19442 Federal Register / Vol. 87, No. 64 / Monday, April 4, 2022 / Proposed Rules 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

42 CFR Part 418 

[CMS–1773–P] 

RIN 0938–AU83 

Medicare Program; FY 2023 Hospice 

Wage Index and Payment Rate Update 

and Hospice Quality Reporting 

Requirements 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Proposed rule. 

SUMMARY: This proposed rule proposes 

to establish a permanent mitigation 

policy to smooth the impact of year-toyear changes in hospice payments 

related to changes in the hospice wage 

index. This rule also proposes updates 

to the hospice wage index, payment 

rates, and aggregate cap amount for 

Fiscal Year (FY) 2023. In addition, this 

rule proposes updates to the Hospice 

Quality Reporting Program (HQRP) 

including the Hospice Outcomes and 

Patient Evaluation tool; an update on 

Quality Measures (QMs) that will be in 

effect in FY 2023 for the HQRP and 

future QMs; updates on the Consumer 

Assessment of Healthcare Providers and 

Systems, Hospice Survey Mode 

Experiment, discusses a request for 

information (RFI) on health equity. 

DATES: To be assured consideration, 

comments must be received at one of 

the addresses provided below, by May 

31, 2022. 

ADDRESSES: In commenting, please refer 

to file code CMS–1773–P. 

Comments, including mass comment 

submissions, must be submitted in one 

of the following three ways (choose only 

one of the ways listed): 

1. Electronically. You may submit 

electronic comments on this regulation 

to http://www.regulations.gov. Follow 

the ‘‘Submit a comment’’ instructions. 

2. By regular mail. You may mail 

written comments to the following 

address ONLY: Centers for Medicare & 

Medicaid Services, Department of 

Health and Human Services, Attention: 

CMS–1773–P, P.O. Box 8010, Baltimore, 

MD 21244–1850. 

Please allow sufficient time for mailed 

comments to be received before the 

close of the comment period. 

3. By express or overnight mail. You 

may send written comments to the 

following address ONLY: Centers for 

Medicare & Medicaid Services, 

Department of Health and Human 

Services, Attention: CMS–1773–P, Mail 

Stop C4–26–05, 7500 Security 

Boulevard, Baltimore, MD 21244–1850. 

For information on viewing public 

comments, see the beginning of the 

SUPPLEMENTARY INFORMATION section. 

FOR FURTHER INFORMATION CONTACT: For 

general questions about hospice 

payment policy, send your inquiry via 

email to: hospicepolicy@cms.hhs.gov. 

For questions regarding the CAHPS®

Hospice Survey, contact Lori Teichman 

at (410) 786–6684 and Lauren Fuentes at 

(410) 786–2290. 

For questions regarding the hospice 

quality reporting program, contact 

Cindy Massuda at (410) 786–0652. 

SUPPLEMENTARY INFORMATION: 

Inspection of Public Comments: All 

comments received before the close of 

the comment period are available for 

viewing by the public, including any 

personally identifiable or confidential 

business information that is included in 

a comment. We post all comments 

received before the close of the 

comment period on the following 

website as soon as possible after they 

have been received: http://

www.regulations.gov. Follow the search 

instructions on that website to view 

public comments. CMS will not post on 

Regulations.gov public comments that 

make threats to individuals or 

institutions or suggest that the 

individual will take actions to harm the 

individual. CMS continues to encourage 

individuals not to submit duplicative 

comments. We will post acceptable 

comments from multiple unique 

commenters even if the content is 

identical or nearly identical to other 

comments. 

Wage index addenda will be available 

only through the internet on our website 

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

Medicare-Fee-for-Service-Payment/ 

Hospice/Hospice-Wage-Index.html. 

I. Executive Summary 

This proposed rule proposes to 

establish a permanent mitigation policy 

to smooth the impact of year-to-year 

changes in the hospice payments related 

to changes in the hospice wage index. 

This rule also proposes updates to the 

hospice wage index as well as updates 

to the hospice payment rates, and cap 

amount for FY 2023 as required under 

section 1814(i) of the Social Security 

Act (the Act). In addition, in this 

proposed rule CMS discusses updates to 

HQRP that include the Hospice 

Outcomes and Patient Evaluation 

(HOPE) tool with national beta testing; 

the Consumer Assessment of Healthcare 

Providers and Systems (CAHPS) 

Hospice Survey with Star Ratings; 

developing a web-based survey; Public 

Reporting; a request for information that 

builds from last year’s discussion on 

health equity, and update on advancing 

a health information exchange. 

Lastly, the overall economic impact of 

this proposed rule is estimated to be 

$580 million in increased payments to 

hospices for FY 2023. 

II. Background 

A. Hospice Care 

Hospice care is a comprehensive, 

holistic approach to treatment that 

recognizes the impending death of a 

terminally ill individual and 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 

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 provides 

compassionate beneficiary and family/ 

caregiver-centered 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 has a medical 

prognosis that his or her life expectancy 

is 6 months or less if the illness runs its 

normal course. The regulations at 

§ 418.22(b)(2) require that clinical 

information and other documentation 

that support the medical prognosis 

accompany the certification and be filed 

in the medical record with it. 

Additionally, the regulations at 

§ 418.22(b)(3) require that the 


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Federal Register / Vol. 87, No. 64 / Monday, April 4, 2022 / Proposed Rules 19443 

1Hospices are also subject to additional Federal 

civil rights laws, including the Age Discrimination 

Act, Section 1557 of the Affordable Care Act, and 

conscience and religious freedom laws. 

2Nelson, R., Should Medical Aid in Dying Be Part 

of Hospice Care? Medscape Nurses. February 26, 

2020. https://www.medscape.com/viewarticle/ 

925769#vp_1. 

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, 

once a terminally ill patient elects to 

receive hospice care, a hospice 

interdisciplinary group (IDG) is 

essential in ensuring the provision of 

primarily home-based services, keeping 

the choices of the patient and family 

first and foremost. The hospice IDG 

works with the beneficiary, family, and 

caregiver(s) 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 and care. 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. 

If, in the judgment of the hospice IDG, 

which includes the hospice physician, 

the patient’s symptoms cannot be 

effectively managed at home, then the 

patient is eligible for general inpatient 

care (GIP), a more medically intense 

level of care. GIP must be provided in 

a Medicare-certified hospice 

freestanding facility, skilled nursing 

facility, or hospital. GIP is provided to 

ensure that any new or worsening 

symptoms are intensively addressed so 

that the beneficiary can return to their 

home and continue to receive routine 

home care (RHC). Limited, short-term, 

intermittent, inpatient respite care (IRC) 

is also available to provide relief for the 

family or other caregivers, or when the 

family or other caregivers are absent. 

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. CHC 

may be covered for as much as 24 hours 

a day, and these periods must be 

predominantly nursing care, in 

accordance with the 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 CHC rate 

(§ 418.302(e)(4)). 

Hospices must comply with 

applicable civil rights laws,1 including 

section 504 of the Rehabilitation Act of 

1973 and the Americans with 

Disabilities Act, under which covered 

entities must take appropriate steps to 

ensure effective communication with 

patients and patient care representatives 

with disabilities, including the 

provisions of auxiliary aids and 

services. In addition, they must take 

reasonable steps to ensure meaningful 

access for individuals with limited 

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 (called hospice aide services); 

physician services; homemaker services; 

medical supplies (including drugs and 

biologicals); medical appliances; 

counseling services (including dietary 

counseling); short-term 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, the 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 (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 Medicare 

does not pay for these volunteer services 

(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 must have an 

interdisciplinary group composed of 

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 end 

of life care. 

C. Medicare Payment and Quality for 

Hospice Care 

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

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

Act, and the 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 based 

on one of four prospectively-determined 

rate categories of hospice care (RHC, 

CHC, IRC, and GIP), based on each day 

a qualified Medicare beneficiary is 

under hospice care (once the individual 

has elected). This per diem payment is 

meant to cover all of the hospice 

services and items needed to manage 

the beneficiary’s care, as required by 

section 1861(dd)(1) of the Act. 

While recent news reports 2 have 

brought to light the potential role 

hospices could play in medical aid in 

dying (MAID) where such practices 

have been legalized in certain states, we 

wish to remind hospices that the 

Assisted Suicide Funding Restriction 

Act of 1997 (Pub. L. 105–12) prohibits 

the use of Federal funds to provide or 

pay for any health care item or service 

or health benefit coverage for the 

purpose of causing, or assisting to cause, 

the death of any individual including 

mercy killing, euthanasia, or assisted 

suicide. This means that while 

payments made to hospices are to cover 

all items, services, and drugs for the 

palliation and management of the 

terminal illness and related conditions, 

Federal funds cannot be used for the 

prohibited activities, even in the context 

of a per diem payment. However, the 

prohibition does not pertain to the 

provision of an item or service for the 

purpose of alleviating pain or 

discomfort, even if such use may 


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increase the risk of death, so long as the 

item or service is not furnished for the 

specific purpose of causing or 

accelerating death. 

1. Omnibus Budget Reconciliation Act 

of 1989 

Section 6005(a) of the Omnibus 

Budget Reconciliation Act of 1989 (Pub. 

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 in subsequent FYs are to be 

the hospital market basket percentage 

increase for the current FY. Section 

4442 of the BBA amended section 

1814(i)(2) of the Act, effective for 

services furnished on or after October 1, 

1997, to require that hospices submit 

claims for payment for hospice care 

furnished in an individual’s home only 

on the basis of the geographic location 

at which the service is furnished. 

Previously, local wage index values 

were applied based on the geographic 

location of the hospice provider, 

regardless of where the hospice care was 

furnished. Section 4443 of the BBA 

amended sections 1812(a)(4) and 

1812(d)(1) of the Act to provide for 

hospice benefit periods of two 90-day 

periods, followed by an unlimited 

number of 60-day periods. 

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 are subject to 

annual reductions related to changes in 

economy-wide productivity, as 

specified in section 1814(i)(1)(C)(iv) 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), required hospices to begin 

submitting quality data, based on 

measures specified by the Secretary of 

the Department of Health and Human 

Services (the Secretary) for FY 2014 and 

subsequent FYs. Since FY 2014, 

hospices that fail to report quality data 

have their market basket percentage 

increase reduced by 2 percentage points. 

Note that with the passage of the 

Consolidated Appropriations Act, 2021 

(hereafter referred to as CAA 2021) (Pub. 

L. 116–260), the reduction changes to 4 

percentage points beginning in FY 2024. 

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

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

PPACA, required, 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, the 

Centers for Medicare & Medicaid 

Services (CMS) 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, 

authorized 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, CMS was 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) 

it was announced that beginning in 

2012, the hospice aggregate cap would 

be calculated using the patient-bypatient proportional methodology, 

within certain limits. Existing hospices 

had 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. 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 

addition, section 3(c) of the IMPACT 

Act requires medical review of hospice 

cases involving beneficiaries receiving 

more than 180 days of 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 percentage update rather than 

using the consumer price index for 

urban consumers (CPI–U) for medical 

care expenditures. 

8. 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 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). As 

with the NOE, the claims processing 

system must be notified of a 

beneficiary’s discharge from hospice or 

hospice benefit revocation within 5 


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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. 

In addition, the FY 2015 Hospice 

Wage Index and Rate Update final rule 

(79 FR 50496) provided background, 

described eligibility criteria, identified 

survey respondents, and otherwise 

implemented the Hospice Experience of 

Care Survey for informal caregivers. 

Hospice providers were required to 

begin using this survey for hospice 

patients 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 submit their 

aggregate cap determinations on a 

timely basis will have their payments 

suspended until the determination is 

completed and received by the Medicare 

contractor (79 FR 50503). 

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 

47142), CMS finalized two different 

payment rates for RHC: A higher per 

diem base payment rate for the first 60 

days of hospice care and a reduced per 

diem base payment rate for subsequent 

days of hospice care. CMS also finalized 

a service intensity add-on (SIA) 

payment payable for certain services 

during the last 7 days of the 

beneficiary’s life. A service intensity 

add-on payment will be made for the 

social worker (SW) visits and nursing 

visits provided by a registered nurse 

(RN), when provided during routine 

home care in the last 7 days of life. The 

SIA payment is in addition to the 

routine home care rate. The SIA 

payment is provided for visits of a 

minimum of 15 minutes and a 

maximum of 4 hours per day (80 FR 

47172). 

In addition to the hospice payment 

reform changes discussed, the FY 2016 

Hospice Wage Index and Rate Update 

final rule 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 would be 

updated by the hospice payment update 

percentage rather than using the CPI–U 

(80 FR 47186). In addition, we finalized 

a provision to align the cap accounting 

year for both the inpatient cap and the 

hospice aggregate cap with the FY for 

FY 2017 and thereafter. Finally, the FY 

2016 Hospice Wage Index and Rate 

Update final rule (80 FR 47144) clarified 

that hospices would have to report all 

diagnoses 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), CMS finalized several new 

policies and requirements related to the 

HQRP. First, CMS codified the 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, CMS would continue to utilize 

the measure in its new endorsed status, 

without going through new notice-andcomment rulemaking. CMS would 

continue to use rulemaking to adopt 

substantive updates made by the NQF to 

the endorsed measures adopted for the 

HQRP; determinations about what 

constitutes a substantive versus nonsubstantive 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: (1) 

Hospice Visits when Death is Imminent 

Measure Pair; and (2) Hospice and 

Palliative Care Composite Process 

Measure-Comprehensive Assessment at 

Admission (81 FR 52173). The data 

collection mechanism for both of these 

measures is the Hospice Item Set (HIS), 

and the measures were effective April 1, 

2017. Regarding the CAHPS® Hospice 

Survey, CMS 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 CAHPS®

requirements due to newness (81 FR 

52182). The exemption is determined by 

CMS and is only for 1 year. 

11. FY 2020 Hospice Wage Index and 

Payment Rate Update Final Rule 

In the FY 2020 Hospice Wage Index 

and Rate Update final rule (84 FR 

38484), we finalized rebased payment 

rates for CHC and GIP and set those 

rates equal to their average estimated FY 

2019 costs per day. We also rebased IRC 

per diem rates equal to the estimated FY 

2019 average costs per day, with a 

reduction of 5 percent to the FY 2019 

average cost per day to account for 

coinsurance. We finalized the FY 2020 

proposal to reduce the RHC payment 

rates by 2.72 percent to offset the 

increases to CHC, IRC, and GIP payment 

rates to implement this policy in a 

budget-neutral manner in accordance 

with section 1814(i)(6) of the Act (84 FR 

38496). 

In addition, we finalized a policy to 

use the current year’s pre-floor, prereclassified hospital inpatient wage 

index as the wage adjustment to the 

labor portion of the hospice rates. 

Finally, in the FY 2020 Hospice Wage 

Index and Rate Update final rule (84 FR 

38505), we finalized modifications to 

the hospice election statement content 

requirements at § 418.24(b), and added 

a requirement for hospices, upon 

request, to furnish an election statement 

addendum effective beginning in FY 

2021. The addendum must list items, 

services, and drugs the hospice has 

determined to be unrelated to the 

terminal illness and related conditions, 

to increase coverage transparency for 

beneficiaries under a hospice election. 

12. Consolidated Appropriations Act, 

2021 

Division CC, section 404 of the CAA 

2021 amended section 1814(i)(2)(B) of 

the Act and extended the provision that 

currently mandates the hospice cap be 

updated by the hospice payment update 

percentage (hospital market basket 

update reduced by the productivity 

adjustment) rather than the CPI–U for 

accounting years that end after 

September 30, 2016 and before October 

1, 2030. Prior to enactment of this 

provision, the hospice cap update was 

set to revert to the original methodology 

of updating the annual cap amount by 

the CPI–U beginning on October 1, 

2025. Division CC, section 407(b) of 

CAA 2021 revised section 

1814(i)(5)(A)(i) to increase the payment 

reduction for hospices who fail to meet 

hospice quality measure reporting 

requirements from 2 percentage points 

to 4 percentage points beginning with 

FY 2024. 

13. FY 2022 Hospice Wage Index and 

Payment Rate Update Final Rule 

In the FY 2022 Hospice Wage Index 

and Rate Update final rule (86 FR 42532 

through 42539), we finalized a policy to 

rebase and revise the labor shares for 

CHC, RHC, IRC and GIP using Medicare 

cost report (MCR) data for freestanding 

hospices (collected via CMS Form 

1984–14, OMB NO. 0938–0758) for 


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2018. We established separate labor 

shares for CHC, RHC, IRC, and GIP 

based on the calculated compensation 

cost weights for each level of care from 

the 2018 MCR data. The revised labor 

shares were implemented in a budget 

neutral manner through the use of labor 

share standardization factors. 

In the FY 2022 final rule, we removed 

the seven original Hospice Item Set 

(HIS) measures from the program 

because a more broadly applicable 

measure (across settings, populations, or 

conditions) for the particular topic is 

available and already publicly reported. 

The Hospice Comprehensive 

Assessment Measure, NQF #3235, is one 

measure that is calculated and rolled up 

by completion of the seven individual 

measures. This measure helps to ensure 

all hospice patients receive a holistic 

comprehensive assessment. Also, in or 

after May 2022, we will start publicly 

reporting the two new claims-based 

measures. Specifically, this includes 

the: (1) Hospice Visits in the Last Days 

of Life (HVLDL) (which replaces the HIS 

Hospice Visits when Death is Imminent 

measure pair); and (2) Hospice Care 

Index (HCI) that includes 10 indicators 

that collectively represent different 

aspects of hospice care and aim to 

convey a comprehensive 

characterization of the quality of care 

furnished by a hospice throughout the 

hospice stay. Related to these changes, 

we finalized reporting eight quarters of 

claims data in order to display small 

providers. We finalized the public 

reporting of Consumer Assessment of 

Healthcare Providers and Systems 

(CAHPS®) Hospice Survey Star ratings 

on Care Compare to begin no sooner 

than FY 2022. 

III. Provisions of the Proposed Rule 

A. Proposed FY 2023 Hospice Wage 

Index and Rate Update 

1. Proposed FY 2023 Hospice Wage 

Index 

The hospice wage index is used to 

adjust payment rates for hospices 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 the Office of Management and 

Budget (OMB) to the Metropolitan 

Statistical Areas (MSAs) definitions. 

In general, OMB issues major 

revisions to statistical areas every 10 

years, based on the results of the 

decennial census. However, OMB 

occasionally issues minor updates and 

revisions to statistical areas in the years 

between the decennial censuses. On 

March 6, 2020, OMB issued Bulletin No. 

20–01, which provided updates to and 

superseded OMB Bulletin No. 18–04 

that was issued on September 14, 2018. 

The attachments to OMB Bulletin No. 

20–01 provided detailed information on 

the update to statistical areas since 

September 14, 2018, and were based on 

the application of the 2010 Standards 

for Delineating Metropolitan and 

Micropolitan Statistical Areas to Census 

Bureau population estimates for July 1, 

2017 and July 1, 2018. (For a copy of 

this bulletin, we refer readers to the 

following website: https://

www.whitehouse.gov/wp-content/ 

uploads/2020/03/Bulletin-20-01.pdf.) In 

OMB Bulletin No. 20–01, OMB 

announced one new Micropolitan 

Statistical Area, one new component of 

an existing Combined Statistical Area 

(CSA), and changes to New England 

City and Town Area (NECTA) 

delineations. In the FY 2021 Hospice 

Wage Index final rule (85 FR 47070) we 

stated that if appropriate, we would 

propose any updates from OMB Bulletin 

No. 20–01 in future rulemaking. After 

reviewing OMB Bulletin No. 20–01, we 

determined that the changes in Bulletin 

20–01 encompassed delineation changes 

that would not affect the Medicare wage 

index for FY 2022. Specifically, the 

updates consisted of changes to NECTA 

delineations and the redesignation of a 

single rural county into a newly created 

Micropolitan Statistical Area. The 

Medicare wage index does not utilize 

NECTA definitions, and, as most 

recently discussed in the FY 2021 

Hospice Wage Index final rule (85 FR 

47070), we include hospitals located in 

Micropolitan Statistical areas in each 

state’s rural wage index. Therefore, in 

the FY 2022 Hospice Wage Index final 

rule (86 FR 42528) we adopted the 

updates set forth in OMB Bulletin No. 

20–01 consistent with our longstanding 

policy of adopting OMB delineation 

updates. 

In the FY 2020 Hospice Wage Index 

final rule (84 FR 38484), we finalized 

the proposal to use the current FY’s 

hospital wage index data to calculate 

the hospice wage index values. In the 

FY 2021 Hospice Wage Index final rule 

(85 FR 47070), we adopted the revised 

OMB delineations with a 5-percent cap 

on wage index decreases, where the 

estimated reduction in a geographic 

area’s wage index would be capped at 

5-percent in FY 2021 and no cap would 

be applied to wage index decreases for 

the second year (FY 2022). For FY 2023, 

the proposed hospice wage index would 

be based on the FY 2023 hospital prefloor, pre-reclassified wage index for 

hospital cost reporting periods 

beginning on or after October 1, 2018 

and before October 1, 2019 (FY 2019 

cost report data). The proposed FY 2023 

hospice wage index would not 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 proposed FY 

2023 hospice wage index would include 

a 5-percent cap on wage index decreases 

as discussed later in this section. The 

appropriate wage index value would be 

applied to the labor portion of the 

hospice 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 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 

2023, the only CBSA without a hospital 

from which hospital wage data can be 

derived is 25980, Hinesville-Fort 

Stewart, Georgia. The FY 2023 wage 

index value for Hinesville-Fort Stewart, 

Georgia is 0.8620. 

There exist some geographic areas 

where there were no hospitals, and thus, 

no hospital wage data on which to base 

the calculation of the hospice wage 

index. In the FY 2008 Hospice Wage 

Index final rule (72 FR 50217 through 

50218), we implemented a methodology 

to update the hospice wage index for 

rural areas without hospital wage data. 

In cases where there was a rural area 

without rural hospital wage data, 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 

of almost all of Puerto Rico’s various 


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urban areas to 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 2023, we 

propose to continue using the most 

recent pre-floor, pre-reclassified 

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. As previously discussed, the 

pre-floor, pre-reclassified hospital wage 

index values below 0.8 will be further 

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. 

The proposed hospice wage index 

applicable for FY 2023 (October 1, 2022 

through September 30, 2023) is 

available on the CMS website at: https:// 

www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/Hospice/HospiceWage-Index.html. 

2. Proposed Permanent Cap on Wage 

Index Decreases 

As discussed in section III.A.1, we 

have proposed and finalized temporary 

transition policies in the past to mitigate 

significant changes to payments due to 

changes to the hospice wage index. 

Specifically, in the FY 2016 Hospice 

Wage Index and Payment Rate Update 

final rule (80 FR 47142) we 

implemented a 50/50 blend for all 

geographic areas consisting of the wage 

index values using the then-current 

OMB area delineations and the wage 

index values using OMB’s new area 

delineations based on OMB Bulletin No. 

13–01. In the FY 2021 Hospice Wage 

Index final rule (85 FR 47070), we 

adopted the revised OMB delineations 

with a 5-percent cap on wage index 

decreases, where the estimated 

reduction in a geographic area’s wage 

index would be capped at 5-percent in 

FY 2021 and no cap would be applied 

to wage index decreases for the second 

year (FY 2022). As explained, we 

believed the 5-percent cap would 

provide greater transparency and be 

administratively less complex than the 

prior methodology of applying a 50/50 

blended wage index. We noted that this 

transition approach struck an 

appropriate balance by providing a 

transition period to mitigate the 

resulting -short-term instability and 

negative impacts on providers and time 

for them to adjust to their new labor 

market area delineations and wage 

index values. 

In the FY 2022 Hospice Wage Index 

and Payment Rate Update final rule (86 

FR 42541), a few commenters stated that 

providers should be protected against 

substantial payment reductions due to 

dramatic reductions in wage index 

values from one year to the next. 

Because we did not propose to modify 

the transition policy that was finalized 

in the FY 2021 Hospice final rule, we 

did not extend the transition period for 

FY 2022. In the FY 2022 Hospice final 

rule, we stated that we continued to 

believe that applying the 5-percent cap 

transition policy in year one provided 

an adequate safeguard against any 

significant payment reductions 

associated with the adoption of the 

revised CBSA delineations in FY 2021, 

allowed for sufficient time to make 

operational changes for future FYs, and 

provided a reasonable balance between 

mitigating some short-term instability in 

hospice payments and improving the 

accuracy of the payment adjustment for 

differences in area wage levels. 

However, we acknowledged that certain 

changes to wage index policy may 

significantly affect Medicare payments. 

In addition, we reiterated that our 

policy principles with regard to the 

wage index include generally using the 

most current data and information 

available and providing that data and 

information, as well as any approaches 

to addressing any significant effects on 

Medicare payments resulting from these 

potential scenarios, in notice and 

comment rulemaking. With these policy 

principles in mind, we considered for 

this FY 2023 Hospice proposed rule 

how best to address the potential 

scenarios, which commenters raised 

concerns; that is, scenarios in which 

changes to wage index policy may 

significantly affect Medicare payments. 

In the past, we have established 

transition policies of limited duration to 

phase in significant changes to labor 

market areas. In taking this approach in 

the past, we sought to mitigate short 

term instability and fluctuations that 

can negatively impact providers due to 

wage index changes. In accordance with 

the requirement of our regulations at 

§ 418.306(c) each labor market is 

established using the most current 

hospital wage data available, including 

any changes made by the OMB to the 

Metropolitan Statistical Areas (MSAs) 

definitions. We have previously stated 

that, because the wage index is a 

relative measure of the value of labor in 

prescribed labor market areas, we 

believe it is important to implement 

new labor market area delineations with 

as minimal a transition as is reasonably 

possible. However, we recognize that 

changes to the wage index have the 

potential to create instability and 

significant negative impacts on certain 

providers even when labor market areas 

do not change. In addition, year-to-year 

fluctuations in an area’s wage index can 

occur due to external factors beyond a 

provider’s control, such as the COVID– 

19 PHE, and for an individual provider, 

these fluctuations can be difficult to 

predict. We also recognize that 

predictability in Medicare payments is 

important to enable providers to budget 

and plan their operations. 

In light of these considerations, we 

are proposing a permanent approach to 

smooth year-to-year changes in 

providers’ wage indexes. We are 

proposing a policy that increases the 

predictability of hospice payments for 

providers, and mitigates instability and 

significant negative impacts to providers 

resulting from changes to the wage 

index. 

As previously discussed, we believed 

that applying a 5-percent cap on wage 

index decreases for FY 2021 provided 

greater transparency and was 

administratively less complex than prior 

transition methodologies. In addition, 

we believed this methodology mitigated 

short term instability and fluctuations 

that can negatively impact providers 

due to wage index changes. Lastly, we 

believed the 5-percent cap applied to all 

wage index decreases for FY 2021 

provided an adequate safeguard against 

significant payment reductions related 

to the adoption of the revised CBSAs. 

However, as discussed earlier in this 

section of the proposed rule, we 

recognize there are circumstances that a 

one-year mitigation policy, like the one 

adopted for FY 2021, would not 

effectively address future years in which 

providers continue to be negatively 

affected by significant wage index 

decreases. 

Typical year-to-year variation in the 

hospice wage index has historically 

been within 5-percent, and we expect 


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this will continue to be the case in 

future years. Therefore, we believe that 

applying a 5-percent cap on all wage 

index decreases in future years, 

regardless of the reason for the decrease, 

would effectively mitigate instability in 

hospice payments due to any significant 

wage index decreases that may affect 

providers in any year that commenters 

raised in the FY 2022 Hospice final rule. 

In addition, we believe that applying a 

5-percent cap on all wage index 

decreases would increase the 

predictability of hospice payments for 

providers, enabling them to more 

effectively budget and plan their 

operations. Lastly, we believe that 

applying a 5-percent cap on all wage 

index decreases, from the prior year, 

would have a small overall impact on 

the labor market area wage index 

system. As discussed in further detail in 

section III.A.4. of this proposed rule, we 

estimate that applying a 5-percent cap 

on all wage index decreases, from the 

prior year, will have a very small effect 

on the wage index budget 

standardization factors for FY 2023. 

Because the wage index is a measure of 

the value of labor (wage and wagerelated costs) in a prescribed labor 

market area relative to the national 

average, we anticipate that most 

providers will not experience year-toyear wage index declines greater than 5- 

percent in any given year. We believe 

that applying a 5-percent cap on all 

wage index decreases, from the prior 

year, would continue to maintain the 

accuracy of the overall labor market area 

wage index system. 

Therefore, for FY 2023 and 

subsequent years, we are proposing to 

apply a permanent 5-percent cap on any 

decrease to a geographic area’s wage 

index from its wage index in the prior 

year, regardless of the circumstances 

causing the decline. That is, we are 

proposing that a geographic area’s wage 

index for FY 2023 would not be less 

than 95 percent of its final wage index 

for FY 2022, regardless of whether the 

geographic area is part of an updated 

CBSA, and that for subsequent years, a 

geographic area’s wage index would not 

be less than 95 percent of its wage index 

calculated in the prior FY. We further 

propose that if a geographic area’s prior 

FY wage index is calculated based on 

the 5-percent cap, then the following 

year’s wage index would not be less 

than 95 percent of the geographic area’s 

capped wage index in the prior FY. For 

example, if a geographic area’s wage 

index for FY 2023 is calculated with the 

application of the 5-percent cap, then its 

wage index for FY 2024 would not be 

less than 95 percent of its capped wage 

index in FY 2023. Likewise, we are 

proposing to make the corresponding 

regulations text changes at § 418.306(c) 

as follows: Starting on October 1, 2022, 

CMS applies a cap on decreases to the 

hospice wage index such that the wage 

index applied to a geographic area is not 

less than 95 percent of the wage index 

applied to that geographic area in the 

prior FY. This 5-percent cap on negative 

wage index changes would be 

implemented in a budget neutral 

manner through the use of wage index 

standardization factors. Furthermore, 

the 5-percent cap would be applied after 

the application of the hospice wage 

index floor. Therefore, pre-floor, prereclassified hospital wage index values 

below 0.8 would be adjusted by the 15 

percent increase, subject to a maximum 

wage index value of 0.8. If there is a 5 

percent decrease from the previous FY’s 

wage index value after the application 

of the hospice wage index floor, then 

the 5-percent cap on wage index 

decreases would also be applied. 

In section III.A.4 of this proposed 

rule, we estimate the impact to 

payments for providers in FY 2023 

based on this proposed policy. We also 

note that we would examine the effects 

of this policy on an ongoing basis in the 

future in order to assess its 

appropriateness. 

3. Proposed FY 2023 Hospice Payment 

Update Percentage 

Section 4441(a) of the 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. In the 

FY 2022 IPPS final rule CMS finalized 

the proposal to rebase and revise the 

IPPS market baskets to reflect a 2018 

base year. We refer readers to the FY 

2022 IPPS final rule for further 

information (86 FR 45194 through 

45208). 

Section 3401(g) of the Affordable Care 

Act 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) as projected by the 

Secretary for the 10-year period ending 

with the applicable FY, year, cost 

reporting period, or other annual 

period) (the ‘‘productivity adjustment’’). 

The United States Department of Labor’s 

Bureau of Labor Statistics (BLS) 

publishes the official measures of 

productivity for the United States 

economy. We note that previously the 

productivity measure referenced in 

section 1886(b)(3)(B)(xi)(II) was 

published by BLS as private nonfarm 

business multifactor productivity. 

Beginning with the November 18, 2021 

release of productivity data, BLS 

replaced the term ‘‘multifactor 

productivity’’ with ‘‘total factor 

productivity’’ (TFP). BLS noted that this 

is a change in terminology only and will 

not affect the data or methodology. As 

a result of the BLS name change, the 

productivity measure referenced in 

section 1886(b)(3)(B)(xi)(II) of the Act is 

now published by BLS as ‘‘private 

nonfarm business total factor 

productivity’’. However, as mentioned, 

the data and methods are unchanged. 

We refer readers to http://www.bls.gov 

for the BLS historical published TFP 

data. A complete description of IGI’s 

TFP projection methodology is available 

on the CMS website at https://

www.cms.gov/Research-Statistics-Dataand-Systems/Statistics-Trends-andReports/MedicareProgramRatesStats/ 

MarketBasketResearch. In addition, in 

the FY 2022 IPPS final rule (86 FR 

45214), we noted that beginning with 

FY 2022, CMS changed the name of this 

adjustment to refer to it as the 

‘‘productivity adjustment’’ rather than 

the ‘‘MFP adjustment’’. 

The proposed hospice payment 

update percentage for FY 2023 is based 

on the proposed inpatient hospital 

market basket update of 3.1 percent 

(based on IHS Global Inc.’s fourth 

quarter 2021 forecast with historical 

data through the third quarter 2021). 

Due to the requirements at sections 

1886(b)(3)(B)(xi)(II) and 1814(i)(1)(C)(v) 

of the Act, the proposed inpatient 

hospital market basket update for FY 

2023 of 3.1 percent must be reduced by 

a productivity adjustment as mandated 

by the Affordable Care Act (currently 

estimated to be 0.4 percentage point for 

FY 2023). In effect, the proposed 

hospice payment update percentage for 

FY 2023 would be 2.7 percent. We also 

propose that if more recent data become 

available after the publication of this 

proposed rule and before the 

publication of the final rule (for 


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example, more recent estimates of the 

inpatient hospital market basket update 

and productivity adjustment), we would 

use such data, if appropriate, to 

determine the hospice payment update 

percentage for FY 2023 in the final rule. 

We continue to believe it is appropriate 

to routinely update the hospice payment 

system so that it reflects the best 

available data about differences in 

patient resource use and costs among 

hospices as required by the statute. 

Therefore, we are proposing to: (1) 

Update hospice payments using the 

methodology outlined and apply the 

2018-based IPPS market basket update 

for FY 2023 of 3.1 percent, reduced by 

the statutorily required productivity 

adjustment of 0.4 percentage point along 

with the wage index budget neutrality 

adjustment to update the payment rates; 

and (2) use the FY 2023 hospice wage 

index which uses the FY 2023 pre-floor, 

pre-reclassified IPPS hospital wage 

index as its basis. 

In the FY 2022 Hospice Wage Index 

final rule (86 FR 42532 through 42539), 

we rebased and revised the labor shares 

for RHC, CHC, GIP and IRC using MCR 

data for freestanding hospices (CMS 

Form 1984–14, OMB Control Number 

0938–0758) from 2018. The current 

labor portion of the payment rates are: 

For RHC, 66.0 percent; for CHC, 75.2 

percent; for GIP, 63.5 percent; and for 

IRC, 61.0 percent. The non-labor portion 

is equal to 100 percent minus the labor 

portion for each level of care. The nonlabor portion of the payment rates are as 

follows: For RHC, 34.0 percent; for CHC, 

24.8 percent; for GIP, 36.5 percent; and 

for IRC, 39.0 percent. 

4. Proposed FY 2023 Hospice Payment 

Rates 

There are four payment categories that 

are distinguished by the location and 

intensity of the hospice 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 

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 an SIA payment for RHC 

when direct patient care is provided by 

an 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 service intensity add-on 

budget neutrality factor (SBNF). The 

SBNF is used to reduce the overall RHC 

rate in order to ensure that SIA 

payments are budget-neutral. At the 

beginning of every FY, SIA utilization is 

compared to the prior year in order 

calculate a budget neutrality 

adjustment. 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. 

Typically, the wage index 

standardization factor is calculated 

using the most recent, complete hospice 

claims data available. However, due to 

the COVID–19 PHE, in the FY 2022 

Hospice Wage Index and Payment Rate 

Update proposed rule we looked at 

using hospice claims data before the 

declaration of the COVID–19 PHE (FY 

2019) to determine if there were 

significant differences between utilizing 

2019 and 2020 claims data. The 

difference between using FY 2019 and 

FY 2020 hospice claims data was 

minimal. Therefore, in the FY 2022 

Hospice Wage Index and Payment Rate 

Update final rule (86 FR 42543), we 

stated that we would continue our 

practice of using the most recent, 

complete hospice claims data available. 

For FY 2023 hospice rate setting, we 

saw minimal differences in using the 

updated data; therefore, we are 

continuing our longstanding policy of 

using the most recent data available. 

Specifically, we are using FY 2021 

claims data with the FY 2023 payment 

rate updates. In order to calculate the 

wage index standardization factor, we 

simulate total payments using FY 2021 

hospice utilization claims data with the 

FY 2022 wage index (pre-floor, prereclassified hospital wage index with 

the hospice floor, without the 5-percent 

cap on wage index decreases) and FY 

2022 payment rates and compare it to 

our simulation of total payments using 

the FY 2023 hospice wage index (prefloor, pre-reclassified hospital wage 

index with hospice floor, with the 5- 

percent cap on wage index decreases) 

and FY 2022 payment rates. By dividing 

payments for each level of care (RHC 

days 1 through 60, RHC days 61+, CHC, 

IRC, and GIP) using the FY 2022 wage 

index and payment rates for each level 

of care by the FY 2023 wage index and 

FY 2022 payment rates, we obtain a 

wage index standardization factor for 

each level of care. The wage index 

standardization factors for each level of 

care are shown in the Tables 1 and 2. 

The proposed FY 2023 RHC rates are 

shown in Table 1. The proposed FY 

2023 payment rates for CHC, IRC, and 

GIP are shown in Table 2. 

TABLE 1—PROPOSED FY 2023 HOSPICE RHC PAYMENT RATES

Code Description 

FY 2022 

payment 

rates 

SIA budget 

neutrality 

factor 

Wage index 

standardization 

factor 

Proposed FY 

2023 hospice 

payment 

update 

Proposed FY 

2023 payment 

rates 

651 ............ Routine Home Care (days 1–60) ............ $203.40 1.0004 1.0008 1.027 $209.14 

651 ............ Routine Home Care (days 61+) ............. 160.74 1.0003 1.0007 1.027 165.25 


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TABLE 2—PROPOSED FY 2023 HOSPICE CHC, IRC, AND GIP PAYMENT RATES

Code Description FY 2022 payment rates 

Wage index 

standardization 

factor 

Proposed FY 

2023 hospice 

payment 

update 

Proposed FY 

2023 payment 

rates 

652 ............ Continuous Home Care Full Rate = 

24 hours of care.

$1,462.52 ($60.94 per hour) ............ 1.0024 1.027 $1,505.61 

655 ............ Inpatient Respite Care ..................... 473.75 .............................................. 1.0007 1.027 486.88 

656 ............ General Inpatient Care .................... 1,068.28 ........................................... 1.0016 1.027 1,098.88 

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 and Rate 

Update final rule (76 FR 47320 through 

47324), we implemented a HQRP as 

required by those sections. Hospices 

were required to begin collecting quality 

data in October 2012 and submit those 

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 proposed FY 2023 rates for 

hospices that do not submit the required 

quality data would be updated by the 

proposed FY 2023 hospice payment 

update percentage of 2.7 percent minus 

2 percentage points. These rates are 

shown in Tables 3 and 4. 

TABLE 3—PROPOSED FY 2023 HOSPICE RHC PAYMENT RATES FOR HOSPICES THAT DO NOT SUBMIT THE REQUIRED

QUALITY DATA

Code Description FY 2022 

payment rates 

SIA budget 

neutrality 

factor 

Wage index 

standardization 

factor 

Proposed FY 

2023 hospice 

payment 

update of 

2.7% minus 2 

percentage 

points = 

+0.7% 

Proposed FY 

2023 payment 

rates 

651 ............ Routine Home Care (days 1–60) ............ $203.40 1.0004 1.0008 1.007 $205.07 

651 ............ Routine Home Care (days 61+) ............. 160.74 1.0003 1.0007 1.007 162.03 

TABLE 4—PROPOSED FY 2023 HOSPICE CHC, IRC, AND GIP PAYMENT RATES FOR HOSPICES THAT DO NOT SUBMIT

THE REQUIRED QUALITY DATA

Code Description FY 2022 payment rates 

Wage index 

standardization 

factor 

Proposed FY 

2023 hospice 

payment 

update of 

2.7% minus 2 

percentage 

points = 

+0.7% 

Proposed FY 

2023 payment 

rates 

652 ............ Continuous Home Care ...................

Full Rate= 24 hours of care ............

$1,462.52 ($60.94 per hour) ............ 1.0024 1.007 $1,476.29 

655 ............ Inpatient Respite Care ..................... $473.75 ............................................ 1.0007 1.007 $477.40 

656 ............ General Inpatient Care .................... 1,068.28 ........................................... 1.0016 1.007 1,077.48 

5. Proposed Hospice Cap Amount for FY 

2023 

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, we 

stated that 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 CPI–U. 

Division CC, section 404 of the CAA 

2021 extended the accounting years 

impacted by the adjustment made to the 

hospice cap calculation until 2030. In 

the FY 2022 Hospice Wage Index final 

rule (86 FR 42539), we finalized 

conforming regulations text changes at 

§ 418.309 to reflect the provisions of the 

CAA 2021. Therefore, for accounting 

years that end after September 30, 2016 

and before October 1, 2030, the hospice 

cap amount is updated by the hospice 

payment update percentage rather than 

using the CPI–U. 

The proposed hospice cap amount for 

the FY 2023 cap year is $32,142.65, 

which is equal to the FY 2022 cap 

amount ($31,297.61) updated by the 

proposed FY 2023 hospice payment 

update percentage of 2.7 percent. 

B. Proposed Updates to the Hospice 

Quality Reporting Program 

1. Background and Statutory Authority 

The Hospice Quality Reporting 

Program (HQRP) specifies reporting 

requirements for the Hospice Item Set 

(HIS), administrative data, and 

Consumer Assessment of Healthcare 

Providers and Systems (CAHPS®) 

Hospice Survey. Section 1814(i)(5) of 

the Act requires the Secretary to 

establish and maintain a quality 


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3Exceptions and Extensions for Quality Reporting 

Requirements for Acute Care Hospitals, PPSExempt Cancer Hospitals, Inpatient Psychiatric 

Facilities, Skilled Nursing Facilities, Home Health 

Agencies, Hospices, Inpatient Rehabilitation 

Facilities, Long-Term Care Hospitals, Ambulatory 

Surgical Centers, Renal Dialysis Facilities, and 

MIPS Eligible Clinicians Affected by COVID–19. 

Available at: https://www.cms.gov/files/document/ 

guidance-memo-exceptions-and-extensions-qualityreporting-and-value-based-purchasingprograms.pdf 

reporting program for hospices. Section 

1814(i)(5)(A)(i) of the Act was amended 

by section 407(b) of Division CC, Title 

IV of the CAA 2021 (Pub. L. 116–260) 

to change the payment reduction for 

failing to meet hospice quality reporting 

requirements from 2 to 4 percentage 

points. This policy will apply beginning 

with FY 2024 annual payment update 

(APU) that is based on CY 2022 quality 

data. Specifically, the Act requires that, 

beginning with FY 2014 through FY 

2023, the Secretary shall reduce the 

market basket update by 2 percentage 

points and beginning with the FY 2024 

APU and for each subsequent year, the 

Secretary shall reduce the market basket 

update by 4 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 

through FY 2023 or 4 percentage points 

beginning in FY 2024 could result in the 

annual market basket update being less 

than zero 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 specified 

year. 

In the FY 2022 Hospice Wage Index 

and Payment Rate Update final rule (86 

FR 42552), we finalized two new 

measures using claims data: (1) Hospice 

Visits in the Last Days of Life (HVLDL); 

and (2) Hospice Care Index (HCI). We 

also finalized a policy that claims-based 

measures will use 8 quarters of data in 

order to report on more hospices. In 

addition, we removed the seven Hospice 

Item Set (HIS) Process Measures from 

the program as individual measures and 

public reporting because the HIS 

Comprehensive Assessment Measure 

(NQF#3235) is sufficient for measuring 

care at admission without the seven 

individual process measures. For a 

detailed discussion of the historical use 

for measure selection and removal for 

the HQRP quality measures, we refer 

readers to the FY 2016 Hospice Wage 

Index and Rate Update final rule (80 FR 

47142) and the FY 2019 Hospice Wage 

Index and Rate Update final rule (83 FR 

38622). In the FY 2022 Hospice Wage 

Index and Rate Update final rule (86 FR 

42553), we finalized § 418.312(b)(2); this 

new provision requires hospices to 

provide administrative data, including 

claims-based measures, as part of the 

HQRP requirements for § 418.306(b). In 

that same final rule, we provided 

CAHPS Hospice Survey updates. We 

finalized temporary changes to our 

public reporting policies based on the 

March 27, 2020 memorandum 3 and 

provided another tip sheet, referred to 

as the Second Edition HRQP Public 

Reporting Tip Sheet (https://

www.cms.gov/files/document/secondedition-hqrp-public-reporting-tipsheetpdf.pdf) on the HQRP 

Requirements and Best Practices web 

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

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

HQRP-Requirements-and-BestPractices). 

As finalized in the FY 2022 Hospice 

Wage Index and Payment Rate Update 

final rule (86 FR 42552), CMS is 

targeting the May 2022 refresh of Care 

Compare/Provider Data Catalogue (PDC) 

for the inaugural display of the two new 

claims-based quality measures (QMs), 

the Hospice Visits in Last Days of Life 

(HVLDL) and the Hospice Care Index 

(HCI). This rule proposes no new 

quality measures but proposes updates 

on already-adopted measures. Table 5 

shows all quality measures finalized in 

the FY 2022 Hospice Wage Index and 

Payment Rate Update final rule and in 

effect for the FY 2023 HQRP. 

TABLE 5—QUALITY MEASURES FINALIZED IN THE FY 2022 HOSPICE WAGE INDEX FINAL RULE AND IN EFFECT FOR FY 

2023 FOR THE HOSPICE QUALITY REPORTING PROGRAM

Hospice quality reporting program 

NQF# Hospice item set 

3235 ........................................... Hospice and Palliative Care Composite Process Measure—HIS-Comprehensive Assessment Measure at Admission includes: 

1. Patients Treated with an Opioid who are Given a Bowel Regimen (NQF #1617). 

2. Pain Screening. 

3. Pain Assessment. 

4. Dyspnea Treatment. 

5. Dyspnea Screening. 

6. Treatment Preferences. 

7. Beliefs/Values Addressed (if desired by the patient). 

Administrative Data, including Claims-based Measures 

3645 Hospice Visits in Last Days of Life (HVLDL). 

Pending NQF endorsement ....... Hospice Care Index (HCI). 


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TABLE 5—QUALITY MEASURES FINALIZED IN THE FY 2022 HOSPICE WAGE INDEX FINAL RULE AND IN EFFECT FOR FY 

2023 FOR THE HOSPICE QUALITY REPORTING PROGRAM—Continued 

Hospice quality reporting program 

NQF# Hospice item set 

1. Continuous Home Care (CHC) or General Inpatient (GIP) Provided. 

2. Gaps in Skilled Nursing Visits. 

3. Early Live Discharges. 

4. Late Live Discharges. 

5. Burdensome Transitions (Type 1)—Live Discharges from Hospice Followed by Hospitalization and 

Subsequent Hospice Readmission. 

6. Burdensome Transitions (Type 2)—Live Discharges from Hospice Followed by Hospitalization with the 

Patient Dying in the Hospital. 

7. Per-beneficiary Medicare Spending. 

8. Skilled Nursing Care Minutes per Routine Home Care (RHC) Day. 

9. Skilled Nursing Minutes on Weekends 

10. Visits Near Death. 

CAHPS Hospice Survey 

2651 ........................................... CAHPS Hospice Survey. 

1. Communication with Family. 

2. Getting timely help. 

3. Treating patient with respect. 

4. Emotional and spiritual support. 

5. Help for pain and symptoms. 

6. Training family to care for the patient. 

7. Rating of this hospice. 

8. Willing to recommend this hospice. 

2. Hospice Outcomes & Patient 

Evaluation (HOPE) Update 

As finalized in the FY 2020 Hospice 

Wage Index and Payment Rate Update 

and Hospice Quality Reporting 

Requirements final rule (84 FR 38484), 

we are developing a hospice patient 

assessment instrument identified as 

HOPE. HOPE contributes to the patient’s 

plan of care through on-going patient 

assessments throughout the hospice 

stay. HOPE is designed to support the 

hospice conditions of participation 

(CoPs), including hospices’ quality 

assessment and performance 

improvement (QAPI) and provide 

quality data to calculate outcome and 

other types of quality measures. Our 

primary objectives for HOPE are to 

provide quality data for the HQRP 

requirements through standardized data 

collection; support survey and 

certification processes; and provide 

additional clinical data that could 

inform future payment refinements. 

HOPE is an on-going patient 

assessment instrument designed to 

capture patient and family care needs 

throughout the hospice stay. HOPE 

supports care planning, quality 

improvement efforts, and health and 

safety of patients enrolled in Medicarecertified hospices. HOPE will include 

key items from the HIS and 

demographics like gender and race. 

Some HIS items will be modified for 

inclusion in HOPE to increase 

specificity. This approach to include 

key demographic information reflects 

stakeholder feedback discussed in the 

FYs 2017 and 2018 Hospice Wage Index 

and Payment Rate Update final rules (81 

FR 52171 and 82 FR 36669, 

respectively). 

HOPE is multidisciplinary, with the 

assessment instrument to be completed 

by nursing, social work, and spiritual 

care staff. We are undergoing testing 

with three distinct disciplinary 

assessments in beta field testing 

described in this section. We stated in 

the FY 2022 Hospice Wage Index and 

Payment Update final rule (86 FR 

42528) that while the standardized 

patient assessment data elements for 

certain post-acute care providers 

required under the IMPACT Act of 2014 

are not applicable to hospices, it is 

reasonable to include some of those 

standardized elements that 

appropriately and feasibly apply to 

hospice. Some patients may move 

through the healthcare system to 

hospice. Therefore, tracking key 

demographic and social risk factor items 

that apply to hospice support our goals 

for continuity of care, overall patient 

care and well-being, interoperability, 

and health equity that is also discussed 

in this rule. 

The draft of HOPE has undergone 

cognitive, pilot, and alpha testing, and 

is undergoing national beta field testing 

to establish reliability, validity, and 

feasibility of the assessment instrument. 

The purpose of the alpha test was to 

establish preliminary reliability and 

validity of the draft assessment items, 

and feasibility of the HOPE assessment. 

Specifically, the objectives were to: 

• Establish inter-rater reliability (IRR) 

of the assessment items. 

• Demonstrate validity of the 

assessment items. 

• Demonstrate feasibility of the 

assessment and time points for data 

collection. 

HOPE alpha testing completed at the 

end of January 2021. Based on the 

quantitative data analyses and feedback 

from assessors in alpha testing, the 

items generally support the feasibility of 

collecting the data items. Alpha testing 

also showed that HOPE exhibited 

acceptable inter-rater reliability ranging 

from moderate to very good with few 

exceptions and demonstrated evidence 

of convergent validity. We used findings 

of the alpha test to inform decisions 

about the next draft of the HOPE 

assessment, which are being tested in 

the national beta test that began in late 

fall 2021 and continuing through 2022. 

National beta testing allows us to 

obtain input from participating hospice 

teams about the assessment instrument 

and field testing to refine and support 

the final draft items and assessment 

time points for HOPE. It also allows us 

to estimate the time to complete the 

HOPE data items. We anticipate 

proposing HOPE in future rulemaking 

after testing and analyses are complete. 


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We continue HOPE development in 

accordance with the Blueprint for the 

CMS Measures Management System. 

HOPE development is grounded in 

information gathering activities to 

identify and refine hospice assessment 

domains and candidate assessment 

items. We appreciate the industry’s and 

national associations’ engagement in 

providing input through information 

sharing activities, including listening 

sessions, expert interviews, key 

stakeholder interviews, and focus 

groups to support HOPE development. 

As CMS proceeds with field testing 

HOPE, we will continue to engage with 

stakeholders through sub-regulatory 

channels. In particular, we will 

continue to host HQRP Forums to allow 

hospices and other interested parties to 

engage with us on the latest updates and 

ask questions on the development of 

HOPE and related quality measures. We 

also have a dedicated email account, 

HospiceAssessment@cms.hhs.gov, for 

comments about HOPE. 

We will use field test results to create 

a final version of HOPE to propose in 

future rulemaking for national 

implementation. We will continue to 

engage all stakeholders throughout this 

process that includes a variety of subregulatory channels and regular HQRP 

communication strategies, such as Open 

Door Forums, Medicare Learning 

Network (MLN), CMS.gov website 

announcements, listserv messaging, and 

other ad hoc publicly announced 

opportunities. We appreciate the 

support for HOPE and reiterate our 

commitment to providing updates and 

engaging stakeholders through subregulatory means. HOPE updates can be 

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

Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/HOPE and 

engagement opportunities, including 

those regarding HOPE are at: https://

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

Hospice-QRP-Provider-EngagementOpportunities. 

3. Update on Future Quality Measure 

(QM) Development 

In the FY 2020 Hospice Wage Index 

and Payment Rate Update final rule (84 

FR 38484), we provided updates related 

to CMS’s process for identifying high 

priority areas of quality measurement 

and improvement and for developing 

quality measures that address those 

priorities. Information on the current 

HQRP quality measures can be found at: 

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

Current-Measures. In this proposed rule, 

we provide contemplated updates for 

hospice quality measure concepts based 

on future use of HOPE and 

administrative data. In section III.B.6 of 

this proposed rule, we are seeking 

public comment from hospices on their 

health equity initiatives and a structural 

composite measure concept to inform 

future measure development. 

To support new measure 

development, our contractor convened 

two technical expert panel (TEP) 

meetings in 2021. The TEP considered 

HOPE-based process measures that may 

be proposed with HOPE in future 

rulemaking. The TEP meetings in 2021 

included HOPE-based process measures 

intended to (1) evaluate the rate at 

which hospices’ use specific processes 

of care; (2) assist in reducing variation 

in care delivery; and (3) determine 

hospices’ compliance with practices 

that are expected to improve outcomes. 

The TEP also considered potential areas 

for future quality measure development. 

We refer the public to the ‘‘2021 

Technical Expert Panel Meetings: 

Hospice Quality Reporting Program 

Summary Report’’ available at: https://

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

Hospice-QRP-Provider-EngagementOpportunities. 

As stated in the FY 2022 Hospice 

Wage Index and Rate Update final rule 

(86 FR 42528), we continue to consider 

developing hybrid quality measures that 

could be calculated from multiple data 

sources: for example, claims, 

assessments (HOPE), or other data 

sources. Hybrid quality measures allow 

for a more comprehensive set of 

information about care processes and 

outcomes than can be calculated using 

claims data alone. As described in the 

‘‘2021 Technical Expert Panel Meetings: 

Hospice Quality Reporting Program 

Summary Report,’’ the TEP discussed 

hybrid concepts such as hospitalizations 

during a hospice election and patterns 

of live discharge using claims data and 

HOPE data elements. 

4. Updates to the CAHPS Hospice 

Survey Participation Requirements for 

the FY 2023 APU and Subsequent Years 

a. Background and Description of the 

CAHPS Hospice Survey 

The CAHPS Hospice Survey is a 

component of the CMS HQRP, which 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 about the development of 

the survey, originally called the Hospice 

Experience of Care Survey, may refer to 

79 FR 50452 and 78 FR 48261. 

b. Overview of the ‘‘CAHPS Hospice 

Survey Measures’’ 

The CAHPS Hospice Survey measures 

were re-endorsed by NQF on November 

20, 2020. The re-endorsement can be 

found on the NQF website at: https://

www.qualityforum.org/Measures_

Reports_Tools.aspx. The survey 

received its initial NQF endorsement on 

October 26, 2016 (NQF #2651). We 

adopted 8 survey-based measures for the 

CY 2018 data collection period and for 

subsequent years. These eight measures 

are publicly reported on a designated 

CMS website, Care Compare, https://

www.medicare.gov/care-compare/. 

c. CAHPS Hospice Survey Mode 

Experiment 

CMS recently conducted a mode 

experiment with the goal of testing the 

effects of adding a web-based mode to 

the CAHPS Hospice Survey. We are 

examining the impact of a web-based 

mode on survey response rates and 

scores. The survey currently has three 

approved modes without any web 

component (mail, telephone, and mail 

with telephone follow-up.). In addition, 

the test will allow for examination of 

the effects of a shortened survey (that is, 

removing existing survey items) on 

response rate and scores; assessment of 

the measure properties of a limited 

number of supplemental survey items 

suggested by stakeholders; and 

calculation of item-level mode 

adjustments for the shortened survey in 

the currently-approved modes of 

CAHPS Hospice Survey administration, 

as well as the proposed new web-based 

mode. 

The mode experiment design applied 

all of the existing CAHPS Hospice 

Survey eligibility criteria, and sampled 

patients/caregivers across five arms. The 

first arm tested a new web-mail mode, 

in which invitations to the web survey 

were sent by email to those with email 

addresses. The email was personalized 

to the respondent and included a link to 

the web version of the survey, which 

can be completed on either a computer 

or a mobile device such as a smartphone 

or tablet. If the respondent did not 

complete the web survey after one week, 

or did not have a valid email address in 

which to send an email, up to two 

surveys were sent by mail. This arm 

used a shortened version of the CAHPS 

Hospice Survey. 

In the next three arms, the shortened 

version of the CAHPS Hospice Survey 

instrument was administered in the 

three currently-approved modes: Mail 

only; telephone-only; and mixed mode 


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(mail with telephone follow up). The 

fifth arm, in which the current survey 

instrument was administered via mail 

only served as a comparison for all other 

arms. Across all arms, half of sampled 

caregivers received a pre-notification 

letter to examine the effects of such a 

letter on response rates. 

Overall (across the five arms), CMS 

sampled 15,000 eligible caregivers from 

around 50 hospices over a six- to sevenmonth period. Caregivers were 

randomized within each hospice to one 

of the five arms. 

We continue to analyze the results of 

the mode experiment and will keep 

stakeholders informed on any plans for 

changes to the survey content or 

administration options through our 

regular stakeholder communication 

channels. In this proposed rule, there 

are no changes to the administration 

procedures or content for the CAHPS 

Hospice Survey. Any changes to the 

CAHPS Hospice Survey will be 

proposed in future rulemaking. 

d. Data Sources 

In the FY 2020 Hospice Wage Index 

and Rate Update final rule (84 FR 

38484), we finalized the participation 

requirements for the CAHPS Hospice 

Survey. To meet the CAHPS Hospice 

Survey requirements for the HQRP, 

hospice facilities must contract with a 

CMS-approved 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. 

e. 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. 

Before the COVID–19 PHE, we reported 

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. As 

finalized in the FY 2022 Hospice Wage 

Index and Payment Rule Update (86 FR 

42528), we are not reporting Q1 2020 

and Q2 2020 data due to the COVID–19 

PHE. Therefore, we have publicly 

reported the most recently available 8 

quarters of CAHPS data that excluded 

Q1 2020 and Q2 2020 data. These data 

were publicly reported starting with the 

February 2022 refresh and will continue 

through the May 2023 refresh on Care 

Compare. The Second Edition HQRP 

Public Reporting Tip Sheet dated Dec. 

2021 on the HQRP Requirements and 

Best Practices web page (https://

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

HQRP-Requirements-and-Best-Practices) 

summarizes CMS’ approach to the 

HQRP as public reporting has resumed 

in February 2022. It also explains the 

HQRP public reporting changes 

associated with the FY 2022 Hospice 

Wage Index and Payment Rule Update 

final rule and provides a summary of 

the data refreshes. 

f. Volume-Based Exemption for CAHPS 

Hospice Survey Data Collection and 

Reporting Requirements 

In the FY 2020 Hospice Wage Index 

and Rate Update final rule (84 FR 

38526), we finalized a policy making a 

volume-based exemption for CAHPS 

Hospice Survey Data Collection and 

Reporting requirements for FY 2021 and 

every year thereafter. 

In this proposed rule, there would be 

no changes to this exemption. The 

exemption request form is available on 

the official CAHPS Hospice Survey 

website: http://www.hospiceCAHP

Ssurvey.org. Hospices that intend to 

claim the size exemption are required to 

submit to CMS their completed 

exemption request form by December 

31, of the data collection year. 

Hospices that served a total of fewer 

than 50 survey-eligible decedent/ 

caregiver pairs in the year before the 

data collection year are eligible to apply 

for the size exemption. Hospices may 

apply for a size exemption by 

submitting the size exemption request 

form. The size exemption is only valid 

for the year on the size exemption 

request form. If the hospice remains 

eligible for the size exemption, the 

hospice must complete the size 

exemption request form for every 

applicable FY APU period, as shown in 

Table 6. 

TABLE 6—SIZE EXEMPTION KEY DATES FY 2023 THROUGH FY 2026 

Fiscal year Data collection year Reference year Size exemption form submission 

deadline 

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

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

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

FY 2026 ......................................... CY 2024 ........................................ CY 2023 ........................................ December 31, 2024. 

g. Newness Exemption for CAHPS 

Hospice Survey Data Collection and 

Public Reporting Requirements 

We previously finalized a one-time 

newness exemption for hospices that 

meet the criteria as stated in the FY 

2017 Hospice Wage Index and Payment 

Rate Update final rule (81 FR 52181). In 

the FY 2019 Hospice Wage Index and 

Payment Rate Update final rule (83 FR 

38642), we continued the newness 

exemption for FY 2023, and all 

subsequent years. We encourage 

hospices to keep the letter they receive 

providing them with their CMS 

Certification Number (CCN). The letter 

can be used to show when you received 

your number. 

h. Survey Participation Requirements 

We previously finalized survey 

participation requirements for FY 2022 

through FY 2025 as stated in the FY 

2018 and FY 2019 Hospice Wage Index 

and Payment Rate Update final rules (82 

FR 36670 and 83 FR 38642 through 

38643). We also continued those 

requirements in all subsequent years (84 

FR 38526). Table 7 restates the data 

submission dates for FY 2023 through 

FY 2025. 

TABLE 7—CAHPS HOSPICE SURVEY DATA SUBMISSION DATES FOR THE APU IN FY 2023, FY 2024, AND FY 2025 

Sample months (month of death) * CAHPS quarterly data submission 

deadlines ** 

FY 2023 APU 


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TABLE 7—CAHPS HOSPICE SURVEY DATA SUBMISSION DATES FOR THE APU IN FY 2023, FY 2024, AND FY 2025— 

Continued 

Sample months (month of death) * CAHPS quarterly data submission 

deadlines ** 

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

CY April–June 2021 (Quarter 2) ............................................................................................................ November 10, 2021. 

CY July–September 2021 (Quarter 3) ................................................................................................... February 9, 2022. 

CY October–December 2021 (Quarter 4) ............................................................................................. May 11, 2022. 

FY 2024 APU 

CY January–March 2022 (Quarter 1) .................................................................................................... August 10, 2022. 

CY April–June 2022 (Quarter 2) ............................................................................................................ November 9, 2022. 

CY July–September 2022 (Quarter 3) ................................................................................................... February 8, 2023. 

CY October–December 2022 (Quarter 4) ............................................................................................. May 10, 2023. 

FY 2025 APU 

CY January–March 2023 (Quarter 1) .................................................................................................... August 9, 2023. 

CY April–June 2023 (Quarter 2) ............................................................................................................ November 8, 2023. 

CY July–September 2023 (Quarter 3) ................................................................................................... February 14, 2024. 

CY October–December 2023 (Quarter 4) ............................................................................................. May 8, 2024. 

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

January). 

** Data submission deadlines are the second Wednesday of the submission months, which are the months August, November, February, and 

May. 

For further information about the 

CAHPS Hospice Survey, we encourage 

hospices and other entities to visit: 

https://www.hospiceCAHPSsurvey.org. 

For direct questions, contact the CAHPS 

Hospice Survey Team at 

hospiceCAHPSsurvey@HCQIS.org or 

call 1–(844) 472–4621. 

i. CAHPS Hospice Survey Star Ratings 

We previously finalized a policy 

requiring us to display Hospice CAHPS 

Survey Star Ratings no sooner than FY 

2022 as stated in the FY 2022 Hospice 

Wage Index and Payment Rule Update 

rule (86 FR 42528). Star Ratings will be 

publicly reported on Care Compare on 

Medicare.gov beginning with the August 

2022 refresh. This start date allowed 

CMS to conduct a dry run of the Star 

Ratings with reporting to hospices via 

preview reports. Hospices first saw their 

Star Ratings in their preview reports 

during the November 2021 and March 

2022 preview periods for the February 

2022 and May 2022 updates of Care 

Compare on Medicare.gov. However, the 

CAHPS Hospice Survey Star Ratings 

will not be publicly reported in 

February or May 2022. The reporting 

period for the dry run covers data from 

Q4 2018 through Q4 2019 and Q3 2020 

through Q1 2021. Detailed information 

about the calculation and display of 

Hospice CAHPS Survey Star Ratings can 

be found on the official CAHPS Hospice 

Survey website: http://www.hospice

CAHPSsurvey.org. There are no changes 

to the Hospice CAHPS Survey Star 

Ratings for FY 2023. 

5. Form, Manner, and Timing of Quality 

Data Submission 

a. Statutory Penalty for Failure To 

Report 

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 was amended by the CAA 2021 and 

the payment reduction for failing to 

meet hospice quality reporting 

requirements is increased from 2 

percent to 4 percent beginning with FY 

2024. The Act requires that, beginning 

with FY 2014 through FY 2023, the 

Secretary shall reduce the market basket 

update by 2 percentage points and then 

beginning in FY 2024 and for each 

subsequent year, the Secretary shall 

reduce the market basket update by 4 

percentage points for any hospice that 

does not comply with the quality data 

submission requirements for that fiscal 

year. Last year, we revised our rule at 

§ 418.306(b)(2) in accordance with this 

statutory change (86 FR 42605). 

b. Compliance 

HQRP Compliance requires 

understanding three timeframes for both 

HIS and CAHPS; (1) The relevant 

Reporting Year, payment FY and the 

Reference Year. The ‘‘Reporting Year’’ 

(HIS)/‘‘Data Collection Year’’ (CAHPS). 

This timeframe is based on the calendar 

year. It is the same calendar year for 

both HIS and CAHPS. If the CAHPS 

Data Collection year is CY 2023, then 

the HIS reporting year is also CY 2023. 

(2) The APU is subsequently applied to 

FY payments based on compliance in 

the corresponding Reporting Year/Data 

Collection Year; and (3) For the CAHPS 

Hospice Survey, the Reference Year is 

the CY prior to the Data Collection Year. 

The Reference Year applies to hospices 

submitting a size exemption from the 

CAHPS survey (there is no similar 

exemption for HIS). For example, for the 

CY 2023 data collection year, the 

Reference Year, is CY 2022. This means 

providers seeking a size exemption for 

CAHPS in CY 2023 would base it on 

their hospice size in CY 2022. 

Submission requirements are codified in 

§ 418.312. 

For every CY all Medicare-certified 

hospices are required to submit HIS and 

CAHPS data according to the 

requirements in § 418.312. Table 8 

summarizes the three timeframes. It 

illustrates how the CY interacts with the 

FY payments, covering the CY 2021 

through CY 2024 data collection periods 

and the corresponding APU application 

from FY 2023 through FY 2026. 

TABLE 8—HQRP REPORTING REQUIREMENTS AND CORRESPONDING

ANNUAL PAYMENT UPDATES

Reporting 

year for HIS 

and data 

collection 

year for 

CAHPS data 

(calendar 

year) 

Annual 

payment 

update 

impacts 

payments for 

the FY 

Reference 

year for 

CAHPS size 

exemption 

(CAHPS only) 

CY 2021 ....... FY 2023 

APU.

CY 2020. 

CY 2022 ....... FY 2024 

APU *.

CY 2021. 

CY 2023 ....... FY 2025 

APU.

CY 2022. 


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4 Joynt KE, Orav E, Jha AK. Thirty-Day 

Readmission Rates for Medicare Beneficiaries by 

Race and Site of Care. JAMA. 2011; 305(7):675–681. 

5Lindenauer PK, Lagu T, Rothberg MB, et al. 

Income Inequality and 30 Day Outcomes After 

TABLE 8—HQRP REPORTING REQUIREMENTS AND CORRESPONDING

ANNUAL PAYMENT UPDATES—Continued 

Reporting 

year for HIS 

and data 

collection 

year for 

CAHPS data 

(calendar 

year) 

Annual 

payment 

update 

impacts 

payments for 

the FY 

Reference 

year for 

CAHPS size 

exemption 

(CAHPS only) 

CY 2024 ....... FY 2026 

APU.

CY 2023. 

* Beginning in FY 2024 and all subsequent 

years, the payment penalty is 4 percent. Prior 

to FY 2024, the payment penalty is 2 percent. 

As illustrated in Table 8, CY 2021 

data submissions compliance impacts 

the FY 2023 APU. CY 2022 data 

submissions compliance impacts the FY 

2024 APU. CY 2023 data submissions 

compliance impacts FY 2025 APU. This 

CY data submission impacting FY APU 

pattern follows for subsequent years. 

c. Submission Data and Requirements 

As finalized in the FY 2016 Hospice 

Wage Index and Payment Rate Update 

final rule (80 FR 47192), hospices’ 

compliance with HIS requirements 

beginning with the FY 2020 APU 

determination (that is, based on HISAdmission and Discharge records 

submitted in CY 2018) are based on a 

timeliness threshold of 90 percent. This 

means CMS requires that hospices 

submit 90 percent of all required HIS 

records within 30-days of the event (that 

is, patient’s admission or discharge). 

The 90-percent threshold is hereafter 

referred to as the timeliness compliance 

threshold. Ninety percent of all required 

HIS records must be submitted and 

accepted within the 30-day submission 

deadline to avoid the statutorilymandated payment penalty. Hospice 

compliance with claims data 

requirements is based on administrative 

data collection. Since Medicare claims 

data are already collected from claims, 

hospices are considered 100 percent 

compliant with the submission of these 

data for the HQRP. There is no 

additional submission requirement for 

administrative data. 

To comply with CMS’ quality 

reporting requirements for CAHPS, 

hospices are required to collect data 

monthly using the CAHPS Hospice 

Survey. Hospices comply by utilizing a 

CMS-approved third-party vendor. 

Approved Hospice CAHPS vendors 

must successfully submit data on the 

hospice’s behalf to the CAHPS Hospice 

Survey Data Center. A list of the 

approved vendors can be found on the 

CAHPS Hospice Survey website: 

www.hospicecahpssurvey.org. Table 9. 

HQRP Compliance Checklist illustrates 

the APU and timeliness threshold 

requirements. 

TABLE 9—HQRP COMPLIANCE CHECKLIST

Annual payment 

update HIS CAHPS 

FY 2023 ............ Submit at least 90 percent of all HIS records within 30 days 

of the event date (patient’s admission or discharge) for patient admissions/discharges occurring 1/1/21–12/31/21.

Ongoing monthly participation in the Hospice CAHPS survey 

1/1/2021–12/31/2021. 

FY 2024 ............ Submit at least 90 percent of all HIS records or its successor 

instrument within 30 days of the event date (patient’s admission or discharge) for patient admissions/discharges occurring 1/1/22–12/31/22.

Ongoing monthly participation in the Hospice CAHPS survey 

1/1/2022–12/31/2022. 

FY 2025 ............ Submit at least 90 percent of all HIS records or its successor 

instrument within 30 days of the event date (patient’s admission or discharge) for patient admissions/discharges occurring 1/1/23–12/31/23.

Ongoing monthly participation in the Hospice CAHPS survey 

1/1/2023–12/31/2023. 

Note: The data source for the claims-based measures will be Medicare claims data that are already collected and submitted to CMS. There is 

no additional submission requirement for administrative data (Medicare claims), and hospices with claims data are 100-percent compliant with 

this requirement. 

Most hospices that fail to meet HQRP 

requirements do so because they miss 

the 90 percent threshold. We offer many 

training and education opportunities 

through our website, which are 

available 24/7, 365 days per year, to 

enable hospice staff to learn at the pace 

and time of their choice. We want 

hospices to be successful with meeting 

the HQRP requirements. We encourage 

hospices to use this website at: https:// 

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

Hospice-Quality-Reporting-TrainingTraining-and-Education-Library. For 

more information about HQRP 

Requirements, we refer readers to visit 

the frequently-updated HQRP website 

and especially the Best Practice, 

Education and Training Library, and 

Help Desk web pages at: https://

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

We also encourage readers to visit the 

HQRP web page and sign-up for the 

Hospice Quality ListServ to stay 

informed about HQRP. 

6. Request for Information Related to the 

HQRP Health Equity Initiative 

CMS defines health equity as ‘‘the 

attainment of the highest level of health 

for all people, where everyone has a fair 

and just opportunity to attain their 

optimal health regardless of race, 

ethnicity, disability, sexual orientation, 

gender identity, socioeconomic status, 

geography, preferred language, or other 

factors that affect access to care and 

health outcomes.’’ CMS is working to 

advance health equity by designing, 

implementing, and operationalizing 

policies and programs that support 

health for all the people served by our 

programs, eliminating avoidable 

differences in health outcomes 

experienced by people who are 

disadvantaged or underserved, and 

providing the care and support that our 

enrollees need to thrive. CMS’ goals are 

in line with Executive Order 13985, on 

the Advancement of Racial Equity and 

Support for the Underserved 

Communities, which can be found at: 

https://www.whitehouse.gov/briefingroom/presidential-actions/2021/06/25/ 

executive-order-on-diversity-equityinclusion-and-accessibility-in-thefederal-workforce/. 

Belonging to an underserved 

community is often associated with 

worse health outcomes.4 5 6 7 8 9 10 11 Such 


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Acute Myocardial Infarction, Heart Failure, and 

Pneumonia: Retrospective Cohort Study. British 

Medical Journal. 2013; 346. 

6Trivedi AN, Nsa W, Hausmann LRM, et al. 

Quality and Equity of Care in U.S. Hospitals. New 

England Journal of Medicine. 2014; 371(24):2298– 

2308. 

7Polyakova, M., et al. Racial Disparities In Excess 

All-Cause Mortality During The Early COVID–19 

Pandemic Varied Substantially Across States. 

Health Affairs. 2021; 40(2): 307–316. 

8Rural Health Research Gateway. Rural 

Communities: Age, Income, and Health Status. 

Rural Health Research Recap. November 2018. 

9https://www.minorityhealth.hhs.gov/assets/ 

PDF/Update_HHS_Disparities_Dept-FY2020.pdf. 

10www.cdc.gov/mmwr/volumes/70/wr/ 

mm7005a1.htm. 

11Poteat TC, Reisner SL, Miller M, Wirtz AL. 

COVID–19 Vulnerability of Transgender Women 

With and Without HIV Infection in the Eastern and 

Southern U.S. Preprint. medRxiv. 

2020;2020.07.21.20159327. Published 2020 Jul 24. 

doi:10.1101/2020.07.21.20159327. 

12Addressing Disparities in Hospice & Palliative 

Care. Nalley, Catlin. Oncology Times: March 20, 

2021–Volume 43–Issue 6–p 1,10doi: 10.1097/ 

01.COT.0000741732.73529.bb. 

13https://journalofethics.ama-assn.org/article/ 

racial-disparities-hospice-moving-analysisintervention/2006-09. 

14Capital Caring, Seasons Execs: Improving 

Hospice Diversity Starts from the Inside Out. 11/17/ 

21. Holly Vossel. Capital Caring, Seasons Execs: 

Improving Hospice Diversity Starts from the Inside 

Out—Hospice & Palliative Care Network of 

Maryland https://hospicenews.com/2021/11/17/ 

capital-caring-seasons-execs-improving-hospicediversity-starts-from-the-inside-out/. 

15 Disparities in Palliative and Hospice Care and 

Completion of Advance Care Planning and 

Directives Among Non-Hispanic Blacks: A Scoping 

Review of Recent Literature (nih.gov). 

16https://www.ncbi.nlm.nih.gov/pmc/articles/ 

PMC3822363/. 

17Naming the Problem: A Structural Racism 

Framework to Examine Disparities in Palliative 

Care—ScienceDirect. 

18 Johnson KS. Racial and ethnic disparities in 

palliative care. J Palliat Med 2013;16:1329–1334. 

19Elk R, Felder TM, Cayir E, Samuel CA. Social 

inequalities in palliative care for cancer patients in 

the United States: astructured review. Semin Oncol 

Nurs 2018;34:303–315. 

20Elliott AM, Alexander SC, Mescher CA, Mohan 

D, Bar-nato AE. Differences in physicians’ verbal 

and nonverbal communication with black and 

white patients at the end of life. J Pain Symptom 

Manage 2016;51:1–8. 

21 Johnson RL, Roter D, Powe NR, Cooper LA. 

Patient race/ethnicity and quality of patientphysician communication during medical visits. 

Am J Public Health 2004;94:2084–2090. 

22Capital Caring, Seasons Execs: Improving 

Hospice Diversity Starts from the Inside Out. 11/17/ 

21. Holly Vossel. Capital Caring, Seasons Execs: 

Improving Hospice Diversity Starts from the Inside 

Out—Hospice & Palliative Care Network of 

Maryland https://hospicenews.com/2021/11/17/ 

capital-caring-seasons-execs-improving-hospicediversity-starts-from-the-inside-out/. 

23https://hospicenews.com/2021/05/27/hospiceproviders-leverage-data-to-reach-the-underserved/. 

24https://www.ncbi.nlm.nih.gov/pmc/articles/ 

PMC3822363/. 

25https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/Quality

InitiativesGenInfo/Downloads/CMS-QualityStrategy.pdf. 

26Report to Congress: Improving Medicare 

PostAcute Care Transformation (IMPACT) Act of 

2014 Strategic Plan for Accessing Race and 

Ethnicity Data. January 5, 2017. Available at https:// 

www.cms.gov/About-CMS/Agency-Information/ 

OMH/Downloads/Research-Reports-2017-Report-toCongress-IMPACT-ACT-of-2014.pdf. 

disparities in health outcomes are the 

result of multiple factors. Although not 

the sole determinants, poor access to 

care and provision of lower quality 

health care are important contributors to 

health disparities notable for CMS 

programs. Health inequities persist in 

hospice and palliative care, where Black 

and Hispanic populations are less likely 

to utilize care and over 80 percent of 

patients are White.12 13 14 15 After 

hospice admission, racial and ethnic 

disparities appear to impact quality of 

care and health outcomes.16 Black 

patients may receive fewer supportive 

care medications despite higher 

symptom burdens, experience care less 

consistent with their expressed 

preferences, and encounter worse endof-life communication.17 18 19 20 21 In 

response to these disparities, 70 percent 

of home health organizations, including 

22 percent that are hospices, indicated 

they would increase the resources 

dedicated to diversity, equity, and 

inclusion in 2021.22 One important 

strategy for addressing these disparities 

is improving data collection to allow for 

better measurement and reporting on 

equity across our programs and 

policies.23 24

We are committed to achieving equity 

in health care outcomes for our 

beneficiaries by supporting providers in 

quality improvement activities to reduce 

health inequities, enabling beneficiaries 

to make more informed decisions, and 

promoting provider accountability for 

health care disparities.25 26 CMS is 

committed to closing the equity gap in 

CMS quality programs. For more 

information on the portfolio of programs 

aimed at making information on the 

quality of health care providers and 

services, including disparities, more 

transparent, we refer readers to the FY 

2022 Hospice Wage Index and Rate 

Update proposed rule (86 FR 19700). 

In the FY 2022 Hospice Wage Index 

and Rate Update final rule, we received 

comments supportive of gathering 

standardized patient assessment data 

elements and additional SDOH data to 

improve health equity. In parallel, 

commenters advocated for education 

efforts for beneficiaries, providers, and 

stakeholders on the benefits of 

collecting and reporting demographic 

and social risk factor data. We received 

many comments about the use of 

standardized patient assessment data 

elements in the hospice setting to assess 

health equity and SDOH, some of which 

raised concerns there may be 

unintended consequences. Many 

commenters noted that hospice patients 

have different goals of care than nonhospice patients, which does not align 

with standardized data elements for 

patient assessment. Commenters 

encouraged CMS to only utilize certain 

aspects of standardized data elements 

for patient assessment (specifically, Zcodes 55–65) in collecting health equity 

data. We refer the readers to review the 

summary of public comments received 

in the FY 2022 Hospice Wage Index and 

Rate Update final rule (86 FR 42528). 

We will continue to take all 

comments and suggestions into account 

as we work to develop policies on this 

important topic. We appreciate hospices 

and national organizations sharing their 

support and commitment to addressing 

health disparities and offering 

meaningful comments for consideration 

in the FY 2022 Hospice Wage Index and 

Rate Update final rule (86 FR 42528). 

Given the value of the comments thus 

far and the ongoing development of 

activities to improve health equity, we 

solicit public comment on the following 

questions: 

• What efforts does your hospice 

employ to recruit staff, volunteers, and 

board members from diverse 

populations to represent and serve 

underserved populations? How does 

your hospice attempt to bridge any 

cultural gaps between your personnel 

and beneficiaries/clients? How does 

your hospice measure whether this has 

an impact on health equity? 

• How does your hospice currently 

identify barriers to access in your 

community or service area? What are 

barriers to collecting data related to 

disparities, social determinants of 

health, and equity? What steps does 

your hospice take to address these 

barriers? 

• How does your hospice collect selfreported data such as race/ethnicity, 

veteran status, socioeconomic status, 

housing, food security, access to 

interpreter services, caregiving status, 

and marital status used to inform its 

health equity initiatives? 

• How is your hospice using 

qualitative data collection and analysis 

methods to measure the impact of its 

health equity initiatives? 

In addition, we are considering a 

structural composite measure based on 

information already collected by 

hospices. Specifically, the structural 

composite measure could include 

organizational activities to address 

access to and quality of hospice care for 

underserved populations. The 

composite structural measure concept 

could include hospice reported data on 

hospice activities to address 


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27https://www.cms.gov/About-CMS/AgencyInformation/OMH/Downloads/CLAS-Toolkit-12-7- 

16.pdf. 28http://pacioproject.org/. 

underserved populations’ access to 

hospice care. For example, a hospice 

could receive a point for each domain 

where data are submitted to a CMS 

portal, regardless of the hospice’s action 

in that domain (such as, reporting 

whether or not the hospice provided 

training for board members, leaders, 

staff and volunteers in culturally and 

linguistically appropriate services 

(CLAS), health equity, and implicit 

bias). The data could reflect the 

hospice’s completed actions for each 

corresponding domain (for a total of 

three points) in a reporting year. A 

hospice could submit information such 

as documentation, examples, or 

narratives to qualify for the measure 

numerator. We are also seeking 

comment on how to score a domain for 

a hospice that submitted data reflecting 

no actions or partial actions in the given 

domain. 

Examples of the domains we are 

considering are described in the 

following outline. We seek comment on 

each of these domains, including 

specific suggestions on items that 

should be added, removed, or revised. 

Domain 1: Hospice commitment to 

reducing disparities is strengthened 

when equity is a key organizational 

priority. Candidate domain 1 could be 

satisfied when a hospice submits data 

on their actions regarding the role of 

health equity and community 

engagement in their strategic plan. 

Hospices could self-report data in the 

reporting year about their actions in 

each of the following areas, and 

submission of data for all elements 

could be required to qualify for the 

measure numerator. 

• Hospice attests whether its strategic 

plan includes approaches to address 

health equity in the reporting year. 

• Hospice reports community 

engagement and key stakeholder 

activities in the reporting year. 

• Hospice reports on any attempts to 

measure input from patients and 

caregivers about care disparities they 

may experience and recommendations 

or suggestions. 

Domain 2: Training board members, 

leaders, staff and volunteers in 

culturally and linguistically appropriate 

services (CLAS),27 health equity, and 

implicit bias is an important step 

hospices take to provide quality care to 

diverse populations. Candidate domain 

2 could focus on hospices’ diversity, 

equity, inclusion and CLAS training for 

board members, employed staff, and 

volunteers by capturing the following 

self-reported actions in the reporting 

year. Submission of relevant data for all 

elements could be required to qualify 

for the measure numerator. 

• Hospice attests whether employed 

staff were trained in CLAS and 

culturally sensitive care mindful of 

social determinants of health (SDOH) in 

the reporting year. Example data 

include specific training programs or 

training requirements for staff. 

• Hospice attests whether it provided 

resources to staff and volunteers about 

health equity, SDOH, and equity 

initiatives in the reporting year. 

Examples include the materials 

provided, webinars, or learning 

opportunities. 

Domain 3: Leaders and staff could 

improve their capacity to address 

disparities by demonstrating routine 

and thorough attention to equity and 

setting an organizational culture of 

equity. This candidate domain could 

capture activities related to 

organizational inclusion initiatives and 

capacity to promote health equity. 

Examples of equity-focused factors 

include proficiency in languages other 

than English, experience working with 

populations in the service area, 

experience working on health equity 

issues, and experience working with 

individuals with disabilities. 

Submission of relevant data for all 

elements could be required to qualify 

for the measure numerator. 

• Hospice attests whether equityfocused factors were included in the 

hiring of hospice senior leadership, 

including chief executives and board of 

trustees, in the previous reporting year. 

• Hospice attests whether equityfocused factors were included in the 

hiring of hospice senior leadership, 

including chief executives and board of 

trustees, is more reflective of the 

services area patient than in the 

previous reporting year. 

• Hospice attests whether equityfocused factors were included in the 

hiring of direct patient care staff (for 

example, RNs, medical social workers, 

aides, volunteers, chaplains, or 

therapists) in the previous reporting 

year. 

• Hospice attests whether equity 

focused factors were included in the 

hiring of indirect care or support staff 

(for example. administrative, clerical, or 

human resources) in the previous 

reporting year. 

We are interested in developing 

health equity measures based on 

information collected by hospices not 

currently available on claims, 

assessments, or other publicly available 

data sources to support development of 

future quality measures. We are 

soliciting public comment on the 

conceptual domains and quality 

measures described in this section. 

Furthermore, we are soliciting public 

comments on publicly reporting a 

composite structural health equity 

quality measure; displaying descriptive 

information on Care Compare from the 

data hospices provide to support health 

equity measures; and the impact of the 

domains and quality measure concepts 

on organizational culture change. 

7. Advancing Health Information 

Exchange Update 

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 and 

patient access to their digital health 

information. 

To further interoperability in postacute care settings, CMS and the Office 

of the National Coordinator for Health 

Information Technology (ONC) 

participate in the Post-Acute Care 

Interoperability Workgroup (PACIO) to 

facilitate collaboration with industry 

stakeholders to develop Health Level 

Seven International® (HL7) Fast 

Healthcare Interoperability Resources®

(FHIR) standards.28 These standards 

could support the exchange and reuse of 

patient assessment data derived from 

the Minimum Data Set (MDS), Inpatient 

Rehabilitation Facility-Patient 

Assessment Instrument (IRF–PAI), 

LTCH Continuity Assessment Record 

and Evaluation (CARE) Data Set (LCDS), 

Outcome and Assessment Information 

Set (OASIS), and other sources. The 

PACIO Project has focused on HL7 FHIR 

implementation guides for functional 

status, cognitive status and new use 

cases on advance directives, reassessment timepoints, and Speech 

Language, Swallowing, Cognitive 

communication and Hearing 

(SPLASCH) pathology. We encourage 

PAC provider and health (IT) vendor 

participation as the efforts advance. 

The CMS Data Element Library (DEL) 

continues to be updated and serves as 

a resource for PAC assessment data 

elements and their associated mappings 

to health IT standards, such as Logical 

Observation Identifiers Names and 

Codes (LOINC) and Systematized 

Nomenclature of Medicine Clinical 

Terms (SNOMED). The DEL furthers 

CMS’ goal of data standardization and 

interoperability. Standards in the DEL 

(https://del.cms.gov/DELWeb/pubHome) 

can be referenced on the CMS website 


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29The Trusted Exchange Framework (TEF): 

Principles for Trusted Exchange (Jan. 2022), https:// 

www.healthit.gov/sites/default/files/page/2022-01/ 

Trusted_Exchange_Framework_0122.pdf. 

30Common Agreement for Nationwide Health 

Information Interoperability Version 1 (Jan. 2022), 

https://www.healthit.gov/sites/default/files/page/ 

2022-01/Common_Agreement_for_Nationwide_

Health_Information_Interoperability_Version_1.pdf. 

31Qualified Health Information Network (QHIN) 

Technical Framework (QTF) Version 1.0 (Jan. 2022), 

https://rce.sequoiaproject.org/wp-content/uploads/ 

2022/01/QTF_0122.pdf. 

and in the ONC Interoperability 

Standards Advisory (ISA). The 2022 ISA 

is available at https://www.healthit.gov/ 

isa. 

The 21st Century Cures Act (Cures 

Act) (Pub. L. 114–255, enacted 

December 13, 2016) required HHS and 

ONC to take steps to further 

interoperability for providers and 

settings across the care continuum. 

Section 4003(b) of the Cures Act 

required ONC to take steps to advance 

interoperability through the 

development of a trusted exchange 

framework and common agreement 

aimed at establishing a universal floor of 

interoperability across the country. On 

January 18, 2022, ONC announced a 

significant milestone by releasing the 

Trusted Exchange Framework 29 and 

Common Agreement Version 1 30. The 

Trusted Exchange Framework is a set of 

non-binding principles for health 

information exchange, and the Common 

Agreement is a contract that advances 

those principles. The Common 

Agreement and the incorporated by 

reference Qualified Health Information 

Network Technical Framework Version 

1 31 establish the technical 

infrastructure model and governing 

approach for different health 

information networks and their users to 

securely share clinical information with 

each other—all under commonly agreed 

to terms. The technical and policy 

architecture of how exchange occurs 

under the Trusted Exchange Framework 

and the Common Agreement follows a 

network-of-networks structure, which 

allows for connections at different levels 

and is inclusive of many different types 

of entities at those different levels, such 

as health information networks, 

healthcare practices, hospitals, public 

health agencies, and Individual Access 

Services (IAS) For more information, we 

refer readers to https://

www.healthit.gov/topic/interoperability/ 

trusted-exchange-framework-andcommon-agreement. 

We invite readers to learn more about 

these important developments and how 

they are likely to affect hospices. 

C. CAA 2021, Section 407. Establishing 

Hospice Program Survey and 

Enforcement Procedures Under the 

Medicare Program; Provisions Update 

Division CC, section 407 of the CAA 

2021, amended Part A of Title XVIII of 

the Act to add a new section 1822, and 

amended sections 1864(a) and 1865(b) 

of the Act, establishing new hospice 

program survey and enforcement 

requirements, required public reporting 

of survey information, and a new 

hospice hotline. 

The law requires public reporting of 

hospice program surveys conducted by 

both State Agencies (SAs) and 

Accrediting Organizations (AOs), as 

well as enforcement actions taken as a 

result of these surveys, on the CMS 

website in a manner that is prominent, 

easily accessible, searchable, and 

presented in a readily understandable 

format. It removes the prohibition at 

section 1865(b) of the Act of public 

disclosure of hospice surveys performed 

by AOs, and requires that AOs use the 

same survey deficiency reports as SAs 

(Form CMS–2567, ‘‘Statement of 

Deficiencies’’ or a successor form) to 

report survey findings. 

The law also requires hospice 

programs to measure and reduce 

inconsistency in the application of 

survey results among all surveyors, and 

requires the Secretary to provide 

comprehensive training and testing of 

SA and AO hospice program surveyors, 

including training with respect to 

review of written plans of care. The 

statute prohibits SA surveyors from 

surveying hospice programs for which 

they have worked in the last 2 years or 

in which they have a financial interest, 

requires hospice program SAs and AOs 

to use a multidisciplinary team of 

individuals for surveys conducted with 

more than one surveyor to include at 

least one registered nurse, and provides 

that each SA must establish a dedicated 

toll-free hotline to collect, maintain, and 

update information on hospice 

programs and to receive complaints. 

The provisions in the CAA 2021 also 

direct the Secretary to create a Special 

Focus Program (SFP) for poorperforming hospice programs, sets out 

authority for imposing enforcement 

remedies for noncompliant hospice 

programs, and requires the development 

and implementation of a range of 

remedies as well as procedures for 

appealing determinations regarding 

these remedies. These remedies can be 

imposed instead of, or in addition to, 

termination of the hospice programs’ 

participation in the Medicare program. 

The remedies include civil money 

penalties (CMPs), suspension of all or 

part of payments, and appointment of 

temporary management to oversee 

operations. 

In the CY 2022 Home Health 

Prospective Payment System (HH PPS) 

final rule (86 FR 62240), we addressed 

provisions related to the hospice survey 

enforcement and other activities 

described in this section. A summary of 

the finalized CAA provisions can be 

found in the CY 2022 HH PPS final rule: 

https://www.govinfo.gov/content/pkg/ 

FR-2021-11-09/pdf/2021-23993.pdf. We 

finalized all the CAA provisions in CY 

2022 rulemaking except for the special 

focus program (SFP). As outlined in the 

CY 2022 HH PPS final rule, we stated 

that we would take into account 

comments that we received and work on 

a revised proposal, seeking additional 

collaboration with stakeholders to 

further develop the methodology for the 

SFP Since the publication of the CY 

2022 HH PPS final rule, we have 

decided to initiate a hospice Technical 

Expert Panel (TEP) in CY 2022. 

Accordingly, CMS plans to use the TEP 

findings to further develop a proposal 

on the methodology for establishing the 

hospice SFP, and we plan to include a 

proposal implementing a SFP in the FY 

2024 Hospice rulemaking proposed rule. 

IV. Response to Comments 

Because of the large number of public 

comments, we normally receive on 

Federal Register documents, we are not 

able to acknowledge or respond to them 

individually. We will consider all 

comments we receive by the date and 

time specified in the DATES section of 

this preamble, and, when we proceed 

with a subsequent document, we will 

respond to the comments in the 

preamble to that document. 

V. Collection of Information 

This document does not impose 

information collection requirements, 

that is, reporting, recordkeeping or 

third-party disclosure requirements. 

Consequently, there is no need for 

review by the Office of Management and 

Budget under the authority of the 

Paperwork Reduction Act of 1995 (44 

U.S.C. 3501 et seq.). 

VI. Regulatory Impact Analysis 

A. Statement of Need 

This proposed rule meets the 

requirements of our regulations at 

§ 418.306(c) and (d), which require 

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 CBSAs or 

previously used MSAs, as well as any 


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19460 Federal Register / Vol. 87, No. 64 / Monday, April 4, 2022 / Proposed Rules 

changes to the methodology for 

determining the per diem payment 

rates. This proposed rule would also 

update payment rates for each of the 

categories of hospice care, described in 

§ 418.302(b), for FY 2023 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. Lastly, 

section 3004 of the Affordable Care Act 

amended the Act to authorize a quality 

reporting program for hospices, and this 

rule does not change the requirements 

for the HQRP 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 

proposed rule would result in an 

estimated increase of $580 million in 

payments to hospices, resulting from the 

hospice payment update percentage of 

2.7 percent for FY 2023. The impact 

analysis of this proposed rule represents 

the projected effects of the changes in 

hospice payments from FY 2022 to FY 

2023. Using the most recent complete 

data available at the time of rulemaking, 

in this case FY 2021 hospice claims data 

as of January 21, 2022, we apply the 

current FY 2022 wage index with the 

current labor shares. Using the same FY 

2021 data, we apply the FY 2023 wage 

index and the current labor share values 

to simulate FY 2022 payments. We then 

apply a budget neutrality adjustment so 

that the aggregate simulated payments 

do not increase or decrease due to 

changes in the wage index. 

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), and the Congressional 

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

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. 

In accordance with the provisions of 

Executive Order 12866, this regulation 

was reviewed by the Office of 

Management and Budget. 

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. Detailed Economic Analysis 

1. Proposed Hospice Payment Update 

for FY 2023 

The FY 2023 hospice payment 

impacts appear in Table 10. We tabulate 

the resulting payments according to the 

classifications (for example, provider 

type, geographic region, facility size), 

and compare the difference between 

current and future payments to 

determine the overall impact. The first 

column shows the breakdown of all 

hospices by provider type and control 

(non-profit, for-profit, government, 

other), facility location, facility size. The 

second column shows the number of 

hospices in each of the categories in the 

first column. The third column shows 

the effect of using the FY 2023 updated 

wage index data with a 5-percent cap on 

wage index decreases. This represents 

the effect of moving from the FY 2022 

hospice wage index to the FY 2023 

hospice wage index with a 5-percent 

cap on wage index decreases. The 

aggregate impact of the changes in 

column three is zero percent, due to the 

hospice wage index standardization 

factor. However, there are distributional 

effects of the FY 2023 hospice wage 

index. The fourth column shows the 

effect of the hospice payment update 

percentage as mandated by section 

1814(i)(1)(C) of the Act, and is 

consistent for all providers. The 

proposed hospice payment update 

percentage of 2.7 percent is based on the 

proposed 3.1 percent inpatient hospital 

market basket update, reduced by a 

proposed 0.4 percentage point 

productivity adjustment. The fifth 

column shows the effect of all the 

proposed changes on FY 2023 hospice 

payments. It is projected aggregate 

payments would increase by 2.7 

percent; assuming hospices do not 

change their billing practices. As 

illustrated in Table 10, the combined 

effects of all the proposals vary by 

specific types of providers and by 

location. We note that simulated 

payments are based on utilization in FY 

2021 as seen on Medicare hospice 

claims (accessed from the CCW in 

January 21, 2022) and only include 

payments related to the level of care and 

do not include payments related to the 

service intensity add-on. 

As illustrated in Table 10, the 

combined effects of all the proposals 

vary by specific types of providers and 

by location. 


khammond on DSKJM1Z7X2PROD with PROPOSALS
Federal Register / Vol. 87, No. 64 / Monday, April 4, 2022 / Proposed Rules 19461 

TABLE 10—PROJECTED IMPACT TO HOSPICES FOR FY 2023 

Hospice subgroup Hospices 

FY 2023 updated 

wage data ≤with 

cap 

FY 2023 proposed hospice 

payment update 

(%) 

Overall total impact for FY 2023 

All Hospices ..................................................................................... 5,186 0.0% 2.7% 2.7% 

Hospice Type and Control: 

Freestanding/Non-Profit ............................................................ 581 ¥0.1 2.7 2.6 

Freestanding/For-Profit ............................................................. 3,508 0.1 2.7 2.8 

Freestanding/Government ........................................................ 42 0.1 2.7 2.8 

Freestanding/Other ................................................................... 352 ¥0.1 2.7 2.6 

Facility/HHA Based/Non-Profit .................................................. 347 ¥0.2 2.7 2.5 

Facility/HHA Based/For-Profit ................................................... 200 ¥0.1 2.7 2.6 

Facility/HHA Based/Government .............................................. 79 ¥0.1 2.7 2.6 

Facility/HHA Based/Other ......................................................... 77 ¥0.3 2.7 2.4 

Subtotal: Freestanding Facility Type ................................. 4,483 0.0 2.7 2.7 

Subtotal: Facility/HHA Based Facility Type ....................... 703 ¥0.2 2.7 2.5 

Subtotal: Non-Profit ........................................................... 928 ¥0.1 2.7 2.6 

Subtotal: For Profit ............................................................ 3,708 0.1 2.7 2.8 

Subtotal: Government ....................................................... 121 0.0 2.7 2.7 

Subtotal: Other .................................................................. 429 ¥0.1 2.7 2.6 

Hospice Type and Control: Rural: 

Freestanding/Non-Profit ............................................................ 132 ¥0.1 2.7 2.6 

Freestanding/For-Profit ............................................................. 351 0.0 2.7 2.7 

Freestanding/Government ........................................................ 24 ¥0.6 2.7 2.1 

Freestanding/Other ................................................................... 49 0.0 2.7 2.7 

Facility/HHA Based/Non-Profit .................................................. 135 ¥0.2 2.7 2.5 

Facility/HHA Based/For-Profit ................................................... 47 ¥0.7 2.7 2.0 

Facility/HHA Based/Government .............................................. 62 ¥0.2 2.7 2.5 

Facility/HHA Based/Other ......................................................... 46 ¥0.1 2.7 2.6 

Facility Type and Control: Urban: 

Freestanding/Non-Profit ............................................................ 449 ¥0.1 2.7 2.6 

Freestanding/For-Profit ............................................................. 3,157 0.1 2.7 2.8 

Freestanding/Government ........................................................ 18 0.3 2.7 3.0 

Freestanding/Other ................................................................... 303 -0.1 2.7 2.6 

Facility/HHA Based/Non-Profit .................................................. 212 ¥0.2 2.7 2.5 

Facility/HHA Based/For-Profit ................................................... 153 -0.1 2.7 2.6 

Facility/HHA Based/Government .............................................. 17 ¥0.1 2.7 2.6 

Facility/HHA Based/Other ......................................................... 31 ¥0.3 2.7 2.4 

Hospice Location: Urban or Rural: 

Rural ......................................................................................... 846 ¥0.1 2.7 2.6 

Urban ........................................................................................ 4,340 0.0 2.7 2.7 

Hospice Location: Region of the Country (Census Division): 

New England ............................................................................ 149 ¥0.5 2.7 2.2 

Middle Atlantic .......................................................................... 282 0.0 2.7 2.7 

South Atlantic ........................................................................... 588 ¥0.2 2.7 2.5 

East North Central .................................................................... 559 ¥0.4 2.7 2.3 

East South Central ................................................................... 256 ¥0.1 2.7 2.6 

West North Central ................................................................... 410 ¥0.5 2.7 2.2 

West South Central .................................................................. 1,015 0.3 2.7 3.0 

Mountain ................................................................................... 538 ¥0.2 2.7 2.5 

Pacific ....................................................................................... 1,340 0.7 2.7 3.4 

Outlying ..................................................................................... 49 ¥0.3 2.7 2.4 

Hospice Size: 

0–3,499 RHC Days (Small) ...................................................... 1,076 0.3 2.7 3.0 

3,500–19,999 RHC Days (Medium) ......................................... 2,457 0.2 2.7 2.9 

20,000+ RHC Days (Large) ...................................................... 1,653 0.0 2.7 2.7 

Source: FY 2021 hospice claims data from CCW accessed on January 21, 2022. 

Note: The overall total impact reflects the addition of the individual impacts, which includes the overall wage index impact of updating the 

wage data with a 5-percent cap on wage index decreases, as well as the proposed 2.7 percent hospice payment update percentage. 

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. 


khammond on DSKJM1Z7X2PROD with PROPOSALS
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2. Regulatory Review Cost Estimation 

If regulations impose administrative 

costs on private entities, such as the 

time needed to read and interpret this 

proposed 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 last year’s proposed rule 

will be the number of reviewers of this 

proposed rule. We acknowledge that 

this assumption may understate or 

overstate the costs of reviewing this 

proposed rule. It is possible that not all 

commenters reviewed last year’s 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 past 

commenters would be a fair estimate of 

the number of reviewers of this 

proposed rule. We welcome any 

comments on the approach in 

estimating the number of entities which 

will review this proposed rule. We also 

recognize that different types of entities 

are in many cases affected by mutually 

exclusive sections of this proposed rule, 

and therefore for the purposes of our 

estimate we assume that each reviewer 

reads approximately 50 percent of the 

rule. We are soliciting public comments 

on this assumption. 

Using the occupational wage 

information from the BLS for medical 

and health service managers (Code 11– 

9111) from May 2020; we estimate that 

the cost of reviewing this rule is $114.24 

per hour, including overhead and fringe 

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

current/oes_nat.htm). This proposed 

rule consists of approximately 20,000 

words. Assuming an average reading 

speed of 250 words per minute, it would 

take approximately 0.67 hours for the 

staff to review half of it. For each 

hospice that reviews the rule, the 

estimated cost is $76.16 (0.67 hours × 

$114.24). Therefore, we estimate that 

the total cost of reviewing this 

regulation is $4,036.48 ($76.16 × 53 

reviewers). 

D. Alternatives Considered 

Since the hospice payment update 

percentage is determined based on 

statutory requirements, we only 

considered not updating hospice 

payment rates by the payment update 

percentage. Payment rates since FY 

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 years must 

be the market basket percentage for that 

FY. Section 3401(g) of the Affordable 

Care Act also mandates that, starting 

with FY 2013 (and in subsequent years), 

the hospice payment update percentage 

will be annually reduced by changes in 

economy-wide productivity as specified 

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

Act. For FY 2023, since the hospice 

payment update percentage is 

determined based on statutory 

requirements at section 1814(i)(1)(C) of 

the Act, we cannot consider not 

updating the hospice payment rates by 

the hospice payment update percentage, 

nor can we consider updating the 

hospice payment rates by the hospice 

payment update percentage. 

E. Accounting Statement 

As required by OMB Circular A–4 

(available at https://

www.whitehouse.gov/sites/ 

whitehouse.gov/files/omb/circulars/A4/ 

a-4.pdf), in Table 11, we have prepared 

an accounting statement showing the 

classification of the expenditures 

associated with the provisions of this 

proposed rule. Table 11 provides our 

best estimate of the possible changes in 

Medicare payments under the hospice 

benefit as a result of the policies in this 

proposed rule. This estimate is based on 

the data for 4,957 hospices in our 

impact analysis file, which was 

constructed using FY 2021 claims 

available in January 2022. All 

expenditures are classified as transfers 

to hospices. 

TABLE 11—ACCOUNTING STATEMENT: 

CLASSIFICATION OF ESTIMATED

TRANSFERS AND COSTS, FROM FY 

2022 TO FY 2023 

Category Transfers 

Annualized Monetized 

Transfers.

$ 580 million*. 

From Whom to 

Whom?.

Federal Government 

to Medicare Hospices. 

*The increase of $580 million in transfer 

payments is a result of the 2.7 percent hospice payment update compared to payments 

in FY 2022. 

F. Regulatory Flexibility Act (RFA) 

The 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 $8.0 

million to $41.5 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. The 

Department of Health and Human 

Services 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 2023 

hospice payment update percentage 

results in an overall increase in 

estimated hospice payments of 2.7 

percent, or $580 million. The 

distributional effects of the proposed FY 

2023 hospice wage index do not result 

in a greater than 5 percent of hospices 

experiencing decreases in payments of 3 

percent or more of total revenue. 

Therefore, the 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 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 603 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 MSA 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 (see 

Table 10). 

G. Unfunded Mandates Reform Act 

(UMRA) 

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. In 2022, that 

threshold is approximately $165 

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 $165 million or more 

in any 1 year. 

H. Federalism 

Executive Order 13132 establishes 

certain requirements that an agency 

must meet when it promulgates a 


khammond on DSKJM1Z7X2PROD with PROPOSALS
Federal Register / Vol. 87, No. 64 / Monday, April 4, 2022 / Proposed Rules 19463 

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. 

I. Conclusion 

We estimate that aggregate payments 

to hospices in FY 2023 will increase by 

$580 million as a result of the market 

basket update, compared to payments in 

FY 2022. We estimate that in FY 2023, 

hospices in urban areas will experience, 

on average, a 2.7 percent increase in 

estimated payments compared to FY 

2022; while hospices in rural areas will 

experience, on average, a 2.6 percent 

increase in estimated payments 

compared to FY 2022. Hospices 

providing services in the Pacific and 

West South Central regions would 

experience the largest estimated 

increases in payments of 3.4 percent 

and 3.0 percent, respectively. Hospices 

serving patients in areas in the New 

England and West North Central regions 

would experience, on average, the 

lowest estimated increase of 2.2 percent 

in FY 2023 payments. 

Chiquita Brooks-LaSure, 

Administrator of the Centers for 

Medicare & Medicaid Services, 

approved this document on March 29, 

2022. 

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 proposes to amend 

42 CFR part 418 as set forth below. 

PART 418—HOSPICE CARE 

■ 1. The authority citation for part 418 

continues to read as follows: 

Authority: 42 U.S.C. 1302 and 1395hh. 

■ 2. Section § 418.306 is amended by 

revising paragraph (c) to read as follows: 

§ 418.306 Annual update of the payment 

rates and adjustment for area wage 

differences. 

* * * * * 

(c) Adjustment for wage differences. 

(1) Each hospice’s labor market is 

determined based on definitions of 

Metropolitan Statistical Areas (MSAs) 

issued by OMB. CMS will issue 

annually, in the Federal Register, a 

hospice wage index based on the most 

current available CMS hospital wage 

data, including changes to the definition 

of MSAs. The urban and rural area 

geographic classifications are defined in 

§ 412.64(b)(1)(ii)(A) through (C) of this 

chapter. The payment rates established 

by CMS are adjusted by the Medicare 

contractor to reflect local differences in 

wages according to the revised wage 

data. 

(2) Beginning on October 1, 2022, 

CMS applies a cap on decreases to the 

hospice wage index such that the wage 

index applied to a geographic area is not 

less than 95 percent of the wage index 

applied to that geographic area in the 

prior fiscal year. 

* * * * * 

Dated: March 29, 2022. 

Xavier Becerra, 

Secretary, Department of Health and Human 

Services. 

[FR Doc. 2022–07030 Filed 3–30–22; 4:15 pm] 

BILLING CODE 4120–01–P 

DEPARTMENT OF THE INTERIOR 

Fish and Wildlife Service 

50 CFR Part 17 

[Docket No. FWS–HQ–ES–2020–0100; 

FF09E21000 FXES1111090FEDR 223] 

RIN 1018–BE92 

Endangered and Threatened Wildlife 

and Plants; Endangered Species 

Status for Amur Sturgeon 

AGENCY: Fish and Wildlife Service, 

Interior. 

ACTION: Proposed rule; reopening of 

public comment period and 

announcement of public hearing. 

SUMMARY: We, the U.S. Fish and 

Wildlife Service (Service), are reopening 

the public comment period on our 

August 25, 2021, proposed rule to list 

the Amur sturgeon (Acipenser 

schrenckii), a fish species from the 

Amur River basin in Russia and China, 

as an endangered species under the 

Endangered Species Act of 1973, as 

amended (Act). We are taking this 

action to conduct a public hearing on 

the petition to list the Amur sturgeon. 

Comments previously submitted need 

not be resubmitted and will be fully 

considered in preparation of the final 

rule. 

DATES: 

Comment submission: The public 

comment period on the proposed rule 

that published on August 25, 2021, at 86 

FR 47457 is reopened. We will accept 

comments received or postmarked on or 

before May 4, 2022. Comments 

submitted electronically using the 

Federal eRulemaking Portal (see 

ADDRESSES, below) must be received by 

11:59 p.m. Eastern Time on the closing 

date, and comments submitted by U.S. 

mail must be postmarked by that date to 

ensure consideration. 

Public hearing: On April 19, 2022, we 

will hold a public hearing on the 

proposed rule to list the Amur sturgeon 

under the Act from 6:00 to 7:30 p.m. 

Eastern Time, using the Zoom platform 

(for more information, see Public 

Hearing, below). 

ADDRESSES: Written comments: You may 

submit comments by one of the 

following methods: 

(1) Electronically: Go to the Federal 

eRulemaking Portal: https://

www.regulations.gov. In the Search box, 

enter FWS–HQ–ES–2020–0100, which 

is the docket number for this 

rulemaking. Then, click on the Search 

button. On the resulting page, in the 

Search panel on the left side of the 

screen, under the Document Type 

heading, check the Proposed Rule box to 

locate this document. You may submit 

a comment by clicking on ‘‘Comment.’’ 

(2) By hard copy: Submit by U.S. mail 

to: Public Comments Processing, Attn: 

FWS–HQ–ES–2020–0100, U.S. Fish and 

Wildlife Service, MS: PRB/3W, 5275 

Leesburg Pike, Falls Church, VA 22041– 

3803. 

We request that you send comments 

only by the methods described above. 

We will post all comments on https:// 

www.regulations.gov. This generally 

means that we will post any personal 

information you provide us (see Public 

Comments, below, for more 

information). 

Document availability: The proposed 

rule and supporting documents, 

including the species status assessment 

report, are available at https://

www.regulations.gov under Docket No. 

FWS–HQ–ES–2020–0100. 

Public hearing: Interested parties may 

present verbal testimony (formal, oral 

comments) at a public hearing, which 

will be held virtually using the Zoom 

platform. See Public Hearing, below, for 

more information. 

FOR FURTHER INFORMATION CONTACT: 

Elizabeth Maclin, Chief, Branch of 

Delisting and Foreign Species, 

Ecological Services, U.S. Fish and 

Wildlife Service, MS: ES, 5275 Leesburg 

Pike, Falls Church, VA 22041–3803; 

telephone, 703–358–2171. Individuals 

in the United States who are deaf, 

deafblind, hard of hearing, or have a 

speech disability may dial 711 (TTY, 

TDD, or TeleBraille) to access 

telecommunications relay services. 

Individuals outside the United States 


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