MA Carve-In Could Forego 6-Month Prognosis Rule for Hospice

Medicare Advantage plans would not necessarily be bound by Medicare’s six-month terminal prognosis requirement under a forthcoming hospice carve-in.

Medicare Advantage plans are offered by private insurance companies approved by CMS, and include HMO, PPO, and fee-for-service plans among other options. The program represents an integrated care model that is designed to promote coordination of services and provide incentives for quality and patient satisfaction.

The U.S. Centers for Medicare & Medicaid Services (CMS) earlier this year announced that it would test coverage of hospice care through Medicare Advantage plans beginning in 2021. The carve-in, according to CMS, is intended to increase access to hospice services and facilitate better coordination between patients’ hospice providers and their other clinicians.


Reactions to the carve-in demo have been mixed, with many lauding the CMS action and others expressing concern about possible payment reductions, changes to what would be covered, or the possibility that plans would dictate the types and amounts of care patients receive.

However, the carve-in may also provide an opportunity to engage patients earlier and care for them longer.

“I do think that the six-month requirement will go away if Medicare Advantage plans want an integrated product,” Mary Ann Boccolini, president and CEO of New Jersey-based Samaritan Healthcare & Hospice, told Hospice News. “It would be a continuum of care and wouldn’t be siloed like it is now. Now a person receives treatment in the acute phase, and then they go to palliation, then goes to hospice when they have a six-month terminal prognosis. I don’t think those strict divisions will be in a Medicare Advantage plan; it would just be a continuum.” 


Within this continuum, the patient would be enrolled in their Medicare Advantage plan and have a primary physician who would be responsible for their care. The physician would direct the patient to the different forms of care they need as their illness progresses, according to Boccolini. The plan would have criteria for when patients could receive certain treatments, be it hospice or chemotherapy, but the hard line that exists between hospice and other health care services may become more flexible. 

Currently two physicians much certify that they expect the patient to expire within six months in order for a patient to receive coverage under the Medicare Hospice Benefit. This rule was established for financial rather than clinical reasons, as it enables Medicare to limit spending on hospice. 

Advocacy groups, such as the National Hospice & Palliative Care Organization (NHPCO) and other members of the industry, have called for elimination of the six-month rule, saying that admission to hospice should be based on patient needs rather than a specific time frame.

“I think in general the hospice benefit does a very good job. I think its sticking points are the requirement that patients have six months or less to live and the idea of all the [types of treatment] that you can’t do while you are on hospice,” B. J. Miller, M.D., a hospice and palliative care physician at the University of California Helen Diller Family Comprehensive Cancer Center told Hospice News last month. “Those things made sense in 1982, but they don’t make much sense anymore.” 

If a patient does not die within six months under the current system, they don’t necessarily have to be discharged or removed from hospice. The provider can re-certify the patient, subject to CMS approval. 

Though most stakeholders agree that many patients come to hospice later than they should have to reap the full benefits — more than 27% are admitted for seven days or fewer according to the NHPCO — some experience much longer lengths of stay, particularly those who suffer from dementia or congestive health failure. 

Dementia patients tend to have the longest lengths of stay, averaging 110 days, followed by cardiac patients and stroke patients, each with average lengths of stay exceeding 80 days.

However, longer lengths of can also attract the attention of CMS. Patient length of stay is one of the top drivers of CMS audits, which can be costly and time consuming for the hospice. Through the audit process the agency seeks to ensure that the hospice is not admitting patients who shouldn’t be eligible for hospice under current rules.

Breaking the six-month barrier could help offset some of the potential payment reductions that could result from the carve-in. Hospices can also leverage their experience in providing interdisciplinary patient-centered care to engage patients at other points in the health care continuum, pre-hospice.

“When we can take care of patients for longer you are going to receive compensation for the additional days you are providing care. But if we have the opportunity to demonstrate our skill sets, payers may see that our interdisciplinary teams can support a patient throughout the trajectory of their illness,” Chuck Lee, CEO of Florida-based Cornerstone Hospice, told Hospice News. “We probably wouldn’t receive the same per diem, but if you look at the opportunity to serve more patients for a longer period of time, organizations could fulfill their mission, meet their needs and be fiscally sound at the same time.”

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