CMS Accepting Applications for Medicare Advantage Hospice Carve-In

The U.S. Centers for Medicare & Medicaid Services (CMS) has issued a Request For Applications (RFAs) for Medicare Advantage plans to offer the Medicare Hospice benefit to their enrollees in the Medicare Advantage Value Based Insurance Design (VBID) Model.

The long awaited and much debated Medicare Advantage hospice carve-in demonstration is set to begin Jan. 1, 2021. Through Medicare Advantage, CMS contracts with private insurance companies to provide coverage for Medicare beneficiaries.

CMS earlier this year announced that it would test coverage of hospice care through Medicare Advantage plans. 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.

“By expanding benefits and coverage and igniting greater coordination, [this model] promises to improve quality of care and quality of life for our nation’s seniors,” said CMS Administrator Seema Verma. “The result of our efforts has been a dramatic increase of participation in the VBID Model and the value-based, coordinated care it can provide.”

The Medicare Advantage program has been growing in recent years. The number of participating beneficiaries tripled between 2019 and 2020, totaling nearly 1.2 million enrollees in 30 states, according to CMS.

CMS has indicated that the full spectrum of services currently offered through the Medicare Hospice Benefit would also be available for patients covered through Medicare Advantage. The agency also indicated that the program would allow for access to palliative care services, transitional concurrent care services, and hospice-specific supplemental benefits to address some social determinants of health. 

The agency defines 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, according to CMS’ definition.

While this definition is consistent with current statute, it does leave some unanswered questions, such as whether palliative care through this program would be provided by an interdisciplinary team. This could lead to inconsistencies in the types of services and coverage that plans provide.

“They gave [plans] some guidance in terms of wanting this to be targeted to subpopulations; they want to ensure that there would be care coordination and advanced care planning on the use of medical and social services, and making sure that that transition from palliative care to hospice would be timely and appropriate,” Mollie Gurian, director, hospice, palliative, and home health policy for LeadingAge. “But in terms of how that would happen —whether it would be more of a medical model with a physician or practitioner or for interdisciplinary team, or a telephonic model — they give some guidance as to recommendations for people based on options that are in the field, but they don’t put in a set of requirements. So I think that you would see some differences across plans depending on what the plan might already be doing or what they’ve been thinking about doing.”

Industry organizations such as the National Hospice & Palliative Care Organization (NHPCO) voiced concerns about the lack of specified requirements for palliative care and concurrent care.

“The 2021 VBID Model represents a missed opportunity for [the Center for Medicare and Medicaid Innovation (CMMI)] to innovate the way hospice care is delivered. While the application mentions ‘palliative care’ and ‘transitional concurrent care,’ and encourages plans to innovate, it does not mandate particular coverage for that care,” said NHPCO President and CEO Edo Banach. “We have seen that innovation without baseline requirements can sometimes lead to barriers to care. Additionally, the model does not waive the six-month prognosis requirement for hospice eligibility. This is a missed opportunity to expand access to hospice. We are also disappointed in the dearth of necessary consumer protections,”

The program contains a number of waives allowing hospice to be carved into Medicare Advantage, as well as waivers for uniformity and accessibility of benefits to allow supplemental benefits to be targeted to hospice patients, among others, according to Gurian from LeadingAge.

The National Partnership for Hospice Innovation (NPHI) was encouraged by the presence of the waivers.

“We applaud [the Center for Medicare and Medicaid Innovation] for explicitly requiring participating [Medicare Advantage] organizations to provide the full Medicare hospice benefit as specified in current law, with the additional consideration of a set of clearly defined waivers we believe will give [Medicare Advantage] plans and hospices flexibility to explore innovative ways to ease transitions to hospice care,” Tom Koutsoumpas, co-founder of the Coalition to Transform Advanced Care and CEO of the NPHI) said in a statement.

Earlier this month, the NHPCO called on CMS to delay implementation of the carve-in past 2021, saying that hospices and health plans do not have sufficient information about how the program will work and would not have adequate time to prepare.

“Given the timing — and given that we’re at the tail end of 2019 — we are growing increasingly concerned that, any attempt to carve hospice into Medicare Advantage would be rushed, wouldn’t be fully baked,” Banach told Hospice News. “We have concerns about individuals continuing to be able to access hospice care for a couple of reasons. First of all, we’ve yet to see full details. Second, health plans also have yet to see full details, and health plans have to bid for the 2021 plan year soon after the [2020] new year, which means that they’re going to bid on something that they don’t fully understand. That’s dangerous.”