Late Tuesday, August 1, 2017 the final hospice rule – FY 2018 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements – was posted. The rule contains the FY2018 finalized payment rates, aggregate cap, and hospice quality reporting changes.  A Healthcare Provider Solutions, Inc. blog post on the FY2018 proposed rule was posted on April 27. There are not any surprises in the final rule as not much changed from the proposed rule.

On July 27, 2017 CMS released Transmittal 3813/Change Request (CR) 10064 – Accepting Hospice Notices of Election via Electronic Data Interchange. Hospices will be happy to hear that this CR will allow the submission of Notices of Election (NOEs) electronically effective January 1, 2018.

Below we will review the final rule and then address electronic processing of the Notice of Election (NOE).

FY2018 Final Rule

CMS did confirm in the final rule that Hospice Compare is slated to go live this month – August 2017. Each day we anxiously await more information which we will share when it becomes available.

CMS Concern – Certification Of Terminal Illness

In the proposed rule, CMS sought comment on amending regulations at 418.25 to specify that the referring physician’s and/or the acute/post acute care facility’s medical record would serve as the basis for initial hospice eligibility determinations and that a hospice’s Medical Director/hospice physician could make an in-person visit to gain information to be used in the initial hospice eligibility determination if needed. Numerous comments were submitted, and hospices should note that in the final rule CMS indicated that it plans to work with the Medicare Administrative Contractors (MACs) to confirm whether they are requesting comprehensive clinical information from hospices during medical review and if not whether such information should be included in the Additional Development Requests (ADRs). CMS reminded providers that a hospice’s admission assessment can accompany the certification of terminal illness; however, CMS expects that the findings of the admission assessment would support the terminal prognosis not establish it. Based on this, hospices should ensure they are gathering the clinical information that medical directors are currently required to consider for the certification of terminal illness. This information includes:

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

Payment Rates

For FY2018 the hospice payment update percentage was finalized at 1 percent with only one rate, the low (tier 1) routine home care rate, changing from what was proposed. This rate dropped by two cents between the final and proposed.The rates were not expected to change much from the proposed rates due to MACRA setting the increase at 1 percent. Tables depicting the final base rates for RHC and the remaining levels of care are below. These numbers represent the national base rate for each level of care not adjusted by CBSA. These also do not reflect the 2% annual payment update reduction for those hospices not meeting quality reporting submission requirement or not participating in the Hospice Quality Reporting Program. Those interested in seeing their specific area’s wage index can find it here.

Table 12: FY 2018 Hospice RHC Payment Rates

Aggregate Cap Amount

The hospice cap amount for the 2018 cap year will be $28,689.04.

NOTE: The FY2017 hospice cap year transitioned to the federal government fiscal year. The requirement that hospices completed their self-determined aggregate cap report five months after the end of the cap year means that this report will be due February 28, 2018.

Hospice Quality Reporting Program (HQRP)

No new HIS measures were proposed for addition and no measures were proposed for removal.

CMS commented on the two priority areas being considered for HQRP for future years. CMS is looking for claims based measures for both priority areas, and in response to comments received, indicated that even though there are some disadvantages to claims based measures the advantages outweigh the disadvantages.

  • Priority Area 1 – Potentially avoidable hospice care transitions• Priority Area 1 – Potentially avoidable hospice care transitionsCMS is looking to compare a hospice’s performance in this area to that of its peers and hopes to reduce the frequency of burdensome transitions that represent disruptions in continuity of care at a time when the patient and family are extremely vulnerable. While no specific measures were provided, CMS did state that expect to focus on live discharges from hospice followed by either death or acute care use during a short period of time.
  • Priority Area 2 –  Access to levels of hospice careThe goal of this measure concept is to assess the rates at which hospices provide different levels of hospice care and again would be a comparison of a hospice’s performance to that of its peers.  One of the concerns of a claims based measure for this area is that the claim only indicates if the hospice billed for the level of care not if the hospice has all of the levels of care available.  CMS responded that it will consider supplementing claims data with other data sources such as the presence of a contract with a hospital to provide general inpatient (GIP) care.  CMS is specifically looking at the GIP level of care and the continuous home care (CHC) level of care.

For the CAHPS Survey data submission, CMS finalized in previous rule that hospices must collect survey data monthly for each calendar year through 2018 to avoid the 2% annual payment update penalty. In the final rule, CMS is extended this methodology through calendar year 2020.

For the CAHPS Hospice Survey, CMS adopted eight survey-based measures for the CY 2018 data collection period and for subsequent years. These eight measures are comprised of six CAHPS Hospice Survey composite measures and two global measures as follows:

Six composite measures:

  • Hospice Team Communication
  • Getting Timely Care
  • Treating Family Member with Respect
  • Getting Emotional and Religious Support
  • Getting Help for Symptoms
  • Getting Hospice Care Training

Two global measures:

  • Rating of Hospice
  • Willingness to Recommend Hospice

CMS also finalized that CAHPS Hospice Survey scores for a given hospice be displayed as “top-box” scores, with the national average top-box score for participating hospices provided for comparison. Top-box scores reflect the proportion of caregiver respondents that endorse the most positive response(s) to a given measure, such as the proportion that rate the hospice a 9 or 10 out of 10, or the proportion that report that they “always” received timely care. The top-box numerator for each question within a measure is the number of respondents that endorse the most positive response(s) to the question. The denominator includes all respondents eligible to respond to the question, with one exception. The exception is the Getting Hospice Care Training measure; for this measure, the measure score is calculated only among those respondents who indicated that their family member received hospice care at home or in an assisted living facility.

As stated above, public reporting of hospice quality data will begin in August 2017. Hospice Compare will include only HIS data to begin. CMS will incorporate Hospice CAHPS survey data in Hospice Compare in winter 2018. This data will begin with survey results from patients who died between April 1, 2015 to March 31, 2017 and will be based on 8 rolling quarters of data. If less than 30 completed CAHPS hospice surveys are returned for a hospice, data will not be displayed in Hospice Compare. Data will be updated for Hospice Compare quarterly.

The proposal to extend the time period a hospice has to submit a request for an extension/exemption of the timely submission of data/participation in HQRP from 30 days to 90 days was finalized. This is effective with FY2019 payment determination timeframes for HIS and CAHPS hospice survey.

Comprehensive Patient Assessment Instrument – HEART

In last year’s proposed rule CMS solicited comments on the use of a comprehensive patient assessment tool in hospice – Hospice Evaluation & Assessment Reporting Tool (HEART). In this year’s proposed rule, CMS indicated it is in the early stages of the development of HEART. Even though CMS previously stated that HEART would serve two primary objectives:

  1. Provide the quality data necessary for HQRP requirements and the current function of the HIS
  2. Provide additional clinical data that could inform future payment refinements

Comments in the final rule clearly show that CMS is not, at this time, focused on using HEART for payment refinements.


CR 10064 updates the Medicare Claims Processing Manual, Chapter 11, Section 20.1 as of July 27, 2017. Changes are effective January 1, 2018. Hospices will use the claim format for submitting the NOE electronically. CMS considers the NOE a notification only even though it is identified via a claim type (81A, 82A). The changes to chapter 11 add explanation for what is required on the NOE and outlines exceptions to the 5-day timely filing requirements for the NOE.

In addition to information about the NOE, there is information about the NOTR – Notice of Termination or Revocation. CMS clarifies that an NOTR should not be used when a patient transfers. Note: If the beneficiary transferred to your hospice during the benefit period, the From date should reflect the date of transfer. Condition codes are not required on an original NOTR. If the hospice is correcting a revocation date using occurrence code 56, the hospice reports condition code D0. If the two codes are not reported together, the NOTR will be returned to the hospice. Hospices may submit an NOTR that corrects a revocation date previously submitted in error. In this case, the hospice reports the correct revocation date in the To Date field and reports the original revocation date using occurrence code 56.

This CR included important changes to other sections of Chapter 11 including the following:

20.1 – Procedures for Hospice Election and Related Transactions

  • 20.1.1 – Notice of Election (NOE)
  • 20.1.2 – Notice of Termination/Revocation (NOTR)
  • 20.1.3 – Change of Provider/Transfer Notice
  • 20.1.4 – Cancellation of an Election
  • 20.1.5 – Change of Ownership Notice

Hospices are encouraged to read these changes, which are indicated in red in the CR, carefully and plan accordingly.

HPS will be hosting our annual two-day Hospice Alliance workshop this month!  SPACE IS LIMITED so be sure to register as soon as possible.