The FY 2019 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements proposed rule was recently made available. The proposed rule is released every year around this time with opportunity for public comment and CMS review of those comments prior to release of the final rule around the end of July and beginning of August. Below is a summary of the proposed rule. In addition to this summary, Healthcare Provider Solutions, Inc. is planning future Blog articles with more detailed information about the quality reporting program updates and comments in the proposed rule.

There were no major surprises in the proposed rule related to FY2019 hospice payments. CMS continues, however, to analyze data from hospice cost reports to inform future payment reforms and policy. Of concern is the fact that CMS found 66% of hospice cost reports would have been rejected had certain edits been in place. The edits, Level I edits, require data values to be entered for ten specified lines on the cost report including Volunteer Services Coordination, Pharmacy, Lab Diagnostics and Plant Operations and Maintenance. The need for complete and accurate information on cost reports could not be more serious.

As part of its analysis of the available cost report data, CMS notes that base payments for the routine home care level of care are higher than costs and base payment rates for other levels of care are lower than costs. CMS made note of this last year too.

CMS also continues its analysis of data utilization and shared current trends as outlined below.

Length of stay:

  • Length of stay remained virtually the same between FY2016 and FY2017
  • Average length of stay for FY2017 was 79.7 days essentially the same as in FY2016 but up from 78.1 days in FY2015
  • Lifetime length of stay in FY2017 was 96.2 days
  • Median length of stay has remained the same over the years at 18 days

Live Discharges:

  • 16.7 percent of all discharges in FY2017 were live discharges – a slight decrease from the previous year
    • 45% beneficiary no longer terminally ill
    • 44% revocations
    • 9% transfers
  • Breakdown of when live discharges occurred
    • 22% days 1-30 of hospice care
    • 10% days 31-60
    • 14% days 61-90
    • 20% days 91-180
    • 35% days 181+
  • CMS noted significant variations in live discharges when comparing these discharges among hospices with 50 or more total discharges, as seen in the table below.








Skilled Visits in Last Days of Life:

CMS continues to have concerns that hospice patients may not be receiving the visits commensurate with symptom burden at end of life, particularly the last week of life. A service intensity add-on (SIA) payment was implemented in FY2016 for skilled visits during the last days of life, in part, to incentivize hospices to make more visits during this time. Additionally, two quality measures – Hospice Visits When Death is Imminent and Hospice and Palliative Care Composite Process Measure – were incorporated in the hospice quality reporting program. FY2017 claims data showed an incremental improvement in visits during this time with 20% of beneficiaries not receiving a skilled visit on the day of death.

Non-hospice Spending:

Non-hospice spending for Part A and Part B items and services has decreased each year since CMS began reporting these findings. Overall, from FY 2011 to FY 2017 non-hospice Medicare spending for Parts A and B during hospice election declined 23 percent. However, there continues to be a non-trivial amount of non-hospice Parts A and B spending on beneficiaries under a hospice election, and CMS will continue to monitor data regarding this issue.

Specific to Medicare Part D drug spending during a hospice election, there has been a decrease in the total dollar amount spent on the four categories of medications that are subject to the prior authorization process – analgesics, anti-nauseants, anti-anxiety, and laxatives. However, there has been an increase in spending on maintenance drugs – beta blockers, calcium channel blockers, corticosteroids, and insulin.

Hospices should be sure to thoroughly analyze whether there are medications, DME, supplies, or services that are related to the patient’s terminal prognosis and reasonable and necessary but not being paid for by the hospice provider.




CMS sought feedback on relieving regulatory burden last year and has acted upon one recommendation in particular and that is detailed line item reporting on hospice claims for drugs and infusion pumps. After determining that this information is not currently used for quality, payment, or program integrity purposes, CMS removed this requirement effective October 1, 2018. This is when hospices will have two options for reporting hospice drug information.

  • Option #1: Continue to report infusion pumps and drugs, with corresponding NDC information, on the hospice claim as separate line items
  • Option #2: Submit total, aggregate DME and drug charges on the claim

CMS released a change request, CR 10573, on April 27, 2018 providing details of these options.


The Bipartisan Budget Act of 2018 amended the Social Security Act such that physician assistants (PA) will be recognized as designated hospice attending physicians, in addition to physicians and nurse practitioners. PA is defined as: a professional who has graduated from an accredited physician assistant educational program who performs such services as he or she is legally authorized to perform (in the state in which the services are performed) in accordance with state law (or state regulatory mechanism provided by state law) and who meets the training, education, and experience requirements as the Secretary may prescribe.

Medicare beneficiaries will be able to choose a PA as their attending physician beginning January 1, 2019.

PAs Cannot:

  • Certify or recertify a hospice patient
  • Conduct F2F encounters
  • Fulfill the physician role on the Interdisciplinary Group (IDG)

PA services that are reasonable and necessary for beneficiaries who elect the PA as their attending will be paid by Medicare at 85% of the physician fee schedule.


No new measures were proposed for FY2019. There were comments related to CMS’ ongoing consideration of social risk factor adjustments to quality measures and impact on the quality reporting program. CMS will continue to analyze data coming from the National Quality Forum (NQF) and other sources in this area.

Updates to Hospice Compare

The Hospice and Palliative Care Composite Process Measure results will be added to Hospice compare in Fall 2019.

The results for the Hospice Visits When Death is Imminent paired measure will be added at a later time in 2019. However, CMS did not give a specific date. It indicated that further analysis is needed, and the measure is not yet approved by the NQF.

CMS proposed an additional measure removal factor, “the costs associated with a measure outweighs the benefit of its continued use in the program”.

CMS plans to remove from Hospice Compare the direct display of the current seven HIS measures after the Hospice and Palliative Care Composite Process Measure results are added to Compare. CMS believes the composite measure provides consumers “a more accessible measure for evaluating the quality of a hospice”. The current seven HIS measures will still be available to consumers via a drop-down box but would not be directly displayed.

CMS is proposing to add Hospice Utilization and Payment Public Use File (Hospice PUF) data to Hospice Compare. The PUF data is derived primarily from hospice claims and the most current PUF data is from FY2015. The data would be in a segregated section of Compare as it contains information not quality measures.

CMS also proposes to align the amount of time hospice providers have to review and correct data with that of post-acute care entities. This is 4.5 months after the end of each calendar year quarter. No changes would be made to the existing HIS timeframe for modifying records, which is 36 months.

There is a proposal to continue the CAHPS exemption for size (less than 50 survey-eligible decedents served in a year) through FY2023 and all future years. Likewise, CMS proposes to extend the CAHPS exemption for newness through FY2023 and future years. The newness exemption exempts hospices that were notified about their Medicare CCN after January 1 from the CAHPS requirements for the corresponding payment year.


In addition to payment and policy proposals, CMS is releasing a Request for Information (RFI) to obtain feedback on positive solutions to better achieve interoperability or the sharing of healthcare data between providers. Specifically, CMS is requesting stakeholder feedback through a RFI on the possibility of revising Conditions of Participation related to interoperability as a way to increase electronic sharing of data by providers. This will inform next steps to advance this critical initiative.

In responding to the RFI, commenters should provide clear and concise proposals that include data and specific examples. CMS will not respond to RFI comment submissions in the final rule, but rather will actively consider all input in developing future regulatory proposals or future sub-regulatory guidance.

As stated in the beginning of this article, HPS will have more detailed information about the proposed rule in future Blog articles. Submit any questions you may have using the “Send a Message to Author” option below.