Hospice leaders in 2025 are concerned about the rising costs of doing business, regulatory headwinds and the prospect of payment through Medicare Advantage.

Currently, coverage for MA enrollees transfers to fee-for-service Medicare when they elect the hospice benefit. Should hospice come under the auspices of MA, it could result in patients dying without support, restricted provider networks limiting choice, diluted services undermining the unique interdisciplinary hospice program and financial burdens on families, according to a recent statement from the National Alliance for Care at Home.

Hospices have their eyes on this issue and need to think about how they should adapt if this comes to pass, according to Susan Ponder-Stansel, CEO of Alivia Care.

“All of us are keeping a wary eye on whether we’re going to find the hospice Medicare benefit part of Medicare Advantage. That’s certainly something that would be a major change in not only our operations, but our care delivery,” Ponder-Stansel said at the Hospice News Elevate Conference in Orlando, Florida. “Given some of the turmoil and some of the quick changes on certain things, we can’t rule it out. Many of us are really looking at what that would be like for our organizations.”

The highest profile attempt to allow hospice coverage through Medicare Advantage was the hospice component of the Value-Based Insurance Design model (VBID), which ended Dec. 31, 2024.

The U.S. Centers for Medicare & Medicaid Services (CMS) cited operational challenges related to the hospice component that limited and decreased participation among Medicare Advantage Organizations (MAOs) and impacted “a thorough evaluation” of the demo.

However, more recent efforts in Congress have sought the same goal. The recently introduced Medicare Advantage Reform Act contains a clause that, if enacted, would require MA health plans to pay for hospice care.

A transition into MA could create significant headwinds for hospices as those plans often pay less than traditional Medicare and often seek to negotiate for discounts. This would be a challenge in an inflationary environment in which the cost of care is going up.

“The other thing that we’re keeping our eye on is just the increased cost of doing business, both with the clinical care that we have to provide and some of the increasing costs of regulatory and administrative burden,” Ponder-Stansel told Hospice News at Elevate. “All of us are looking at margin compression and wanting to make sure that we can still fulfill our mission by having a margin.”

A large segment of that regulatory burden comes in the form of audits by Medicare Administrative Contractors (MACs) and associated financial clawbacks.

Auditing activity has ramped up in the hospice space as regulators seek to improve program integrity and quality oversight. More than half of hospice providers reported having multiple types of audits within a six-month span in a 2024 survey. Sometimes, more than one audit occurs simultaneously for the same provider.

The arrival of a new presidential administration can muddy the waters, Scott Levy, chief government affairs officer for the National Alliance for Care at Home, said at Elevate.

Thus far, the Trump team’s perspectives on hospice policy has yet to materialize. However, the administration has taken a sharp anti-regulatory stance that potentially could lead to some relief, Levy said.

To date, the Trump administration has fired hundreds of workers from the U.S. Department of Health and Human Services and CMS, which also could impact enforcement efforts and day-to-day operations at those agencies.

“A lot of the pressures that are out there are government, regulatory related. Anytime a new government comes into place, there’s consternation, but there’s also opportunities that can be found,” Levy told Hospice News at Elevate. “This administration has put out a request to have regulations submitted to the [White House] Office of Management and Budget to identify things that we believe are burdensome and that take away from our ability to provide care. So there’s an opportunity there.”