CMS May Be Mulling Changes to the Hospice Benefit

The U.S. Centers for Medicare & Medicaid Services’ (CMS) 2025 proposed hospice rule contained requests for information (RFIs) that could signal changes in the agency’s thinking on key issues.

Through RFIs, CMS tries to take the pulse of providers’ positions on certain questions that could impact the Medicare Hospice Benefit. In its 2025 proposal, one key RFI includes queries on higher-acuity palliative services like dialysis, transfusions, radiation or chemotherapy, among others. A second RFI addressed social determinants of health.

The agency has voiced a concern that patients in need often do not receive these services.

“The national trends that examine hospice enrollment and service utilization for those beneficiary populations with complex palliative needs and potentially high-cost medical care needs reveal that there may be an underuse of the hospice benefit, despite the demonstrated potential to both improve quality of care and lower costs … ,” CMS indicated in the proposal. “We seek to strengthen the notion that in order to provide the highest level of care for hospice beneficiaries, we must provide ongoing focus to those services that enforce CMS’ definitions of hospice and palliative care and eliminate any barriers to accessing hospice care.”

Regarding this issue, CMS posed several questions:

• Should CMS consider defining palliative services, specifically regarding high-cost treatments?
• Note, CMS is not seeking a change to the definition of palliative care but rather should CMS consider defining palliative services with regard to high-cost treatments?
• Should there be documentation that all other palliative measures have been exhausted prior to billing for a payment for a higher-cost treatment? If so, would that continue to be a barrier for hospices?
• Should there be separate payments for different types of higher-cost palliative treatments or one standard payment for any higher-cost treatment that would exceed the per diem rate?

Dialysis: A key example

In addition to the potential of these services to reduce symptom burden and improve quality of life, making them more available could help patients come to hospice sooner. Many delay electing the benefit due to fears of losing services like dialysis.

“Dialysis is a good example. A lot of kidney patients don’t end up on hospice because they don’t want to give up the dialysis. The dialysis is making them more comfortable,” Mollie Gurian, vice president of home-based and HCBS public policy for LeadingAge, told Hospice News. “We’re hopeful that a payment mechanism, like what CMS is alluding to, through this RFI would allow more hospices to offer that on a consistent basis, of course, when it’s medically appropriate for the patient given their condition.”

Patients with advanced chronic kidney disease and end-stage renal disease represent an underserved population in hospice. Only 2.3% of Medicare decedents who received hospice care in 2018 had a kidney condition as their principal diagnosis, according to the National Hospice and Palliative Care Organization (NHPCO).

Only a fraction of dialysis patients receive specialized palliative care that can effectively target their issues, a 2021 Kaiser Health News report indicated.

Other stakeholders are also looking for change on issues like these, including access to transfusions. Sens. Jacky Rosen (D-Nev.), Tammy Baldwin (D-Wisc.) and John Barrasso (R-Wy.) last year introduced a bill intended to improve quality and access to blood transfusion care for hospice patients.

The Improving Access to Transfusion Care for Hospice Patients Act would create a payment model for blood transfusion services within the Medicare Hospice Benefit. This would allow hospice providers to bill Medicare separately for transfusion services

These concerns have led to similar calls for an additional payment within the hospice benefit to cover services like these.

“The RFI signals a shift in how CMS may be approaching Medicare hospice payments. We are pleased to see CMS consider the barriers that impair beneficiaries’ access to certain palliative services and recognition that these services often require considerable resources,” Patrick Harrison, senior director of regulatory and compliance at NHPCO, and Sarah Simmons, director of quality for NHPCO, told Hospice News in a joint email. “If implemented correctly, we believe that higher payments could help to close resource gaps and facilitate the continued delivery of high-intensity palliative care services, in recognition of the increased costs necessary to provide these services.”

RFI on social determinants

Stakeholders in the health care space, including CMS, are increasingly recognizing the importance of addressing social determinants of health. In the 2025 proposal, the agency posed questions on four crucial social determinants: housing instability, food Insecurity, utility challenges and transportation challenges.

In addition to their impacts on quality of life, these factors could impede patients’ ability to receive hospice care in their homes. Social determinants like these are also an important consideration in work to improve health equity, which CMS has also identified as a priority.

“For the last two years,[CMS] has been asking, ‘What are you all looking at in terms of health equity, and how can we track this?’ So it’s exciting to finally see some direction from them,” Katy Barnett, director of home care and hospice operations for LeadingAge, told Hospice News. “There’s kind of the growing existential crisis that so many hospice patients have. They can’t die comfortably because they don’t know where they are going to spend their last days, or they’re behind on rent.”

CMS put forth the following questions in the proposed rule on these four determinants:

• For each of the domains: Are these items relevant for hospice patients? Are these items relevant for hospice caregivers?
• Which of these items are most suitable for hospice?
• How might the items need to be adapted to improve relevance for hospice patients and their caregivers?
• Would you recommend adjusting the listed timeframes for any items? Would you recommend revising any of the items’ response options?
• Are there additional [social determinants] domains that would also be useful for identifying and addressing health equity issues in hospice?

Questions like these could be a sign that CMS may be looking to “modernize” some aspects of the hospice benefit, according to David Baird, vice president for hospice policy at the National Association for Home Care & Hospice (NAHC).

“At a broader level, it reflects CMS’ overall interest in payment modernization for hospice,” Baird told Hospice News in an email. “While in the past, CMS has mostly tested payment and delivery innovations within CMMI demonstrations, their explicit questions in the RFI about potential separate payment mechanisms for these kinds of services signal their interest in potentially bringing updates to the core hospice system.”