CMS Will Not ‘Unbundle’ Hospice Care Under Medicare Advantage

The U.S. Centers for Medicare & Medicaid Services (CMS) has affirmed that beneficiaries receiving hospice care covered under a Medicare Advantage carve-in would not lose access to services they currently receive as part of the hospice benefit.

This affirmation addresses a question that has lived in the minds of hospice providers since the agency announced that it would test the inclusion of the Medicare Hospice Benefit in the Medicare Advantage Value-Based Insurance Design (VBID) Model beginning in 2021.

“Will they offer hospice as the unit of service it currently is—the bundled, integrated, flexible interdisciplinary service?” National Association of Home Care & Hospice (NAHC) President William Dombi queried in a recent interview with Hospice News. “Will they cover the therapies hospice currently offers, from nursing and pharmaceuticals to massage therapy or pet therapy?”


CMS today conducted the first in a series of webinars that will provide the first details of how the carve-in demonstration will work, including the question of whether hospices services will be “unbundled.”

“Hospice provides a wide range of services, reimbursed through a capitated, per diem rate based on four levels of care,” said Gary Bacher, chief strategy officer for the agency’s Center for Medicare & Medicaid Innovation, in the webinar. “It’s important that access to those services continues. Our goal is that the benefit remains in tact and that the kinds of services available today remain available to beneficiaries.”

Medicare Advantage plans are offered by private insurance companies approved by the US Centers for Medicare & Medicaid Services, and include HMO, PPO, and fee-for-service plans among other options. Plans pay a capitated monthly rate per beneficiary, rather than paying a separate fee for each service provided as with traditional Medicare. The plans have been increasingly popular among consumers.


Though they continue to seek more specifics on the carve-in from CMS, industry organizations reacted positively to the agency’s assurances.

“We are encouraged to hear that CMS intends to ensure that beneficiaries continue to have access to the full range of services they currently receive under the Medicare hospice benefit,” National Hospice & Palliative Care Organization (NHPCO) President Edo Banach told Hospice News. “We are also encourged to hear CMS discuss access, choice, and characterize the model as voluntary. We look forward to hearing about [the agency’s] palns for achieving these laudatory goals.”

Medicare Advantage plans currently do not cover hospice care. When a patient on such a plan enters hospice, coverage for non-curative care related to the patient’s terminal illness reverts to the fee-for-service hospice benefit. The Medicare Advantage plan would continue to cover any therapies unrelated to the patient’s terminal illness. For example, if a terminal cancer patient also suffers from diabetes, their Medicare Advantage plan would cover the diabetes treatments while the hospice benefit could cover care related to the patient’s cancer.

According to CMS, this dichotomy is one of the issues the hospice carve-in seeks to address.

“Under the current system there is no final responsibility in regards to the full range of services the patient receives,” Bacher said. “There is no one accountable party, and this fragmentation creates gaps in care. By addressing the fragmentation issue, we can provide a more seamless, coordinated care.”

Another concept that CMS will explore is allowing hospice patients access to concurrent care. Beneficiaries in the hospice benefit must stop all curative treatment when they enroll. Under the carve-in, the patient may be able continue some treatments after entering hospice.

Details about concurrent care under the carve-in are forthcoming. So far, the agency has indicated that it would offer “some flexibility” related to concurrent care that would ensure a more “gradual transition” to hospice.

Since the carve-in demonstration was announced, smaller hospice providers, many of which are nonprofits, have voiced concerns that they may be left in the cold if Medicare Advantage plans prefer to contract primarily with large national or regional chains. While CMS did not address this question explicitly, they gave assurances that patients would be able to choose to receive care from the providers of their choice, even if they are out of the plan’s network.

“One of the things we want to ensure is continued access to choice of hospice. Under Medicare Advantage there are different types of plans, and one of those is a PPO,” Bacher said. “We can build on existing provisions for accessing care, including providers not included in the network.”

Industry respondents indicated that further discussion of this issue was necessary to fully address the concerns of smaller providers.

“While PPO plans may allow broader beneficiary choice, that choice may come at a cost if the hospice is not part of a plan’s network. It was not clear that beneficiaries would have full choice under other types of MA plans,” Theresa Forster, vice president for Hospice Policy at NAHC told Hospice News. “The most effective way to ensure patient choice is to require that MA plans have an ‘open network’ under which plans pay any hospice provider chosen by the patient, but CMS did not indicate that this option is under consideration.”

Hospices can begin to apply the carve-in demonstration near the end of this year, to allow for inclusion in the 2021-plan-year application period that will begin in June 2020. A second webinar, due in late April or early May, is expected to delve more deeply into key design considerations that relate to ensuring beneficiary access, payment, and quality of care, as well as offer stakeholders an opportunity to ask questions and voice concerns, a CMS spokesperson told Hospice News.