Wednesday Feature: Hospice Proposed Rule for 2025

Happy Hump Day! As I wrote in a post on Monday regarding CMS’ Proposed Rule for SNFs, ’tis the season. This time of year, is when CMS drops proposed changes to reimbursement and other programmatic elements for all provider types, save Home Health which comes a little later (Home Health rate year is calendar year whereas other PPS providers and Hospice follow the Federal Fiscal Year of October 1). Late last week CMS dropped a Fact Sheet with proposed changes to the Medicare Hospice program, including rates. Yesterday, the Proposed Rule text was published. It (the text of the rule) is available here: Hospice Proposed Rule 2025  For folks wanting the “Cliff Note” version, the Fact Sheet is available via this link: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2025-hospice-payment-rate-update-proposed-rule-cms-1810-p

As I reviewed the Proposed Rule, I didn’t catch very many significant changes from the 2024 Final Rule (https://rhislop3.com/2023/08/07/hospice-2024-final-rule-and-home-health-update-preserving-access-legislation/)   other than an adoption of the most recent statistical area delineations per the OMB (Mangement and Budget). The policy modifies existing rural and metropolitan (urban) statistical areas impacting the geographic wage index for Medicare payments.

Hospices affected by the change to their geographic wage index by the policy would be able to apply for a 5%-cap on any decrease to the wage index from the previous year. The cap was finalized in FY 2023 to prevent a geographic area’s wage index from dipping below 95% of its previous wage index.

CMS is proposing a 2.6% hospice payment increase for the fiscal year (FY) 2025, adding about $705 million to payments ins 2025 vs. 2024. The Proposed Rule calculates the increase via a 3.0% market basket percentage increase less a 0.4 percentage point productivity adjustment. Hospices that do not submit required quality data will face a penalty of a -1.4% update.  See below for the rate tables proposed for 2025.

As Hospice followers and readers know, hospices are subject to two payment caps. For 2025, CMS proposes the aggregate cap amount to factor at $34,364.85 per Medicare patient. The IMPACT Act of 2014 changed the cap calculation formula such that each year, the new per beneficiary amount inflates at the same percentage as the rate change.

The aggregate cap calculation is a function of the hospice taking all Medicare reimbursements paid on behalf of patients and dividing by the number of Medicare patients in a given fiscal year.  For 2024, as long as the total per beneficiary as calculated is no more than $34,264.85, no dollars are returned to Medicare.

The inpatient cap remains the same, standing at no more than 20% of all Medicare days paid to the hospice. Simply put, out of the total of reimbursed days, no more than 20% can be at the General Inpatient Level (GIP). Additional days over the 20% must be repaid to Medicare (net of the routine home care rate).

The rule also contains a regulatory “tweak” concerning patient certification requirements and who can provide the written certification (likely to die within six months). The current language states that the Hospice Medical Director and/or physician designee can provide the certification. CMS is proposing to add language allowing a physician member of the hospice IDG (interdisciplinary group) as another approved certifier.

In terms of the Hospice Quality Reporting Program (HQRP), the proposed rule would add two new process measures — Timely Reassessment of Pain Impact and Timely Reassessment of Non-Pain Symptom Impact, beginning in FY 2028. The measures are to use data from the new HOPE instrument. The rule proposes to adopt and implement the HOPE-level data collection tool starting in FY 2025, replacing the existing Hospice Item Set (HIS).

 With respect to the Hospice CAHPS Survey, the rule seeks to make a number of modifications. Recall, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey was designed to measure and review the experiences of patients who died while receiving hospice care, as well as the experiences of their informal primary caregivers. Specifically, the changes being proposed are:

• The addition of a web-mail mode (email invitation to a web survey, with mail follow-up to non-responders).
• A shortened and simplified survey.
• Modifications to survey administration protocols including a prenotification letter and extended field period.
• The addition of a new, two-item Care Preferences measure.
• Revisions to the existing Hospice Team Communication measure and the existing Getting Hospice Care Training measure.
• The removal of three nursing home items and additional survey items impacted by other proposed changes in this rule.