38622 Federal Register / Vol. 83, No. 151 / Monday, August 6, 2018 / Rules and Regulations 

1Meaningful Measures web page: https://

www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/QualityInitiativesGenInfo/ 

MMF/General-info-Sub-Page.html. 

2See Remarks by Administrator Seema Verma at 

the Health Care Payment Learning and Action 

Network (LAN) Fall Summit, as prepared for 

delivery on October 30, 2017: https://www.cms.gov/ 

Newsroom/MediaReleaseDatabase/Fact-sheets/ 

2017-Fact-Sheet-items/2017-10-30.html. 

3See section VIII.A.8.c. of the preamble of this 

final rule where we solicited comments on the 

potential future development and adoption of 

eCQMs. 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Part 418 

[CMS–1692–F] 

RIN 0938–AT26 

Medicare Program; FY 2019 Hospice 

Wage Index and Payment Rate Update 

and Hospice Quality Reporting 

Requirements 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Final rule. 

SUMMARY: This final rule updates the 

hospice wage index, payment rates, and 

cap amount for fiscal year (FY) 2019. 

The rule also makes conforming 

regulations text changes to recognize 

physician assistants as designated 

hospice attending physicians effective 

January 1, 2019. Finally, the rule 

includes changes to the Hospice Quality 

Reporting Program. 

DATES: These regulations are effective 

on October 1, 2018. 

FOR FURTHER INFORMATION CONTACT: 

Debra Dean-Whittaker, (410) 786– 

0848 for questions regarding the 

CAHPS® Hospice Survey. 

Cindy Massuda, (410) 786–0652 for 

questions regarding the hospice quality 

reporting program. 

For general questions about hospice 

payment policy, send your inquiry via 

email to: hospicepolicy@cms.hhs.gov. 

SUPPLEMENTARY INFORMATION: 

I. Executive Summary 

A. Purpose 

This final rule updates the hospice 

payment rates for fiscal year (FY) 2019, 

as required under section 1814(i) of the 

Social Security Act (the Act). This rule 

also revises the hospice regulations as a 

result of section 51006 of the Bipartisan 

Budget Act of 2018, which amended 

section 1861(dd)(3)(B) of the Act such 

that, effective January 1, 2019, physician 

assistants (PAs) will be recognized as 

designated hospice attending physicians 

in addition to physicians and nurse 

practitioners. Finally, this rule includes 

changes to the hospice quality reporting 

program (HQRP), consistent with the 

requirements of section 1814(i)(5) of the 

Act. In accordance with section 

1814(i)(5)(A) of the Act, hospices that 

fail to meet quality reporting 

requirements receive a 2 percentage 

point reduction to their payments. 

B. Summary of the Major Provisions 

Section III.B.1 of this rule updates the 

hospice wage index with updated wage 

data and makes the application of the 

updated wage data budget neutral for all 

four levels of hospice care. In section 

III.B.2 of this final rule, we discuss the 

FY 2019 hospice payment update 

percentage of 1.8 percent. Sections 

III.B.3 and III.B.4 of this final rule 

update the hospice payment rates and 

hospice cap amount for FY 2019 by the 

hospice payment update percentage 

discussed in section III.B.2 of this final 

rule. We also include regulations text 

changes in section III.C and section III.D 

pertaining to the definition of 

‘‘attending physician’’ and ‘‘cap 

period.’’ 

Finally, in section III.E of this rule, we 

discuss updates to the HQRP, including: 

Data review and correction timeframes 

for data submitted using the HIS; 

extension of the Consumer Assessment 

of Healthcare Providers and Systems 

(CAHPS®) Hospice Survey participation 

requirements, exemption criteria and 

public reporting policies to future years; 

procedures to announce quality measure 

readiness for public reporting and 

public reporting timelines; removal of 

routine public reporting of the 7 HIS 

measures; and public display of public 

use file data on the Hospice Compare 

website. 

C. Summary of Impacts 

The overall economic impact of this 

final rule is estimated to be $340 million 

in increased payments to hospices 

during FY 2019. 

D. Improving Patient Outcomes and 

Reducing Burden Through Meaningful 

Measures 

Regulatory reform and reducing 

regulatory burden are high priorities for 

CMS. To reduce the regulatory burden 

on the healthcare industry, lower health 

care costs, and enhance patient care, in 

October 2017, we launched the 

Meaningful Measures Initiative.1 This 

initiative is one component of our 

agency-wide Patients Over Paperwork 

Initiative,2 which is aimed at evaluating 

and streamlining regulations with a goal 

to reduce unnecessary cost and burden, 

increase efficiencies, and improve 

beneficiary experience. The Meaningful 

Measures Initiative is aimed at 

identifying the highest priority areas for 

quality measurement and quality 

improvement in order to assess the core 

quality of care issues that are most vital 

to advancing our work to improve 

patient outcomes. The Meaningful 

Measures Initiative represents a new 

approach to quality measures that 

fosters operational efficiencies, and it 

will reduce costs, including collection 

and reporting burden, while producing 

quality measurement that is more 

focused on meaningful outcomes. 

The Meaningful Measures Framework 

has the following objectives: 

• Address high-impact measure areas 

that safeguard public health; 

• Patient-centered and meaningful to 

patients; 

• Outcome-based where possible; 

• Fulfill each program’s statutory 

requirements; 

• Minimize the level of burden for 

health care providers (for example, 

through a preference for EHR-based 

measures where possible, such as 

electronic clinical quality measures 3); 

• Significant opportunity for 

improvement; 

• Address measure needs for 

population based payment through 

alternative payment models; and 

• Align across programs and/or with 

other payers. 

In order to achieve these objectives, 

we have identified 19 Meaningful 

Measures areas and mapped them to six 

overarching quality priorities as shown 

in the Table 1 below. 


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TABLE 1—MEANINGFUL MEASURES

Quality priority Meaningful measure area 

Making Care Safer by Reducing Harm Caused in the Delivery of Care Healthcare-Associated Infections. 

Preventable Healthcare Harm. 

Strengthen Person and Family Engagement as Partners in Their Care Care is Personalized and Aligned with Patient’s Goals. 

End of Life Care according to Preferences. 

Patient’s Experience of Care. 

Patient Reported Functional Outcomes. 

Promote Effective Communication and Coordination of Care ................. Medication Management. 

Admissions and Readmissions to Hospitals. 

Transfer of Health Information and Interoperability. 

Promote Effective Prevention and Treatment of Chronic Disease .......... Preventive Care. 

Management of Chronic Conditions. 

Prevention, Treatment, and Management of Mental Health. 

Prevention and Treatment of Opioid and Substance Use Disorders. 

Risk Adjusted Mortality. 

Work with Communities to Promote Best Practices of Healthy Living .... Equity of Care. 

Community Engagement. 

Make Care Affordable .............................................................................. Appropriate Use of Healthcare. 

Patient-focused Episode of Care. 

Risk Adjusted Total Cost of Care. 

By including Meaningful Measures in 

our programs, we believe that we can 

also address the following cross-cutting 

measure criteria: 

• Eliminating disparities; 

• Tracking measurable outcomes and 

impact; 

• Safeguarding public health; 

• Achieving cost savings; 

• Improving access for rural 

communities; and 

• Reducing burden. 

We believe that the Meaningful 

Measures Initiative will improve 

outcomes for patients, their families, 

and health care providers while 

reducing burden and costs for clinicians 

and providers as well as promoting 

operational efficiencies. 

We received numerous supportive 

comments from stakeholders regarding 

the Meaningful Measures Initiative and 

the impact of its implementation in 

CMS’ quality programs. Many of these 

comments pertained to specific program 

proposals, and are discussed in the 

appropriate program-specific sections of 

this final rule. Commenters also 

provided insights and recommendations 

for the ongoing development of the 

Meaningful Measures Initiative. We look 

forward to continuing to work with 

stakeholders to refine and further 

implement the Meaningful Measures 

Initiative, and will take commenters’ 

insights and recommendations into 

account moving forward. 

E. Advancing Health Information 

Exchange 

The Department of Health and Human 

Services (HHS) has a number of 

initiatives designed to encourage and 

support the adoption of interoperable 

health information technology and to 

promote nationwide health information 

exchange to improve health care. The 

Office of the National Coordinator for 

Health Information Technology (ONC) 

and CMS work collaboratively to 

advance interoperability across settings 

of care. 

The Improving Medicare Post-Acute 

Care Transformation Act of 2014 

(Pub. L. 113 185) (IMPACT Act) requires 

assessment data to be standardized and 

interoperable to allow for exchange of 

the data among post-acute providers and 

other providers. To further progress 

toward the goal of interoperability, we 

are developing a Data Element Library 

to serve as a publically available 

centralized, authoritative resource for 

standardized data elements and their 

associated mappings to health IT 

standards. These interoperable data 

elements can reduce provider burden by 

allowing the use and reuse of healthcare 

data, support provider exchange of 

electronic health information for care 

coordination, person-centered care, and 

support real-time, data driven, clinical 

decision making. Once available, 

standards in the Data Element Library 

can be referenced on the CMS website 

and in the ONC Interoperability 

Standards Advisory (ISA). 

The 2018 Interoperability Standards 

Advisory (ISA) is available at: https://

www.healthit.gov/standards-advisory. 

Most recently, the 21st Century Cures 

Act (Pub. L. 114–255), enacted in 2016, 

requires HHS to take new steps to 

enable the electronic sharing of health 

information, ensuring interoperability 

for providers and settings across the 

care continuum. Specifically, the 

Congress directed ONC to ‘‘develop or 

support a trusted exchange framework, 

including a common agreement among 

health information networks 

nationally.’’ This framework (https://

beta.healthit.gov/topic/interoperability/ 

trusted-exchange-framework-andcommon-agreement) sets out a common 

set of principles for trusted exchange 

and minimum terms and conditions for 

trusted exchange in order to enable 

interoperability across disparate health 

information networks. In another 

important provision, the Congress 

established new authority for HHS to 

discourage ‘‘information blocking’’, 

defined as practices likely to interfere 

with, prevent, or materially discourage 

access, exchange, or use of electronic 

health information. We suggested that 

hospice providers learn more about 

these important developments and how 

they are likely to affect hospices. 

II. Background 

A. Hospice Care 

Hospice care is a comprehensive, 

holistic approach to treatment that 

recognizes that the impending death of 

an individual, upon his or her choice, 

warrants a change in the focus from 

curative care to palliative care for relief 

of pain and for symptom management. 

Medicare regulations define ‘‘palliative 

care’’ as patient and family-centered 

care that optimizes quality of life by 

anticipating, preventing, and treating 

suffering. Palliative care throughout the 

continuum of illness involves 

addressing physical, intellectual, 

emotional, social, and spiritual needs 

and to facilitate patient autonomy, 

access to information, and choice (42 

CFR 418.3). Palliative care is at the core 

of hospice philosophy and care 

practices, and is a critical component of 

the Medicare hospice benefit. 

The goal of hospice care is to help 

terminally ill individuals continue life 


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38624 Federal Register / Vol. 83, No. 151 / Monday, August 6, 2018 / Rules and Regulations 

with minimal disruption to normal 

activities while remaining primarily in 

the home environment. A hospice uses 

an interdisciplinary approach to deliver 

medical, nursing, social, psychological, 

emotional, and spiritual services 

through a collaboration of professionals 

and other caregivers, with the goal of 

making the beneficiary as physically 

and emotionally comfortable as 

possible. Hospice is compassionate 

beneficiary and family/caregivercentered care for those who are 

terminally ill. 

As referenced in our regulations at 

§ 418.22(b)(1), to be eligible for 

Medicare hospice services, the patient’s 

attending physician (if any) and the 

hospice medical director must certify 

that the individual is ‘‘terminally ill,’’ as 

defined in section 1861(dd)(3)(A) of the 

Act and our regulations at § 418.3; that 

is, the individual’s prognosis is for a life 

expectancy of 6 months or less if the 

terminal illness runs its normal course. 

The regulations at § 418.22(b)(3) require 

that the certification and recertification 

forms include a brief narrative 

explanation of the clinical findings that 

support a life expectancy of 6 months or 

less. 

Under the Medicare hospice benefit, 

the election of hospice care is a patient 

choice and once a terminally ill patient 

elects to receive hospice care, a hospice 

interdisciplinary group is essential in 

the seamless provision of services. 

These hospice services are provided 

primarily in the individual’s home. The 

hospice interdisciplinary group works 

with the beneficiary, family, and 

caregivers to develop a coordinated, 

comprehensive care plan; reduce 

unnecessary diagnostics or ineffective 

therapies; and maintain ongoing 

communication with individuals and 

their families about changes in their 

condition. The beneficiary’s care plan 

will shift over time to meet the changing 

needs of the individual, family, and 

caregiver(s) as the individual 

approaches the end of life. 

While the goal of hospice care is to 

allow the beneficiary to remain in his or 

her home, circumstances during the end 

of life may necessitate short-term 

inpatient admission to a hospital, 

skilled nursing facility (SNF), or hospice 

facility for necessary pain control or 

acute or chronic symptom management 

that cannot be managed in any other 

setting. These acute hospice care 

services ensure that any new or 

worsening symptoms are intensively 

addressed so that the beneficiary can 

return to his or her home. Limited, 

short-term, intermittent, inpatient 

respite care (IRC) is also available 

because of the absence or need for relief 

of the family or other caregivers. 

Additionally, an individual can receive 

continuous home care (CHC) during a 

period of crisis in which an individual 

requires continuous care to achieve 

palliation or management of acute 

medical symptoms so that the 

individual can remain at home. 

Continuous home care may be covered 

for as much as 24 hours a day, and these 

periods must be predominantly nursing 

care, in accordance with our regulations 

at § 418.204. A minimum of 8 hours of 

nursing care, or nursing and aide care, 

must be furnished on a particular day to 

qualify for the continuous home care 

rate (§ 418.302(e)(4)). 

Hospices are expected to comply with 

all civil rights laws, including the 

provision of auxiliary aids and services 

to ensure effective communication with 

patients and patient care representatives 

with disabilities consistent with section 

504 of the Rehabilitation Act of 1973 

and the Americans with Disabilities Act. 

Additionally, they must provide 

language access for such persons who 

are limited in English proficiency, 

consistent with Title VI of the Civil 

Rights Act of 1964. Further information 

about these requirements may be found 

at http://www.hhs.gov/ocr/civilrights. 

B. Services Covered by the Medicare 

Hospice Benefit 

Coverage under the Medicare Hospice 

benefit requires that hospice services 

must be reasonable and necessary for 

the palliation and management of the 

terminal illness and related conditions. 

Section 1861(dd)(1) of the Act 

establishes the services that are to be 

rendered by a Medicare-certified 

hospice program. These covered 

services include: Nursing care; physical 

therapy; occupational therapy; speechlanguage pathology therapy; medical 

social services; home health aide 

services (now called hospice aide 

services); physician services; 

homemaker services; medical supplies 

(including drugs and biologicals); 

medical appliances; counseling services 

(including dietary counseling); shortterm inpatient care in a hospital, 

nursing facility, or hospice inpatient 

facility (including both respite care and 

procedures necessary for pain control 

and acute or chronic symptom 

management); continuous home care 

during periods of crisis, and only as 

necessary to maintain the terminally ill 

individual at home; and any other item 

or service which is specified in the plan 

of care and for which payment may 

otherwise be made under Medicare, in 

accordance with Title XVIII of the Act. 

Section 1814(a)(7)(B) of the Act 

requires that a written plan for 

providing hospice care to a beneficiary 

who is a hospice patient be established 

before care is provided by, or under 

arrangements made by, that hospice 

program; and that the written plan be 

periodically reviewed by the 

beneficiary’s attending physician (if 

any), the hospice medical director, and 

an interdisciplinary group (described in 

section 1861(dd)(2)(B) of the Act). The 

services offered under the Medicare 

hospice benefit must be available to 

beneficiaries as needed, 24 hours a day, 

7 days a week (section 1861(dd)(2)(A)(i) 

of the Act). 

Upon the implementation of the 

hospice benefit, the Congress also 

expected hospices to continue to use 

volunteer services, though these 

services are not reimbursed by Medicare 

(see section 1861(dd)(2)(E) of the Act). 

As stated in the FY 1983 Hospice Wage 

Index and Rate Update proposed rule 

(48 FR 38149), the hospice 

interdisciplinary group should comprise 

paid hospice employees as well as 

hospice volunteers, and that ‘‘the 

hospice benefit and the resulting 

Medicare reimbursement is not 

intended to diminish the voluntary 

spirit of hospices.’’ This expectation 

supports the hospice philosophy of 

community based, holistic, 

comprehensive, and compassionate endof-life care. 

C. Medicare Payment for Hospice Care 

Sections 1812(d), 1813(a)(4), 

1814(a)(7), 1814(i), and 1861(dd) of the 

Act, and our regulations in 42 CFR part 

418, establish eligibility requirements, 

payment standards and procedures; 

define covered services; and delineate 

the conditions a hospice must meet to 

be approved for participation in the 

Medicare program. Part 418, subpart G, 

provides for a per diem payment in one 

of four prospectively-determined rate 

categories of hospice care (routine home 

care (RHC), CHC, IRC, and general 

inpatient care (GIP)), based on each day 

a qualified Medicare beneficiary is 

under hospice care (once the individual 

has elected). This per diem payment is 

to include all of the hospice services 

and items needed to manage the 

beneficiary’s care, as required by section 

1861(dd)(1) of the Act. There has been 

little change in the hospice payment 

structure since the benefit’s inception. 

The per diem rate based on level of care 

was established in 1983, and this 

payment structure remains today with 

some adjustments, as noted below. 

1. Omnibus Budget Reconciliation Act 

of 1989 

Section 6005(a) of the Omnibus 

Budget Reconciliation Act of 1989 (Pub. 


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Federal Register / Vol. 83, No. 151 / Monday, August 6, 2018 / Rules and Regulations 38625 

L. 101–239) amended section 

1814(i)(1)(C) of the Act and provided 

changes in the methodology concerning 

updating the daily payment rates based 

on the hospital market basket 

percentage increase applied to the 

payment rates in effect during the 

previous federal fiscal year. 

2. Balanced Budget Act of 1997 

Section 4441(a) of the Balanced 

Budget Act of 1997 (BBA) (Pub. L. 105– 

33) established that updates to the 

hospice payment rates beginning FY 

2002 and subsequent FYs be the 

hospital market basket percentage 

increase for the FY. 

3. FY 1998 Hospice Wage Index Final 

Rule 

The FY 1998 Hospice Wage Index 

final rule (62 FR 42860), implemented a 

new methodology for calculating the 

hospice wage index and instituted an 

annual Budget Neutrality Adjustment 

Factor (BNAF) so aggregate Medicare 

payments to hospices would remain 

budget neutral to payments calculated 

using the 1983 wage index. 

4. FY 2010 Hospice Wage Index Final 

Rule 

The FY 2010 Hospice Wage Index and 

Rate Update final rule (74 FR 39384) 

instituted an incremental 7-year phaseout of the BNAF beginning in FY 2010 

through FY 2016. The BNAF phase-out 

reduced the amount of the BNAF 

increase applied to the hospice wage 

index value, but was not a reduction in 

the hospice wage index value itself or in 

the hospice payment rates. 

5. The Affordable Care Act 

Starting with FY 2013 (and in 

subsequent FYs), the market basket 

percentage update under the hospice 

payment system referenced in sections 

1814(i)(1)(C)(ii)(VII) and 

1814(i)(1)(C)(iii) of the Act is subject to 

annual reductions related to changes in 

economy-wide productivity, as 

specified in section 1814(i)(1)(C)(iv) of 

the Act. In FY 2013 through FY 2019, 

the market basket percentage update 

under the hospice payment system will 

be reduced by an additional 0.3 

percentage point (although for FY 2014 

to FY 2019, the potential 0.3 percentage 

point reduction is subject to suspension 

under conditions specified in section 

1814(i)(1)(C)(v) of the Act). 

In addition, sections 1814(i)(5)(A) 

through (C) of the Act, as added by 

section 3132(a) of the Patient Protection 

and Affordable Care Act (PPACA) 

(Pub. L. 111–148), require hospices to 

begin submitting quality data, based on 

measures to be specified by the 

Secretary of the Department of Health 

and Human Services (the Secretary), for 

FY 2014 and subsequent FYs. Beginning 

in FY 2014, hospices that fail to report 

quality data will have their market 

basket percentage increase reduced by 2 

percentage points. 

Section 1814(a)(7)(D)(i) of the Act, as 

added by section 3132(b)(2) of the 

PPACA, requires, effective January 1, 

2011, that a hospice physician or nurse 

practitioner have a face-to-face 

encounter with the beneficiary to 

determine continued eligibility of the 

beneficiary’s hospice care prior to the 

180th-day recertification and each 

subsequent recertification, and to attest 

that such visit took place. When 

implementing this provision, we 

finalized in the FY 2011 Hospice Wage 

Index final rule (75 FR 70435) that the 

180th-day recertification and 

subsequent recertifications would 

correspond to the beneficiary’s third or 

subsequent benefit periods. Further, 

section 1814(i)(6) of the Act, as added 

by section 3132(a)(1)(B) of the PPACA, 

authorizes the Secretary to collect 

additional data and information 

determined appropriate to revise 

payments for hospice care and other 

purposes. The types of data and 

information suggested in the PPACA 

could capture accurate resource 

utilization, which could be collected on 

claims, cost reports, and possibly other 

mechanisms, as the Secretary 

determined to be appropriate. The data 

collected could be used to revise the 

methodology for determining the 

payment rates for RHC and other 

services included in hospice care, no 

earlier than October 1, 2013, as 

described in section 1814(i)(6)(D) of the 

Act. In addition, we were required to 

consult with hospice programs and the 

Medicare Payment Advisory 

Commission (MedPAC) regarding 

additional data collection and payment 

revision options. 

6. FY 2012 Hospice Wage Index Final 

Rule 

In the FY 2012 Hospice Wage Index 

final rule (76 FR 47308 through 47314) 

we announced that beginning in 2012, 

the hospice aggregate cap would be 

calculated using the patient-by-patient 

proportional methodology, within 

certain limits. We allowed existing 

hospices the option of having their cap 

calculated through the original 

streamlined methodology, also within 

certain limits. As of FY 2012, new 

hospices have their cap determinations 

calculated using the patient-by-patient 

proportional methodology. If a hospice’s 

total Medicare payments for the cap 

year exceed the hospice aggregate cap, 

then the hospice must repay the excess 

back to Medicare. 

7. FY 2015 Hospice Wage Index and 

Payment Rate Update Final Rule 

The FY 2015 Hospice Wage Index and 

Rate Update final rule (79 FR 50452) 

finalized a requirement that requires the 

Notice of Election (NOE) be filed within 

5 calendar days after the effective date 

of hospice election. If the NOE is filed 

beyond this 5-day period, hospice 

providers are liable for the services 

furnished during the days from the 

effective date of hospice election to the 

date of NOE filing (79 FR 50474). 

Similar to the NOE, the claims 

processing system must be notified of a 

beneficiary’s discharge from hospice or 

hospice benefit revocation within 5 

calendar days after the effective date of 

the discharge/revocation (unless the 

hospice has already filed a final claim) 

through the submission of a final claim 

or a Notice of Termination or 

Revocation (NOTR). 

The FY 2015 Hospice Wage Index and 

Rate Update final rule (79 FR 50479) 

also finalized a requirement that the 

election form include the beneficiary’s 

choice of attending physician and that 

the beneficiary provide the hospice with 

a signed document when he or she 

chooses to change attending physicians. 

Hospice providers are required to 

begin using a Hospice Experience of 

Care Survey for informal caregivers of 

hospice patients as of 2015. The FY 

2015 Hospice Wage Index and Rate 

Update final rule (79 FR 50496) 

provided background, eligibility criteria, 

survey respondents, and 

implementation of the Hospice 

Experience of Care Survey for informal 

caregivers, that hospices are required to 

use as of 2015. 

Finally, the FY 2015 Hospice Wage 

Index and Rate Update final rule 

required providers to complete their 

aggregate cap determination not sooner 

than 3 months after the end of the cap 

year, and not later than 5 months after, 

and remit any overpayments. Those 

hospices that fail to timely submit their 

aggregate cap determinations will have 

their payments suspended until the 

determination is completed and 

received by the Medicare contractor (79 

FR 50503). 

8. IMPACT Act of 2014 

The Improving Medicare Post-Acute 

Care Transformation Act of 2014 

(IMPACT Act) (Pub. L. 113–185) became 

law on October 6, 2014. Section 3(a) of 

the IMPACT Act mandated that all 

Medicare certified hospices be surveyed 

every 3 years beginning April 6, 2015 

and ending September 30, 2025. In 


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addition, section 3(c) of the IMPACT 

Act requires medical review of hospice 

cases involving beneficiaries receiving 

more than 180 days care in select 

hospices that show a preponderance of 

such patients; section 3(d) of the 

IMPACT Act contains a new provision 

mandating that the cap amount for 

accounting years that end after 

September 30, 2016, and before October 

1, 2025 be updated by the hospice 

payment update rather than using the 

consumer price index for urban 

consumers (CPI–U) for medical care 

expenditures. 

9. FY 2016 Hospice Wage Index and 

Payment Rate Update Final Rule 

In the FY 2016 Hospice Wage Index 

and Rate Update final rule (80 FR 

47172), we created two different 

payment rates for RHC that resulted in 

a higher base payment rate for the first 

60 days of hospice care and a reduced 

base payment rate for subsequent days 

of hospice care. We also created a 

Service Intensity Add-on (SIA) payment 

payable for services during the last 7 

days of the beneficiary’s life, equal to 

the CHC hourly payment rate multiplied 

by the amount of direct patient care 

provided by a registered nurse (RN) or 

social worker that occurs during the last 

7 days (80 FR 47177). 

In addition to the hospice payment 

reform changes discussed, the FY 2016 

Hospice Wage Index and Rate Update 

final rule (80 FR 47186) implemented 

changes mandated by the IMPACT Act, 

in which the cap amount for accounting 

years that end after September 30, 2016 

and before October 1, 2025 is updated 

by the hospice payment update 

percentage rather than using the CPI–U. 

This was applied to the 2016 cap year, 

starting on November 1, 2015 and 

ending on October 31, 2016. In addition, 

we finalized a provision to align the cap 

accounting year for both the inpatient 

cap and the hospice aggregate cap with 

the fiscal year for FY 2017 and 

thereafter. Finally, the FY 2016 Hospice 

Wage Index and Rate Update final rule 

(80 FR 47144) clarified that hospices 

must report all diagnoses of the 

beneficiary on the hospice claim as a 

part of the ongoing data collection 

efforts for possible future hospice 

payment refinements. 

10. FY 2017 Hospice Wage Index and 

Payment Rate Update Final Rule 

In the FY 2017 Hospice Wage Index 

and Rate Update final rule (81 FR 

52160), we finalized several new 

policies and requirements related to the 

HQRP. First, we codified our policy that 

if the National Quality Forum (NQF) 

made non-substantive changes to 

specifications for HQRP measures as 

part of the NQF’s re-endorsement 

process, we would continue to utilize 

the measure in its new endorsed status, 

without going through new notice-andcomment rulemaking. We would 

continue to use rulemaking to adopt 

substantive updates made by the NQF to 

the endorsed measures we have adopted 

for the HQRP; determinations about 

what constitutes a substantive versus 

non-substantive change would be made 

on a measure-by-measure basis. Second, 

we finalized two new quality measures 

for the HQRP for the FY 2019 payment 

determination and subsequent years: 

Hospice Visits when Death is Imminent 

Measure Pair and Hospice and Palliative 

Care Composite Process MeasureComprehensive Assessment at 

Admission (81 FR 52173). The data 

collection mechanism for both of these 

measures is the HIS, and the measures 

were effective April 1, 2017. Regarding 

the CAHPS® Hospice Survey, we 

finalized a policy that hospices that 

receive their CMS Certification Number 

(CCN) after January 1, 2017 for the FY 

2019 Annual Payment Update (APU) 

and January 1, 2018 for the FY 2020 

APU will be exempted from the Hospice 

Consumer Assessment of Healthcare 

Providers and Systems (CAHPS®) 

requirements due to newness (81 FR 

52182). The exemption is determined by 

CMS and is for 1 year only. 

D. Trends in Medicare Hospice 

Utilization 

Since the implementation of the 

hospice benefit in 1983, and especially 

within the last decade, there has been 

substantial growth in hospice benefit 

utilization. The number of Medicare 

beneficiaries receiving hospice services 

has grown from 513,000 in FY 2000 to 

nearly 1.5 million in FY 2017. Similarly, 

Medicare hospice expenditures have 

risen from $2.8 billion in FY 2000 to 

approximately $17.7 billion in FY 2017. 

Our Office of the Actuary (OACT) 

projects that hospice expenditures are 

expected to continue to increase, by 

approximately 8 percent annually, 

reflecting an increase in the number of 

Medicare beneficiaries, more beneficiary 

awareness of the Medicare hospice 

benefit for end-of-life care, and a 

growing preference for care provided in 

home and community-based settings. 

There have also been changes in the 

diagnosis patterns among Medicare 

hospice enrollees. While in 2002, lung 

cancer was the top principal diagnosis, 

neurologically based diagnoses have 

topped the list for the past 5 years. 

Additionally, in FY 2013, ‘‘debility’’ 

and ‘‘adult failure to thrive’’ were the 

first and sixth most common hospice 

claims-reported diagnoses, respectively, 

accounting for approximately 14 percent 

of all diagnoses; however, effective 

October 1, 2014, these diagnoses are no 

longer permitted as principal diagnosis 

codes on hospice claims. As a result of 

this, the most common hospice claimsreported diagnoses have changed from 

primarily cancer diagnoses to 

neurological and organ-based failure 

diagnoses. The top 20 most frequently 

hospice claims-reported diagnoses for 

FY 2017 are in Table 2 below. 

TABLE 2—THE TOP TWENTY PRINCIPAL HOSPICE DIAGNOSES, FY 2017 

Rank ICD–10/reported principal diagnosis Count Percentage 

1 ..................... G30.9 Alzheimer’s disease, unspecified ..................................................................................... 155,066 10 

2 ..................... J44.9 Chronic obstructive pulmonary disease ............................................................................ 77,758 5 

3 ..................... I50.9 Heart failure, unspecified ................................................................................................... 69,216 4 

4 ..................... G31.1 Senile degeneration of brain, not elsewhere classified ................................................... 66,309 4 

5 ..................... C34.90 Malignant Neoplasm Of Unsp Part Of Unsp Bronchus Or Lung ................................... 53,137 3 

6 ..................... G20 Parkinson’s disease ............................................................................................................. 40,186 3 

7 ..................... G30.1 Alzheimer’s disease with late onset ................................................................................. 38,710 2 

8 ..................... I25.10 Atherosclerotic heart disease of native coronary art without angina pectoris ................. 34,761 2 

9 ..................... J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation .................................. 33,547 2 

10 ................... I67.2 Cerebral atherosclerosis .................................................................................................... 30,146 2 

11 ................... C61 Malignant neoplasm of prostate .......................................................................................... 25,215 2 

12 ................... I63.9 Cerebral infarction, unspecified .......................................................................................... 22,825 1 

13 ................... N18.6 End stage renal disease ................................................................................................... 21,549 1 

14 ................... C18.9 Malignant neoplasm of colon, unspecified ....................................................................... 21,543 1 

15 ................... C25.9 Malignant neoplasm of pancreas, unspecified ................................................................. 20,851 1 


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TABLE 2—THE TOP TWENTY PRINCIPAL HOSPICE DIAGNOSES, FY 2017—Continued 

Rank ICD–10/reported principal diagnosis Count Percentage 

16 ................... I51.9 Heart disease, unspecified ................................................................................................. 18,794 1 

17 ................... I11.0 Hypertensive heart disease with heart failure .................................................................... 18,345 1 

18 ................... I67.9 Cerebrovascular disease, unspecified ............................................................................... 18,234 1 

19 ................... I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through 

stage 4 chronic kidney disease, or unspecified chronic kidney disease.

15,632 1 

20 ................... A41.9 Sepsis, unspecified organism ........................................................................................... 14,012 1 

Note(s): The frequencies shown represent beneficiaries that had a least one claim with the specific ICD–10 code reported as the principal diagnosis. Beneficiaries could be represented multiple times in the results if they have multiple claims during that time period with different principal diagnoses. 

Source: FY 2017 hospice claims data from the CCW, accessed and merged with ICD–10 codes on January 10, 2018. 

In the FY 2016 Hospice Wage Index 

and Rate Update final rule (80 FR 

47201), we clarified that hospices will 

report all diagnoses identified in the 

initial and comprehensive assessments 

on hospice claims, whether related or 

unrelated to the terminal prognosis of 

the individual, effective October 1, 

2015. Analysis of FY 2017 hospice 

claims show that 100 percent of 

hospices reported more than one 

diagnosis, 89 percent submitted at least 

two diagnoses, and 81 percent included 

at least three diagnoses. 

III. Provisions of the Final Rule 

On May 8, 2018, we published the FY 

2019 Hospice Wage Index and Payment 

Rate Update and Hospice Quality 

Reporting Requirements proposed rule 

in the Federal Register (83 FR 20934 

through 20970) and provided a 60-day 

comment period. In that proposed rule, 

we proposed to update the hospice wage 

index, payment rates, and cap amount 

for fiscal year (FY) 2019. In addition, we 

proposed regulations text changes to 

recognize physician assistants as 

designated hospice attending physicians 

effective January 1, 2019. Finally, we 

proposed changes to the Hospice 

Quality Reporting Program. We received 

56 public comments on the proposed 

rule, including comments from hospice 

agencies, national provider associations, 

patient organizations, nurses, and 

advocacy groups. 

Below we provide a summary of each 

proposed provision, a summary of the 

public comments received and our 

responses to them, and the policies we 

are finalizing in the FY 2019 Hospice 

Wage Index and Payment Rate Update 

and Hospice Quality Reporting 

Requirements final rule. 

A. Monitoring for Potential Impacts— 

Affordable Care Act Hospice Reform 

In the FY 2019 Hospice Wage Index 

and Payment Rate Update proposed rule 

(83 FR 20934), we provided a summary 

of analysis conducted on hospice length 

of stay, live discharge rates, skilled 

visits in the last days of life, and nonhospice spending. Additionally, we 

discussed initial analyses of data from 

recently revised cost reports. We will 

continue to monitor the impact of future 

payment and policy changes and will 

provide the industry with periodic 

updates on our analysis in future 

rulemaking and/or announcements on 

the Hospice Center web page at: https:// 

www.cms.gov/Center/Provider-Type/ 

Hospice-Center.html. 

We received comments on the hospice 

monitoring analysis and CMS’s plans for 

future monitoring efforts with regard to 

hospice payment reform outlined in the 

proposed rule. The comments and our 

responses are described below: 

Comment: Commenters expressed 

continued support for our plans to 

monitor the impact of hospice payment 

reform and suggested the use of 

monitoring results in order to better 

target program integrity efforts. One 

commenter suggested that providers 

would benefit from CMS providing data 

assessing the impact of the payment 

changes that occurred in early 2016 and 

the degree to which they are on track 

with the re-distributional impact that 

CMS anticipated as a part of its 

modeling. A commenter suggested that 

CMS focus on short lengths of stays in 

hospice rather than long length of stays 

as long length of stays, which could be 

an indicator of problematic behavior, 

noting that the median length of stay 

has remained constant at 18 days, and 

the commenter suggested that the focus 

of analysis should be on beneficiary 

access to hospice services. One 

commenter recommended that CMS 

revisit and clarify what should be 

covered under the hospice per diem, 

noting that clarification would enhance 

care for patients and families, allow for 

easier comparison of programs, and 

allow for increased program integrity 

efforts based on this data point. Finally, 

a few commenters noted concerns with 

increased scrutiny of claims for GIP care 

and the variability of costs for GIP care 

depending on whether the hospice 

provides the care in a facility or 

contracts with another entity. 

Commenters suggested that CMS 

provide further education and 

clarification of acceptable GIP 

utilization for hospice providers as a 

means of encouraging them to provide 

the most appropriate level of care for the 

patient. 

Response: We appreciate the 

comments provided regarding the 

ongoing analysis presented, and we plan 

continue to monitor hospice trends and 

vulnerabilities within the hospice 

benefit, while also investigating the 

means by which we can educate the 

provider community regarding the 

hospice benefit and appropriate billing 

practices. We will also consider these 

suggestions for future monitoring 

efforts, program integrity, and for 

potential policy or payment 

refinements. Additionally, we refer 

readers to sections 1812(d), 1813(a)(4), 

1814(a)(7), 1814(i), and 1861(dd) of the 

Act, our regulations in the Code of 

Federal Regulations (CFR) 42 CFR part 

418, which establish eligibility 

requirements, payment standards, and 

procedures; define covered services; and 

delineate the conditions a hospice must 

meet to be approved for participation in 

the Medicare program and the CMS 

Hospice Center web page for more 

information (https://www.cms.gov/ 

Center/Provider-Type/HospiceCenter.html). 

Comment: Several commenters 

recommended that CMS move to 

implement additional Level 1 edits for 

the hospice cost reports in order to 

address existing gaps in data collection 

to meet minimum standards of 

accuracy. In addition, many 

commenters suggested that CMS should 

wait until the latest cost report changes 

(including imposition of additional 

Level 1 edits) are reflected in the data 

to ensure greater accuracy of data 

inputs. 

Response: We appreciate support of 

the Level 1 edits to further address 

accuracy in cost reporting. As several 

commenters noted, on April 13, 2018, 

CMS issued Transmittal 3 revising the 

Medicare Provider Reimbursement 


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Manual—Part 2, Provider Cost 

Reporting Forms and Instructions, 

Chapter 43, Form CMS–1984–14. 

Transmittal 3 made several changes to 

the Hospice Cost Report, including the 

imposition of Level 1 and Level 2 edits 

(https://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/ 

2018Downloads/R3P243.pdf). These 

changes are effective for cost reporting 

periods ending on or after December 31, 

2017. We will continue to analyze 

Medicare hospice cost report data as it 

becomes available in determining 

whether additional hospice payment 

reform changes are needed to better 

align hospice payments with costs. 

B. FY 2019 Hospice Wage Index and 

Rate Update 

1. FY 2019 Hospice Wage Index 

The hospice wage index is used to 

adjust payment rates for hospice 

agencies under the Medicare program to 

reflect local differences in area wage 

levels, based on the location where 

services are furnished. The hospice 

wage index utilizes the wage adjustment 

factors used by the Secretary for 

purposes of section 1886(d)(3)(E) of the 

Act for hospital wage adjustments. Our 

regulations at § 418.306(c) require each 

labor market to be established using the 

most current hospital wage data 

available, including any changes made 

by Office of Management and Budget 

(OMB) to the Metropolitan Statistical 

Areas (MSAs) definitions. 

We use the previous FY’s hospital 

wage index data to calculate the hospice 

wage index values. For FY 2019, the 

hospice wage index will be based on the 

FY 2018 hospital pre-floor, prereclassified wage index. This means that 

the hospital wage data used for the 

hospice wage index are not adjusted to 

take into account any geographic 

reclassification of hospitals including 

those in accordance with section 

1886(d)(8)(B) or 1886(d)(10) of the Act. 

The appropriate wage index value is 

applied to the labor portion of the 

payment rate based on the geographic 

area in which the beneficiary resides 

when receiving RHC or CHC. The 

appropriate wage index value is applied 

to the labor portion of the payment rate 

based on the geographic location of the 

facility for beneficiaries receiving GIP or 

IRC. 

In the FY 2006 Hospice Wage Index 

final rule (70 FR 45135), we adopted the 

policy that, for urban labor markets 

without a hospital from which hospital 

wage index data could be derived, all of 

the Core-Based Statistical Areas 

(CBSAs) within the state would be used 

to calculate a statewide urban average 

pre-floor, pre-reclassified hospital wage 

index value to use as a reasonable proxy 

for these areas. For FY 2019, the only 

CBSA without a hospital from which 

hospital wage data can be derived is 

25980, Hinesville-Fort Stewart, Georgia. 

In the FY 2008 Hospice Wage Index 

final rule (72 FR 50214), we adopted a 

policy for instances where there are 

rural areas without rural hospital wage 

data. In such instances, we use the 

average pre-floor, pre-reclassified 

hospital wage index data from all 

contiguous CBSAs, to represent a 

reasonable proxy for the rural area. The 

term ‘‘contiguous’’ means sharing a 

border (72 FR 50217). Currently, the 

only rural area without a hospital from 

which hospital wage data could be 

derived is Puerto Rico. However, for 

rural Puerto Rico, we would not apply 

this methodology due to the distinct 

economic circumstances that exist there 

(for example, due to the close proximity 

to one another of almost all of Puerto 

Rico’s various urban and non-urban 

areas, this methodology would produce 

a wage index for rural Puerto Rico that 

is higher than that in half of its urban 

areas); instead, we would continue to 

use the most recent wage index 

previously available for that area. For 

FY 2019, we proposed to continue to 

use the most recent pre-floor, prereclassified hospital wage index value 

available for Puerto Rico, which is 

0.4047, subsequently adjusted by the 

hospice floor. 

As described in the August 8, 1997 

Hospice Wage Index final rule (62 FR 

42860), the pre-floor and prereclassified hospital wage index is used 

as the raw wage index for the hospice 

benefit. These raw wage index values 

are subject to application of the hospice 

floor to compute the hospice wage index 

used to determine payments to 

hospices. Pre-floor, pre-reclassified 

hospital wage index values below 0.8 

are adjusted by a 15 percent increase 

subject to a maximum wage index value 

of 0.8. For example, if County A has a 

pre-floor, pre-reclassified hospital wage 

index value of 0.3994, we would 

multiply 0.3994 by 1.15, which equals 

0.4593. Since 0.4593 is not greater than 

0.8, then County A’s hospice wage 

index would be 0.4593. In another 

example, if County B has a pre-floor, 

pre-reclassified hospital wage index 

value of 0.7440, we would multiply 

0.7440 by 1.15 which equals 0.8556. 

Because 0.8556 is greater than 0.8, 

County B’s hospice wage index would 

be 0.8. 

On February 28, 2013, OMB issued 

OMB Bulletin No. 13–01, announcing 

revisions to the delineation of MSAs, 

Micropolitan Statistical Areas, and 

Combined Statistical Areas, and 

guidance on uses of the delineation in 

these areas. In the FY 2016 Hospice 

Wage Index and Rate Update final rule 

(80 FR 47178), we adopted the OMB’s 

new area delineations using a 1-year 

transition. In that final rule, we stated 

that beginning October 1, 2016, the 

wage index for all hospice payments 

would be fully based on the new OMB 

delineations. 

On August 15, 2017, OMB issued 

bulletin No. 17–01, which is available at 

https://www.whitehouse.gov/sites/ 

whitehouse.gov/files/omb/bulletins/ 

2017/b-17-01.pdf. In this bulletin, OMB 

announced that one Micropolitan 

Statistical Area, Twin Falls, Idaho, now 

qualifies as a Metropolitan Statistical 

Area. The new CBSA (46300) comprises 

the principal city of Twin Falls, Idaho 

in Jerome County, Idaho and Twin Falls 

County, Idaho. The FY 2019 hospice 

wage index value for CBSA 46300, Twin 

Falls, Idaho, will be 0.8000. 

The hospice wage index applicable 

for FY 2019 (October 1, 2018 through 

September 30, 2019) is available on our 

website at: http://www.cms.gov/ 

Medicare/Medicare-Fee-for-ServicePayment/Hospice/index.html. 

A summary of the comments we 

received regarding the wage index and 

our responses to those comments appear 

below: 

Comment: A commenter stated that in 

FY 2018, the wage index for Spokane, 

WA had increased, which helped 

increase wages for employees and 

reduced turnover. However, the 

commenter noted that in the FY 2019 

proposed rule, this increase is reversing. 

The commenter stated that using older 

wage index data, not allowing 

reclassification, and not accounting for 

outward migration speaks to the need 

for wage index reform for the hospice 

payment system. One commenter stated 

that in rural Kentucky and Indiana, the 

costs of providing hospice care exceed 

Medicare payments. The commenter 

further asserted that a lower 

reimbursement rate for rural areas when 

compared to urban areas is not sensible, 

given that urban areas have 

infrastructure that facilitates access to 

care. Another commenter expressed 

concern with the continued use of the 

pre-floor, pre-reclassified hospital wage 

index to adjust the hospice payment 

rates and stated that this causes 

continued volatility of the hospice wage 

index from one year to the next. The 

commenter stated that the volatility is 

often based on inaccurate or incomplete 

hospital cost report data. 

Response: The annual changes in the 

wage index reflect real variations in 

costs of providing care in various 


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uploads/2017/11/bulletins_b03-04.pdf. 

geographic locations. We utilize 

efficient means to ensure and review the 

accuracy of the hospital cost report data 

and resulting wage index. The hospice 

wage index is derived from the prefloor, pre-reclassified wage index, 

which is calculated based on cost report 

data from hospitals. All Inpatient 

Prospective Payment System (IPPS) 

hospitals must complete the wage index 

survey (Worksheet S–3, Parts II and III) 

as part of their Medicare cost reports. 

Cost reports will be rejected if 

Worksheet S–3 is not completed. In 

addition, our Medicare contractors 

perform desk reviews on all hospitals’ 

Worksheet S–3 wage data, and we run 

edits on the wage data to further ensure 

the accuracy and validity of the wage 

data. Our review processes result in an 

accurate reflection of the applicable 

wages for the areas given. In addition, 

we finalized a hospice wage index 

standardization factor in FY 2017 to 

ensure overall budget neutrality when 

updating the hospice wage index with 

more recent hospital wage data. 

Applying a wage index standardization 

factor to hospice payments will 

eliminate the aggregate effect of annual 

variations in hospital wage data. Our 

policy of utilizing a hospice wage index 

standardization factor provides a 

safeguard to the Medicare program as 

well as to hospices because it will 

mitigate fluctuations in the wage index 

by ensuring that wage index updates 

and revisions are implemented in a 

budget neutral manner. 

We note that the current statute and 

regulations that govern the hospice 

payment system do not currently 

provide a mechanism for allowing 

hospices to seek geographic 

reclassification. The reclassification 

provision is found in section 

1886(d)(10)(C)(i) of the Act, which 

states, ‘‘The Board shall consider the 

application of any subsection (d) 

hospital requesting that the Secretary 

change the hospital’s geographic 

classification . . . ’’ This provision is 

only applicable to hospitals as defined 

in section 1886(d) of the Act. In 

addition, we do not believe that using 

hospital reclassification data would be 

appropriate, as these data are specific to 

the requesting hospitals and they may or 

may not apply to a given hospice. 

Comment: One commenter expressed 

concern that the proposed FY 2019 

hospice wage index will be based on the 

OMB geographic area wage delineations. 

The commenter was particularly 

concerned with the New York City 

CBSA and the fact that the CBSA 

contains counties from New Jersey 

where labor costs are lower. 

Response: The OMB’s CBSA 

designations reflect the most recent 

available geographic classifications and 

are a reasonable and appropriate 

method of defining geographic areas for 

the purposes of wage adjusting the 

hospice payment rates. 

Comment: One commenter expressed 

concern that hospices in Montgomery 

County, Maryland, which are included 

in CBSA 43524 (Silver SpringFrederick-Rockville, MD), are 

reimbursed at a lower rate than hospices 

in the greater Washington DC area that 

are included in CBSA 47894 

(Washington-Arlington-Alexandria, 

DCVA-MD-WV). The commenters 

request that CMS reconsider CBSA 

43524 (Silver Spring-FrederickRockville, MD). 

Response: CBSA delineations are 

determined by the OMB. The OMB 

reviews its Metropolitan Area 

definitions preceding each decennial 

census to reflect recent population 

changes. The OMB’s CBSA designations 

reflect the most recent available 

geographic classifications and were a 

reasonable and appropriate way to 

define geographic areas for purposes of 

wage index values. Ten years ago, in our 

FY 2006 Hospice Wage Index final rule 

(70 FR 45130), we finalized the 

adoption of the revised labor market 

area definitions as discussed in the 

OMB Bulletin No. 03–04 (June 6, 2003). 

In the December 27, 2000 Federal 

Register (65 FR 82228 through 82238), 

OMB announced its new standards for 

defining metropolitan and micropolitan 

statistical areas. According to that 

notice, OMB defines a CBSA, beginning 

in 2003, as ‘‘a geographic entity 

associated with at least one core of 

10,000 or more population, plus 

adjacent territory that has a high degree 

of social and economic integration with 

the core as measured by commuting ties. 

The general concept of the CBSAs is 

that of an area containing a recognized 

population nucleus and adjacent 

communities that have a high degree of 

integration with that nucleus. The 

purpose of the standards is to provide 

nationally consistent definitions for 

collecting, tabulating, and publishing 

federal statistics for a set of geographic 

areas. CBSAs include adjacent counties 

that have a minimum of 25 percent 

commuting to the central counties of the 

area. This is an increase over the 

minimum commuting threshold for 

outlying counties applied in the 

previous MSA definition of 15 percent. 

Based on the OMB’s current 

delineations, Montgomery County 

(along with Frederick County, 

Maryland) belongs in a separate CBSA 

from the areas defined in the 

Washington-Arlington-Alexandria, DCVA CBSA. Unlike IPPS, inpatient 

rehabilitation facility (IRF), and SNF, 

where each provider uses a single 

CBSA, hospice agencies may be 

reimbursed based on more than one 

wage index. Payments are based upon 

the location of the beneficiary for 

routine and continuous home care or 

the location of the agency for respite 

and general inpatient care. It is very 

likely that hospices in Montgomery 

County, Maryland provide RHC and 

CHC to patients in the ‘‘WashingtonArlington-Alexandria, DC-VA’’ CBSA in 

addition to serving patients in the 

‘‘Baltimore-Columbia-Towson, 

Maryland’’ CBSA. 

While CMS and other stakeholders 

have explored potential alternatives to 

the current CBSA-based labor market 

system (we refer readers to our website: 

https://www.cms.gov/Medicare/ 

Medicare-Fee-for-Service-Payment/ 

AcuteInpatientPPS/Wage-IndexReform.html), no consensus has been 

achieved regarding how best to 

implement a replacement system. As 

discussed in the FY 2005 IPPS final rule 

(69 FR 49027), ‘‘While we recognize that 

MSAs are not designed specifically to 

define labor market areas, we believe 

they do represent a useful proxy for this 

purpose.’’ We further believe that using 

the most current OMB delineations will 

increase the integrity of the hospice 

wage index by creating a more accurate 

representation of geographic variation in 

wage levels. We recognize that the OMB 

cautions that the delineations should 

not be used to develop and implement 

federal, state, and local nonstatistical 

programs and policies without full 

consideration of the effects of using 

these delineations for such purposes. As 

discussed in the OMB Bulletin No. 03– 

04 (June 6, 2003), The OMB stated that, 

‘‘In cases where there is no statutory 

requirement and an agency elects to use 

the Metropolitan, Micropolitan, or 

Combined Statistical Area definitions in 

nonstatistical programs, it is the 

sponsoring agency’s responsibility to 

ensure that the definitions are 

appropriate for such use. When an 

agency is publishing for comment a 

proposed regulation that would use the 

definitions for a nonstatistical purpose, 

the agency should seek public comment 

on the proposed use.’’ 4 While we 

recognize that OMB’s geographic area 

delineations are not designed 

specifically for use in nonstatistical 

programs or for program purposes, 

including the allocation of federal 

funds, we continue to believe that the 


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OMB’s geographic area delineations 

represent a useful proxy for 

differentiating between labor markets 

and that the geographic area 

delineations are appropriate for use in 

determining Medicare hospice 

payments. In implementing the use of 

CBSAs for hospice payment purposes in 

our FY 2006 rule (70 FR 45130), we 

considered the effects of using these 

delineations. We have used CBSAs for 

determining hospice payments for 10 

years (since FY 2006). In addition, other 

provider types, such as IPPS hospital, 

home health, SNF, IRF), and the ESRD 

program, have used CBSAs to define 

their labor market areas for the last 

decade. 

Final Decision: After considering the 

comments received in response to the 

proposed rule and for the reasons 

discussed above, we are finalizing our 

proposal to use the pre-floor, prereclassified hospital inpatient wage 

index as the wage adjustment to the 

labor portion of the hospice rates. For 

FY 2019, the updated wage data are for 

hospital cost reporting periods 

beginning on or after October 1, 2013 

and before October 1, 2014 (FY 2014 

cost report data). 

The wage index applicable for FY 

2019 is available on our website at 

http://www.cms.gov/Medicare/ 

Medicare-Fee-for-Service-Payment/ 

Hospice/index.html. The hospice wage 

index for FY 2019 will be effective 

October 1, 2018 through September 30, 

2019. 

2. FY 2019 Hospice Payment Update 

Percentage 

Section 4441(a) of the Balanced 

Budget Act of 1997 (BBA) (Pub. L. 105– 

33) amended section 1814(i)(1)(C)(ii)(VI) 

of the Act to establish updates to 

hospice rates for FYs 1998 through 

2002. Hospice rates were to be updated 

by a factor equal to the inpatient 

hospital market basket percentage 

increase set out under section 

1886(b)(3)(B)(iii) of the Act, minus 1 

percentage point. Payment rates for FYs 

since 2002 have been updated according 

to section 1814(i)(1)(C)(ii)(VII) of the 

Act, which states that the update to the 

payment rates for subsequent FYs must 

be the inpatient market basket 

percentage increase for that FY. The Act 

historically required us to use the 

inpatient hospital market basket as the 

basis for the hospice payment rate 

update. 

Section 3401(g) of the PPACA 

mandated that, starting with FY 2013 

(and in subsequent FYs), the hospice 

payment update percentage would be 

annually reduced by changes in 

economy-wide productivity as specified 

in section 1886(b)(3)(B)(xi)(II) of the 

Act. The statute defines the productivity 

adjustment to be equal to the 10-year 

moving average of changes in annual 

economy-wide private nonfarm business 

multifactor productivity (MFP). In 

addition to the MFP adjustment, section 

3401(g) of the ACA also mandated that 

in FY 2013 through FY 2019, the 

hospice payment update percentage 

would be reduced by an additional 0.3 

percentage point (although for FY 2014 

to FY 2019, the potential 0.3 percentage 

point reduction is subject to suspension 

under conditions specified in section 

1814(i)(1)(C)(v) of the Act). 

The hospice payment update 

percentage for FY 2019 is based on the 

inpatient hospital market basket update 

of 2.9 percent (based on IHS Global 

Inc.’s second-quarter 2018 forecast with 

historical data through the first-quarter 

2018). Due to the requirements at 

sections 1886(b)(3)(B)(xi)(II) and 

1814(i)(1)(C)(v) of the Act, the inpatient 

hospital market basket update for FY 

2019 of 2.9 percent must be reduced by 

a MFP adjustment as mandated by the 

PPACA (0.8 percentage point for FY 

2019). The inpatient hospital market 

basket update for FY 2019 is reduced 

further by 0.3 percentage point, as 

mandated by the PPACA. In effect, the 

hospice payment update percentage for 

FY 2019 is 1.8 percent. 

Currently, the labor portion of the 

hospice payment rates is as follows: for 

RHC, 68.71 percent; for CHC, 68.71 

percent; for General Inpatient Care, 

64.01 percent; and for Respite Care, 

54.13 percent. The non-labor portion is 

equal to 100 percent minus the labor 

portion for each level of care. Therefore, 

the non-labor portion of the payment 

rates is as follows: for RHC, 31.29 

percent; for CHC, 31.29 percent; for 

General Inpatient Care, 35.99 percent; 

and for Respite Care, 45.87 percent. 

Beginning with cost reporting periods 

starting on or after October 1, 2014, 

freestanding hospice providers are 

required to submit cost data using CMS 

Form 1984–14 (https://www.cms.gov/ 

Regulations-and-Guidance/Legislation/ 

PaperworkReductionActof1995/PRAListing-Items/CMS-1984-14.html). We 

are currently analyzing this data for 

possible use in updating the labor 

portion of the hospice payment rates. 

Any changes to the labor portions 

would be proposed in future rulemaking 

and would be subject to public 

comments. 

A summary of the comments we 

received regarding the payment update 

percentage and our responses to those 

comments appear below: 

Comment: Several commenters noted 

their support of the hospice payment 

update percentage. 

Response: We appreciate the 

comments in support of the hospice 

payment update percentage. 

Comment: Several commenters stated 

that the FY 2019 payment update of 1.8 

percent is inadequate. One commenter 

stated that the payment update is 

insufficient to sustainably cover the 

broad range of services and high-quality 

care that their members provide 

regardless of diagnosis, location and 

payment source. Another commenter 

suggested that the multifactor 

productivity (MFP) adjustment is not 

related to hospice care productivity, but 

instead, is a uniform adjustment factor 

that is being applied to all proposed 

prospective payment rate increases for 

2019. The commenter suggests that CMS 

should identify and report specific 

productivity performances for each 

unique healthcare category. Another 

commenter expressed concern that the 

1.8 percent increase would not cover the 

2 percent decrease in reimbursement 

that would be imposed should 

sequestration be required in 2019. 

Response: The hospice payment 

update percentage and the application 

of the MFP are required by statute, as 

previously described in detail in this 

section, and we do not have regulatory 

authority to alter the update. Likewise, 

sequestration is determined outside of 

CMS’ authority and the hospice 

payment updates are statutory. 

Final Decision: We are implementing 

the hospice payment update percentage 

as discussed in the proposed rule. Based 

on IHS Global Insight, Inc.’s updated 

forecast, the hospice payment update 

percentage for FY 2019 will be 1.8 

percent for hospices that submit the 

required quality data and ¥0.2 percent 

(FY 2019 hospice payment update of 1.8 

percent minus 2 percentage points) for 

hospices that do not submit the required 

quality data. 

3. FY 2019 Hospice Payment Rates 

There are four payment categories that 

are distinguished by the location and 

intensity of the services provided. The 

base payments are adjusted for 

geographic differences in wages by 

multiplying the labor share, which 

varies by category, of each base rate by 

the applicable hospice wage index. A 

hospice is paid the RHC rate for each 

day the beneficiary is enrolled in 

hospice, unless the hospice provides 

CHC, IRC, or GIP. CHC is provided 

during a period of patient crisis to 

maintain the patient at home; IRC is 

short-term care to allow the usual 

caregiver to rest and be relieved from 


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caregiving; and GIP is to treat symptoms 

that cannot be managed in another 

setting. 

As discussed in the FY 2016 Hospice 

Wage Index and Rate Update final rule 

(80 FR 47172), we implemented two 

different RHC payment rates, one RHC 

rate for the first 60 days and a second 

RHC rate for days 61 and beyond. In 

addition, in that final rule, we 

implemented a Service Intensity Add-on 

(SIA) payment for RHC when direct 

patient care is provided by a RN or 

social worker during the last 7 days of 

the beneficiary’s life. The SIA payment 

is equal to the CHC hourly rate 

multiplied by the hours of nursing or 

social work provided (up to 4 hours 

total) that occurred on the day of 

service, if certain criteria are met. In 

order to maintain budget neutrality, as 

required under section 1814(i)(6)(D)(ii) 

of the Act, the new RHC rates were 

adjusted by a SIA budget neutrality 

factor. 

As discussed in the FY 2016 Hospice 

Wage Index and Rate Update final rule 

(80 FR 47177), we will continue to make 

the SIA payments budget neutral 

through an annual determination of the 

SIA budget neutrality factor (SBNF), 

which will then be applied to the RHC 

payment rates. The SBNF will be 

calculated for each FY using the most 

current and complete utilization data 

available at the time of rulemaking. For 

FY 2019, we calculated the SBNF using 

FY 2017 utilization data. For FY 2019, 

the SBNF that would apply to days 1 

through 60 is calculated to be 0.9991. 

The SBNF that would apply to days 61 

and beyond is calculated to be 0.9998. 

In the FY 2017 Hospice Wage Index 

and Rate Update final rule (81 FR 

52156), we initiated a policy of applying 

a wage index standardization factor to 

hospice payments in order to eliminate 

the aggregate effect of annual variations 

in hospital wage data. In order to 

calculate the wage index 

standardization factor, we simulate total 

payments using the FY 2019 hospice 

wage index and compare it to our 

simulation of total payments using the 

FY 2018 hospice wage index. By 

dividing payments for each level of care 

using the FY 2019 wage index by 

payments for each level of care using 

the FY 2018 wage index, we obtain a 

wage index standardization factor for 

each level of care (RHC days 1 through 

60, RHC days 61+, CHC, IRC, and GIP). 

The wage index standardization factors 

for each level of care are shown in the 

tables below. 

The FY 2019 RHC rates are shown in 

Table 3. The FY 2019 payment rates for 

CHC, IRC, and GIP are shown in 

Table 4. 

TABLE 3—FY 2019 HOSPICE RHC PAYMENT RATES

Code Description FY 2018 

payment rates 

SIA budget 

neutrality 

factor 

Wage index 

standardization 

factor 

FY 2019 

hospice 

payment 

update 

FY 2019 

payment rates 

651 ................. Routine Home Care (days 1–60) .. $192.78 × 0.9991 × 1.0009 × 1.018 $196.25 

651 ................. Routine Home Care (days 61+) .... 151.41 × 0.9998 × 1.0007 × 1.018 154.21 

TABLE 4—FY 2019 HOSPICE CHC, IRC, AND GIP PAYMENT RATES

Code Description FY 2018 

payment rates 

Wage index 

standardization 

factor 

FY 2019 

hospice 

payment 

update 

FY 2019 

payment rates 

652 ................. Continuous Home Care; Full Rate = 24 hours of 

care; $41.56 = FY 2019 hourly rate.

$976.42 × 1.0034 × 1.018 $997.38 

655 ................. Inpatient Respite Care ................................................ 172.78 × 1.0007 × 1.018 176.01 

656 ................. General Inpatient Care ................................................ 743.55 × 1.0015 × 1.018 758.07 

Sections 1814(i)(5)(A) through (C) of 

the Act require that hospices submit 

quality data, based on measures to be 

specified by the Secretary. In the FY 

2012 Hospice Wage Index final rule (76 

FR 47320 through 47324), we 

implemented a Hospice Quality 

Reporting Program (HQRP) as required 

by section 3004 of the PPACA. Hospices 

were required to begin collecting quality 

data in October 2012, and submit that 

quality data in 2013. Section 

1814(i)(5)(A)(i) of the Act requires that 

beginning with FY 2014 and each 

subsequent FY, the Secretary shall 

reduce the market basket update by 2 

percentage points for any hospice that 

does not comply with the quality data 

submission requirements with respect to 

that FY. The FY 2019 rates for hospices 

that do not submit the required quality 

data would be updated by the FY 2019 

hospice payment update percentage of 

1.8 percent minus 2 percentage points. 

These rates are shown in Tables 5 

and 6. 

TABLE 5—FY 2019 HOSPICE RHC PAYMENT RATES FOR HOSPICES THAT DO NOT SUBMIT THE REQUIRED QUALITY DATA

Code Description FY 2018 

payment rates 

SIA budget 

neutrality 

factor 

Wage index 

standardization 

factor 

FY 2019 

hospice 

payment 

update of 

1.8% minus 2 

percentage 

points = ¥0.2% 

FY 2019 

payment rates 

651 ................. Routine Home Care (days 1–60) .. $192.78 × 0.9991 × 1.0009 × 0.998 $192.39 

651 ................. Routine Home Care (days 61+) .... 151.41 × 0.9998 × 1.0007 × 0.998 151.18 


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TABLE 6—FY 2019 HOSPICE CHC, IRC, AND GIP PAYMENT RATES FOR HOSPICES THAT DO NOT SUBMIT THE

REQUIRED QUALITY DATA

Code Description FY 2018 

payment rates 

Wage index 

standardization 

factor 

FY 2019 

hospice payment update of 

1.8% minus 2 

percentage 

points = ¥0.2% 

FY 2019 

payment rates 

652 ................. Continuous Home Care; Full Rate = 24 hours of 

care; $40.74 = FY 2019 hourly rate.

$976.42 × 1.0034 × 0.998 $977.78 

655 ................. Inpatient Respite Care ................................................ 172.78 × 1.0007 × 0.998 172.56 

656 ................. General Inpatient Care ................................................ 743.55 × 1.0015 × 0.998 743.18 

A summary of the comments we 

received regarding the payment rates 

and our responses to those comments 

appear below: 

Comment: Several commenters 

mentioned the SIA payment and stated 

that CMS should allow visits by 

Licensed Practical Nurses (LPNs) in the 

last 7 days of life to be eligible for SIA 

payment due to short length of stays and 

clinical demands of hospice patients. 

Response: We finalized the SIA 

payment policy in the FY 2016 Hospice 

Wage Index and Payment Update final 

rule (80 FR 47141) and we did not 

solicit comments on a proposal to 

modify these policy parameters in the 

FY 2019 Hospice Wage Index and 

Payment Rate update proposed rule (83 

FR 20934). However, we will continue 

to consider and monitor for potential 

refinements to this policy, including 

current monitoring efforts that were 

described in the FY 2019 Hospice Wage 

Index and Payment Rate Update 

proposed rule (83 FR 20934) in response 

to these policy changes, and we will 

take these comments into account as we 

continue to do so. 

Final Decision: We are implementing 

the updates to hospice payment rates as 

discussed in the proposed rule. 

4. Hospice Cap Amount for FY 2019 

As discussed in the FY 2016 Hospice 

Wage Index and Rate Update final rule 

(80 FR 47183), we implemented changes 

mandated by the IMPACT Act of 2014 

(Pub. L. 113–185). Specifically, for 

accounting years that end after 

September 30, 2016 and before October 

1, 2025, the hospice cap is updated by 

the hospice payment update percentage 

rather than using the consumer price 

index for urban consumers (CPI–U). The 

hospice cap amount for the 2019 cap 

year will be $29,205.44, which is equal 

to the 2018 cap amount ($28,689.04) 

updated by the FY 2019 hospice 

payment update percentage of 1.8 

percent. 

A summary of the comments we 

received regarding the hospice cap 

amount and our responses to those 

comments appear below: 

Comment: One commenter suggested 

resetting and lowering the cap amount 

by an additional 10 to 15 percent, which 

the commenter stated will help to keep 

intact the original intent of the hospice 

philosophy and shift the narrative back 

towards the spirit of the community. 

Response: We appreciate the 

commenter’s suggestion that CMS 

should reset and lower the annual cap 

amount. However, the restriction set 

forth in section 1814(i)(2)(B) of the Act, 

as amended by section 3(d) of the 

IMPACT Act, does not give us 

discretion to adjust the cap amount. 

Final Decision: We are implementing 

the changes to the hospice cap amount 

as discussed in the proposed rule. 

C. Request for Information Update— 

Comments Related to Hospice Claims 

Processing 

In the FY 2018 Hospice Wage Index 

and Rate Update proposed rule (82 FR 

20789), we solicited public comments to 

start a national conversation about 

improvements that can be made to the 

health care delivery system that reduce 

unnecessary burdens for clinicians, 

other providers, and patients and their 

families. We specifically stated that we 

would not respond to the comment 

submissions in the FY 2018 final rule. 

Instead, we would review the submitted 

request for information comments and 

actively consider them as we develop 

future regulatory proposals or future 

sub-regulatory policy guidance. After 

reviewing all submitted responses to our 

requests for information in the FY 2018 

proposed rule, one recommendation in 

particular warranted a revision to our 

current policy. Commenters suggested 

that CMS remove the requirement to 

report detailed drug data on the hospice 

claim as a way to reduce burden for 

hospices. We initially began asking for 

this information via Hospice Change 

Request 8358 in support of hospice 

payment reform (https://www.cms.gov/ 

Medicare/Medicare-Fee-for-Service

Payment/Hospice/Downloads/ 

R2747CP.pdf). 

In the FY 2019 Hospice Wage Index 

and Rate Update proposed rule, (83 FR 

20953), we provided an update that 

effective October 1, 2018, we proposed 

to no longer require the reporting of 

detailed drug data on the hospice claim 

as this information is not currently used 

for quality, payment, or program 

integrity purposes. Rescinding this 

requirement could result in a significant 

reduction of burden to Medicare 

hospices, potentially reducing the 

number of line items on hospice claims 

by approximately 21.5 million, in 

aggregate. Therefore, in the FY 2019 

proposed rule, we stated that we would 

allow hospice two options for reporting 

hospice drug information: (1) Hospice 

providers would have the option to 

continue reporting infusion pumps and 

drugs, with corresponding NDC 

information, on separate line items on 

hospice claims, though it is no longer 

mandatory to report it this way; or (2) 

Hospice providers can submit total 

aggregate DME and drug charges on the 

claim. 

While the majority of commenters 

were supportive of this proposal and 

agreed that it would help to reduce 

regulatory burden, we did receive some 

comments primarily asking for more 

clarification regarding the options for 

reporting. A summary of the comments 

we received regarding this change in 

drug reporting and our responses to 

those comments appear below: 

Comments: Several commenters 

wanted to know if they needed to 

choose one option, and others requested 

clarification regarding options for 

submission. Some commenters asked if 

the reporting method could be 

determined on a case by case basis or if 

all claims had to be submitted using the 

same reporting option, meaning whether 

some claims could be reported with 

detailed line item information while 

others reported in the aggregate. One 

commenter suggested that it could be 

easier to report in the aggregate, 

depending on the responsiveness of the 


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physician or pharmacy that was 

involved in the patient’s care. One 

commenter requested clarification if the 

claim would include all DME or just 

infusion pumps and drugs that were an 

item of DME. One commenter asked if 

this process would account for potential 

delay from receiving invoices from 

pharmacies. Several commenters raised 

concerns about the costs associated with 

retraining personnel to accurately 

capture claims data and vendor 

activities to build software and reports. 

Several commenters also noted concerns 

regarding whether there would be 

sufficient time for training and software 

revisions and testing prior to 

implementation. 

Response: We appreciate the 

commenters’ feedback regarding this 

sub-regulatory change. We will allow 

hospices two options for reporting 

hospice drug information. Providers 

will have the option to continue to 

report infusion pumps and drugs, with 

corresponding NDC information, on the 

hospice claim as separate line items. 

This submission option will no longer 

be mandatory. Alternatively, hospices 

can submit total, aggregate DME and 

drug charges on the claim. At this time, 

there is no claims processing edit 

prohibiting providers to submit both 

separate line item drug data and 

aggregate drug data on the claim. 

However, we encourage providers to 

select one consistent mechanism for 

reporting this data. In order to 

implement this change, we have issued 

a detailed sub-regulatory change 

request, effective October 1, 2018, that 

provides further guidance. Change 

Request 10573 and related educational 

materials are available for review at the 

following URL: https://www.cms.gov/ 

Regulations-and-Guidance/Guidance/ 

Transmittals/2018Downloads/ 

R4035CP.pdf. 

We received several comments that 

were outside the scope of the CY 2019 

Hospice Wage Index and Rate Update 

proposed rule. We received comments 

regarding the timely posting of 

beneficiary’s hospice status in the 

Medicare system and the 

communication process between the 

CWF and the Part D MarX system, 

sequential billing, feedback on working 

with the Quality Improvement 

Organizations (QIOs) on beneficiary 

appeals of hospice discharges, the role 

of recreational therapy under the 

Medicare hospice benefit, and 

utilization of CHC and the midnightmidnight rule. 

We thank commenters for their 

feedback and we will consider these 

suggestions for potential policy 

refinements. As we stated in the FY 

2018 proposed rule, we will actively 

consider all input as we develop future 

regulatory proposals or future subregulatory policy guidance. 

D. Regulations Text Changes in 

Recognition of Physician Assistants as 

Designated Attending Physicians 

When electing the Medicare hospice 

benefit, the beneficiary agrees to forgo 

the right to have Medicare payment 

made for services related to the 

beneficiary’s terminal illness and 

related conditions, except when such 

services are provided by the designated 

hospice and the beneficiary’s designated 

attending physician as outlined in 

section 1812(d)(2)(A) of the Act. The 

designated attending physician plays an 

important role in the care of a Medicare 

hospice beneficiary. If a beneficiary 

designates an attending physician, the 

beneficiary or his or her representative 

acknowledges that the identified 

attending physician was his or her 

choice and that the attending physician 

identified by the beneficiary, at the time 

he or she elects to receive hospice care, 

has the most significant role in the 

determination and delivery of the 

individual’s medical care. The 

designated attending physician is 

required to certify that the beneficiary is 

terminally ill and participates as a 

member of the hospice IDG that 

establishes and/or or updates the 

individual’s plan of care, ensuring that 

the Medicare beneficiary receives high 

quality hospice care. 

Under the current regulations at 

§ 418.3, the attending physician is 

defined as a doctor of medicine or 

osteopathy who is legally authorized to 

practice medicine or surgery by the state 

in which he or she performs that 

function, or a nurse practitioner, and is 

identified by the individual as having 

the most significant role in the 

determination and delivery of the 

individual’s medical care. In the FY 

2019 Hospice Wage Index and Rate 

Update proposed rule (83 FR 20953), we 

stated that section 51006 of the 

Bipartisan Budget Act of 2018 (Pub. L. 

115–123) amended section 

1861(dd)(3)(B) of the Social Security Act 

such that, effective January 1, 2019, 

physician assistants (PAs) will be 

recognized as designated hospice 

attending physicians, in addition to 

physicians and nurse practitioners. We 

proposed to change the definition of 

‘‘attending physician’’ under § 418.3 to 

include physician assistants (PAs). 

In the proposed rule, we also stated 

that, effective January 1, 2019, Medicare 

will pay for medically reasonable and 

necessary services provided by PAs to 

Medicare beneficiaries who have elected 

the hospice benefit and who have 

selected a PA as their attending 

physician. PAs are paid 85 percent of 

the fee schedule amount for their 

services as attending physicians. 

Attending physician services provided 

by PAs may be separately billed to 

Medicare only if the PA is the 

beneficiary’s designated attending 

physician, services are medically 

reasonable and necessary, services 

would normally be performed by a 

physician in the absence of the PA, 

whether or not the PA is directly 

employed by the hospice, and services 

are not related to the certification of 

terminal illness. Since PAs are not 

physicians, as defined in 1861(r)(1) of 

the Act, they may not act as medical 

directors or physicians of the hospice or 

certify the beneficiary’s terminal illness 

and hospices may not contract with a 

PA for their attending physician 

services as described in section 

1861(dd)(2)(B)(i)(III) of the Act, which 

sets out the requirements of the 

interdisciplinary group as including at 

least one physician, employed by or 

under contract with the agency or 

organization. All of these provisions 

apply to PAs without regard to whether 

they are hospice employees. We also 

proposed to amend 42 CFR 418.304 

(Payment for physician and nurse 

practitioner services) in the regulations 

to include the details outlined above 

regarding Medicare payment for 

designated hospice attending physician 

services provided by physician 

assistants. 

We solicited comments on the above 

proposals to expand the definition of 

‘‘attending physician’’ at § 418.3 to 

include physician assistants (PA), and 

to amend the regulations at § 418.304 to 

allow payment for PA attending 

physician services. A summary of the 

comments and our responses to those 

comments are provided below: 

Comment: Many commenters 

expressed support and appreciation for 

the inclusion of physician assistants as 

designated hospice attending 

physicians, as commenters noted that 

PAs have an important role in providing 

hospice care, including supplying care 

to rural areas, and believe that this 

change will increase access to hospice 

services for Medicare beneficiaries. 

Response: We thank commenters for 

their support. Inclusion of PAs in the 

definition of attending physician for the 

Medicare hospice benefit will lead to 

more flexibility for hospice beneficiaries 

and providers alike. 

Comment: Several commenters 

suggested aligning the nurse practitioner 

and physician assistant rules in regards 

to hospice face-to-face encounters and 


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certifying terminal illness. One 

commenter stated that the exclusion of 

PAs from being able to provide the faceto-face encounter falls short of the goals 

of expanding the number of providers 

assisting this vulnerable population. 

This commenter stated that allowing 

PAs to conduct the face-to-face 

encounter and to certify terminal illness 

ensures greater continuity of care and 

prevent patients from having to engage 

with another healthcare professional for 

this encounter. One commenter 

recommended that the regulations at 

§ 418.22, which describe the 

requirements for the certification of 

terminal illness, be amended to include 

PAs. A commenter recommended that 

the regulations at § 418.22 be amended 

to add physician assistant. 

Response: We appreciate commenters’ 

suggestions that PAs be permitted to 

both perform hospice face-to-face 

encounters and certify terminal illness 

for hospice beneficiaries. As we 

described in the FY 2019 Hospice Wage 

Index and Rate Update proposed rule 

(83 FR 20953), the BBA of 2018 did not 

make changes to allow PAs to certify 

terminal illness or perform the face-toface encounter for Medicare 

beneficiaries. In regards to the 

certification of terminal illness, section 

51006 of the BBA of 2018 amended 

section 1814(a)(7)(A)(i)(I) of the Act 

explicitly to exclude physician 

assistants from certifying terminal 

illness. We reiterate that no one other 

than a medical doctor or doctor of 

osteopathy can certify or re-certify 

terminal illness. Additionally, PAs were 

not authorized by section 51006 of the 

Bipartisan Budget Act of 2018 (Pub. L. 

115–123) to perform the required 

hospice face-to-face encounter for recertifications. The hospice face-to-face 

encounter is required per section 

1814(a)(7)(D)(i) of the Act, which 

continues to state that only a hospice 

physician or a hospice nurse 

practitioner can perform the encounter. 

We wish to note that the regulations at 

§ 418.22 will continue to state that the 

hospice face-to-face encounter must be 

performed by a hospice physician or 

hospice nurse practitioner and that only 

a medical doctor or doctor of osteopathy 

can certify or re-certify terminal illness. 

Comment: Several commenters 

suggested developing and supporting 

appropriate education and training 

programs for PAs and other clinicians 

who serve as attending physicians in 

hospice care to ensure that they have 

the experience and training needed to 

deliver quality end-of-life care to 

beneficiaries. 

Response: We appreciate the 

commenter’s interest in the 

development of educational materials 

and programs for PAs regarding the role 

of the attending physician in the 

Medicare hospice benefit. We expect 

that providers will appropriately train 

staff according to the existing rules and 

regulations that govern Medicare 

hospice care and remain in compliance 

with state practice acts. 

Comment: A few commenters noted 

that there may be issues regarding state 

hospice licensure requirements and the 

scope of practice of PAs as an 

individual state. The commenters note 

that some states may not allow PAs to 

serve as the hospice patient’s attending 

physician, and these state laws and 

regulations would apply. 

Response: We thank the commenter 

for noting that the states’ scope of 

practice governance may not permit a 

PA to serve as a hospice beneficiary’s 

attending physician. We note that 

hospice providers are responsible for 

reviewing the state hospice licensure 

requirements and scope of practice 

regulations for PAs to ensure that PAs 

are allowed to serve as a hospice 

patient’s attending physician in 

accordance with state law and make 

staffing decisions accordingly. 

Comment: One commenter stated that 

an advanced registered nurse 

practitioner (ARNP) and a PA cannot be 

a member of the hospice 

interdisciplinary group (IDG) other than 

as the attending physician. The 

commenter suggested that CMS 

continue exploring how these 

credentialed healthcare providers can 

work at the top of their licenses and 

assist providers in gaining efficiency 

and enhancing the members of the IDG. 

Response: We thank the commenter 

for the comment regarding the 

composition of the IDG. The Condition 

of participation, ‘‘Interdisciplinary 

group, care planning, and coordination 

of services’’, described at § 418.56, states 

that ‘‘the hospice must designate an 

interdisciplinary group or groups as 

specified in paragraph (a) of this section 

which, in consultation with the 

patient’s attending physician, must 

prepare a written plan of care for each 

patient.’’ Therefore, the attending 

physician, which could include an NP 

or a PA, does, in fact, play an essential 

role in the function of the IDG. 

Additionally, § 418.56 states ‘‘the 

interdisciplinary group must include, 

but is not limited to, individuals who 

are qualified and competent to practice 

in the following professional roles: (i) A 

doctor of medicine or osteopathy (who 

is an employee or under contract with 

the hospice). (ii) A registered nurse. (iii) 

A social worker. (iv) A pastoral or other 

counselor.’’ The required members of 

the IDG are described in the CoPs, but 

other professionals, including NPs and 

PAs, are not excluded from participating 

in the IDG as appropriate for the 

beneficiary’s plan of care. 

Final Decision: Effective for January 1, 

2019, we are finalizing statutorilyrequired updates to the regulations to 

expand the definition of attending 

physician at § 418.3 to include 

physician assistants (PA). We are also 

finalizing amendments to the 

regulations at § 418.304 to include the 

details regarding Medicare payment for 

designated hospice attending physician 

services provided by physician 

assistants. 

E. Proposed Technical Correction 

Regarding Hospice Cap Period 

Definition 

In the FY 2016 Hospice Wage Index 

and Rate Update final rule (80 FR 

47142), we finalized aligning the cap 

period, for both the inpatient cap and 

the hospice aggregate cap, with the 

federal FY for FY 2017 and later. 

Therefore, the cap year now begins 

October 1 and ends on September 30 (80 

FR 47186). We proposed to make a 

technical correction in § 418.3 to reflect 

the revised timeframes for hospice cap 

periods. Specifically, we proposed that 

§ 418.3 would specify that the cap 

period means the twelve-month period 

ending September 30 used in the 

application of the cap on overall 

hospice reimbursement specified in 

§ 418.309. 

Additionally, we are making a 

technical correction in § 418.309 to 

reflect the revised timeframes for 

hospice cap periods. Specifically, we 

are inserting a reference to the 

definition of ‘‘cap period’’ as defined in 

§ 418.3 and removing language setting 

out specific month and day information. 

We inadvertently did not propose to 

amend the regulations at § 418.309, but 

we now believe it is appropriate to make 

a technical correction to the regulations 

text; the specific changes we are making 

in the regulations simply codify the 

final policies previously finalized in the 

FY 2016 Hospice Wage Index and Rate 

Update final rule (80 FR 47142), and do 

not reflect any additional substantive 

changes. 

Final Decision: We did not receive 

any comments on our proposed changes 

therefore, we are finalizing the changes 

to the regulations text regarding the 

hospice cap period as discussed in the 

proposed rule. 


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5See, for example United States Department of 

Health and Human Services. ‘‘Healthy People 2020: 

Disparities. 2014.’’ Available at: http://

www.healthypeople.gov/2020/about/foundationhealth-measures/Disparities; or National Academies 

of Sciences, Engineering, and Medicine. Accounting 

for Social Risk Factors in Medicare Payment: 

Identifying Social Risk Factors. Washington, DC: 

National Academies of Sciences, Engineering, and 

Medicine 2016. 

6 Department of Health and Human Services 

Office of the Assistant Secretary for Planning and 

Evaluation (ASPE), ‘‘Report to Congress: Social Risk 

Factors and Performance Under Medicare’s ValueBased Purchasing Programs.’’ December 2016. 

Available at: https://aspe.hhs.gov/pdf-report/reportcongress-social-risk-factors-and-performanceunder-medicares-value-based-purchasingprograms. 

7Available at: http://www.qualityforum.org/SES_

Trial_Period.aspx. 

F. Updates to the Hospice Quality 

Reporting Program (HQRP) 

1. Background and Statutory Authority 

The Hospice Quality Reporting 

Program includes HIS and CAHPS. 

Section 3004(c) of the Affordable Care 

Act amended section 1814(i)(5) of the 

Act to authorize a quality reporting 

program for hospices. Section 

1814(i)(5)(A)(i) of the Act requires that 

beginning with FY 2014 and each 

subsequent FY, the Secretary shall 

reduce the market basket update by 2 

percentage points for any hospice that 

does not comply with the quality data 

submission requirements for that FY. 

Depending on the amount of the annual 

update for a particular year, a reduction 

of 2 percentage points could result in 

the annual market basket update being 

less than 0 percent for a FY and may 

result in payment rates that are less than 

payment rates for the preceding FY. Any 

reduction based on failure to comply 

with the reporting requirements, as 

required by section 1814(i)(5)(B) of the 

Act, would apply only for the particular 

year involved. Any such reduction 

would not be cumulative nor be taken 

into account in computing the payment 

amount for subsequent FYs. Section 

1814(i)(5)(C) of the Act requires that 

each hospice submit data to the 

Secretary on quality measures specified 

by the Secretary. The data must be 

submitted in a form, manner, and at a 

time specified by the Secretary. 

2. General Considerations Used for 

Selection of Quality Measures for the 

Hospice QRP 

a. Background 

The ‘‘Meaningful Measures’’ initiative 

is intended to provide a framework for 

quality measurement and improvement 

work at CMS. While this framework 

serves to focus on those core issues that 

are most vital to providing high-quality 

care and improving patient outcomes, it 

also takes into account opportunities to 

reduce paperwork and reporting burden 

on providers associated with quality 

measurement. To that end, we have 

begun assessing our programs’ quality 

measures in accordance with the 

Meaningful Measures framework. We 

refer readers to the Executive Summary 

for more information on the 

‘‘Meaningful Measures’’ initiative. 

Comment: CMS received several 

comments that supported the 

Meaningful Measures Initiative. 

Additionally, commenters stated that 

the ‘‘Strengthen Person and Family 

Engagement as Partners in Their Care’’ 

Quality Priority, as set out in 83 FR 

20935 is an important area that is 

central to the provision of hospice care 

delivery. One commenter stated that the 

following Meaningful Measure Areas are 

applicable to hospice patients: End of 

Life Care according to Preferences, 

Patient’s Experience of Care, Patient 

Reported Functional Outcomes (83 FR 

20935). One commenter stated that 

adverse event reporting in the hospice 

setting can be challenging due to the 

variety of levels and settings of care. 

CMS received a few comments 

regarding quality measure development 

processes. Commenters recommended 

that CMS seek stakeholder input as part 

of the quality measure development 

process. Additionally, measure 

development across all care settings 

should consider special populations 

such as those that are terminally ill, and 

that expected declines in functional 

status due to advanced illness should 

not negatively impact the provider. 

Further, CMS should pursue 

development of quality measures that 

are important for hospice patients at the 

end of life, such as person and family 

engagement, pain and symptom 

management, effective communication, 

care coordination, and care concordant 

with patients’ wishes. Finally, one 

commenter requested that CMS be 

transparent in its planning and 

development of potential HQRP quality 

measures and inform and engage 

stakeholders as frequently as possible. 

Response: Since no changes were 

proposed regarding Meaningful 

Measures or quality measure 

development processes, comments 

received are outside the scope of the 

current rule. We discuss quality 

development processes in the FY 2018 

Hospice final rule (82 FR 36652 through 

36654), and we refer readers to that 

detailed discussion. 

b. Accounting for Social Risk Factors in 

the Hospice QRP 

In the FY 2018 Hospice Wage Index 

final rule (82 FR 36652 through 36654), 

we discussed the importance of 

improving beneficiary outcomes 

including reducing health disparities. 

We also discussed our commitment to 

ensuring that medically complex 

patients, as well as those with social 

risk factors, receive excellent care. We 

discussed how studies show that social 

risk factors, such as being near or below 

the poverty level, as set out annually in 

HHS guidelines, https://

www.federalregister.gov/documents/ 

2018/01/18/2018-00814/annual-updateof-the-hhs-poverty-guidelines, belonging 

to a racial or ethnic minority group, or 

living with a disability, can be 

associated with poor health outcomes 

and how some of this disparity is 

related to the quality of health care.5

Among our core objectives, we aim to 

improve health outcomes, attain health 

equity for all beneficiaries, and ensure 

that complex patients as well as those 

with social risk factors receive excellent 

care. Within this context, reports by the 

Office of the Assistant Secretary for 

Planning and Evaluation (ASPE) and the 

National Academy of Medicine have 

examined the influence of social risk 

factors in CMS value-based purchasing 

programs.6 As we noted in the FY 2018 

Hospice Wage Index final rule (82 FR 

36652 through 36654), ASPE’s report to 

Congress, which was required by 

section 2(d) of the IMPACT Act, found 

that, in the context of value-based 

purchasing programs, dual eligibility 

was the most powerful predictor of poor 

health care outcomes among those 

social risk factors that they examined 

and tested. ASPE is continuing to 

examine this issue in its second report 

required by the IMPACT Act, which is 

due to Congress in the fall of 2019. In 

addition, as we noted in the FY 2018 

IPPS/LTCH PPS final rule (82 FR 

38428), the National Quality Forum 

(NQF) undertook a 2-year trial period in 

which certain new measures and 

measures undergoing maintenance 

review have been assessed to determine 

if risk adjustment for social risk factors 

is appropriate for these measures.7 The 

trial period ended in April 2017 and a 

final report is available at: http://

www.qualityforum.org/SES_Trial_

Period.aspx. The trial concluded that 

‘‘measures with a conceptual basis for 

adjustment generally did not 

demonstrate an empirical relationship’’ 

between social risk factors and the 

outcomes measured. This discrepancy 

may be explained in part by the 

‘‘methods used for adjustment and the 

limited availability of robust data on 

social risk factors’’. NQF has extended 


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8Available at: http://www.qualityforum.org/ 

WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=

86357. 

the socioeconomic status (SES) trial,8

allowing further examination of social 

risk factors in outcome measures. 

In the FY 2018/CY 2018 proposed 

rules for our quality reporting and 

value-based purchasing programs, we 

solicited feedback on which social risk 

factors provide the most valuable 

information to stakeholders and the 

methodology for illuminating 

differences in outcomes rates among 

patient groups within provider that 

would also allow for a comparison of 

those differences, or disparities, across 

providers. Feedback we received across 

our quality reporting programs included 

encouraging CMS to explore whether 

factors that could be used to stratify or 

risk adjust the measures (beyond dual 

eligibility); considering the full range of 

differences in patient backgrounds that 

might affect outcomes; exploring risk 

adjustment approaches; and offering 

careful consideration of what type of 

information display would be most 

useful to the public. 

We also sought public comment on 

confidential reporting and future public 

reporting of some of our measures 

stratified by patient dual-eligibility. In 

general, commenters noted that 

stratified measures could serve as tools 

for hospitals to identify gaps in 

outcomes for different groups of 

patients, improve the quality of health 

care for all patients, and empower 

consumers to make informed decisions 

about health care. We were encouraged 

to stratify measures by other social risk 

factors such as age, income, and 

educational attainment. With regard to 

value-based purchasing programs, 

commenters also cautioned CMS to 

balance fair and equitable payment 

while avoiding payment penalties that 

mask health disparities or discouraging 

the provision of care to more medically 

complex patients. Commenters also 

noted that value-based payment 

program measure selection, domain 

weighting, performance scoring, and 

payment methodology must account for 

social risk. 

As discussed in last year’s final rule, 

82 FR 36652 through 36654, we are 

considering options to improve health 

disparities among patient groups within 

and across hospitals by increasing the 

transparency of disparities as shown by 

quality measures. We also are 

considering how this work applies to 

other CMS quality programs in the 

future. We refer readers to the FY 2018 

IPPS/LTCH PPS final rule (82 FR 38403 

through 38409) for more details, where 

we discuss the potential stratification of 

certain Hospital Inpatient Quality 

Reporting Program outcome measures. 

Furthermore, we continue to consider 

options to address equity and disparities 

in our value-based purchasing 

programs. 

We plan to continue working with 

ASPE, the public, and other key 

stakeholders on this important issue to 

identify policy solutions that achieve 

the goals of attaining health equity for 

all beneficiaries and minimizing 

unintended consequences. 

Comment: CMS received several 

comments that supported the 

administration’s continued investigation 

of ways that social risk factors can be 

applied to quality measure 

development. Several commenters 

recommended additional research on 

the inclusion of social determinants of 

health in the development of quality 

measures, especially for those that apply 

to the seriously and terminally ill 

population. Commenters also provided 

several recommendations for possible 

social risk factors, including native 

language of the patient, income level, 

race and ethnicity, adequacy of 

caregiver support, presence of PTSD, 

and number of facility-based patients. 

Response: We appreciate commenters’ 

continued support of our efforts to 

attain health equity for all beneficiaries. 

Since no changes were proposed to the 

social risk factors, comments received 

are outside the scope of the current rule. 

We addressed these issues in the FY 

2018 final rule (82 FR 36652 through 

36654), and we refer readers to that 

detailed discussion. 

c. New Measure Removal Factor 

In the FY 2016 Hospice Final Rule (80 

FR 47186), we adopted seven factors for 

measure removal. We are adopting an 

eighth factor to consider when 

evaluating measures for removal from 

the HQRP measure set: The costs 

associated with a measure outweighs 

the benefit of its continued use in the 

program. 

As we discussed in the Executive 

Summary, we are engaging in efforts to 

ensure that the HQRP measure set 

continues to promote improved health 

outcomes for beneficiaries while 

minimizing the overall costs associated 

with the program. These costs are multifaceted and include not only the burden 

associated with reporting, but also the 

costs associated with complying with 

the program. We have identified several 

different types of costs, including, but 

not limited to: (1) Provider and clinician 

information collection burden and 

burden associated with the submitting/ 

reporting of quality measures to CMS; 

(2) the provider and clinician cost 

associated with complying with other 

Hospital IQR programmatic 

requirements; (3) the provider and 

clinician cost associated with 

participating in multiple quality 

programs, and tracking multiple similar 

or duplicative measures within or across 

those programs; (4) the cost to CMS 

associated with the program oversight of 

the measure including measure 

maintenance and public display; and/or 

(5) the provider and clinician cost 

associated with compliance to other 

federal and/or state regulations 

(depending upon the measure). For 

example, it may be needlessly costly 

and/or of limited benefit to retain or 

maintain a measure for which our 

analyses show no longer meaningfully 

supports program objectives (for 

example, informing beneficiary choice 

or payment scoring). It may also be 

costly for health care providers to track 

the confidential feedback and preview 

reports, as well as publicly reported 

information on a measure we use in 

more than one program. We may also 

have to expend unnecessary resources 

to maintain the specifications for the 

measure, including the tools we need to 

collect, validate, analyze, and publicly 

report the measure data. Furthermore, 

beneficiaries may find it confusing to 

see public reporting on the same 

measure in different programs. There 

also may be other burdens associated 

with a measure that arise on a case-bycase basis. 

When these costs outweigh the 

evidence supporting the continued use 

of a measure in the HQRP, it may be 

appropriate to remove the measure from 

the program. Although we recognize 

that one of the main goals of the HQRP 

is to improve beneficiary outcomes by 

incentivizing health care providers to 

focus on specific care issues and making 

public data related to those issues, we 

also recognize that those goals can have 

limited utility where, for example, the 

publicly reported data is of limited use 

because it cannot be easily interpreted 

by beneficiaries and used to influence 

their choice of providers. In these cases, 

removing the measure from the HQRP 

may better accommodate the costs of 

program administration and compliance 

without sacrificing improved health 

outcomes and beneficiary choice. 

We will remove measures based on 

this factor on a case-by-case basis. We 

might, for example, decide to retain a 

measure that is burdensome for health 

care providers to report if we conclude 

that the benefit to beneficiaries justifies 

the reporting burden. Our goal is to 

move the program forward in the least 

burdensome manner possible, while 


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maintaining a parsimonious set of 

meaningful quality measures and 

continuing to incentivize improvement 

in the quality of care provided to 

patients. 

We solicited public comment on our 

proposal to adopt an additional measure 

removal factor, ‘‘the costs associated 

with a measure outweighs the benefit of 

its continued use in the program,’’ 

beginning with the FY 2019 Hospice 

Wage Index final rule. The vast majority 

of commenters supported our proposal 

to adopt an eighth criterion for measure 

removal. Most commenters were 

appreciative of CMS acknowledging 

burden of measures as an important 

criterion for retaining measures in the 

HQRP. However, one commenter 

disagreed with this proposal as 

discussed further below. A summary of 

the comments we received on this 

proposal and our responses to those 

comments appear below: 

Comment: Several commenters raised 

concerns and provided 

recommendations. Among those who 

supported the proposal, several 

commenters requested CMS seek public 

input before removing any measure 

from the HQRP under this criterion. 

Commenters noted that cost and 

benefits could be hard to define, and 

that interested parties may have 

different perspectives about relative 

costs versus benefits of a measure. 

Moreover, one commenter noted that 

benefits can be difficult to quantify (for 

example, timely care, good 

communication, quality of life). Thus, 

commenters recommended CMS seek 

public input prior to removing a 

measure based on this criterion in order 

to obtain meaningful stakeholder input 

on benefits of a measure, especially in 

instances where a measure may be 

costly, but provides value in 

distinguishing quality of hospice care. 

Commenters also recommended that if 

CMS decides a measure is appropriate 

for removal based on this criterion, that 

CMS announce removal of the measure 

through rulemaking. 

Response: We appreciate the 

commenters input regarding the 

measure removal factor. We agree with 

commenters who suggested that CMS 

seek public input prior to removing 

measures under this measure removal 

factor. We value transparency in our 

processes, and continually seek 

stakeholder input through education 

and outreach sessions, other webinars, 

rulemaking, and other collaborative 

engagements with stakeholders. We 

intend to continue to adopt and remove 

measures through our previously 

identified processes, which include 

notice and comment rulemaking for 

proposed adoption and removal of 

measures. The only exception to this is 

that we may immediately remove a 

measure from the Hospice Program if we 

identify the measure as having 

unintended consequences that may 

adversely affect patient safety. 

Comment: The commenter who 

disagreed with this proposal stated that 

the existing seven criteria were 

sufficient for determining removal of a 

measure from the HQRP, and stated the 

eighth factor could open the door for 

providers to argue for dropping a 

measure they do not want collected for 

reasons other than true cost versus 

benefit concerns (for example, arguing 

to drop a measure they are performing 

poorly on by stating the measure’s costs 

outweigh the benefits). 

Response: We agree that it is possible 

that providers may recommend removal 

of measures they do not support based 

on the case that these measures are 

costly. However, input from providers is 

only one element of our case-by-case 

analysis of measures. We also intend to 

consider input from other stakeholders, 

including patients, caregivers, advocacy 

organizations, healthcare researchers, 

and other parties as appropriate to each 

measure. We will weigh the input 

received from stakeholders with our 

own analysis of each measure to make 

a case-by-case determination of whether 

it’s appropriate to remove a measure 

based on its costs outweighing the 

benefit of its continued use in the 

program. 

Overall, in our assessment of measure 

sets across quality reporting and valuebased purchasing programs under the 

Meaningful Measure Initiative, we 

identified measures that were no longer 

sufficiently beneficial to justify their 

costs within their respective programs. 

However, none of the previously 

finalized measure removal factors 

applied to these measures. Therefore, 

we determined that our measure 

removal factors were incomplete 

without this newly identified factor. 

Final Decision: After consideration of 

the comments, we are finalizing our 

proposal to adopt an additional measure 

removal factor for the HQRP, ‘‘the costs 

associated with a measure outweighs 

the benefit of its continued use in the 

program,’’ for FY 2019 and subsequent 

years. 

3. Previously Adopted Quality Measures 

for FY 2019 Payment Determination and 

Future Years 

In the FY 2014 Hospice Wage Index 

final rule (78 FR 48257), and in 

compliance with section 1814(i)(5)(C) of 

the Act, we finalized the specific 

collection of data items that support the 

following 7 National Quality Forum 

(NQF)-endorsed measures for hospice: 

• NQF #1617 Patients Treated with 

an Opioid who are Given a Bowel 

Regimen, 

• NQF #1634 Pain Screening, 

• NQF #1637 Pain Assessment, 

• NQF #1638 Dyspnea Treatment, 

• NQF #1639 Dyspnea Screening, 

• NQF #1641 Treatment Preferences, 

• NQF #1647 Beliefs/Values 

Addressed (if desired by the patient). 

We finalized the following 2 

additional measures in the FY 2017 

Hospice Wage Index final rule, effective 

April 1, 2017. Data collected will, if not 

reported, affect payments for FY 2019 

and subsequent years. (81 FR 52163 

through 52173): 

• Hospice Visits when Death is 

Imminent, 

• Hospice and Palliative Care 

Composite Process Measure— 

Comprehensive Assessment at 

Admission. 

The Hospice and Palliative Care 

Composite Process Measure— 

Comprehensive Assessment at 

Admission measure (hereafter referred 

to as ‘‘the Hospice Comprehensive 

Assessment Measure’’) underwent an 

off-cycle review by the NQF Palliative 

and End-of-Life Standing Committee 

and successfully received NQF 

endorsement in July 2017. 

Data for the Hospice Visits when 

Death is Imminent measure pair is being 

collected using new items added to the 

HIS V2.00.0, effective April 1, 2017. 

This one measure comprises a measure 

pair assessing hospice staff visits to 

patients at the end of life. Measure 1: 

Percentage of patients receiving at least 

one visit from registered nurses, 

physicians, nurse practitioners, or 

physician assistants in the last 3 days of 

life. Measure 2: Percentage of patients 

receiving at least two visits from 

medical social workers, chaplains or 

spiritual counselors, licensed practical 

nurses or hospice aides in the last 7 

days of life. We will need at least 4 

quarters of reliable data to conduct the 

necessary analyses to support 

submission to NQF. We will also need 

to assess the quality of data submitted 

in the first quarter of item 

implementation to determine whether 

they can be used in the analyses. We 

have begun analysis of the data, and, 

pending analysis, we will submit the 

Hospice Visits when Death is Imminent 

measure pair to NQF for endorsement 

review in accordance with NQF project 

timelines and call for measures. We will 

use a similar process to analyze and 

submit new quality measures to NQF for 

endorsement in future years. Providers 

will be notified of measure endorsement 


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and public reporting through subregulatory channels. 

In the FY 2015 Hospice Wage Index 

final rule (79 FR 50491 through 50496), 

we also finalized the Consumer 

Assessment of Healthcare Providers and 

Systems (CAHPS®) Hospice Survey to 

support quality measures based on 

patient and family experience of care. 

We refer readers to section III.F.5 of the 

FY 2019 final rule for details regarding 

the CAHPS® Hospice Survey, including 

public reporting of selected survey 

measures. 

TABLE 7—PREVIOUSLY FINALIZED QUALITY MEASURES AFFECTING THE FY 2019 PAYMENT DETERMINATION AND

SUBSEQUENT YEARS

NQF No. Hospice item set quality measure 

Year the measure 

was first adopted 

for use in APU 

determination 

1641 ................ Treatment Preferences ...................................................................................................................................... FY 2016 

1647 ................ Beliefs/Values Addressed (if desired by the patient) ........................................................................................ FY 2016 

1634 ................ Pain Screening ................................................................................................................................................... FY 2016 

1637 ................ Pain Assessment ............................................................................................................................................... FY 2016 

1639 ................ Dyspnea Screening ............................................................................................................................................ FY 2016 

1638 ................ Dyspnea Treatment ........................................................................................................................................... FY 2016 

1617 ................ Patients Treated with an Opioid Who are Given a Bowel Regimen ................................................................. FY 2016 

3235 ................ The Hospice and Palliative Care Composite Process Measure—Comprehensive Assessment at Admission FY 2019 

TBD ................ Hospice Visits when Death is Imminent ............................................................................................................ FY 2019 

A summary of the comments we 

received regarding Hospice Visits and 

our response to those comments appear 

below: 

Comment: CMS received several 

comments pertaining to the Hospice 

Visits when Death is Imminent Measure 

Pair. Even though commenters 

supported the Hospice Visits when 

Death is Imminent Measure Pair, they 

recommended updates to Measure Pair, 

such as excluding patients with a length 

of stay of 7 days or less, aligning the 

measure pair and the SIA 

reimbursement structure, and 

accounting for patient or family refusal 

of services in measure specifications. 

Response: Since no changes were 

proposed to Hospice Visits when Death 

is Imminent Measure Pair, comments 

received are outside the scope of the 

current rule. We addressed these issues 

in the FY 2017 final rule (81 FR 52162 

through 52169), and we refer the reader 

to that detailed discussion. 

4. Form, Manner, and Timing of Quality 

Data Submission 

a. Background 

Section 1814(i)(5)(C) of the Act 

requires that each hospice submit data 

to the Secretary on quality measures 

specified by the Secretary. Such data 

must be submitted in a form and 

manner, and at a time specified by the 

Secretary. Section 1814(i)(5)(A)(i) of the 

Act requires that beginning with the FY 

2014 and for each subsequent FY, the 

Secretary shall reduce the market basket 

update by 2 percentage points for any 

hospice that does not comply with the 

quality data submission requirements 

for that FY. 

b. Revised Data Review and Correction 

Timeframes for Data Submitted Using 

the HIS 

In the FY 2015 Hospice Wage Index 

final rule (79 FR 50486), we finalized 

our policy requiring that hospices 

complete and submit HIS records for all 

patient admissions to hospice on or after 

July 1, 2014. For each HQRP reporting 

year, we require that hospices submit 

data in accordance with the reporting 

requirements specified in the FY 2015 

Hospice final rule (79 FR 50486) for the 

designated reporting period. Electronic 

submission is required for all HIS 

records. For more information about HIS 

data collection and submission policies 

and procedures, we refer readers to the 

FY 2018 Hospice Wage Index final rule 

(82 FR 36663) and the CMS HQRP 

website: http://www.cms.gov/Medicare/ 

Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/ 

Hospice-Item-Set-HIS.html. For more 

information about CAHPS® Hospice 

Survey data submission policies and 

timelines, we refer readers to section 

III.F.5 of the FY 2019 final rule. 

Hospices currently have 36 months to 

modify HIS records. However, only data 

modified before the public reporting 

‘‘freeze date’’ are reflected in the 

corresponding CMS Hospice Compare 

website refresh. For more information 

about the HIS ‘‘freeze date’’, see the 

Public Reporting: Key Dates for 

Providers page on the CMS HQRP 

website: https://www.cms.gov/ 

Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/Public-ReportingKey-Dates-for-Providers.html. 

To ensure that the data reported on 

Hospice Compare is accurate, we 

proposed that hospices be provided a 

distinct period of time to review and 

correct the data that is to be publically 

reported. This approach would allow 

hospices a time frame in which they 

may analyze their data and make 

corrections (up until 11:59:59 p.m. ET of 

the quarterly deadline) prior to 

receiving their preview reports. Once 

the preview reports are received, it is 

infeasible to make corrections to the 

data underlying the quality measure 

scores that are to be made public. 

Therefore, we proposed that for data 

reported using the HIS that there be a 

specified time period for data review 

and a correlating data correction 

deadline for public reporting at which 

point the data is frozen for the 

associated quarter. Similar to the 

policies outlined in the FY 2016 SNF 

final rule (81 FR 24271) and the FY 

2016 IPPS/LTCH final rule (80 FR 

49754), at this deadline for public 

reporting, we proposed that data from 

HIS records with target dates within the 

correlating quarter become a frozen 

‘‘snapshot’’ of data for public reporting 

purposes. Any record-level data 

correction after the date on which the 

data are frozen will not be incorporated 

into measure calculation for the 

purposes of public reporting on the 

CMS Hospice Compare website. For 

each calendar quarter of data submitted 

using the HIS, approximately 4.5 

months after the end of each CY quarter 

we proposed a deadline, or freeze date 

for the submissions of corrections to 

records. We note that this new data 

correction deadline for HIS records is 

separate and apart from the established 

30-day data submission deadline. More 

information about the data submission 

deadline can be found at https:// 

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Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/ 

. 

Specifically, each data correction 

deadline will occur on the 15th of the 

CY month that is approximately 4.5 

months after the end of each CY quarter, 

and hospices will have up until 

11:59:59 p.m. ET on that date to submit 

corrections or requests for inactivation 

of their data for the quarter involved. 

For example, for data reported in CY 

Q1, the freeze date will be August 15th, 

for CY Q2 the freeze date will be 

November 15th and so on. Under this 

policy, any modification to or 

inactivation of records that occur after 

the proposed correction deadline will 

not be reflected in publicly reported 

data on the CMS Hospice Compare 

website. For example, for the data 

collected during the 1st quarter, that is 

January 1st through March 31st of a 

given year, the hospice will have until 

11:59:59 p.m. ET on August 15th of that 

year to ensure all of their data is correct. 

Any modifications to first quarter data 

that are submitted to us after August 

15th would not be reflected during any 

subsequent Hospice Compare refresh. 

We believe that this is a reasonable 

amount of time to allow providers to 

make any necessary corrections to 

submitted data prior to public reporting. 

This revised policy aligns HQRP with 

the policies and procedures that exist in 

our other quality reporting programs 

including the post-acute care programs, 

which also enable providers to review 

their data and make necessary 

corrections within the specified time 

frame of approximately 4.5 months 

following the end of a given CY quarter 

and prior to the public reporting of such 

data. 

We proposed that beginning January 

1, 2019, HIS records with target dates on 

or after January 1, 2019 will have a data 

correction deadline for public reporting 

of approximately 4.5 months after the 

end of each CY quarter in which the 

target date falls, and that hospices will 

have until 11:59:59 p.m. ET on the 

deadline to submit corrections. 

We also proposed that for the 

purposes of public reporting, the first 

quarterly freeze date for CY 2019 data 

corrections will be August 15, 2019. To 

accommodate those HIS records with 

target dates prior to January 1, 2019 and 

still within a target period for public 

reporting, we also proposed to extend to 

hospices the opportunity to review their 

data and submit corrections up until the 

CY 19 Q1 deadline of 11:59:59 p.m. ET 

on August 15, 2019. Table 8 presents the 

proposed data correction deadlines for 

public reporting beginning in CY 2019. 

TABLE 8—DATA CORRECTION DEADLINES FOR PUBLIC REPORTING BEGINNING CY 2019 

Data reporting period * 

Data correction 

deadline for public 

reporting * 

Prior to January 1, 2019 ............................................................................................................................................................ August 15, 2019 

January 1, 2019–March 31, 2019 ............................................................................................................................................. August 15, 2019 

April 1, 2019–June 30, 2019 ..................................................................................................................................................... November 15, 2019 

July 1, 2019–September 30, 2019 ............................................................................................................................................ February 15, 2020 

October 1,2019–December 31, 2019 ........................................................................................................................................ May 15, 2020 

* This CY time period involved is intended to inform both CY 2019 data and to serve as an illustration for the review and correction deadlines 

that are associated with each calendar year of data reporting quarter. 

We received multiple comments 

pertaining to the revised data review 

and correction timeframes for data 

submitted using the HIS. A summary of 

the comments we received on this 

proposal and our responses to those 

comments appear below: 

Comment: A majority of the 

commenters supported the proposed 4.5 

month data correction deadline for 

publicly reported HIS data. Commenters 

noted that this timeframe was sufficient 

for providers to review their data and 

make necessary corrections prior to 

public reporting. One commenter 

questioned why CMS would create a 

shorter, 4.5 month timeframe for data 

corrections when hospices may submit 

claims for services up to 12 months 

from the date of service. This 

commenter suggested that quality data 

corrections should be permitted for a 

similar amount of time. Additionally, 

CMS received one comment that 

emphasized the importance of 

widespread provider education related 

to the data correction deadline for 

public reporting of HIS data. This 

commenter stated that providers may 

experience challenges submitting and 

reviewing data in a shorter timeframe 

due to various circumstances, such as if 

the hospice is converting to a new EHR 

or if HIS data collection is not integrated 

into the hospice’s routine assessment. 

Response: We appreciate the 

commenters’ support of a 4.5 month 

data correction deadline for publicly 

reported HIS data. CMS expects that the 

data that hospices submit to CMS is as 

accurate as possible upon the initial 

submission of that data, and that 

corrections should not be the rule, but 

rather the exception here. When a 

hospice does need to make a 

modification or inactivation requests, 

they will continue to be permitted for 

up to 36 months from the assessment 

target date. However, HIS data that are 

submitted more than 4.5 months from 

the end of the corresponding CY quarter 

will impact data displayed on Hospice 

Compare because that data will not be 

reflected in the hospices measure scores 

that are displayed on Hospice Compare. 

More information about modification 

and inactivation requests can be found 

in the HIS Manual (Section 3.6) 

available under the downloads section 

of the HIS web page on the CMS HQRP 

website: https://www.cms.gov/ 

Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/Hospice-Item-SetHIS.html. 

Requiring that data be reviewed and 

corrected for public reporting purposes 

within a defined period of time will 

result in more timely and accurate data 

on Hospice Compare, ensuring that 

consumers have access to a resource 

with consistent and accurate 

representations of hospice performance. 

We appreciate the commenter’s 

recommendation to align HQRP and 

claims policy. Although this new policy 

will not align HQRP and claims data 

submission requirements, it will align 

the HQRP with the policies and 

procedures that exist in other quality 

reporting programs including the postacute care programs. Based on 

experiences in other settings, this 

timeframe allows hospices sufficient 

time to submit, review, and correct their 

data prior to public reporting of that 

data. 

Finally, we agree that widespread 

education will be necessary to ensure 

that providers understand the data 

correction deadline for public reporting 


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of HIS data. We will provide future 

education and outreach activities to 

educate providers about the data 

correction deadline for public reporting 

through HQRP communication 

channels, which include postings on the 

CMS HQRP website, announcements in 

the MLN eNews, and Open Door 

Forums. 

Final Decision: After consideration of 

the comments, we are finalizing our 

proposal to implement public reporting 

data review and correction timeframes 

for data submitted using the HIS, 

starting on January 1, 2019. 

5. CAHPS® Hospice Survey 

Participation Requirements for the FY 

2023 APU and Subsequent Years 

The CAHPS® Hospice Survey of 

CMS’ HQRP is used to collect data on 

the experiences of hospice patients and 

the primary caregivers listed in their 

hospice records. Readers who want 

more information are referred to our 

extensive discussion of the Hospice 

Experience of Care prior to our proposal 

for the public reporting of measures may 

refer to 79 FR 50452 and 78 FR 48261. 

a. Background and Description of the 

CAHPS® Hospice Survey 

The CAHPS® Hospice Survey is the 

first standardized national survey 

available to collect information on 

patients’ and informal caregivers’ 

experience of hospice care. Patientcentered experience measures are a key 

component of the CMS Quality Strategy, 

emphasizing patient-centered care by 

rating experience as a means to 

empower patients and their caregivers 

and improving the quality of their care. 

In addition, the survey introduces 

standard survey administration 

protocols that allow for fair comparisons 

across hospices. 

Although the development of the 

CAHPS® Hospice Survey predates the 

Meaningful Measures initiative, it used 

many of the Meaningful Measure 

principles in its development. The 

overarching quality priority of 

‘‘Strengthen Person and Family 

Engagement as Partners in Their Care’’ 

includes Meaningful Measure areas 

such as ‘‘Care is personalized and 

Aligned with Patient’s Goals,’’ ‘‘End of 

Life Care According to Preferences’’ and 

‘‘Patients Experience of Care.’’ The 

survey questions were developed with 

input from caregivers of patients who 

died under hospice care. The survey 

focuses on topics that are meaningful to 

caregivers/patients and supports our 

efforts to put the patient and their 

family members first. 

Details regarding CAHPS® Hospice 

Survey national implementation, survey 

administration, participation 

requirements, exemptions from the 

survey’s requirements, hospice patient 

and caregiver eligibility criteria, fielding 

schedules, sampling requirements, 

survey instruments, and the languages 

that are available for the survey, are all 

available on the official CAHPS® 

Hospice Survey website: https://

www.HospiceCAHPSsurvey.org, and in 

the CAHPS® Hospice Survey Quality 

Assurance Guidelines (QAG), which are 

posted on the website. 

b. Overview of the CAHPS® Hospice 

Survey Measures 

The CAHPS® Hospice Survey is 

administered after the patient is 

deceased and queries the decedent’s 

primary, informal caregiver (usually a 

family member) regarding the patient 

and family experience of care, unlike 

the Hospital CAHPS® Survey deployed 

in 2006 (71 FR 48037 through 48039) 

and other subsequent CAHPS® surveys. 

National implementation of the 

CAHPS® Hospice Survey commenced 

January 1, 2015 as stated in the FY 2015 

Hospice Wage Index and Payment Rate 

Update final rule (79 FR 50452). 

The survey consists of 47 questions 

and is available (using the mailed 

version) in English, Spanish, Chinese, 

Russian, Portuguese, Vietnamese, 

Polish, and Korean. It covers topics such 

as access to care, communications, 

getting help for symptoms, and 

interactions with hospice staff. The 

survey also contains 2 global rating 

questions and asks for self-reported 

demographic information (race/ 

ethnicity, educational attainment level, 

languages spoken at home, among 

others). The CAHPS® Hospice Survey 

measures received NQF endorsement on 

October 26th, 2016 (NQF #2651). 

Measures derived from the CAHPS® 

Hospice Survey include 6 multi-item 

(composite) measures and 2 global 

ratings measures. They received NQF 

endorsement on October 26, 2016 (NQF 

#2651). We adopted these 8 surveybased measures for the CY 2018 data 

collection period and for subsequent 

years. These 8 measures are reported on 

Hospice Compare. 

Comment: CMS received several 

comments relating to the range of 

responses to the CAHPS Survey. One 

commenter stated that the range of 

positive versus negative responses is too 

narrow. Another commented on the 

validity of a measure ‘‘when the 

national benchmark scores are all low in 

one area.’’ This commenter also asks if 

anyone is evaluating these questions. 

Response: We are continually 

analyzing the Hospice CAHPS to ensure 

there is sufficient variation to justify 

their inclusion on Hospice Compare. 

Currently, the data show sufficient 

variability across hospices to justify 

their publication on Hospice Compare. 

As part of our application for reendorsement of the CAHPS® Hospice 

Survey Measures by the NQF next year 

(2019), the survey data will be fully 

analyzed again. The measures for the 

CAHPS® Hospice Survey are reviewed 

by NQF, the CAHPS Consortium, and 

the Measures Application Partnership 

(MAP) which is a joint program through 

HHS and the NQF. 

We are uncertain what the commenter 

means by scores all being low in one 

area. We are not sure if this refers to the 

survey domain or a geographic region. 

Data may still be valid even if they 

demonstrate limited variability by 

domain or geographic area. 

Final Decision: After consideration of 

the comments, we are finalizing our 

proposal to continue treating the 

preferred language of the caregiver as a 

recommended variable. 

c. Data Sources 

As discussed in the CAHPS® Hospice 

Survey QAG V4.0 (http://www.hospice

CAHPSsurvey.org/en/quality-assuranceguidelines/), the survey has three 

administration methods: Mail only, 

telephone only, and mixed mode (mail 

with telephone follow-up of nonrespondents). We previously finalized 

the participation requirements for the 

FY 2020, FY 2021, and FY 2022 APUs 

(82 FR 36673). We proposed to extend 

the same participation requirements to 

all future years, for example, the FY 

2023, FY 2024 and FY 2025 Annual 

Payment and subsequent updates. To 

summarize, to meet the CAHPS® 

Hospice Survey requirements for the 

HQRP, we proposed that hospice 

facilities must contract with a CMSapproved vendor to collect survey data 

for eligible patients on a monthly basis 

and report that data to CMS on the 

hospice’s behalf by the quarterly 

deadlines established for each data 

collection period. The list of approved 

vendors is available at: http://

www.hospiceCAHPSsurvey.org/en/ 

approved-vendor-list. 

Hospices are required to provide lists 

of the patients who died under their 

care, along with the associated primary 

caregiver information, to their 

respective survey vendors to form the 

samples for the CAHPS® Hospice 

Survey. We emphasize the importance 

of hospices providing complete and 

accurate information to their respective 

survey vendors in a timely manner. 

Comment: One commenter suggested 

that we change the Quality Assurance 

Guidelines Manual for the CAHPS® 


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Hospice Survey so that the ‘‘preferred 

language’’ variable would become a 

required field for hospices to submit to 

CMS. 

Response: We encourage hospices, 

with a significant caregiver population 

that speaks any of the languages the 

survey offers, to offer the CAHPS® 

Hospice Survey in all applicable 

languages. CMS also encourages 

hospices that serve patient populations 

that speak languages other than those 

noted to request that CMS create an 

official translation of the CAHPS® 

Hospice Survey in those languages. 

Send any requests to our technical 

assistance team at: 

hospicecahpssurvey@HCQIS.org or call 

them at: 1–844–472–4621. Currently the 

survey is offered in English and Spanish 

for the mail and telephone versions of 

the survey. In addition the mail survey 

is offered in the following languages: 

Traditional and simplified Chinese, 

Russian, Vietnamese, Portuguese, Polish 

and Korean. Approximately 99 percent 

of the hospice surveys are completed in 

English. 

Final Decision: After consideration of 

the comments, we are finalizing our 

proposal to continue treating the 

preferred language of the caregiver as a 

recommended variable. 

Hospices must contract with an 

approved CAHPS® Hospice Survey 

vendor to conduct the survey on their 

behalf. Hospices are responsible for 

making sure their respective survey 

vendors meet all data submission 

deadlines. Vendor failures to submit 

data on time are the responsibility of the 

hospices. We solicited public comment 

on this proposal. 

Comment: One commenter noted that 

validating their CAHPS Hospice survey 

data ‘‘against the files that are submitted 

to the vendor is a multiple day process, 

and if discrepancies are identified, often 

the timeline for survey submission etc. 

has expired and no way to get those 

days back.’’ This commenter further 

noted that there appear to be no 

repercussions for vendors who miss 

their data submission deadlines. The 

commenter also suggested that vendors 

also should have some responsibilities. 

Response: We appreciate the 

commenter’s concerns about the process 

of submitting survey data to their 

vendor, however, we want to clarify that 

CMS has no legal authority to directly 

regulate survey vendors. We do 

encourage hospices to monitor their 

vendors by checking data submissions 

reports regularly to ensure that data are 

being submitted on time, and to hold 

their vendors accountable for 

performance issues. 

Comment: Two commenters described 

expenses associated with participating 

in the CAHPS Hospice Survey as 

unfunded burdens. One commenter 

indicated that providing a 

reimbursement rate close to the actual 

market basket rate would ensure the 

availability of funds to meet the 

additional administrative burden of the 

survey. The other commenter indicates 

the survey places an unfunded burden 

on hospices and requests that CMS 

consider including an additional 

administrative reimbursement 

mechanism to help cover these costs. 

Response: We take a number of steps 

to reduce the burden of the cost of 

participating in the CAHPS Hospice 

Survey. First, we exempt the smallest 

hospices from participating. Second, we 

approved a variety of modes of data 

collection (mail, telephone, and mail 

with telephone follow-up) which incur 

different costs. Third, we have approved 

a wide variety of vendors with different 

costs and mixed of services, so that 

hospices can choose the vendor that is 

most compatible with their needs. 

Comment: One commenter suggested 

fast-tracking studies to compare 

responses and response rates of 

alternative modes of conducting the 

survey, including using tablets, text 

messages, and other real-time survey 

options. 

Response: We have started examining 

the possibility of electronic survey 

options. What we have found out so far 

is that email or web-based surveys alone 

often have very low response rates. 

Electronic surveys would be useful 

mostly to supplement current survey 

modes. We are continuing to explore 

email and web alternatives. We are not 

currently considering so called ‘‘realtime’’ modes of survey administration, 

such as in-person interviews with 

tablets. In-person interviewing is very 

expensive if conducted by a third-party 

vendor. It runs the risk of significant 

bias if the survey is conducted by a 

hospice staff member. For these reasons, 

we do not believe these are appropriate 

techniques for the CAHPS® Hospice 

Survey. Text messaging is mostly useful 

for very short surveys or to provide a 

link to a web survey. We do not 

anticipate shortening our questionnaire 

to an extent that would be compatible 

with text messaging without a link. That 

said, we are continuing to examine the 

possibilities of using alternative survey 

methods across all of the CAHPS 

surveys. 

Comment: One commenter suggested 

that CMS review cover letters and 

phone script introductions for the 

CAHPS Hospice Survey. They stated 

that the current versions require too 

high a reading level. 

Response: The CAHPS Hospice 

Survey team has recently decided to 

launch a study of the cover letter and 

phone script to determine how it can be 

made more readable to all members of 

the public. This research will include a 

review of the grade level of each item 

and feedback from respondents. 

Final Decision: After consideration of 

the comments, we are finalizing our 

proposals to continuing to require that 

hospice providers use CMS-approved 

vendors to conduct the CAHPS® 

Hospice Survey using one of the three 

approved modes, mail, telephone or 

mixed mode (mail with telephone 

follow-up). 

d. Public Reporting of CAHPS® Hospice 

Survey Results 

We began public reporting of the 

results of the CAHPS® Hospice Survey 

on Hospice Compare as of February 

2018. The first report of CAHPS® data 

covered survey results from deaths 

occurring between Quarter 2, 2015 and 

Quarter 1, 2017. We report the most 

recent 8 quarters of data on the basis of 

a rolling average, with the most recent 

quarter of data being added and the 

oldest quarter of data removed from the 

averages for each data refresh. We 

detailed the calculation of these 

measures in 82 FR 36674. We refresh 

the data 4 times a year in the months of 

February, May, August, and November. 

We will not publish CAHPS® data for 

any hospice that has fewer than 30 

completed surveys, due to concerns 

about statistical reliability. We proposed 

to use the same public reporting policies 

in future years. 

Comment: A couple of commenters 

suggested that CMS report more recent 

data for the CAHPS® Hospice Survey by 

reducing the number of quarters of data 

being reported. 

Response: Currently, the CAHPS® 

Hospice Survey reports data on Hospice 

Compare using a rolling average of the 

eight most recent quarters of data. We 

use 8 quarters to maximize the number 

of hospices that are included on the 

Compare site. Among the 4,643 hospices 

on the active agency list for the most 

recent public reporting period (Q4 

2015–Q3 2017), 61 percent (2,832) had 

30 completes over 8 quarters (Q4 2015– 

Q3 2017) and 49 percent (2,262) had 30 

completes over 4 quarters (Q4 2016–Q3 

2017). For this reason, we plan to 

continue to report eight quarters of data. 

Final Decision: After consideration of 

the comments, we are finalizing our 

proposal to continue to report eight 

quarters of data on Hospice Compare. 


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e. Volume-Based Exemption for 

CAHPS® Hospice Survey Data 

Collection and Reporting Requirements 

We previously finalized a volumebased exemption for CAHPS® Hospice 

Survey Data Collection and Reporting 

requirements in the FY 2017 final rule 

(82 FR 36671). We proposed to continue 

our policy for a volume-based 

exemption for CAHPS® Hospice Survey 

Data Collection for FY 2023 and every 

year thereafter. For example, for the FY 

2023 APU, hospices that have fewer 

than 50 survey eligible decedents/ 

caregivers in the period from January 1, 

2020 through December 31, 2020 

(reference year) are eligible to apply for 

an exemption from CAHPS® Hospice 

Survey data collection and reporting 

requirements (corresponds to the CY 

2021 data collection period). To qualify, 

hospices must submit an exemption 

request form for the FY 2023 APU. The 

exemption request form is available on 

the official CAHPS® Hospice Survey 

website: http://www.hospice

CAHPSsurvey.org. 

Hospices that intend to claim the size 

exemption are required to submit to 

CMS their total unique patient count for 

the period of January 1, 2020 through 

December 31, 2020 (reference year). The 

due date for submitting the exemption 

request form for the FY 2023 APU is 

December 31, 2021. Exemptions for size 

are active for 1 year only. If a hospice 

continues to meet the eligibility 

requirements for this exemption in 

future FY APU periods, the organization 

needs to request the exemption annually 

for every applicable FY APU period. 

For FY 2024 APU, hospices that have 

fewer than 50 survey eligible decedents/ 

caregivers in the period from January 1, 

2021 through December 31, 2021 

(reference year) are eligible to apply for 

an exemption from CAHPS® Hospice 

Survey data collection and reporting 

requirements. Hospices that intend to 

claim the size exemption are required to 

submit to CMS their total unique patient 

count for the period of January 1, 2021 

through December 31, 2021. The due 

date for submitting the exemption 

request form for the FY 2024 APU is 

December 31, 2022. Exemptions for size 

are active for 1 year only. If a hospice 

continues to meet the eligibility 

requirements for this exemption in 

future FY APU periods, the organization 

must request the exemption annually for 

every applicable FY APU period. 

For the FY 2025 APU, hospices that 

have fewer than 50 survey eligible 

decedents/caregivers in the period from 

January 1, 2022 through December 31, 

2022 (reference year) are eligible to 

apply for an exemption from CAHPS® 

Hospice Survey data collection and 

reporting requirements for the FY 2025 

payment determination. Hospices that 

intend to claim the size exemption are 

required to submit to CMS their total 

unique patient count for the period of 

January 1, 2022 through December 31, 

2022. The due date for submitting the 

exemption request form for the FY 2025 

APU is December 31, 2023. If a hospice 

continues to meet the eligibility 

requirements for this exemption in 

future FY APU periods, the organization 

must request the exemption annually for 

every applicable FY APU period. 

TABLE 9—SIZE EXEMPTION KEY DATES FY 2023, FY 2024 AND FY 2025 

Fiscal year Data collection 

year 

Reference year 

(count total 

number of 

unique patients 

in this year) 

Size exemption form 

submission deadline 

FY 2023 ................................................................................................................... 2021 2020 December 31, 2021. 

FY 2024 ................................................................................................................... 2022 2021 December 31, 2022. 

FY 2025 ................................................................................................................... 2023 2022 December 31, 2023. 

We received no comments about the 

size exemption for hospices. 

Final Decision: We are finalizing our 

proposal to exempt to small hospices 

from data collection for the CAHPS® 

Hospice Survey through FY 2015 and 

subsequent years. 

f. Newness Exemption for CAHPS® 

Hospice Survey Data Collection and 

Reporting Requirements 

We previously finalized a one-time 

newness exemption for hospices that 

meet the criteria (81 FR 52181). We 

proposed to continue the newness 

exemption for FY 2023, FY 2024, FY 

2025, and all future years. 

Specifically, hospices that are notified 

about their Medicare CCN after January 

1, 2021 are exempted from the FY 2023 

APU CAHPS® Hospice Survey 

requirements due to newness. Likewise, 

hospices notified about their Medicare 

CCN after January 1, 2022 are exempted 

from the FY 2024 APU CAHPS® 

Hospice Survey requirements due to 

newness. Hospices notified about their 

Medicare CCN after January 1, 2023 are 

exempted from the FY 2025 APU 

CAHPS® Hospice Survey requirements 

due to newness. No action is required 

on the part of the hospice to receive this 

exemption. The newness exemption is a 

one-time exemption from the survey. 

We encourage hospices to keep the 

letter they receive providing them with 

their CCN. The letter can be used to 

show when you received your number. 

We proposed that this newness 

exemption to the CAHPS® Hospice 

Survey will apply to all future years. 

Comment: One commenter stated that 

they supported a number of the changes 

being made permanent in this rule, 

including the ‘‘newness’’ exemption 

from the CAHPS survey, as well as the 

annual exemption for very small 

programs. 

Response: We appreciate the 

commenter’s support. We have been 

extending the newness exemption to 

hospices since data collection started in 

2015. Hospices that received their CMS 

Certification Number (CCN) after the 

start of the data collection year (January 

1) are exempted from data collection for 

that year. CMS identifies the hospices 

that qualify for the newness exemption. 

We plan to continue to offer the 

newness exemption without change. 

Final Decision: After consideration of 

the comments, we are finalizing our 

proposal to continue offering the 

‘‘newness’’ exemption for the CAHPS® 

Hospice Survey to hospices that receive 

their CCN number after the data 

collection year starts. 

g. Requirements for the FY 2023 APU 

To meet participation requirements 

for the FY 2023 APU, Medicare-certified 

hospices must collect CAHPS® Hospice 

Survey data on an ongoing monthly 

basis from January 2021 through 

December 2021 (all 12 months) to 

receive their full payment for the FY 

2023 APU. All data submission 

deadlines for the FY 2023 APU are in 

Table 10. CAHPS® Hospice Survey 

vendors must submit data by the 

deadlines listed in Table 10 for all APU 

periods listed in the table and moving 


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forward. There are no late submissions 

permitted after the deadlines, except for 

extraordinary circumstances beyond the 

control of the provider as discussed 

above. 

TABLE 10—CAHPS® HOSPICE SURVEY DATA SUBMISSION DATES FOR THE APU IN FY 2023, FY 2024, AND FY 2025 

Sample months 1

(month of death) 

CAHPS Quarterly 

data submission 

deadlines 2

FY 2023 APU 

CY January–March 2021 (Quarter 1) ...................................................................................................................................... August 11, 2021. 

CY April–June 2021 (Q2) ........................................................................................................................................................ November 10, 2021. 

CY July–September 2021 (Q3) ............................................................................................................................................... February 9, 2022. 

CY October–December 2021 (Q4) .......................................................................................................................................... May 11, 2022. 

FY 2024 APU 

CY January–March 2022 (Q1) ................................................................................................................................................ August 10, 2022. 

CY April–June 2022 (Q2) ........................................................................................................................................................ November 9, 2022. 

CY July–September 2022 (Q3) ............................................................................................................................................... February 8, 2023. 

CY October–December 2022 (Q4) .......................................................................................................................................... May 10, 2023. 

FY 2025 APU 

CY January–March 2023 (Q1) ................................................................................................................................................ August 9, 2023. 

CY April–June 2023 (Q2) ........................................................................................................................................................ November 8, 2023. 

CY July–September 2023 (Q3) ............................................................................................................................................... February 14, 2024. 

CY October–December 2023 (Q40) ........................................................................................................................................ May 8, 2024. 

1 Data collection for each sample month initiates 2 months following the month of patient death (for example, in April for deaths occurring in 

January). 2 Data submission deadlines are the second Wednesday of the submission months, which are the months August, November, February, and 

May. 

h. Requirements for the FY 2024 APU 

To meet participation requirements 

for the FY 2024 APU, Medicare-certified 

hospices must collect CAHPS® Hospice 

Survey data on an ongoing monthly 

basis from January 2022 through 

December 2022 (all 12 months) to 

receive their full payment for the FY 

2024 APU. All data submission 

deadlines for the FY 2024 APU are in 

Table 10. CAHPS® Hospice Survey 

vendors must submit data by the 

deadlines listed in Table 10 for all APU 

periods listed in the table and moving 

forward. There are no late submissions 

permitted after the deadlines, except for 

extraordinary circumstances beyond the 

control of the provider as discussed 

above. 

i. Requirements for the FY 2025 APU 

To meet participation requirements 

for the FY 2025 APU, Medicare-certified 

hospices must collect CAHPS® Hospice 

Survey data on an ongoing monthly 

basis from January 2023 through 

December 2023 (all 12 months) to 

receive their full payment for the FY 

2025 APU. All data submission 

deadlines for the FY 2025 APU are in 

Table 10. CAHPS® Hospice Survey 

vendors must submit data by the 

deadlines listed in Table 10 for all APU 

periods listed in the table and moving 

forward. There are no late submissions 

permitted after the deadlines, except for 

extraordinary circumstances beyond the 

control of the provider as discussed 

above. 

j. For Further Information About the 

CAHPS® Hospice Survey 

We encourage hospices and other 

entities to learn more about the survey 

on: https://www.hospice

CAHPSsurvey.org. For direct questions, 

contact the CAHPS® Hospice Survey 

Team at hospiceCAHPSsurvey@

HCQIS.org or telephone 1–844–472– 

4621. 

6. Public Display of Quality Measures 

and Other Hospice Data for the HQRP 

Under section 1814(i)(5)(E) of the Act, 

the Secretary is required to establish 

procedures for making any quality data 

submitted by hospices available to the 

public. These procedures shall ensure 

that a hospice has the opportunity to 

review the data that is to be made public 

prior to such data being made public; 

the data will be available on our public 

website. 

To meet the PPACA’s requirement for 

making quality measure data public, we 

launched the Hospice Compare website 

in August 2017. This website allows 

consumers, providers, and other 

stakeholders to search for all Medicarecertified hospice providers and view 

their information and quality measure 

scores. Since its release, the CMS 

Hospice Compare website has reported 

7 HIS Measures (NQF #1641, NQF 

#1647, NQF #1634, NQF #1637, NQF 

#1639, NQF #1638, and NQF #1617). In 

February 2018, CAHPS® Hospice 

Survey measures (NQF #2651) were 

added to the website. 

a. Adding Quality Measures to 

Publically Available Websites— 

Procedures To Determine Quality 

Measure Readiness for Public Reporting 

Quality measures are added to 

Hospice Compare once they meet 

readiness standards for public reporting, 

which is determined through the 

following processes. 

First, we assess the reliability and 

validity of each quality measure to 

determine the scientific acceptability of 

each measure. This acceptability 

analysis is the first step in determining 

a measure’s readiness for public 

reporting. We evaluate the quality 

measures using the NQF Measure 

Evaluation Criteria found on the NQF 

website here: http://

www.qualityforum.org/Measuring_

Performance/Submitting_Standards/ 

Measure_Evaluation_

Criteria.aspx#scientific. Analyses to 

assess scientific acceptability of new 

measures are important to determine if 

the measure produces reliable and 

credible results when implemented. 


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Reliability testing demonstrates that a 

measure is correctly specified by 

ensuring that ‘‘measure data elements 

are repeatable, producing the same 

results a high proportion of time when 

assessed in the same population in the 

same time period and/or that the 

measure score is precise.’’ Validity 

testing demonstrates that measure 

specifications are consistent with the 

focus of the measure and that the 

measure score can accurately 

distinguish between quality of care 

provided by providers. Reliability and 

validity are tested at both the data item 

and quality measure levels. For 

example, at the item-level, we examine 

the missing data rate and cross validate 

the data elements between the 

assessment data and Medicare claims to 

ensure validity of the data elements. At 

the quality measure level, we conduct 

split-half analysis, consistency analysis 

across time, stability analysis, and 

signal-to-noise analysis to demonstrate 

the reliability of the measures. We 

examine the relationships between 

different quality measures assessing 

similar quality areas to demonstrate the 

validity of the quality measures. 

To establish reliability and validity of 

the quality measures, at least 4 quarters 

of data are analyzed. The first quarter of 

data after new adoption of, or changes 

to, standardized data collection tools 

may reflect the learning curve of the 

hospices; we first analyze these data 

separately to determine the 

appropriateness to use them to establish 

reliability and validity of quality 

measures. 

To further inform which of the 

measures are eligible for public 

reporting, we then examine the 

distribution of hospice-level 

denominator size for each quality 

measure to assess whether the 

denominator size is large enough to 

generate the statistically reliable scores 

necessary for public reporting. The goal 

of this analysis is to establish the 

minimum denominator size for public 

reporting, which is referred to as 

reportability analysis. Reportability 

analysis is necessary because, if a 

hospice QM score is generated from a 

denominator that is too small, the 

observed measure score may be a biased 

assessment of the provider’s 

performance, yielding scores that are 

statistically unreliable. Thus, we have 

set a minimum denominator size for 

public reporting, as well as the data 

selection period necessary to generate 

the minimum denominator size for the 

CMS Hospice Compare website. 

This approach to testing reliability, 

validity, and reportability of quality 

measures (QMs) is consistent with the 

approach taken in other CMS quality 

reporting programs. Further, CMS 

provides hospices the opportunity to 

review their measures through their 

Certification and Survey Provider 

Enhanced Reports (CASPER) and 

additionally publishes the methodology 

related to the calculation of each quality 

measure in the Hospice Quality Measure 

User’s Manual, which is updated with 

the addition of each quality measure to 

the Hospice QRP. Since December 2016, 

two provider feedback reports have been 

available to providers: The HospiceLevel Quality Measure Report and the 

Patient Stay-Level Quality Measure 

Report. These confidential feedback 

reports are available to each hospice 

using the CASPER system, and are part 

of the class of CASPER reports known 

as Quality Measure (QM) Reports. These 

reports are for the purposes of internal 

provider quality improvement and are 

available to hospices on-demand. We 

encourage providers to use the CASPER 

QM Reports to review their HIS quality 

measures regularly to ensure submitted 

quality measure data is correct. For 

more information on the CASPER QM 

Reports, we refer readers to the CASPER 

QM Factsheet on the HQRP website at: 

https://www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/ 

HQRP-Requirements-and-BestPractices.html. 

Because we follow the above outlined 

processes in determining the readiness 

for a quality measure to be publicly 

reported, and perform the necessary 

analysis to determine and demonstrate 

that our measures meet the NQF 

measure evaluation criteria prior to 

publicly reporting provider performance 

on these quality metrics, we proposed to 

announce to providers any future intent 

to publicly report an already-adopted 

quality measure on Hospice Compare or 

other CMS website, including timing, 

through sub-regulatory means. 

Conducting these analyses and 

announcing measure timelines and 

readiness for public reporting through 

sub-regulatory channels will allow us to 

implement measures for public 

reporting in a more expeditious, yet still 

transparent manner, benefitting the 

public by providing QM data as soon as 

it is determined to meet the minimum 

standards for public reporting. We will 

continue to provide updates about 

public reporting of QMs through the 

normal CMS HQRP communication 

channels, including postings and 

announcements on the CMS HQRP 

website, MLN eNews communications, 

national provider association calls, and 

announcements on Open Door Forums. 

Note that we are not making any 

changes to how CMS adopts substantive 

measures for the HQRP. 

We received multiple comments on 

this proposal to announce to providers 

any future intent to publicly report a 

quality measure on Hospice Compare, 

including timing, through subregulatory means. A summary of the 

comments we received on this topic and 

our responses to those comments are 

below: 

Comment: CMS received several 

comments on this proposal. Most 

commenters supported this proposal. 

Although commenters appreciated CMS’ 

interest to move measures to public 

reporting in an expeditious manner, 

several commenters had concerns about 

this proposal and several were not 

supportive of it. Those who 

conditionally supported this proposal 

requested CMS develop separate 

processes for announcing readiness for 

public reporting and public reporting 

timelines for NQF- vs. non-NQFendorsed measures. Some commenters 

stated that this proposal had the 

potential to reduce opportunities for 

public input and decrease transparency. 

Specific concerns from commenters are 

addressed in further detail below: 

Several commenters had concerns 

about this proposal; the majority of 

concerns stemmed from the desire to 

maintain transparency and opportunity 

for stakeholder input that CMS has 

established in the HQRP measure 

implementation processes to-date. 

Commenters appreciated CMS’ 

methodical approach to-date and 

expressed concern that, without 

proposing public reporting 

implementation dates through 

rulemaking, there may not be 

opportunity for providers to comment, 

provide input, or give feedback before a 

public reporting date is set. One 

commenter stated that a sub-regulatory 

process may fracture communication 

channels for conveying information to 

the public, limiting opportunity for 

review and input. 

Apart from the annual rulemaking 

cycle, should CMS move forward with 

a sub-regulatory process, a couple of 

commenters suggested that CMS 

develop criteria that would guide CMS’ 

decision regarding which measures are 

displayed on Hospice Compare, and that 

regardless of the channel (regulatory or 

sub-regulatory), CMS consider public 

comments and feedback on quality 

measures proposed to be added to 

Hospice Compare to promote 

transparency and to solicit provider 

input. 

Among conditionally supportive 

commenters, some recommended 

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NQF-endorsed measures. Commenters 

stated that a sub-regulatory process 

would be appropriate for NQF-endorsed 

measures, as these measures will have 

undergone a thorough review process 

and the public will have had ample 

opportunity to comment on these 

measures. However, commenters stated 

that for measures that are not NQFendorsed, it would be most appropriate 

for CMS to go through formal 

rulemaking processes prior to 

publishing these measures on Hospice 

Compare and for CMS to continue to 

submit such measures to public notice 

through rulemaking prior to any public 

display. Commenters suggested CMS to 

receive full stakeholder input through 

the rulemaking process on quality 

measures that are not NQF-endorsed. 

Other comments received related to 

this proposal included a statement from 

one commenter that it is ‘‘too early’’ to 

implement a sub-regulatory process, 

given the relative newness of the HQRP 

and Hospice Compare. Additionally, a 

couple of commenters recommended 

that in addition to the processes 

described in the proposed rule for 

assessing readiness (validity and 

reliability testing, etc.) and the NQF 

endorsement processes, CMS implement 

a user testing process that enables CMS 

to identify those measures for which 

performance can be translated into 

reliable and actionable information for 

beneficiaries. 

Response: We agree with commenters 

that a transparent process and allowing 

ample opportunity for public input 

prior to displaying a measure on 

Hospice Compare is a vital component 

of moving a measure from data 

collection to public reporting. We agree 

that stakeholder input is invaluable to 

this process, and our intent is to 

continue to communicate clearly with 

providers and continue to solicit their 

input on all aspects of the measure 

development lifecycle. As set out at 

section 1814(i)(5)(E) of the Act, the 

statutory requirements for public 

reporting of quality measures (1) allow 

providers an opportunity to review their 

data prior to public reporting of any 

data and (2) require CMS to display 

measures for public reporting. This is 

evidenced where the statute states: The 

‘‘Secretary shall establish procedures for 

making data . . . available to the 

public’’ and ‘‘the Secretary shall report 

quality measures that relate to hospice 

care provided by hospice program on 

the internet website of the Medicare & 

Medicaid Services.’’ Now that we have 

communicated in this rule the 

procedure for determining readiness for 

public reporting through rulemaking, 

we can announce readiness and 

timelines for publicly reporting 

measures through sub-regulatory 

channels. The annual rulemaking cycle 

is not the only channel by which 

information can be communicated to the 

public in a transparent and collaborative 

manner. Sub-regulatory channels can be 

equally effective and timelier at 

communicating information to the 

public. Therefore, we view this proposal 

not as a loss of opportunity for dialogue 

or transparency, but as a way to change 

the channel by which we communicate 

with the public to receive input on one 

specific aspect of the QM development 

and implementation lifecycle. 

Moreover, we stated that this process 

has the potential to improve timeliness 

of communication with the public as we 

would no longer have to wait for the 

annual rulemaking cycle to commence 

conversations about readiness for public 

reporting. The commenters’ concerns 

about transparency and public input can 

be addressed through sub-regulatory 

channels. 

In the context of commenters’ 

concerns—especially those about NQFvs. non-NQF-endorsed measures—we 

would like to clarify that this policy 

does not eliminate opportunities for 

providers to comment on the public 

reporting of newly adopted measures 

through rulemaking. Specifically, 

several commenters requested CMS 

‘‘ensure there is a formal public notice 

and comment process prior to 

publishing the measures on Hospice 

Compare’’ and that CMS ‘‘continue to 

submit such [non-NQF-endorsed] 

measures to public notice through 

rulemaking prior to any public display’’. 

We would like to clarify that this policy 

will not change how measures are 

adopted in the HQRP, only how we 

communicate when measures are ready 

to be displayed on Hospice Compare. 

New measures to be adopted in the 

HQRP will have been reviewed and 

supported by the consensus-based entity 

Measure Application Partnership, 

convened by the NQF, and the public 

can comment on the measures as part of 

that process. We will continue to 

propose measures (NQF- or non-NQFendorsed) for adoption in the HQRP 

through the annual rulemaking process, 

which will allow opportunities for 

providers to comment—through 

rulemaking—on proposed measures. 

When measures are proposed for initial 

adoption through rulemaking, providers 

have the opportunity to voice concerns 

about any aspect of the proposed 

measure, including public reporting. 

Thus, this policy aligns with 

commenters who requested that CMS 

‘‘ensure a formal public notice and 

comment process prior to publishing 

measures on Hospice Compare’’ and 

that CMS ‘‘continue to submit such 

[non-NQF-endorsed] measures to public 

notice through rulemaking prior to any 

public display’’. 

Regarding comments on the process 

that CMS uses to determine readiness 

for Hospice Compare, we direct 

providers to the text in the proposed 

rule, 83 FR 20960, which outlines our 

process for determining readiness for 

public display (for example, validity 

and reliability analyses; reportability 

analysis), which does include a user 

testing process. 

Final Decision: After consideration of 

the comments, we are finalizing our 

proposal to announce to providers any 

future intent to publicly report a quality 

measure on Hospice Compare or other 

CMS website, including timing, through 

sub-regulatory means. 

b. Quality Measures To Be Displayed on 

Hospice Compare in FY 2019 

We anticipate that we will begin 

public reporting of the HIS-based 

Hospice Comprehensive Assessment 

Measure (NQF #3235), a composite 

measure of the 7 original HIS Measures 

(NQF #1641, NQF #1647, NQF #1634, 

NQF #1637, NQF #1639, NQF #1638, 

and NQF #1617), on the CMS Hospice 

Compare website in Fall 2018. For more 

information on how this measure is 

calculated, see the HQRP QM User’s 

Manual v2.00 in the ‘‘Downloads’’ 

section of the Current Measures page on 

the CMS HQRP website: https://

www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/ 

Current-Measures.html. The reporting 

period for which the measure will be 

displayed on the CMS Hospice Compare 

website will align with the currently 

established procedures for the 7 HIS 

measures. For more information about 

reporting periods, see the Public 

Reporting: Key Dates for Providers page 

on the CMS HQRP website: https://

www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/ 

Public-Reporting-Key-Dates-forProviders.html. We used the analytic 

approach described above to determine 

reliability, validity, and reportability of 

the HIS-based Hospice Comprehensive 

Assessment Measure (NQF #3235). 

Reliability and validity testing found 

that the Hospice Comprehensive 

Assessment Measure had high reliability 

and validity. For more information 

about the reliability and validity of this 

measure, see the NQF Palliative and 

End-of-Life Care Off-Cycle Measure 

Review 2017 Publication available for 


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download here: https://

www.qualityforum.org/Publications/ 

2017/09/Palliative_and_End-of-Life_

Care_Off-Cycle_Measure_Review_

2017.aspx. Per the approach described 

above, we then conducted reportability 

analysis. Based on reportability analysis 

results, we determined this measure, 

calculated based on a 12-rolling month 

data selection period, to be eligible for 

public reporting with a minimum 

denominator size of 20 patient stays. A 

majority of hospices, using rolling 4 

quarters of data, have at least 20 patient 

stays eligible for the calculation and 

public reporting of the Hospice 

Comprehensive Assessment Measure. 

We plan to begin public reporting of the 

Hospice Comprehensive Assessment 

Measure with a minimum denominator 

size of 20. 

We also will begin public reporting of 

the HIS-based Hospice Visits when 

Death is Imminent Measure Pair in FY 

2019. The same analytic approach 

described above will be applied to 

determine the reliability, validity, and 

reportability of the Hospice Visits when 

Death is Imminent Measure Pair. This 

measure pair assesses hospice staff 

visits to patients at the end of life. Draft 

specifications for the Hospice Visits 

when Death is Imminent measure pair 

are available on the CMS HQRP website 

here: https://www.cms.gov/Medicare/ 

Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/ 

Current-Measures.html. With the 

finalization of our proposal to announce 

future intentions to publicly display 

hospice quality measures through subregulatory means, the exact timeline for 

public reporting of this measure pair 

will be announced through regular subregulatory channels once necessary 

analyses and measure specifications are 

finalized. 

A summary of the comments received 

and our responses to those comments 

are below: 

Comment: CMS received several 

supportive comments on the public 

display of the Hospice Comprehensive 

Assessment measure and the Hospice 

Visits when Death is Imminent Measure 

Pair in FY 2019. Most commenters 

focused on the Hospice Visits when 

Death is Imminent Measure Pair and 

were conditionally supportive of 

publicly reporting the measure pair. 

Those who were conditionally 

supportive asked that the measures be 

accompanied by text explaining the 

measures when publicly reported. CMS 

also received a comment opposing the 

public display of these measures in FY 

2019, which is discussed below. 

Response: We appreciate the 

commenters’ support of publicly 

displaying these two measures in FY 

2019. We address commenters’ specific 

concerns with respect to the public 

display of these measures below. 

Comment: CMS received one 

comment that oppose public display of 

the Hospice Comprehensive Assessment 

Measure and Hospice Visits when Death 

is Imminent Measure Pair in FY 2019. 

This commenter stated that stakeholders 

have not had enough feedback data on 

their own individual measure 

performance to become comfortable 

with these measures and take steps to 

improve their measure performance 

prior to public reporting. The 

commenter suggested that CMS finalize 

policies to ensure hospices are able to 

review, analyze, and act on measure 

performance data before they are 

publicly reported. 

Response: As statutorily required by 

section 1815(i)(5)(E) of the Act, we must 

‘‘ensure that a hospice program has the 

opportunity to review data that is to be 

made public with respect to the hospice 

program prior to such data being made 

public.’’ As such, we are not only 

committed, but statutorily obligated, to 

ensuring providers have the opportunity 

to review, analyze, and act on measure 

performance data before any measure 

performance data are publicly 

displayed. In accordance with the 

statutory requirements of the Act, we 

implemented the CASPER QM reports 

and the Provider Preview Reports as the 

manner by which hospices review their 

data prior to public reporting. The 

Preview Reports allow providers the 

opportunity to view their data exactly as 

it will be displayed on Hospice 

Compare, prior to any display. Should 

a provider find an error in the data to 

be displayed, the provider can follow 

the established process to request 

review of the data inaccuracy; should 

the inaccuracy be verified, we suppress 

that provider’s data for that quarter. 

This process provides a safeguard for 

ensuring that the data reported on 

Compare are accurate. In addition, the 

CASPER QM reports allow providers to 

view their performance prior to Preview 

reports and prior to any public display, 

thus giving providers the opportunity to 

identify areas for improvement and 

implement performance improvement 

projects prior to the start of public 

reporting. For more information about 

these reports, see section III.F.6a of this 

final rule. The Hospice Comprehensive 

Assessment Measure was added to the 

CASPER QM report in February 2018, 

allowing providers ample time to assess 

their performance on the measure and 

implement performance improvement 

projects as appropriate. We will also 

post the Hospice Visits when Death is 

Imminent Measure, which comprises a 

pair of measures, to the CASPER QM 

reports before public reporting of the 

measures so that providers can become 

familiar with them. Both measures, the 

Hospice Comprehensive Assessment 

Measure and Death is Imminent 

Measure, will also appear on providers’ 

Preview Reports to ensure the scores to 

be displayed are accurate. Preview 

Reports will be released approximately 

2 months prior to the Hospice Compare 

refresh in which measures are released. 

We will announce the timeline for 

reporting of these measures on the 

CASPER QM reports, Provider Preview 

Reports, and Hospice Compare once 

determined via the CMS HQRP website, 

listserv messages via the Post-Acute 

Care QRP listserv, MLN Connects® 

National Provider Calls & Events, MLN 

Connects® Provider eNews and 

announcements on Open Door Forums 

and Special Open Door Forums. 

Comment: Several commenters stated 

that the Hospice Visits when Death is 

Imminent Measure Pair, when publicly 

reported, may be confusing or 

misleading for consumers. For example, 

commenters shared that multiple 

factors, such as a patient and family’s 

right to refuse visits, may account for 

lower performance on the measure pair. 

The commenters recommended that the 

measures be accompanied by text 

explaining this nuance when publicly 

reported. 

Response: We are committed to 

ensuring that all publicly reported data 

is presented in an appropriate and 

meaningful manner to the public. As 

such, we work with our website 

development contractor to ensure that 

the Hospice Compare website is 

regularly tested for usability, 

readability, and navigation. We 

complete user access testing (UAT) with 

each refresh of the Hospice Compare 

website to ensure that the publicly 

posted data is accurate and clear. 

Furthermore, text on the Hospice 

Compare website complies with the 

Plain Language Act of 2010. In addition 

to complying with the Plain Language 

Act, we also take into account variations 

in health and general literacy, as well as 

solicit input from key stakeholders and 

technical experts in the development 

and presentation of publicly available 

data. 

As we add more measures to the 

Hospice Compare website, including the 

Hospice Comprehensive Assessment 

Measure and Hospice Visits when Death 

is Imminent Measure Pair, we will, with 

consultation from key stakeholders, 

carefully craft explanatory language to 

ensure that consumers understand the 

measure’s intent, relationship to quality, 


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and any necessary measure-specific 

nuance. 

Comment: CMS received several 

general comments about public 

reporting of HIS-based measures. A few 

commenters were concerned that 

providers could easily change selfreported HIS data to avoid unfavorable 

scores being publicly reported on the 

Hospice Compare website. Another 

commenter stated that CMS should 

make more timely updates to quality 

data on Hospice Compare. This 

commenter stated that the lack of timely 

updates to the site may disincentive 

providers from implementing quality 

improvement efforts because it could 

take a year or longer to have updated 

data reflected on the Hospice Compare 

website. Another commenter stated that 

the measures currently on the Hospice 

Compare website were not clear as to if 

they are process measures, outcome 

measures, or measures of consumer 

feedback. Another commenter stated 

that consumers may misunderstand the 

current measures’ intent and 

relationship to quality. Finally, CMS 

received one comment asking that CMS 

finalize policies so that measures will 

not be publicly posted based on the first 

year of performance data. 

Response: Because no changes were 

proposed to validation of HIS data, 

frequency of updates to Hospice 

Compare, process for writing text for 

Hospice Compare, or data eligible for 

public reporting, comments received are 

outside the scope of the current rule. 

We acknowledge the commenter’s 

concern regarding the validity of selfreported HIS measures. Publicly 

reported QMs rely on the submission of 

valid and reliable data at the patient 

level. Our measure development 

contractor conducts ongoing testing and 

validation of the QM data to identify 

data irregularities and trends. 

Furthermore, we are taking steps to 

ensure that publicly reported data are 

accurate. See section III.F.4b for more 

details on our finalized proposal to add 

a 4.5 month data correction deadline for 

public reporting for HIS data. This 

deadline will ensure that providers 

cannot correct data indefinitely and 

result in consumers receiving an 

inconsistent and potentially inaccurate 

view of hospice performance. By 

ensuring that data are reviewed and 

corrected prior to public reporting, data 

on Hospice Compare will be a 

consistent and accurate representation 

of hospice performance. 

We are also committed to posting data 

on the Hospice Compare website that 

are as timely as possible. However, there 

will be an inevitable lag between data 

submission and public reporting on 

Hospice Compare to allow for sufficient 

time for us to process the data, 

including completing any required 

testing and validation, and for hospices 

to review and correct any inaccuracies. 

This lag in public reporting is consistent 

across Quality Reporting Programs. 

In reference to the text posted on 

Hospice Compare, we agree that it is 

important for consumers to be able to 

distinguish between process, outcome, 

and consumer feedback measures. 

Therefore, we have decided to separate 

the data into two sections on the 

Hospice Compare website: ‘Family 

experience of care’ and ‘Quality of 

patient care’. Both sections have 

accompanying text explaining their data 

source. The website explains that the 

‘Family experience of care’ data comes 

from a national survey that asks a family 

member or friend of a hospice patient 

about their hospice care experience. The 

‘Quality of patient care’ section explains 

that this data is reported by hospices 

using the Hospice Item Set (HIS). 

Furthermore, we have included text 

explaining why these measures should 

be important to consumers. 

In response to the commenter’s 

recommendation of finalized policies so 

that measures will not be publicly 

posted based on the first year of 

performance data, we would like to 

remind readers that quality measures 

are added to Hospice Compare once 

they meet NQF readiness standards for 

public reporting, which is determined 

through the process outlined in section 

III.F.6a of this final rule. We analyze at 

least the first year of performance data 

to establish reliability and validity of 

the quality measures. If this data and the 

resultant quality measure scores are 

found to be reliable, valid, and 

scientifically acceptable from 

comprehensive analyses, we would 

publicly report this data if they meet 

NQF readiness standards. 

Comment: A few commenters 

supported adding any new data to the 

Hospice Compare website. These 

commenters asked that no new data be 

added to Hospice Compare until after 

CMS correct any inaccurate data posted 

on the website. These commenters 

stated that the search function was 

returning inaccurate results and 

provider demographic data was 

incorrect on Hospice Compare. 

Moreover, the commenters stated that 

the data was updated too frequently, 

resulting in ‘‘week-to-week’’ changes 

and user confusion. 

Response: Because no changes were 

proposed to the Hospice Compare 

search functionality or posted 

demographic data, comments received 

are outside the scope of the current rule. 

However these comments made 

inaccurate statements that we want to 

correct. We are committed to posting 

accurate data to the Hospice Compare 

website, and goes to great lengths to 

ensure accuracy. Since the launch of the 

website, we would like to reassure the 

public of the accuracy of quality 

measure data on Hospice Compare. 

Quality measure data accuracy has 

never been questioned or an issue on 

Hospice Compare. 

The one area we have addressed is 

improving the accuracy of the 

demographic data and search function. 

We have been transparent about 

addressing these issues with 

communications provided on both the 

Hospice Quality Reporting and the 

Hospice Compare websites. As 

explained in our communications, the 

demographic data reflects what hospices 

have provided. Updates to demographic 

data need to be made through the 

hospice provider’s MAC. Information 

about updating hospice demographic 

data can be found in the How to Update 

Demographic Data document in the 

downloads section of the Public 

Reporting: Background and 

Announcements page on the CMS 

HQRP website: https://www.cms.gov/ 

Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/Public-ReportingBackground-and-Announcements.html. 

We also recognize that updates to 

provider’s demographic data (for 

example, address, telephone number, 

ownership) may take up to 6-months to 

appear on the Hospice Compare 

website. The process to update 

demographic data is independent of 

updating quality measure data or service 

areas and is controlled by the Medicare 

Administrative Contractor (MAC). It is 

important for hospices to review their 

HIS and CAHPS® Provider Preview 

Reports to verify that the demographic 

data is accurate. If inaccurate or 

outdated demographic data are included 

on the Preview Report or on Hospice 

Compare, hospice providers should 

follow guidance in the How to Update 

Demographic Data document in the 

downloads section of the Public 

Reporting: Background and 

Announcements page on the CMS 

HQRP website: https://www.cms.gov/ 

Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/Public-ReportingBackground-and-Announcements.html. 

As for the search function, we agree 

with providers that the accuracy of the 

search function is integral to the success 

of any Compare website. The search 

function, though, relates only to 

demographic results. The resulting 


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quality data provided about each 

hospice is accurate and has always 

been, including from the launch of 

Hospice Compare website. The current 

search function file, uploaded in May 

2018, has addressed the accuracy and 

specificity of the Compare search 

function, as it is based on three sources 

of data: Claims, HIS, and geographic 

data. In response to comments about the 

accuracy of the Hospice Compare search 

function, we appreciate commenters’ 

concerns but believe that, since the 

launch of Compare, the refinements we 

have made to the data underlying the 

search function have addressed the 

accuracy of the search function. We 

strive to continually improve and will 

continue to refine methods and data 

underlying the search function as 

appropriate. At this time, the search 

function works well because it is based 

on the geographic data using Core-Based 

Statistical Areas (CBSAs) that match to 

the paid claims and reflect the service 

areas of the Medicare-certified hospices. 

Since claims data lag, the CBSA’s reflect 

the service areas at that time. Therefore 

to add more timely service area data, the 

unique zip codes from the HIS files are 

added. Consequently any new zip codes 

added to a service area likely come from 

HIS data and thereby update the search 

function during these quarterly 

refreshes. This is expected as part of the 

search function in the same way that 

updates to HIS and CAHPS quality data 

are expected quarterly on Hospice 

Compare. Therefore, in response to the 

commenter’s concern about frequency of 

data updates on Compare and how that 

impacts the consistency of the search 

function, we would like to note that the 

file used to power the search function 

is updated quarterly, at the same time 

we update the quality measure data 

displayed on Hospice Compare. These 

quarterly updates to Hospice Compare 

are the regular refresh timeframes for 

this website so that Hospice Compare 

provides users with updated data from 

HIS and CAHPS® Hospice Surveys, 

which we believe stakeholders want the 

most recently available data. These 

quarterly refreshes also update the 

database of zip codes used to power the 

search function with new data collected 

from the HIS, providing a more 

comprehensive set of hospice service 

areas. 

c. Updates to the Public Display of HIS 

Measures 

As discussed previously, we strive to 

put patients first, ensuring they are 

empowered to make decisions about 

their own healthcare, along with their 

clinicians, using data-driven 

information that are increasingly 

aligned with a parsimonious set of 

meaningful quality measures that drive 

quality improvement. We recognize that 

the HQRP represents a key component 

in bringing quality measurement, 

transparency, and improvement to the 

hospice care setting. To that end, we 

have begun analyzing our programs’ 

measures in accordance with the 

Meaningful Measures framework to 

ensure high quality care that empowers 

patients to make decisions about their 

own healthcare, using consumable, 

data-driven information. 

With this framework in mind, we 

evaluated our measure set and 

specifically the measure Hospice and 

Palliative Care Composite Process 

Measure—Comprehensive Assessment 

at Admission (NQF #3235) which we 

intend to publicly display on the 

Hospice Compare website in FY 2019. 

Through feedback received, we have 

learned that while the 7 original HIS 

measures (NQF #1641, NQF #1647, NQF 

#1634, NQF #1637, NQF #1639, NQF 

#1638, and NQF #1617) that represent 

the individual care processes captured 

in this composite measure are 

important, the composite measure 

provides for consumers a more 

accessible measure for evaluating the 

quality of a hospice. 

The composite measure is more 

illustrative than the individual, high 

performing measures based on analyses. 

The hospice performance scores on the 

7 component measures that comprise 

the composite measure are high (a score 

of 90 percent or higher on most 

component measures); however, 

analyses also show that, on average, a 

much lower percentage of patient stays 

received all seven desirable care 

processes at admission. Thus, by 

assessing hospices’ performance of a 

comprehensive assessment through an 

all-or-none calculation methodology, 

the composite measure sets a higher 

standard of care for hospices and reveals 

a larger performance gap. Meaning, the 

composite measure holds hospices to a 

higher standard by requiring them to 

perform all seven care processes for a 

given patient admission. The 

performance gap identified by the 

composite measure creates 

opportunities for quality improvement 

and may motivate providers to conduct 

a greater number of high priority care 

processes for as many patients as 

possible upon admission to hospice. 

The table below shows the mean 

measure score across all hospices for 

Hospice and Palliative Care Composite 

Process Measure—Comprehensive 

Assessment Measure at Admission and 

the 7 component measures that will no 

longer be routinely individually 

displayed on Hospice Compare once the 

composite measure is displayed. 

TABLE 11—MEAN MEASURE SCORE OF

THE HOSPICE AND PALLIATIVE CARE

COMPOSITE PROCESS MEASURE— 

COMPREHENSIVE ASSESSMENT

MEASURE AT ADMISSION AND 7 

ORIGINAL HIS COMPONENT MEASURES

Measure title 

Measure 

score 

(percent) 

Hospice and Palliative Care 

Composite Process Measure—Comprehensive Assessment at Admission (NQF 

#3235) ................................... 71.3 

Component Measure: Treatment Preferences (NQF 

#1641) ................................... 98.8 

Component Measure: Beliefs/ 

Values (NQF #1647) ............. 95.9 

Component Measure: Pain 

Screening (NQF #1634) ........ 93.2 

Component Measure: Pain Assessment (NQF #1637) ........ 72.5 

Component Measure: Dyspnea 

Screening (NQF #1639) ........ 98.5 

Component Measure: Dyspnea 

Treatment (NQF #1638) ....... 92.8 

Component Measure: Bowl 

Regimen (NQF #1617) ......... 97.5 

Further, reporting of these 7 

component measures alongside the 

composite measure may be redundant 

and may result in confusion and burden 

for users as they attempt to interpret 

data displayed on the Hospice Compare 

website. However, we also recognize 

that the component measures may be 

useful to some individuals using 

Hospice Compare. Therefore, while we 

will no longer directly display the 7 

component measures as individual 

measures on Hospice Compare, once the 

composite measure is displayed, we will 

still provide the public the ability to 

view these component measures in a 

manner that avoids confusion on 

Hospice Compare. We plan to achieve 

this by reformatting the display of the 

component measures so that they are 

only viewable in an expandable/ 

collapsible format under the composite 

measure itself, thus allowing users the 

opportunity to view the component 

measure scores that were used to 

calculate the main composite measure 

score. 

This will change only the display of 

data on Hospice Compare for the HISbased measure(s). This will not change 

any current HIS data collection 

procedures outlined in the FY 2018 

Hospice final rule (82 FR 36663 through 

36664). Providers will still collect all 


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HIS items in the current version of the 

HIS (HIS V2.00.0), including the 7 

aforementioned component measures. 

Providers will continue to follow the 

coding guidelines and policies outlined 

in the HIS Manual V2.00, which can be 

found under the Downloads section of 

the HIS page of the HQRP website 

https://www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/ 

Hospice-Item-Set-HIS.html. Therefore, 

this change to the display of data on 

Hospice Compare will not impact data 

collection. Additionally, because the 

composite measure is composed of the 

7 aforementioned component measures, 

these component measures will still be 

reported on CASPER QM reports and 

HIS provider preview reports for 

providers’ internal quality purposes. 

We received multiple comments on 

this proposal to no longer directly 

display the 7 component measures as 

individual measures on Hospice 

Compare, once Hospice Comprehensive 

Assessment measure is displayed. A 

summary of the comments we received 

on this topic and our responses to those 

comments are below: 

Comment: CMS received multiple 

comments that were supportive of no 

longer directly displaying the 7 

component HIS measures as individual 

measures on Hospice Compare once the 

Hospice Comprehensive Assessment 

measure is publicly reported. 

Commenters noted that displaying the 7 

component measures in an expandable/ 

collapsible format under the Hospice 

Comprehensive Assessment measure is 

preferable for consumers. In addition to 

receiving comments indicating general 

support, commenters also raised several 

concerns about the proposed changes to 

display of HIS data on Compare. 

Response: We appreciate commenters’ 

support of no longer directly displaying 

the 7 component HIS measures as 

individual measures on Hospice 

Compare once the Hospice 

Comprehensive Assessment measure is 

publicly reported. We address 

commenters’ specific concerns with 

respect to the public display of the 

Hospice Comprehensive Assessment 

measure and its composite of the 7 

component original HIS measures 

below. 

Comment: Many commenters stated 

that, since the Hospice Comprehensive 

Assessment measure is a composite of 

the 7 HIS measures, a low score for one 

of the 7 HIS measures could easily skew 

providers’ scores on the Hospice 

Comprehensive Assessment measure. 

One commenter stated that this could be 

especially problematic for small hospice 

providers. Commenters stated that the 

reformatted display of Hospice Compare 

would make it more difficult for 

consumers to find or even hide the 

scores for the 7 component measures 

hospices were performing well and that 

may be more easily interpretable to 

them in favor of directly displaying the 

one Hospice Comprehensive 

Assessment measure with less favorable 

performance. 

Response: We agree with commenters 

that the 7 component HIS measures may 

be useful to some consumers of the site. 

Therefore, as stated in the proposed 

rule, we will not be removing the 

measures, nor will we obfuscate the 

display of these measures on Compare. 

We plan to display the 7 component HIS 

measures directly under the Hospice 

Comprehensive Assessment measure in 

an expandable/collapsible format. We 

will make it clear that the 7 component 

measures are available for those who 

would like more information about 

provider quality scores. Furthermore, as 

with the currently displayed HIS 

measures, we will include text 

explaining the Hospice Comprehensive 

Assessment measure and its relation to 

quality care. 

Analyses indicate that the Hospice 

Comprehensive Assessment measure is 

more illustrative than the component, 

high performing measures and, on 

average, a much lower percentage of 

patient stays received all 7 desirable 

care processes at admission. Thus, by 

assessing hospices’ performance of a 

comprehensive assessment through an 

all-or-none calculation methodology, 

the Hospice Comprehensive Assessment 

measure sets a higher standard of care 

for hospices and reveals a larger 

performance gap. This performance gap 

creates opportunities for quality 

improvement and may motivate 

providers to conduct a greater number 

of high priority care processes for as 

many patients as possible upon 

admission to hospice. Furthermore, 

discussions with key stakeholders 

indicate that, because of this 

performance gap, the Hospice 

Comprehensive Assessment measure is 

a more indicative measure for 

consumers when evaluating quality of 

care provided by a hospice. In summary, 

by directly displaying only this measure 

we will: (a) Provide consumers with one 

measure to easily compare providers on 

quality of care; and (b) incentivize 

hospices to conduct a greater number of 

care processes for as many patients as 

possible. We also recognize that the 7 

component measures are useful to 

consumers and we are committed to 

making them easily accessible, while 

keeping the Hospice Compare site as 

user-friendly as possible. 

As with the currently reported 7 HIS 

measures, the Hospice Comprehensive 

Assessment Measure will be reported 

with a minimum denominator size of 20 

patient stays. This minimum 

denominator size ensures that quality 

measure scores are based on a large 

enough denominator to generate a 

statistically reliable score for public 

reporting. Therefore, hospices with 

small denominator sizes (<20 patient 

stays) for the Hospice Comprehensive 

Assessment Measure, which may be at 

higher risk of a skewed score, will not 

have scores for this measure reported on 

Hospice Compare. 

Comment: Many commenters noted 

that many providers have high scores on 

the current seven HIS-based QMs and 

that the limited range of scores could 

make it difficult for consumers to 

differentiate between high- and lowquality providers. One commenter 

suggested eliminating the seven 

measures for this reason. 

Response: We agree that many 

hospice providers are performing well 

on the seven HIS-based QMs. The 

overall distribution and variability of 

the scores of the seven HIS QMs that are 

currently publicly displayed initially 

indicate that most hospices are 

completing the important care processes 

for most hospice patients around 

hospice admission. However, there is 

still noticeable room for improvement. 

Analysis completed by RTI International 

shows that a low percentage of hospices 

have perfect scores for most measures 

and a small percentage of hospices have 

very low scores. Moreover, interviews 

with caregivers found that public 

display of these measures would be 

useful in avoiding low-performing 

providers. Additionally, publicly 

reporting these measures inform 

consumers of the important care 

processes that they should expect upon 

hospice admission. Last but not the 

least, the seven HIS QMs allow 

consumers to review the QMs associated 

with the individual care processes that 

they feel are particularly applicable to 

them. 

Final Decision: After consideration of 

the comments, we are finalizing our 

proposal to no longer directly display 

the 7 component measures as individual 

measures on Hospice Compare, once the 

Hospice Comprehensive Assessment 

measure is displayed. 

d. Display of Public Use File Data and/ 

or Other Publicly Available CMS Data 

on the Hospice Compare Website 

In the FY 2016 Hospice Wage Index 

final rule (80 FR 47199), we announced 

that we would make available hospice 

data in a public data set, the Medicare 


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Provider Utilization and Payment Data: 

Physician and Other Supplier Public 

Use File (PUF), as part of our ongoing 

efforts to make healthcare more 

transparent, affordable, and 

accountable. Hospice data has been 

available at the provider-level in the 

Medicare Provider Utilization and 

Payment Data: Physician and Other 

Supplier PUF since 2016 and is located 

at: https://www.cms.gov/ResearchStatistics-Data-and-Systems/StatisticsTrends-and-Reports/Medicare-ProviderCharge-Data/Hospice.html. The primary 

data source for the Hospice PUF is the 

CMS Chronic Condition Data 

Warehouse (CCW), a database with 100 

percent of Medicare enrollment and feefor-service adjudicated claims data. 

These Hospice PUFs serve as a 

resource for the health care community 

by providing information on services 

provided to Medicare beneficiaries by 

hospice providers. The Hospice PUF 

contains information on utilization, 

payment (Medicare payment and 

standard payment), submitted charges, 

primary diagnoses, sites of service, and 

hospice beneficiary demographics 

organized by CMS Certification Number 

(6-digit provider identification number) 

and state. While these files are 

extensively downloaded by the public 

and especially researchers, currently the 

files are not in a format that would be 

considered user-friendly for many of the 

consumers who would look for hospice 

information to support provider 

selection. 

As part of our ongoing efforts to make 

the Hospice Compare website more 

informative to our beneficiaries, loved 

ones, and their families, we proposed to 

post information from these PUF and/or 

other publicly available CMS data to the 

Hospice Compare website in a userfriendly way. We proposed to use 

information available in these public 

files to develop a new section of the 

Hospice Compare website that will 

provide additional information along 

with the HIS and CAHPS® quality 

measures and demographic information 

already displayed. Other Compare 

websites, such as the Nursing Home 

Compare and the End Stage Renal 

Disease Compare websites, have an 

information section similar to what we 

anticipate posting. 

Information on the Hospice Compare 

website for each hospice includes data 

from the PUF and/or other publicly 

available CMS data displayed in a 

consumer-friendly format. This means 

that we may display the data as shown 

from the PUF or present the data after 

additional calculations. For example, 

the data could be averaged over 

multiple years, displayed as a 

percentage rather than the raw number 

so it has meaning to end-users, or other 

calculations in a given year or over 

multiple years. Any calculation will be 

performed on data exclusively from the 

source file like the PUF or other 

publicly available CMS data. The data 

may be displayed with supporting 

narrative when needed to make the data 

more understandable. 

Examples, provided for illustration of 

how CMS could use the PUF or other 

publicly available CMS data, include: 

• Percent of days a hospice provided 

routine home care (RHC) to patients, 

averaged over multiple years, 

• Percent of primary diagnosis of 

patients served by the hospice (cancer, 

dementia, circulatory/heart disease, 

stroke, respiratory disease) which would 

be a calculation of the total number of 

patients by diagnosis and dividing by 

the total number of patients that the 

hospice served, and 

• Site of service (long term care or 

non-skilled nursing facility, skilled 

nursing facility, inpatient hospital) with 

a notation of yes, based on whether the 

hospice serves patients in that facility 

type. 

While these types of information are 

not quality measures, they capture 

information that many consumers seek 

during the provider selection process 

and, therefore, will help them to make 

an informed decision. For example, 

information about conditions treated by 

the hospice could show a patient with 

dementia if a hospice specializes or is 

experienced in caring for patients with 

this condition. Additionally, if a patient 

has a specific need, like receiving 

hospice care in a nursing home, 

information from the PUF could help 

this patient or their loved ones 

determine if a provider in their service 

area has provided care in this setting. 

Analyses of the PUF data show variation 

between hospice providers in the data 

points outlined above, indicating that 

these data points could be meaningful to 

consumers in comparing services 

provided by hospices based on the 

factors most important to them. PUF 

data can serve as one more piece of 

information, along with quality of care 

metrics from the HIS and CAHPS®

Hospice Survey, to help consumers 

effectively and efficiently compare 

hospice providers and make an 

informed decision about their care in a 

stressful time. 

By averaging or trending data over 

multiple years, the data applies to 

hospices broadly regardless of size or 

location or other factors. We anticipate 

that over time and as appropriate, we 

may add other items from the PUF or 

other publicly available CMS data to the 

Hospice Compare website through subregulatory processes and plan to inform 

the public through regular HQRP 

communication strategies, such as Open 

Door Forums, Medicare Learning 

Network, Spotlight announcements and 

other opportunities. 

We received multiple comments on 

this proposal to add data from the 

Hospice PUF to Hospice Compare. A 

summary of the comments we received 

and our responses to those comments 

are below: 

Comment: A majority of commenters 

supported the plan to post information 

from the PUF and/or other publicly 

available CMS data on the Hospice 

Compare website. Commenters stated 

this information would ‘‘give users 

additional insight into the industry and 

the specific provider.’’ Of those that 

were supportive, some were 

conditionally supportive. Those 

commenters supported display of PUF 

data as long as the public is involved in 

decision-making as to which data points 

would be posted and how. Those who 

supported the proposal stated that 

posting of PUF data could lead to 

consumer confusion and unintended 

consequences. 

Response: We thank commenters for 

their support of this plan to post 

information from the PUF and/or other 

publicly available CMS data on the 

Hospice Compare website. We address 

commenters’ specific concerns below. 

Comment: In addition to the three 

data points outlined in the proposal, 

several commenters suggested CMS add 

other data points from the PUF to 

Hospice Compare. Commenters 

suggested data points such as hospice 

size and business model. 

Response: We support these 

commenters’ suggestions. The purpose 

of adding information from the PUF or 

other publically available CMS data is to 

provide additional useful information to 

consumers as they consider hospice. We 

will take these into consideration as we 

determine which data points will be 

added to Hospice Compare. 

Comment: Many commenters stated 

that displaying data from the PUF 

would be misleading for consumers 

since consumers may misinterpret this 

data as quality data. For this reason, 

some commenters supported posting 

PUF data to Hospice Compare. To 

mitigate any potential consumer 

confusion, commenters suggested that 

CMS solicit input from stakeholders, 

through rulemaking or other stakeholder 

engagement activities, to guide 

decisions on (1) what type of 

information is displayed on Hospice 

Compare, (2) what kind of 

transformations or calculations are done 


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to the data before it is publicly posted, 

and (3) how the data that is to be 

displayed will be explained in a 

consumer-friendly manner. One 

commenter also suggested CMS mature 

the PUF data before use. 

Response: We agree that it is 

important to clearly distinguish between 

PUF data, which is informational data 

and quality measure data posted to 

Hospice Compare. As such, we plan to 

display data from the PUF in a distinct 

section of the Hospice Compare website, 

separate from the sections containing 

HIS and CAHPS® quality data. This will 

be similar to the approach taken on 

other CMS Compare websites. We will 

also include text to explain the data 

displayed from the PUF and will make 

clear this data provides information 

about hospice characteristics and is not 

a reflection of the quality of care a 

hospice provides. As with other data 

and text currently on Hospice Compare, 

we will, with consultation from key 

stakeholders, carefully craft explanatory 

language to ensure that consumers 

understand the PUF data and how the 

data are meant for informational 

purposes only. 

We are committed to soliciting input 

from providers, key stakeholders, and 

the public when considering any 

refinements to Hospice Compare, 

including addition of PUF and/or other 

publicly available CMS data. As 

discussed in our response in section 

III.F.6a, the annual rulemaking cycle is 

not the only method by which this 

information can be communicated to the 

public and feedback can be solicited. 

Sub-regulatory channels can be equally 

or more effective at communicating and 

collaborating with the public since we 

can communicate more frequently 

through sub-regulatory means like Open 

Door Forums, Special Open Door 

Forums, and Medicare Learning 

Network, HQRP Spotlight Page and its 

other web pages. 

In reference to the comment 

suggesting ‘‘maturing’’ of PUF data 

before public reporting, we would like 

to clarify that PUF data is based on 100 

percent fee-for-service final action 

claims. Thereby, the PUF reports out the 

hospices’ data from their paid claims 

using data files that were produced after 

24 months of maturity. Therefore, 

stakeholders have confidence in this 

data that will be used on Hospice 

Compare. We would also note that the 

PUF data are currently reported on our 

website for the public and that this data 

will be reported in a more user-friendly 

format to improve usability by 

consumers. For more information about 

the PUF and methodology used to 

calculate the data, see the Medicare 

Hospice Utilization & Payment Public 

Use File: A Methodological Overview 

here: https://www.cms.gov/ResearchStatistics-Data-and-Systems/StatisticsTrends-and-Reports/Medicare-ProviderCharge-Data/Downloads/Hospice_

Methodology.pdf. 

Comment: A few commenters shared 

that the display of PUF data on Hospice 

Compare could lead to unintended 

consequences and, therefore, were 

unsupportive of displaying this data. 

Specifically, commenters shared that 

posting data about primary diagnoses 

served could lead consumers to falsely 

assume a hospice does not serve a 

particular diagnosis group, and that this 

would disproportionately affect small 

hospices. 

Response: We agree that it is 

important to prevent unintended 

consequences of publicly posted data. 

To mitigate concerns, we plan to (1) 

average data over multiple years and (2) 

include text explaining the purpose of 

these data points and how consumers 

can use them. By averaging data over 

multiple years, changes in case mix 

from year-to-year will be accounted for. 

Moreover, data for small providers (≤10 

hospice beneficiaries in a calendar year) 

or data points with ≤10 beneficiaries 

(that is, if a provider had ≤10 

beneficiaries with a primary diagnosis 

of, for example, cancer) are suppressed 

in the PUF and cannot be displayed on 

Hospice Compare. We will make clear 

that information from the PUF is one 

more resource along with, but separate 

from, the quality of care data to help 

consumers make a more informed 

choice of hospice provider. 

Final Decision: After consideration of 

the comments, we are finalizing our 

proposal to display data from the 

Hospice PUF on Hospice Compare. 

Comment: CMS received several 

comments related to the Hospice 

Evaluation & Assessment Reporting 

Tool (HEART). Commenters highlighted 

the importance of developing a tool that 

reflects the holistic nature of hospice 

and expressed curiosity related to the 

timeline for HEART implementation 

and next steps for HEART development. 

Additionally, commenters emphasized 

the importance of using widespread 

processes to gather provider input 

related to HEART and ongoing 

education and support for future 

HEART implementation. Finally, 

commenters requested that HEART pilot 

test findings be broadly disseminated 

and explored, and that public comment 

be solicited through traditional 

rulemaking, prior to industry-wide 

implementation. 

Response: Because no changes were 

proposed to the potential new hospice 

data collection mechanism that is 

preliminarily being called the HEART, 

comments received are outside the 

scope of the current rule. We addressed 

these issues in the FY 2018 Hospice 

Wage Index final rule (82 FR 36638), 

and we refer the reader to that detailed 

discussion and the HQRP web page on 

HEART at https://www.cms.gov/ 

Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/index.html. 

IV. Collection of Information 

Requirements 

Under the Paperwork Reduction Act 

of 1995, we are required to provide 30- 

day notice in the Federal Register and 

solicit public comment before a 

collection of information requirement is 

submitted to the Office of Management 

and Budget (OMB) for review and 

approval. In order to fairly evaluate 

whether an information collection 

should be approved by OMB, section 

3506(c)(2)(A) of the Paperwork 

Reduction Act of 1995 requires that we 

solicit comment on the following issues: 

• The need for the information 

collection and its usefulness in carrying 

out the proper functions of our agency. 

• The accuracy of our estimate of the 

information collection burden. 

• The quality, utility, and clarity of 

the information to be collected. 

• Recommendations to minimize the 

information collection burden on the 

affected public, including automated 

collection techniques. 

We are solicited public comment on 

each of these issues for the following 

sections of this document that contain 

information collection requirements. 

A. ICRs Regarding Hospice Item Set 

In the FY 2014 Hospice Wage Index 

final rule (78 FR 48257), and in 

compliance with section 1814(i)(5)(C) of 

the Act, we finalized the specific 

collection of data items that support the 

following 7 NQF endorsed measures for 

hospice: 

• NQF #1617 Patients Treated with 

an Opioid who are Given a Bowel 

Regimen, 

• NQF #1634 Pain Screening, 

• NQF #1637 Pain Assessment, 

• NQF #1638 Dyspnea Treatment, 

• NQF #1639 Dyspnea Screening, 

• NQF #1641 Treatment Preferences, 

• NQF #1647 Beliefs/Values 

Addressed (if desired by the patient). 

We finalized the following two 

additional measures in the FY 2017 

Hospice Wage Index final rule affecting 

FY 2019 payment determinations (81 FR 

52163 through 52173): 

• Hospice Visits when Death is 

Imminent 


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• Hospice and Palliative Care 

Composite Process Measure— 

Comprehensive Assessment at 

Admission 

We received no comments on the ICRs 

Regarding Hospice Item Set. 

In section III.F of this rule, we are 

reformatting the 7 original HIS measures 

for purposes of public reporting display 

on Hospice Compare. This will not 

change any current HIS data collection 

procedures outlined in the FY 2018 

Hospice final rule (82 FR 36663 through 

36664). The HIS V2.00.0 was approved 

by the OMB on April 17, 2017 under 

OMB control number 0938–1153 (CMS– 

10390) for 1 year. The information 

collection request (ICR) is currently 

pending OMB approval for 3 years. 

B. ICRs Regarding CAHPS® Hospice 

Survey 

National Implementation of the 

Hospice Experience of Care Survey 

(CAHPs Hospice Survey) data measures 

(82 FR 36672) would not impose any 

new or revised reporting, recordkeeping, 

or third-party disclosure requirements 

and therefore, does not require 

additional OMB review under the 

authority of the Paperwork Reduction 

Act of 1995 (44 U.S.C. 3501 et seq.). The 

information collection requirements and 

burden have been approved by OMB 

through December 31, 2020 under OMB 

control number 0938–1257 (CMS– 

10537). 

C. Submission of PRA-Related 

Comments 

We have submitted a copy of this final 

rule to OMB for its review of the rule’s 

information collection and 

recordkeeping requirements. The 

requirements are not effective until they 

have been approved by OMB. 

V. Regulatory Impact Analysis 

A. Statement of Need 

This final rule meets the requirements 

of our regulations at § 418.306(c), which 

requires annual issuance, in the Federal 

Register, of the hospice wage index 

based on the most current available 

CMS hospital wage data, including any 

changes to the definitions of Core-Based 

Statistical Areas (CBSAs), or previously 

used Metropolitan Statistical Areas 

(MSAs). This final rule would also 

update payment rates for each of the 

categories of hospice care, described in 

§ 418.302(b), for FY 2019 as required 

under section 1814(i)(1)(C)(ii)(VII) of the 

Act. The payment rate updates are 

subject to changes in economy-wide 

productivity as specified in section 

1886(b)(3)(B)(xi)(II) of the Act. In 

addition, the payment rate updates may 

be reduced by an additional 0.3 

percentage point (although for FY 2014 

to FY 2019, the potential 0.3 percentage 

point reduction is subject to suspension 

under conditions specified in section 

1814(i)(1)(C)(v) of the Act). Lastly, 

section 3004 of the PPACA amended the 

Act to authorize a quality reporting 

program for hospices and this rule 

discusses changes in the requirements 

for the hospice quality reporting 

program in accordance with section 

1814(i)(5) of the Act. 

B. Overall Impacts 

We estimate that the aggregate impact 

of the payment provisions in this rule 

will result in an increase of $340 

million in payments to hospices, 

resulting from the hospice payment 

update percentage of 1.8 percent. The 

impact analysis of this rule represents 

the projected effects of the changes in 

hospice payments from FY 2018 to FY 

2019. Using the most recent data 

available at the time of rulemaking, in 

this case FY 2017 hospice claims data, 

we apply the current FY 2018 wage 

index and labor-related share values to 

the level of care per diem payments and 

SIA payments for each day of hospice 

care to simulate FY 2018 payments. 

Then, using the same FY 2017 data, we 

apply the FY 2019 wage index and 

labor-related share values to simulate 

FY 2019 payments. Certain events may 

limit the scope or accuracy of our 

impact analysis, because such an 

analysis is susceptible to forecasting 

errors due to other changes in the 

forecasted impact time period. The 

nature of the Medicare program is such 

that the changes may interact, and the 

complexity of the interaction of these 

changes could make it difficult to 

predict accurately the full scope of the 

impact upon hospices. 

We have examined the impacts of this 

rule as required by Executive Order 

12866 on Regulatory Planning and 

Review (September 30, 1993), Executive 

Order 13563 on Improving Regulation 

and Regulatory Review (January 18, 

2011), the Regulatory Flexibility Act 

(RFA) (September 19, 1980, Pub. L. 96– 

354), section 1102(b) of the Social 

Security Act, section 202 of the 

Unfunded Mandates Reform Act of 1995 

(March 22, 1995; Pub. L. 104–4), 

Executive Order 13132 on Federalism 

(August 4, 1999), the Congressional 

Review Act (5 U.S.C. 804(2)), and 

Executive Order 13771 on Reducing 

Regulation and Controlling Regulatory 

Costs (January 30, 2017). 

Executive Orders 12866 and 13563 

direct agencies to assess all costs and 

benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, distributive impacts, and 

equity). Section 3(f) of Executive Order 

12866 defines a ‘‘significant regulatory 

action’’ as an action that is likely to 

result in a rule: (1) Having an annual 

effect on the economy of $100 million 

or more in any 1 year, or adversely and 

materially affecting a sector of the 

economy, productivity, competition, 

jobs, the environment, public health or 

safety, or state, local or tribal 

governments or communities (also 

referred to as ‘‘economically 

significant’’); (2) creating a serious 

inconsistency or otherwise interfering 

with an action taken or planned by 

another agency; (3) materially altering 

the budgetary impacts of entitlement 

grants, user fees, or loan programs or the 

rights and obligations of recipients 

thereof; or (4) raising novel legal or 

policy issues arising out of legal 

mandates, the President’s priorities, or 

the principles set forth in the Executive 

Order. 

A regulatory impact analysis (RIA) 

must be prepared for major rules with 

economically significant effects ($100 

million or more in any 1 year). We 

estimate that this rulemaking is 

‘‘economically significant’’ as measured 

by the $100 million threshold, and 

hence also a major rule under the 

Congressional Review Act. Accordingly, 

we have prepared a RIA that, to the best 

of our ability presents the costs and 

benefits of the rulemaking. 

C. Anticipated Effects 

The Regulatory Flexibility Act (RFA) 

requires agencies to analyze options for 

regulatory relief of small businesses if a 

rule has a significant impact on a 

substantial number of small entities. 

The great majority of hospitals and most 

other health care providers and 

suppliers are small entities by meeting 

the Small Business Administration 

(SBA) definition of a small business (in 

the service sector, having revenues of 

less than $7.5 million to $38.5 million 

in any 1 year), or being nonprofit 

organizations. For purposes of the RFA, 

we consider all hospices as small 

entities as that term is used in the RFA. 

HHS’s practice in interpreting the RFA 

is to consider effects economically 

‘‘significant’’ only if greater than 5 

percent of providers reach a threshold of 

3 to 5 percent or more of total revenue 

or total costs. The effect of the FY 2018 

hospice payment update percentage 

results in an overall increase in 

estimated hospice payments of 1.8 

percent, or $340 million. Therefore, the 


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Secretary has determined that this rule 

will not create a significant economic 

impact on a substantial number of small 

entities. 

In addition, section 1102(b) of the 

Social Security Act requires us to 

prepare a regulatory impact analysis if 

a rule may have a significant impact on 

the operations of a substantial number 

of small rural hospitals. This analysis 

must conform to the provisions of 

section 604 of the RFA. For purposes of 

section 1102(b) of the Act, we define a 

small rural hospital as a hospital that is 

located outside of a metropolitan 

statistical area and has fewer than 100 

beds. This rule will only affect hospices. 

Therefore, the Secretary has determined 

that this rule will not have a significant 

impact on the operations of a substantial 

number of small rural hospitals. 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 (UMRA) 

also requires that agencies assess 

anticipated costs and benefits before 

issuing any rule whose mandates 

require spending in any 1 year of $100 

million in 1995 dollars, updated 

annually for inflation. The 2018 UMRA 

threshold is $150 million. This rule is 

not anticipated to have an effect on 

state, local, or tribal governments, in the 

aggregate, or on the private sector of 

$150 million or more. 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 

proposed rule (and subsequent final 

rule) that imposes substantial direct 

requirement costs on state and local 

governments, preempts state law, or 

otherwise has Federalism implications. 

We have reviewed this rule under these 

criteria of Executive Order 13132, and 

have determined that it will not impose 

substantial direct costs on state or local 

governments. 

If regulations impose administrative 

costs on private entities, such as the 

time needed to read and interpret this 

final rule, we should estimate the cost 

associated with regulatory review. Due 

to the uncertainty involved with 

accurately quantifying the number of 

entities that will review the rule, we 

assume that the total number of unique 

commenters on the published proposed 

rule will be the number of reviewers of 

this final rule. We acknowledge that this 

assumption may understate or overstate 

the costs of reviewing this final rule. It 

is possible that not all commenters 

reviewed the proposed rule in detail, 

and it is also possible that some 

reviewers chose not to comment on the 

proposed rule. For these reasons we 

thought that the number of comments 

received on the proposed rule would be 

a fair estimate of the number of 

reviewers of this final rule. 

Using the wage information from the 

Bureau of Labor Statistics (BLS) for 

medical and health service managers 

(Code 11–9111), we estimate that the 

cost of reviewing this rule is $107.38 per 

hour, including overhead and fringe 

benefits (https://www.bls.gov/oes/ 

current/oes_nat.htm). Assuming an 

average reading speed of 250 words per 

minute, we estimate that it would take 

approximately 1 hour for the staff to 

review half of this rule which consists 

of approximately 30,000 words. For 

each hospice that reviews the rule, the 

estimated cost is $107.38 (1 hour × 

$107.38). Therefore, we estimate that 

the total cost of reviewing this 

regulation is $9,664.20 ($107.38 × 90 

reviewers). 

D. Detailed Economic Analysis 

The FY 2019 hospice payment 

impacts appear in Table 12. We tabulate 

the resulting payments according to the 

classifications in Table 12 (for example, 

facility type, geographic region, facility 

ownership), and compare the difference 

between current and future payments to 

determine the overall impact. 

The first column shows the 

breakdown of all hospices by urban or 

rural status, census region, hospitalbased or freestanding status, size, and 

type of ownership, and hospice base. 

The second column shows the number 

of hospices in each of the categories in 

the first column. 

The third column shows the effect of 

the annual update to the wage index. 

This represents the effect of using the 

FY 2019 hospice wage index. The 

aggregate impact of this change is zero 

percent, due to the hospice wage index 

standardization factor. However, there 

are distributional effects of the FY 2019 

hospice wage index. 

The fourth column shows the effect of 

the hospice payment update percentage 

for FY 2019. The 1.8 percent hospice 

payment update percentage is based on 

the 2.9 percent inpatient hospital 

market basket update, reduced by a 0.8 

percentage point productivity 

adjustment and by a 0.3 percentage 

point adjustment as required by statute, 

and is constant for all providers. 

The fifth column shows the effect of 

all the changes on FY 2019 hospice 

payments. It is projected that aggregate 

payments would increase by 1.8 

percent, assuming hospices do not 

change their service and billing 

practices. 

As illustrated in Table 12, the 

combined effects of all the proposals 

vary by specific types of providers and 

by location. 

TABLE 12—IMPACT TO HOSPICES FOR FY 2019 

Number of 

providers 

Updated 

wage data 

(%) 

FY 2019 

hospice payment 

update 

(%) 

FY 2019 

total change 

(%) 

All Hospices ..................................................................................... 4,440 0.0 1.8 1.8 

Urban Hospices ............................................................................... 3,550 0.0 1.8 1.8 

Rural Hospices ................................................................................ 890 0.1 1.8 1.9 

Urban Hospices—New England ...................................................... 127 0.0 1.8 1.8 

Urban Hospices—Middle Atlantic .................................................... 250 0.0 1.8 1.8 

Urban Hospices—South Atlantic ..................................................... 443 ¥0.1 1.8 1.7 

Urban Hospices—East North Central .............................................. 399 ¥0.1 1.8 1.7 

Urban Hospices—East South Central ............................................. 149 0.0 1.8 1.8 

Urban Hospices—West North Central ............................................. 242 0.2 1.8 2.0 

Urban Hospices—West South Central ............................................ 695 0.4 1.8 2.2 

Urban Hospices—Mountain ............................................................. 359 ¥0.3 1.8 1.5 

Urban Hospices—Pacific ................................................................. 845 0.1 1.8 1.9 

Urban Hospices—Outlying .............................................................. 41 0.4 1.8 2.2 

Rural Hospices—New England ....................................................... 27 1.6 1.8 3.4 

Rural Hospices—Middle Atlantic ..................................................... 35 0.0 1.8 1.8 

Rural Hospices—South Atlantic ...................................................... 108 0.0 1.8 1.8 


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38654 Federal Register / Vol. 83, No. 151 / Monday, August 6, 2018 / Rules and Regulations 

TABLE 12—IMPACT TO HOSPICES FOR FY 2019—Continued 

Number of 

providers 

Updated 

wage data 

(%) 

FY 2019 

hospice payment 

update 

(%) 

FY 2019 

total change 

(%) 

Rural Hospices—East North Central ............................................... 138 ¥0.1 1.8 1.7 

Rural Hospices—East South Central .............................................. 111 0.0 1.8 1.8 

Rural Hospices—West North Central .............................................. 168 0.3 1.8 2.1 

Rural Hospices—West South Central ............................................. 168 0.1 1.8 1.9 

Rural Hospices—Mountain .............................................................. 93 ¥0.4 1.8 1.4 

Rural Hospices—Pacific .................................................................. 42 0.1 1.8 1.9 

Rural Hospices—Outlying ................................................................ 6 ¥0.3 1.8 1.5 

0–3,499 RHC Days (Small) ............................................................. 999 0.2 1.8 2.0 

3,500–19,999 RHC Days (Medium) ................................................ 2,044 0.1 1.8 1.9 

20,000+ RHC Days (Large) ............................................................. 1,397 0.0 1.8 1.8 

Non-Profit Ownership ...................................................................... 1,028 0.0 1.8 1.8 

For Profit Ownership ........................................................................ 2,858 0.0 1.8 1.8 

Government Ownership ................................................................... 141 0.2 1.8 2.0 

Other Ownership .............................................................................. 413 ¥0.1 1.8 1.7 

Freestanding Facility Type .............................................................. 3,638 0.0 1.8 1.8 

HHA/Facility-Based Facility Type .................................................... 802 ¥0.1 1.8 1.7 

Source: FY 2017 hospice claims from the Chronic Conditions Data Warehouse (CCW) Research Identifiable Files (RIFs) as of May 29, 2018. 

Region Key: New England = Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont; Middle Atlantic = Pennsylvania, 

New Jersey, New York; South Atlantic = Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, 

West Virginia; East North Central = Illinois, Indiana, Michigan, Ohio, Wisconsin; East South Central = Alabama, Kentucky, Mississippi, Tennessee; West North Central = Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota; West South Central = Arkansas, Louisiana, Oklahoma, Texas; Mountain = Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming; Pacific = Alaska, California, 

Hawaii, Oregon, Washington; Outlying = Guam, Puerto Rico, Virgin Islands. 

E. Accounting Statement 

As required by OMB Circular A–4 

(available at http://

www.whitehouse.gov/omb/circulars/ 

a004/a-4.pdf), in Table 13, we have 

prepared an accounting statement 

showing the classification of the 

expenditures associated with the 

provisions of this final rule. Table 13 

provides our best estimate of the 

possible changes in Medicare payments 

under the hospice benefit as a result of 

the policies in this final rule. This 

estimate is based on the data for 4,440 

hospices in our impact analysis file, 

which was constructed using FY 2017 

claims available in May 2018. All 

expenditures are classified as transfers 

to hospices. 

TABLE 13—ACCOUNTING STATEMENT: 

CLASSIFICATION OF ESTIMATED

TRANSFERS AND COSTS, FROM FY 

2018 TO FY 2019 

Category Transfers 

Annualized Monetized 

Transfers.

$340 million *

From Whom to 

Whom?.

Federal Government 

to Medicare Hospices. 

* The net increase of $340 million in transfer 

payments is a result of the 1.8 percent hospice payment update compared to payments 

in FY 2018. 

F. Regulatory Reform Analysis Under 

E.O. 13771 

Executive Order 13771, entitled 

‘‘Reducing Regulation and Controlling 

Regulatory Costs,’’ was issued on 

January 30, 2017 (82 FR 9339, February 

3, 2017) and requires that the costs 

associated with significant new 

regulations ‘‘shall, to the extent 

permitted by law, be offset by the 

elimination of existing costs associated 

with at least two prior regulations.’’ It 

has been determined that this rule is an 

action that primarily results in transfers 

and does not impose more than de 

minimis costs as described above and 

thus is not a regulatory or deregulatory 

action for the purposes of Executive 

Order 13771. 

G. Conclusion 

We estimate that aggregate payments 

to hospices in FY 2019 will increase by 

$340 million, or 1.8 percent, compared 

to payments in FY 2018. We estimate 

that in FY 2019, hospices in urban and 

rural areas will experience, on average, 

1.8 percent and 1.9 percent increases, 

respectively, in estimated payments 

compared to FY 2018. Hospices 

providing services in the urban West 

South Central and Outlying regions and 

the rural New England region would 

experience the largest estimated 

increases in payments of 2.2 percent 

and 3.4 percent, respectively. Hospices 

serving patients in rural areas in the 

Mountain region would experience, on 

average, the lowest estimated increase of 

1.4 percent in FY 2019 payments. 

In accordance with the provisions of 

Executive Order 12866, this regulation 

was reviewed by the Office of 

Management and Budget. 

List of Subjects in 42 CFR Part 418 

Health facilities, Hospice care, 

Medicare, Reporting and recordkeeping 

requirements. 

For the reasons set forth in the 

preamble, the Centers for Medicare & 

Medicaid Services amends 42 CFR 

chapter IV as set forth below: 

PART 418—HOSPICE CARE 

■ 1. The authority citation for part 418 

continues to read as follows: 

Authority: Secs. 1102 and 1871 of the 

Social Security Act (42 U.S.C. 1302 and 

1395hh). 

■ 2. Section 418.3 is amended— 

■ a. In the definition of ‘‘Attending 

physician’’, by revising paragraph (1); 

and 

■ b. By revising the definition of ‘‘Cap 

period’’. 

The revisions read as follows: 

§ 418.3 Definitions. 

* * * * * 

Attending physician * * * 

(1)(i) Doctor of medicine or 

osteopathy legally authorized to practice 

medicine and surgery by the State in 

which he or she performs that function 

or action; or 


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Federal Register / Vol. 83, No. 151 / Monday, August 6, 2018 / Rules and Regulations 38655 

(ii) Nurse practitioner who meets the 

training, education, and experience 

requirements as described in § 410.75(b) 

of this chapter; or 

(iii) Physician assistant who meets the 

requirements of § 410.74(c) of this 

chapter. 

* * * * * 

Cap period means the twelve-month 

period ending September 30 used in the 

application of the cap on overall 

hospice reimbursement specified in 

§ 418.309. 

* * * * * 

■ 3. Section 418.304 is amended by 

revising the section heading and adding 

paragraph (f) to read as follows: 

§ 418.304 Payment for physician, and 

nurse practitioner, and physician assistant 

services. 

* * * * * 

(f)(1) Effective January 1, 2019, 

Medicare pays for attending physician 

services provided by physician 

assistants to Medicare beneficiaries who 

have elected the hospice benefit and 

who have selected a physician assistant 

as their attending physician. This 

applies to physician assistants without 

regard to whether they are hospice 

employees. 

(2) The employer or a contractor of a 

physician assistant must bill and receive 

payment for physician assistant services 

only if the— 

(i) Physician assistant is the 

beneficiary’s attending physician as 

defined in § 418.3; 

(ii) Services are medically reasonable 

and necessary; 

(iii) Services are performed by a 

physician in the absence of the 

physician assistant and, the physician 

assistant services are furnished under 

the general supervision of a physician; 

and 

(iv) Services are not related to the 

certification of terminal illness specified 

in § 418.22. 

(3) The payment amount for physician 

assistant services when serving as the 

attending physician for hospice patients 

is 85 percent of what a physician is paid 

under the Medicare physician fee 

schedule. 

■ 4. Section 418.309 is amended by 

revising paragraph (b)(1) to read as 

follows: 

§ 418.309 Hospice aggregate cap. 

* * * * * 

(b) * * * 

(1) In the case in which a beneficiary 

received care from only one hospice, the 

hospice includes in its number of 

Medicare beneficiaries those Medicare 

beneficiaries who have not previously 

been included in the calculation of any 

hospice cap, and who have filed an 

election to receive hospice care in 

accordance with § 418.24 during the cap 

period as defined in § 418.3, using the 

best data available at the time of the 

calculation. 

* * * * * 

Dated: July 26, 2018. 

Seema Verma, 

Administrator, Centers for Medicare & 

Medicaid Services. 

Dated: July 26, 2018. 

Alex M. Azar II, 

Secretary, Department of Health and Human 

Services. 

[FR Doc. 2018–16539 Filed 8–1–18; 4:15 pm] 

BILLING CODE 4120–01–P 


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