On the evening of April 8th, the Centers for Medicare & Medicaid Services (CMS) released the fiscal year (FY) 2022 proposed rule for hospices. This proposed rule includes the annual payment and quality reporting updates, a request for feedback on hospice utilization, and a proposal to make certain blanket waivers permanent that were adopted in response to the COVID-19 pandemic.
Comments on the proposed rule are due on June 7, 2021.
CMS Predicts Increase in Hospice Payments for FY 2022
For FY 2022, CMS proposes a hospice payment update of 2.3 percent. Overall, CMS estimates that payments to hospices will increase by $530 million in FY 2022, as compared to FY 2021. The proposed hospice cap amount for FY 2022 is $31,389.06, which is the FY 2021 amount updated by the 2.3 percent FY 2022 hospice payment update. CMS proposes the following hospice payment rates:
Proposed FY 2022 Hospice RHC, CHC, IRC, and GIP Payment Rates
| Code | Description | FY 2021 Payment Rates | Proposed FY 2022 Payment Rates |
| 651 | Routine Home Care (days 1-60) | $199.25 | $203.81 |
| 651 | Routine Home Care (days 61+) | $157.49 | $161.02 |
| 652 | Continuous Home Care
Full Rate = 24 hours of care |
$1,432.41
($59.68 per hour) |
$1,465.79
($61.07 per hour) |
| 655 | Inpatient Respite Care | $461.09 | $474.43 |
| 656 | General Inpatient Care | $1,045.66 | $1,070.35 |
These rates would apply to hospices that submit the required quality data. Source: CMS.
In this rule, CMS proposes to rebase the labor shares for continuous home care (CHC), routine home care (RHC), inpatient respite care (IRC), and general inpatient care (GIP) using Medicare cost report data for freestanding hospice facilities from 2018.
Proposed and Current Labor shares by Level of Care
| Proposed Labor shares | Current Labor shares | |
| Continuous Home Care | 74.6% | 68.71% |
| Routine Home Care | 64.7% | 68.71% |
| Inpatient Respite Care | 60.1% | 54.13% |
| General Inpatient Care | 62.8% | 64.01% |
Source: CMS.
Finally, CMS proposes that hospices will be allowed to provide the election statement addendum within 5 days of the request from a beneficiary of the beneficiary’s representative if that request is within 5 days of the day of hospice election.
Feedback Requested on Hospice Utilization
CMS includes in the proposed rule an analysis of hospice utilization, noting the number of Medicare beneficiaries that receive hospice services has grown from around 580,000 individuals in FY 2001 to over 1.6 million in FY 2019. In this time, expenditures have risen from $3.5 billion to approximately $20 billion. The analysis also included the top hospice diagnoses and an analysis of length of stay and levels of care. In light of this analysis, CMS solicits feedback on the following topics:
- How changes in patient characteristics and diagnoses may have influence how care is provided;
- What factors determine how and when skilled visits are made as an individual approaches the end of life;
- What factors influence whether or how certain services are provided; and
- Whether the hospice election statement addendum has altered how hospices make care decisions.
CMS Proposes Making Two Blanket Waivers Permanent
CMS proposes to make certain blanket waivers that were issued in response to the COVID-19 pandemic permanent. These are:
- Revising the hospice aide competency evaluation requirement to allow for the use of pseudo-patients; and
- Conducting a competency evaluation on deficient and related skills if a hospice verifies a supervising nurse’s finding of an area of concern in the performance of a hospice aide.
CMS Proposes New Hospice Quality Measure, Introduction of Star Ratings for Hospices
Beginning with FY 2022, CMS proposes removing the seven process measures in the Hospice Item Set (HIS) from the Hospice Quality Reporting Program (HQRP). CMS states that the currently used HIS Comprehensive Assessment Measure is a more broadly applicable measure and includes a criterion that requires hospices to perform all seven care processes.
The agency notes that the proposal is to remove the seven process measures but does not change the requirement to submit the HIS admission assessment. A hospice that does not report the HIS data used for the HIS Comprehensive Assessment Measures will then not be compliant with HQRP requirements. CMS does note that the agency is continuing to develop the patient assessment instrument, Hospice Outcomes & Patient Evaluation (HOPE), which the agency anticipates will eventually replace the HIS.
CMS also proposes a new hospice measure, called the Hospice Care Index, which is comprised of ten indicators calculated from Medicare claims data that represent different aspects of hospice services. These indicators will represent the difference aspects of hospice service, which CMS believes will provide a comprehensive characterization of hospices, instead of a characterization based on a single care dimension. This new measure would be added to the HQRP starting in FY 2022, with public reporting beginning no earlier than May 2022.
CMS proposes to introduce Star Ratings for public reporting of CAHPS Hospice Survey results on the Care Compare or successor website, beginning no sooner than FY 2022. Calculation of the CAHPS Hospice Survey Star Ratings would be comparable to other CAHPS Star Ratings programs and would range from one to five, with five stars being the best rating. Scores would be based on the top-box score for each of the eight CAHPS Hospice Survey measures.
CMS is soliciting comments on all of their proposals and is also requesting information on the following topics related to the HQRP:
- Advancing digital quality measurement;
- Use of Fast Healthcare Interoperability Resources (FHIR); and
- Health equity.
The request for information (RFI0 on health equity comes in response to Executive Order 13985, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, which was signed by President Biden in the first days of his administration. This mirrors similar RFIs included in the recently released proposed rules for inpatient rehabilitation facilities, inpatient psychiatric facilities, and skilled nursing facilities.
Changes to Publicly Displayed Quality Data Proposed in Response to COVID-19 Public Health Emergency
In response to the COVID-19 PHE, CMS chose to freeze the quarterly refresh of publicly displayed hospice quality data, planning to hold the data constant after the November 2020 refresh (which included data from all four quarter of 2019). CMS now proposes to use three quarters of HIS data for the final impacted public reporting refresh of the Care Compare site (February 2022). Data from Q3 2020, Q4 2020, and Q1 2021 data would be displayed beginning February 2022 instead of continuing to display the data from the November 2020 freeze (Q1 through Q4 2019). For CAHPS data, CMS proposes to display the most recent eight quarters of CAHPS Hospice Survey data, excluding Q1 and Q2 2020. This would start with the February 2022 refresh.
Hospice Rule Includes Proposal for Home Health Quality Reporting Program
For the January 2022 through July 2024 public reporting refresh cycle, CMS proposes to report fewer quarters of data for the Home Health Quality Reporting Program (HH QRP) in response to the COVID-19 public health emergency (PHE) exceptions granted in March 2020. As the home health rulemaking cycle runs on a calendar year, CMS is using the hospice proposed rule to make this proposal in order to ensure the policy is finalized far enough in advance of any future data refresh.