NAHC-NHPCO Alliance Comments on Hospice CARE Act

WASHINGTON & ALEXANDRIA, Virginia—The NAHC-NHPCO Alliance submitted a comment letter to the office of Rep. Earl Blumenauer (OR-3) on the discussion draft of the Hospice Care Accountability, Reform, and Enforcement Act (Hospice CARE Act), along with an overview and section-by-section summary. 

The Hospice CARE Act focuses on hospice payment reform and program integrity. The two trade organizations said they have worked closely with Blumenauer for years on these issues and are committed to continuing the dialogue to secure optimal outcomes for hospice providers and the continued delivery of quality care for patients and their families.

The NAHC-NHPCO Alliance said it recognizes the need for increased program integrity to combat bad actors while striving to ensure that access to care is not negatively impacted or that undue burdens are placed on quality providers. The Alliance submitted a draft outline of comments following roundtables with its members and anticipate additional conversations with congressional stakeholders in response to the formal comment submissions.

“While some of our provisional positions on a handful of the proposals are listed as “oppose”, we want to stress that we are intent on, and eager to, engage in further productive discussions about how best to address the issues or challenges that such proposals are intended to respond to,” the Alliance said in the comment letter. “We affirm that we are not reflexively resistant to significant changes, but rather must have sufficient time to evaluate their potential impacts in order to avoid potential future negative unintended consequences on patients, families and hospices.”

The letter addresses the Alliance’s desire to ensure the integrity of hospice care and payment reforms for hospice care under the Medicare program. 

The Alliance’s comments regarding the integrity of hospice care

• Subsection (a). Mandatory Temporary Moratorium on Enrollment: 
  • (1) Moratoria—Support with modification
  • (2) Prepayment medical review during moratoria—Support with modification
  • (3) Revalidation—Support with modification
  • (4) Publication of ownership and managing control information—Support with modification
  • (5) Report to Congress on hospice ownership—Support with modification
• Subsection (b). Authority to Extend Oversight of Newly-Enrolled Hospice Programs
  • (6) Authority to extend oversight period for newly enrolled hospices—More information needed before developing position 
• Subsection (c). Increase Survey Frequency for Certain Hospice Programs
  • (7) Increased surveys for new hospices and those five years or “younger”—More information needed before developing a position
• Subsection (d). Prohibition on Payment for Failure to Meet Quality Data Reporting Requirements 
  • (8) Prohibiting all payment to hospice programs that fail to meet quality data reporting requirements—Support with modification
• Subsection (e). Independence of Attending Physician
  • (9) Prohibiting a physician that is employed by or has an ownership, financial, or contractual relationship with a hospice program from certifying terminal illness for a patient at that hospice for the initial 90-day election period through the role of the patient’s attending physician—Oppose
• Subsection (f). Allowing Nurse Practitioners to Certify Terminal Illness
  • (10) Allowing nurse practitioners (NPs) to certify terminal illness—Support with modification
• Subsection (g). Allowable Use of Supporting Materials in Medicare Review of Hospice
  • (11) Requirement for medical reviewers to use medical documentation from the hospice patient’s attending physician—Oppose
• Subsection (h). Inclusion of Hospice Care as a Designated Health Service 
  • (12) Requiring hospices be subject to the requirements of physician self-referral law (the so-called “Stark” law)—More information needed before developing a position
• Subsection (i). Prohibition on Certain Changes in Majority Ownership 
  • (13) Extending the 36-month change of majority ownership (CHOW) rule to 60 months—Oppose
• Subsection (j). Medical Review of Hospice Outliers and Care Unrelated to Terminal Condition 
  • (14) Medical review of claims from hospices with outlier utilization patterns—Oppose
  • (15) Medical review of claims from non-hospice providers for “unrelated” care—More information needed before developing a position 
• Subsection (k). Required Provision of Addendum of Non-Covered Services 
  • (16) Required provision of the addendum of non-covered services to all patients—More information needed before developing a position
• Subsection (l). Provision of Explanation of Benefits Upon Hospice Election 21 
  • (17) Provision of explanation of benefits (EOB) upon hospice election—Support with modification
• Subsection (m). Medical Review of Hospice Care Contractor Requirements 
  • (18) Required training for hospice medical review contractors—Support
  • (19) Report to Congress on hospice medical review activities—Support
• Subsection (n). Requiring Face-to-Face Encounters Before Recertification of Terminal Illness
  • (20) Requiring a face-to-face (F2F) recertification visit before all recertification periods, only allowing these F2F visits to be performed no more than 10 days before such recertification periods and prohibiting F2F visits from being performed via telehealth—Oppose
• Subsection (o). Ensuring Medical Director and Physician Availability 
  • (21) Requirement for immediate availability of the hospice medical director or physician—More information needed before developing a position
  • (22) Prohibition on physicians serving as the medical director for more than two hospices—Support with modification

The Alliances comments on the payment reforms for hospice care under the Medicare program

• Subsection (a). Adjusted Payment for Hospice Care 
  • (23) Align hospice payment rates to the costs of providing care—Oppose
  • (24) Creation of new blended per-diem + “per-visit” payment structure for RHC—Oppose
  • (24) Creation of new blended per-diem + “per-visit” payment structure for RHC—Support with modification
  • (26) Requirement that the plan of care for high-cost palliative treatments be reviewed by an independent oncologist or nephrologist—More information needed before developing a position
  • (27) Removing payment coverage of home health aide and homemaker services from the hospice benefit for hospice patients residing in a skilled nursing facility or nursing facility—Oppose
  • (28) Outlier payments for RHC—Oppose
  • (29) Update the aggregate cap calculation to account for the other payment changes in the draft legislation—Oppose
• Subsection (b). Wage Adjusting Caps 
  • (30) Wage-adjustment of the aggregate cap—More information needed before developing a position
  • (31) Reducing the aggregate cap by the sequestration amount—Oppose
• Subsection (c). Modification of Requirements Relating to ShortTerm Inpatient Care
  • (32) Changes Inpatient Respite Care (IRC) level of care to only allow five IRC days in a given benefit period—Oppose
  • (33) Adding coverage of a transitional inpatient respite care period of an additional 15 days—Support with modification
  • (34) Reduces the current inpatient day cap from 20% of a hospice’s total Medicare patient care days to 10%—More information needed before developing a position
  • (35) Requiring that days that a patient receives palliative chemotherapy, radiation, transfusions, or dialysis would count towards the overall cap on inpatient days—More information needed before developing a position
• Subsection (d). Hospital Discharge Planning Requirements 
  • (36) Requiring hospitals to include more information and education about hospice in a patient’s discharge planning evaluation—Support with modification 
• Subsection (e). Payment for Respite Care Furnished in the Home 
  • (37) Creation of a short-term in-home respite level of care—Support with modification

Topics not addressed in the draft bill that the Alliance said should be considered

• Special Focus Program (SFP) Fixes
• Eliminate the Medicaid room-and-board pass through requirement and have Medicaid NF payment made directly to the NF. 
• Provide funding for hospice interoperability initiatives 
• Tracking of and reimbursement for chaplain services
• Late Referral/Admissions to Hospice Study
• Upstream incentives to support more awareness of and timely access to hospice and palliative care incentives 

Visit the NAHC-NHPCO Alliance’s full comment letter to read its reasoning, questions and concerns, considerations and recommendations regarding each of the sections and subsections. 

The National Association for Home Care & Hospice (NAHC) and the National Hospice and Palliative Care Organization (NHPCO) have joined together under the “NAHC-NHPCO Alliance.” The Alliance represents the majority of quality hospice providers across the country who are committed to supporting patients and families at the end of life.