index and Rate Update final rule (83 FR 38622), we also adopted an eighth factor for removal of a measure. Results of this experiment will Start Printed Page 42575help to inform changes to the survey in the future. Each indicator equally affects the single HCI score, reflecting the equal importance of each aspect of care delivered from admission to discharge. In addition, the HCI and HOPE will complement each other, providing related but distinct information to providers and consumers to compare hospices. However, we also believe that we must strike a balance between the benefits of reporting fewer years of more timely data with the need to be more inclusive of smaller hospices, which MedPAC has found have higher live discharge rates than larger hospices. They suggested that the display of star ratings be delayed because CMS needs to provide additional opportunities for providers to learn about and comment on the details of the methodology. Given that HCI is scored relative to the national average, scores will be accounted for as part of the measure calculation. As discussed in the FY 2022 Hospice proposed rule (86 FR 19718) and above, we proposed to derive Direct patient care salaries and contract labor costs using (for CHC as an example) Worksheet A-1 column 7, lines 26 through 37 on the cost report, which would capture any staff transportation costs reported in these cost centers on Worksheet A-1. We further refined the HCI based on this feedback, focusing on those indicators with the strongest consistency with CAHPS Hospice scores and/or which quality experts have identified as salient issues for measurement and observation. 6. Therefore, we proposed to include direct patient care salaries and contract labor for social workers and counselors in the calculation of the labor shares. Comment: A few commenters questioned whether it is CMS's intent for the CAHPS to be the sole star rating vehicle for hospice care or whether there would be another star rating for HOPE measures when it is implemented? As with the NOE, the claims processing system must be notified of a beneficiary's discharge from hospice or hospice benefit revocation within 5 calendar days after the effective date of the discharge/revocation (unless the hospice has already filed a final claim) through the submission of a final claim or a Notice of Termination or Revocation (NOTR). The goal of hospice care is to help terminally ill individuals continue life with minimal disruption to normal activities while remaining primarily in the home environment. MedPAC reported that nearly half of Medicare hospice expenditures are for patients that have had at least 180 or more days on hospice, and expressed a concern that some programs do not appropriately discharge patients whose medical condition makes them no longer eligible for hospice services, or, that hospices selectively enroll patients with non-cancer diagnoses and longer predicted lengths of stay in hospice. The ten indicators, aggregated into a single HCI score, convey a broad overview of the quality of the provision of hospice care services and validates well with CAHPS Willingness to Recommend and Rating of this Hospice. The HIS Comprehensive Assessment Measure's all or none criterion requires hospices to perform all seven care processes in order to receive credit. 19. They stated in some instances, Medical Directors are employees and salaries would be reported; however, other hospices contract for this position. These changes may arise from revisions to the OMB delineations of statistical areas resulting from the decennial census data, periodic updates to the OMB delineations in the years between the decennial censuses, or other wage index policy changes. While CMS and other stakeholders have explored potential alternatives to the current CBSA-based labor market system, no consensus has been achieved regarding how best to implement a replacement system. Response: We appreciate commenters' concerns that HQRP measures will not be able to adequately differentiate hospices if they become topped out. We also understand why commenters might expect process measures to be prone to topping out. CMS has taken this into consideration in designing the HCI measure. Hospitalizations are found by looking at all fee-for-service Medicare inpatient claims. Our proposal for using the 90-day run-off strikes a balance between allowing time for hospices to make corrections to their claims, while also seeking to post more rather than less up-to-date information. As stated in the FY 2022 Hospice proposed rule (86 FR 19718 through 19719) and above, for purposes of calculating the IRC and GIP compensation cost weights, we excluded providers that reported costs greater than zero on Worksheet A-3, column 7, line 25 (Inpatient CareContracted) for IRC and Worksheet A-4, column 7, line 25 (Inpatient CareContracted) for GIP. OMB approved the proposal to replace the HVWDII measure with the HVLDL measure and remove Section O from the discharge assessment on February 16, 2021. We will also explore the feasibility of conducting a dry run of the star ratings with reporting to hospices via preview reports, which would occur prior to the start of the public display of the ratings. Response: As stated in the FY 2022 hospice proposed rule (86 FR 19717 through 19719) as well as above, we proposed that Direct patient care salaries and contract labor costs be equal to costs reported on Worksheet A-1 (for CHC) or Worksheet A-2 (for RHC) or Worksheet A-3 (for IRC) or Worksheet A-4 (for GIP), column 7, for lines 26 through 37 (86 FR 19718). The HQRP will post a revised QM Users' Manual that contains HCI and HVLDL no later than October 1, 2021 at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures. For each scenario, we divided hospices in quintiles based on their HIS Comprehensive Assessment Measure score, such that higher scores are in a higher quintile. 24. In the FY 2016 Hospice Wage Index and Rate Update final rule (80 FR 47142), CMS finalized two different payment rates for RHC: A higher per diem base payment rate for the first 60 days of hospice care and a reduced per diem base payment rate for subsequent days of hospice care. 49. We will continue to apply ideas shared by the Caregiver Workgroup participants as we refine plans for the measure's public display to minimize the risk of misinterpretation. This explanation must be clearly noted on the addendum itself, but is not required to be documented in both places. Hospices bill each day of CHC on a separate line item on the hospice claim. These results serve as evidence of the measure's reliability by indicating that a hospice's HCI scores would not normally fluctuate a great deal from one year to the next. Their response confirmed our understanding that the data included in HCI will be useful for patients and families as they compare and select hospice providers. These commenters requested that CMS further clarify that technology-based visits are permissible outside of a PHE under the same circumstances and conditions as under a PHE, provided applicable HIPAA requirements are met, and requested that CMS establish modifiers that can be used on claims to designate such visits. Because of quality implications for hospices who pursue such business models, the live discharge after long hospice enrollments was included in the index. For each scenario, we calculated the reportability as the percent of hospices meeting the 20-case minimum for public reporting (the public reporting threshold). For purposes of the RFA, we consider all hospices as small entities as that term is used in the RFA. CMS also finalized a service intensity add-on (SIA) payment payable for certain services during the last 7 days of the beneficiary's life. In accordance with the provisions of Executive Order 12866, this regulation was reviewed by OMB. However, patterns of variation across providers could signal less service provider availability and access for patients on weekends. If additional data points become available, CMS will consider modifying the measure in light of the new data. The FY 2022 hospice payment rates are effective for care and services provided on or after October 1, 2021, through September 30, 2022.