The U.S. Centers for Medicare & Medicaid Services (CMS) will allow hospice patients to receive concurrent care through the Medicare Advantage hospice carve-in, and will permit health plans to further restrict utilization of out-of-network providers.
Originally slated to complete in 2024, CMS recently extended the carve-in, formally known as the hospice component of the value-based insurance design model (VBID). During those additional years, patients will be able to receive curative treatments in tandem with hospice care.
“Typically, Medicare enrollees who choose hospice services give up their right to receive health care services that are ‘curative.’ Under the model extension, beginning in 2025, CMS will more closely align flexibilities for concurrent care with those offered in other CMS Innovation Center models,” CMS indicated today on its website. “By offering greater flexibility for [Medicare Advantage Organizations (MAOs)] to partner with in-network providers to deliver innovation, this will allow patients to receive more person-centered care at end of life.”
The voluntary demonstration is designed to assess payer and provider performance related to hospice within Medicare Advantage.
The opportunity to provide concurrent care is among the most significant departures from the structure of the traditional Medicare Hospice Benefit, which requires patients to forgo other forms of care.
But today’s update from CMS contained another critical change from prior years. Beginning in 2026, MAOs will be able to limit their hospice coverage to providers within their networks. Previously, CMS mandated that participating payers reimburse hospices outside of their networks at the same rate.
“Participating MAOs have developed networks of hospices that can deliver timely, comprehensive and high-quality services aligned with enrollee preferences in a culturally-sensitive and equitable fashion,” CMS indicated. “Under the model extension, beginning in 2026, participating MAOs will have more flexibility to require their enrollees to only receive hospice services from hospice providers in their network, as long as the MAOs meet CMS’s qualitative and quantitative network adequacy requirements.”
This change is expected to help ensure that model enrollees have greater care continuity and receive higher quality hospice care, according to CMS.
The hospice program is one component of the larger VBID demonstration by the Center for Medicare & Medicaid Innovation. Further changes will occur in the larger model during the extension years.
For one, CMS will require participating health plans to offer supplemental benefits to address health-related social needs in at least two of three health-related social needs areas: food, transportation and housing insecurity and/or living environment.
Currently, providing those benefits is optional for VBID payers.
CMS will also introduce components designed to address health-related social needs in socioeconomically disadvantaged areas, targeted to beneficiaries in underserved communities, as well as new data collection requirements.
“While existing VBID model flexibilities have allowed for focus on health-related social needs, current targeting criteria are based on income, and therefore, miss enrollees who still may be relatively disadvantaged, and have health-related social needs, but do not qualify for these programs,” the agency said.