[Federal Register Volume 87, Number 64 (Monday, April 4, 2022)]
[Proposed Rules]
[Pages 19442-19463]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2022-07030]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 418
[CMS-1773-P]
RIN 0938-AU83
Medicare Program; FY 2023 Hospice Wage Index and Payment Rate
Update and Hospice Quality Reporting Requirements
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
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SUMMARY: This proposed rule proposes to establish a permanent
mitigation policy to smooth the impact of year-to-year changes in
hospice payments related to changes in the hospice wage index. This
rule also proposes updates to the hospice wage index, payment rates,
and aggregate cap amount for Fiscal Year (FY) 2023. In addition, this
rule proposes updates to the Hospice Quality Reporting Program (HQRP)
including the Hospice Outcomes and Patient Evaluation tool; an update
on Quality Measures (QMs) that will be in effect in FY 2023 for the
HQRP and future QMs; updates on the Consumer Assessment of Healthcare
Providers and Systems, Hospice Survey Mode Experiment, discusses a
request for information (RFI) on health equity.
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, by May 31, 2022.
ADDRESSES: In commenting, please refer to file code CMS-1773-P.
Comments, including mass comment submissions, must be submitted in
one of the following three ways (choose only one of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-1773-P, P.O. Box 8010,
Baltimore, MD 21244-1850.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-1773-P, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: For general questions about hospice
payment policy, send your inquiry via email to:
[email protected].
For questions regarding the CAHPS[supreg] Hospice Survey, contact
Lori Teichman at (410) 786-6684 and Lauren Fuentes at (410) 786-2290.
For questions regarding the hospice quality reporting program,
contact Cindy Massuda at (410) 786-0652.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following
website as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that website to
view public comments. CMS will not post on Regulations.gov public
comments that make threats to individuals or institutions or suggest
that the individual will take actions to harm the individual. CMS
continues to encourage individuals not to submit duplicative comments.
We will post acceptable comments from multiple unique commenters even
if the content is identical or nearly identical to other comments.
Wage index addenda will be available only through the internet on
our website at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Wage-Index.html.
I. Executive Summary
This proposed rule proposes to establish a permanent mitigation
policy to smooth the impact of year-to-year changes in the hospice
payments related to changes in the hospice wage index. This rule also
proposes updates to the hospice wage index as well as updates to the
hospice payment rates, and cap amount for FY 2023 as required under
section 1814(i) of the Social Security Act (the Act). In addition, in
this proposed rule CMS discusses updates to HQRP that include the
Hospice Outcomes and Patient Evaluation (HOPE) tool with national beta
testing; the Consumer Assessment of Healthcare Providers and Systems
(CAHPS) Hospice Survey with Star Ratings; developing a web-based
survey; Public Reporting; a request for information that builds from
last year's discussion on health equity, and update on advancing a
health information exchange.
Lastly, the overall economic impact of this proposed rule is
estimated to be $580 million in increased payments to hospices for FY
2023.
II. Background
A. Hospice Care
Hospice care is a comprehensive, holistic approach to treatment
that recognizes the impending death of a terminally ill individual and
warrants a change in the focus from curative care to palliative care
for relief of pain and for symptom management. Medicare regulations
define ``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 (42 CFR 418.3). Palliative care is at the core of hospice
philosophy and care practices, and is a critical component of the
Medicare hospice benefit.
The goal of hospice care is to help terminally ill individuals
continue life with minimal disruption to normal activities while
remaining primarily in the home environment. A hospice uses an
interdisciplinary approach to deliver medical, nursing, social,
psychological, emotional, and spiritual services through a
collaboration of professionals and other caregivers, with the goal of
making the beneficiary as physically and emotionally comfortable as
possible. Hospice provides compassionate beneficiary and family/
caregiver-centered care for those who are terminally ill.
As referenced in our regulations at Sec. 418.22(b)(1), to be
eligible for Medicare hospice services, the patient's attending
physician (if any) and the hospice medical director must certify that
the individual is ``terminally ill,'' as defined in section
1861(dd)(3)(A) of the Act and our regulations at Sec. 418.3; that is,
the individual has a medical prognosis that his or her life expectancy
is 6 months or less if the illness runs its normal course. The
regulations at Sec. 418.22(b)(2) require that clinical information and
other documentation that support the medical prognosis accompany the
certification and be filed in the medical record with it. Additionally,
the regulations at Sec. 418.22(b)(3) require that the
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certification and recertification forms include a brief narrative
explanation of the clinical findings that support a life expectancy of
6 months or less.
Under the Medicare hospice benefit, once a terminally ill patient
elects to receive hospice care, a hospice interdisciplinary group (IDG)
is essential in ensuring the provision of primarily home-based
services, keeping the choices of the patient and family first and
foremost. The hospice IDG works with the beneficiary, family, and
caregiver(s) to develop a coordinated, comprehensive care plan; reduce
unnecessary diagnostics or ineffective therapies; and maintain ongoing
communication with individuals and their families about changes in
their condition and care. The beneficiary's care plan will shift over
time to meet the changing needs of the individual, family, and
caregiver(s) as the individual approaches the end of life.
If, in the judgment of the hospice IDG, which includes the hospice
physician, the patient's symptoms cannot be effectively managed at
home, then the patient is eligible for general inpatient care (GIP), a
more medically intense level of care. GIP must be provided in a
Medicare-certified hospice freestanding facility, skilled nursing
facility, or hospital. GIP is provided to ensure that any new or
worsening symptoms are intensively addressed so that the beneficiary
can return to their home and continue to receive routine home care
(RHC). Limited, short-term, intermittent, inpatient respite care (IRC)
is also available to provide relief for the family or other caregivers,
or when the family or other caregivers are absent. Additionally, an
individual can receive continuous home care (CHC) during a period of
crisis, in which an individual requires continuous care to achieve
palliation or management of acute medical symptoms so that the
individual can remain at home. CHC may be covered for as much as 24
hours a day, and these periods must be predominantly nursing care, in
accordance with the regulations at Sec. 418.204. A minimum of 8 hours
of nursing care, or nursing and aide care, must be furnished on a
particular day to qualify for the CHC rate (Sec. 418.302(e)(4)).
Hospices must comply with applicable civil rights laws,\1\
including section 504 of the Rehabilitation Act of 1973 and the
Americans with Disabilities Act, under which covered entities must take
appropriate steps to ensure effective communication with patients and
patient care representatives with disabilities, including the
provisions of auxiliary aids and services. In addition, they must take
reasonable steps to ensure meaningful access for individuals with
limited English proficiency, consistent with Title VI of the Civil
Rights Act of 1964. Further information about these requirements may be
found at: http://www.hhs.gov/ocr/civilrights.
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\1\ Hospices are also subject to additional Federal civil rights
laws, including the Age Discrimination Act, Section 1557 of the
Affordable Care Act, and conscience and religious freedom laws.
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B. Services Covered by the Medicare Hospice Benefit
Coverage under the Medicare hospice benefit requires that hospice
services must be reasonable and necessary for the palliation and
management of the terminal illness and related conditions. Section
1861(dd)(1) of the Act establishes the services that are to be rendered
by a Medicare-certified hospice program. These covered services
include: Nursing care; physical therapy; occupational therapy; speech-
language pathology therapy; medical social services; home health aide
services (called hospice aide services); physician services; homemaker
services; medical supplies (including drugs and biologicals); medical
appliances; counseling services (including dietary counseling); short-
term inpatient care in a hospital, nursing facility, or hospice
inpatient facility (including both respite care and procedures
necessary for pain control and acute or chronic symptom management);
continuous home care during periods of crisis, and only as necessary to
maintain the terminally ill individual at home; and any other item or
service, which is specified in the plan of care and for which payment
may otherwise be made under Medicare in accordance with Title XVIII of
the Act.
Section 1814(a)(7)(B) of the Act requires that a written plan for
providing hospice care to a beneficiary who is a hospice patient be
established before care is provided by, or under arrangements made by,
the hospice program; and that the written plan be periodically reviewed
by the beneficiary's attending physician (if any), the hospice medical
director, and an interdisciplinary group (section 1861(dd)(2)(B) of the
Act). The services offered under the Medicare hospice benefit must be
available to beneficiaries as needed, 24 hours a day, 7 days a week
(section 1861(dd)(2)(A)(i) of the Act).
Upon the implementation of the hospice benefit, the Congress also
expected hospices to continue to use volunteer services, though
Medicare does not pay for these volunteer services (section
1861(dd)(2)(E) of the Act). As stated in the FY 1983 Hospice Wage Index
and Rate Update proposed rule (48 FR 38149), the hospice must have an
interdisciplinary group composed of paid hospice employees as well as
hospice volunteers, and that ``the hospice benefit and the resulting
Medicare reimbursement is not intended to diminish the voluntary spirit
of hospices.'' This expectation supports the hospice philosophy of
community based, holistic, comprehensive, and compassionate end of life
care.
C. Medicare Payment and Quality for Hospice Care
Sections 1812(d), 1813(a)(4), 1814(a)(7), 1814(i), and 1861(dd) of
the Act, and the regulations in 42 CFR part 418, establish eligibility
requirements, payment standards and procedures; define covered
services; and delineate the conditions a hospice must meet to be
approved for participation in the Medicare program. Part 418, subpart
G, provides for a per diem payment based on one of four prospectively-
determined rate categories of hospice care (RHC, CHC, IRC, and GIP),
based on each day a qualified Medicare beneficiary is under hospice
care (once the individual has elected). This per diem payment is meant
to cover all of the hospice services and items needed to manage the
beneficiary's care, as required by section 1861(dd)(1) of the Act.
While recent news reports \2\ have brought to light the potential
role hospices could play in medical aid in dying (MAID) where such
practices have been legalized in certain states, we wish to remind
hospices that the Assisted Suicide Funding Restriction Act of 1997
(Pub. L. 105-12) prohibits the use of Federal funds to provide or pay
for any health care item or service or health benefit coverage for the
purpose of causing, or assisting to cause, the death of any individual
including mercy killing, euthanasia, or assisted suicide. This means
that while payments made to hospices are to cover all items, services,
and drugs for the palliation and management of the terminal illness and
related conditions, Federal funds cannot be used for the prohibited
activities, even in the context of a per diem payment. However, the
prohibition does not pertain to the provision of an item or service for
the purpose of alleviating pain or discomfort, even if such use may
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increase the risk of death, so long as the item or service is not
furnished for the specific purpose of causing or accelerating death.
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\2\ Nelson, R., Should Medical Aid in Dying Be Part of Hospice
Care? Medscape Nurses. February 26, 2020. https://www.medscape.com/viewarticle/925769#vp_1.
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1. Omnibus Budget Reconciliation Act of 1989
Section 6005(a) of the Omnibus Budget Reconciliation Act of 1989
(Pub. L. 101-239) amended section 1814(i)(1)(C) of the Act and provided
changes in the methodology concerning updating the daily payment rates
based on the hospital market basket percentage increase applied to the
payment rates in effect during the previous Federal fiscal year.
2. Balanced Budget Act of 1997
Section 4441(a) of the Balanced Budget Act of 1997 (BBA) (Pub. L.
105-33) established that updates to the hospice payment rates beginning
FY 2002 and in subsequent FYs are to be the hospital market basket
percentage increase for the current FY. Section 4442 of the BBA amended
section 1814(i)(2) of the Act, effective for services furnished on or
after October 1, 1997, to require that hospices submit claims for
payment for hospice care furnished in an individual's home only on the
basis of the geographic location at which the service is furnished.
Previously, local wage index values were applied based on the
geographic location of the hospice provider, regardless of where the
hospice care was furnished. Section 4443 of the BBA amended sections
1812(a)(4) and 1812(d)(1) of the Act to provide for hospice benefit
periods of two 90-day periods, followed by an unlimited number of 60-
day periods.
3. FY 1998 Hospice Wage Index Final Rule
The FY 1998 Hospice Wage Index final rule (62 FR 42860) implemented
a new methodology for calculating the hospice wage index and instituted
an annual Budget Neutrality Adjustment Factor (BNAF) so aggregate
Medicare payments to hospices would remain budget neutral to payments
calculated using the 1983 wage index.
4. FY 2010 Hospice Wage Index Final Rule
The FY 2010 Hospice Wage Index and Rate Update final rule (74 FR
39384) instituted an incremental 7-year phase-out of the BNAF beginning
in FY 2010 through FY 2016. The BNAF phase-out reduced the amount of
the BNAF increase applied to the hospice wage index value, but was not
a reduction in the hospice wage index value itself or in the hospice
payment rates.
5. The Affordable Care Act
Starting with FY 2013 (and in subsequent FYs), the market basket
percentage update under the hospice payment system referenced in
sections 1814(i)(1)(C)(ii)(VII) and 1814(i)(1)(C)(iii) of the Act are
subject to annual reductions related to changes in economy-wide
productivity, as specified in section 1814(i)(1)(C)(iv) of the Act.
In addition, sections 1814(i)(5)(A) through (C) of the Act, as
added by section 3132(a) of the Patient Protection and Affordable Care
Act (PPACA) (Pub. L. 111-148), required hospices to begin submitting
quality data, based on measures specified by the Secretary of the
Department of Health and Human Services (the Secretary) for FY 2014 and
subsequent FYs. Since FY 2014, hospices that fail to report quality
data have their market basket percentage increase reduced by 2
percentage points. Note that with the passage of the Consolidated
Appropriations Act, 2021 (hereafter referred to as CAA 2021) (Pub. L.
116-260), the reduction changes to 4 percentage points beginning in FY
2024.
Section 1814(a)(7)(D)(i) of the Act, as added by section 3132(b)(2)
of the PPACA, required, effective January 1, 2011, that a hospice
physician or nurse practitioner have a face-to-face encounter with the
beneficiary to determine continued eligibility of the beneficiary's
hospice care prior to the 180th day recertification and each subsequent
recertification, and to attest that such visit took place. When
implementing this provision, the Centers for Medicare & Medicaid
Services (CMS) finalized in the FY 2011 Hospice Wage Index final rule
(75 FR 70435) that the 180th day recertification and subsequent
recertifications would correspond to the beneficiary's third or
subsequent benefit periods. Further, section 1814(i)(6) of the Act, as
added by section 3132(a)(1)(B) of the PPACA, authorized the Secretary
to collect additional data and information determined appropriate to
revise payments for hospice care and other purposes. The types of data
and information suggested in the PPACA could capture accurate resource
utilization, which could be collected on claims, cost reports, and
possibly other mechanisms, as the Secretary determined to be
appropriate. The data collected could be used to revise the methodology
for determining the payment rates for RHC and other services included
in hospice care, no earlier than October 1, 2013, as described in
section 1814(i)(6)(D) of the Act. In addition, CMS was required to
consult with hospice programs and the Medicare Payment Advisory
Commission (MedPAC) regarding additional data collection and payment
revision options.
6. FY 2012 Hospice Wage Index Final Rule
In the FY 2012 Hospice Wage Index final rule (76 FR 47308 through
47314) it was announced that beginning in 2012, the hospice aggregate
cap would be calculated using the patient-by-patient proportional
methodology, within certain limits. Existing hospices had the option of
having their cap calculated through the original streamlined
methodology, also within certain limits. As of FY 2012, new hospices
have their cap determinations calculated using the patient-by-patient
proportional methodology. If a hospice's total Medicare payments for
the cap year exceed the hospice aggregate cap, then the hospice must
repay the excess back to Medicare.
7. IMPACT Act of 2014
The Improving Medicare Post-Acute Care Transformation Act of 2014
(IMPACT Act) (Pub. L. 113-185) became law on October 6, 2014. Section
3(a) of the IMPACT Act mandated that all Medicare certified hospices be
surveyed every 3 years beginning April 6, 2015 and ending September 30,
2025. In addition, section 3(c) of the IMPACT Act requires medical
review of hospice cases involving beneficiaries receiving more than 180
days of care in select hospices that show a preponderance of such
patients; section 3(d) of the IMPACT Act contains a new provision
mandating that the cap amount for accounting years that end after
September 30, 2016, and before October 1, 2025 be updated by the
hospice payment percentage update rather than using the consumer price
index for urban consumers (CPI-U) for medical care expenditures.
8. FY 2015 Hospice Wage Index and Payment Rate Update Final Rule
The FY 2015 Hospice Wage Index and Rate Update final rule (79 FR
50452) finalized a requirement that the Notice of Election (NOE) be
filed within 5 calendar days after the effective date of hospice
election. If the NOE is filed beyond this 5-day period, hospice
providers are liable for the services furnished during the days from
the effective date of hospice election to the date of NOE filing (79 FR
50474). As with the NOE, the claims processing system must be notified
of a beneficiary's discharge from hospice or hospice benefit revocation
within 5
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calendar days after the effective date of the discharge/revocation
(unless the hospice has already filed a final claim) through the
submission of a final claim or a Notice of Termination or Revocation
(NOTR).
The FY 2015 Hospice Wage Index and Rate Update final rule (79 FR
50479) also finalized a requirement that the election form include the
beneficiary's choice of attending physician and that the beneficiary
provide the hospice with a signed document when he or she chooses to
change attending physicians.
In addition, the FY 2015 Hospice Wage Index and Rate Update final
rule (79 FR 50496) provided background, described eligibility criteria,
identified survey respondents, and otherwise implemented the Hospice
Experience of Care Survey for informal caregivers. Hospice providers
were required to begin using this survey for hospice patients as of
2015.
Finally, the FY 2015 Hospice Wage Index and Rate Update final rule
required providers to complete their aggregate cap determination not
sooner than 3 months after the end of the cap year, and not later than
5 months after, and remit any overpayments. Those hospices that fail to
submit their aggregate cap determinations on a timely basis will have
their payments suspended until the determination is completed and
received by the Medicare contractor (79 FR 50503).
9. FY 2016 Hospice Wage Index and Payment Rate Update Final Rule
In the FY 2016 Hospice Wage Index and Rate Update final rule (80 FR
47142), CMS finalized two different payment rates for RHC: A higher per
diem base payment rate for the first 60 days of hospice care and a
reduced per diem base payment rate for subsequent days of hospice care.
CMS also finalized a service intensity add-on (SIA) payment payable for
certain services during the last 7 days of the beneficiary's life. A
service intensity add-on payment will be made for the social worker
(SW) visits and nursing visits provided by a registered nurse (RN),
when provided during routine home care in the last 7 days of life. The
SIA payment is in addition to the routine home care rate. The SIA
payment is provided for visits of a minimum of 15 minutes and a maximum
of 4 hours per day (80 FR 47172).
In addition to the hospice payment reform changes discussed, the FY
2016 Hospice Wage Index and Rate Update final rule implemented changes
mandated by the IMPACT Act, in which the cap amount for accounting
years that end after September 30, 2016 and before October 1, 2025
would be updated by the hospice payment update percentage rather than
using the CPI-U (80 FR 47186). In addition, we finalized a provision to
align the cap accounting year for both the inpatient cap and the
hospice aggregate cap with the FY for FY 2017 and thereafter. Finally,
the FY 2016 Hospice Wage Index and Rate Update final rule (80 FR 47144)
clarified that hospices would have to report all diagnoses on the
hospice claim as a part of the ongoing data collection efforts for
possible future hospice payment refinements.
10. FY 2017 Hospice Wage Index and Payment Rate Update Final Rule
In the FY 2017 Hospice Wage Index and Rate Update final rule (81 FR
52160), CMS finalized several new policies and requirements related to
the HQRP. First, CMS codified the policy that if the National Quality
Forum (NQF) made non-substantive changes to specifications for HQRP
measures as part of the NQF's re-endorsement process, CMS would
continue to utilize the measure in its new endorsed status, without
going through new notice-and-comment rulemaking. CMS would continue to
use rulemaking to adopt substantive updates made by the NQF to the
endorsed measures adopted for the HQRP; determinations about what
constitutes a substantive versus non-substantive change would be made
on a measure-by-measure basis. Second, we finalized two new quality
measures for the HQRP for the FY 2019 payment determination and
subsequent years: (1) Hospice Visits when Death is Imminent Measure
Pair; and (2) Hospice and Palliative Care Composite Process Measure-
Comprehensive Assessment at Admission (81 FR 52173). The data
collection mechanism for both of these measures is the Hospice Item Set
(HIS), and the measures were effective April 1, 2017. Regarding the
CAHPS[supreg] Hospice Survey, CMS finalized a policy that hospices that
receive their CMS Certification Number (CCN) after January 1, 2017 for
the FY 2019 Annual Payment Update (APU) and January 1, 2018 for the FY
2020 APU will be exempted from the Hospice CAHPS[supreg] requirements
due to newness (81 FR 52182). The exemption is determined by CMS and is
only for 1 year.
11. FY 2020 Hospice Wage Index and Payment Rate Update Final Rule
In the FY 2020 Hospice Wage Index and Rate Update final rule (84 FR
38484), we finalized rebased payment rates for CHC and GIP and set
those rates equal to their average estimated FY 2019 costs per day. We
also rebased IRC per diem rates equal to the estimated FY 2019 average
costs per day, with a reduction of 5 percent to the FY 2019 average
cost per day to account for coinsurance. We finalized the FY 2020
proposal to reduce the RHC payment rates by 2.72 percent to offset the
increases to CHC, IRC, and GIP payment rates to implement this policy
in a budget-neutral manner in accordance with section 1814(i)(6) of the
Act (84 FR 38496).
In addition, we finalized a policy to use the current year's pre-
floor, pre-reclassified hospital inpatient wage index as the wage
adjustment to the labor portion of the hospice rates. Finally, in the
FY 2020 Hospice Wage Index and Rate Update final rule (84 FR 38505), we
finalized modifications to the hospice election statement content
requirements at Sec. 418.24(b), and added a requirement for hospices,
upon request, to furnish an election statement addendum effective
beginning in FY 2021. The addendum must list items, services, and drugs
the hospice has determined to be unrelated to the terminal illness and
related conditions, to increase coverage transparency for beneficiaries
under a hospice election.
12. Consolidated Appropriations Act, 2021
Division CC, section 404 of the CAA 2021 amended section
1814(i)(2)(B) of the Act and extended the provision that currently
mandates the hospice cap be updated by the hospice payment update
percentage (hospital market basket update reduced by the productivity
adjustment) rather than the CPI-U for accounting years that end after
September 30, 2016 and before October 1, 2030. Prior to enactment of
this provision, the hospice cap update was set to revert to the
original methodology of updating the annual cap amount by the CPI-U
beginning on October 1, 2025. Division CC, section 407(b) of CAA 2021
revised section 1814(i)(5)(A)(i) to increase the payment reduction for
hospices who fail to meet hospice quality measure reporting
requirements from 2 percentage points to 4 percentage points beginning
with FY 2024.
13. FY 2022 Hospice Wage Index and Payment Rate Update Final Rule
In the FY 2022 Hospice Wage Index and Rate Update final rule (86 FR
42532 through 42539), we finalized a policy to rebase and revise the
labor shares for CHC, RHC, IRC and GIP using Medicare cost report (MCR)
data for freestanding hospices (collected via CMS Form 1984-14, OMB NO.
0938-0758) for
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2018. We established separate labor shares for CHC, RHC, IRC, and GIP
based on the calculated compensation cost weights for each level of
care from the 2018 MCR data. The revised labor shares were implemented
in a budget neutral manner through the use of labor share
standardization factors.
In the FY 2022 final rule, we removed the seven original Hospice
Item Set (HIS) measures from the program because a more broadly
applicable measure (across settings, populations, or conditions) for
the particular topic is available and already publicly reported. The
Hospice Comprehensive Assessment Measure, NQF #3235, is one measure
that is calculated and rolled up by completion of the seven individual
measures. This measure helps to ensure all hospice patients receive a
holistic comprehensive assessment. Also, in or after May 2022, we will
start publicly reporting the two new claims-based measures.
Specifically, this includes the: (1) Hospice Visits in the Last Days of
Life (HVLDL) (which replaces the HIS Hospice Visits when Death is
Imminent measure pair); and (2) Hospice Care Index (HCI) that includes
10 indicators that collectively represent different aspects of hospice
care and aim to convey a comprehensive characterization of the quality
of care furnished by a hospice throughout the hospice stay. Related to
these changes, we finalized reporting eight quarters of claims data in
order to display small providers. We finalized the public reporting of
Consumer Assessment of Healthcare Providers and Systems (CAHPS[supreg])
Hospice Survey Star ratings on Care Compare to begin no sooner than FY
2022.
III. Provisions of the Proposed Rule
A. Proposed FY 2023 Hospice Wage Index and Rate Update
1. Proposed FY 2023 Hospice Wage Index
The hospice wage index is used to adjust payment rates for hospices
under the Medicare program to reflect local differences in area wage
levels, based on the location where services are furnished. The hospice
wage index utilizes the wage adjustment factors used by the Secretary
for purposes of section 1886(d)(3)(E) of the Act for hospital wage
adjustments. Our regulations at Sec. 418.306(c) require each labor
market to be established using the most current hospital wage data
available, including any changes made by the Office of Management and
Budget (OMB) to the Metropolitan Statistical Areas (MSAs) definitions.
In general, OMB issues major revisions to statistical areas every
10 years, based on the results of the decennial census. However, OMB
occasionally issues minor updates and revisions to statistical areas in
the years between the decennial censuses. On March 6, 2020, OMB issued
Bulletin No. 20-01, which provided updates to and superseded OMB
Bulletin No. 18-04 that was issued on September 14, 2018. The
attachments to OMB Bulletin No. 20-01 provided detailed information on
the update to statistical areas since September 14, 2018, and were
based on the application of the 2010 Standards for Delineating
Metropolitan and Micropolitan Statistical Areas to Census Bureau
population estimates for July 1, 2017 and July 1, 2018. (For a copy of
this bulletin, we refer readers to the following website: https://www.whitehouse.gov/wp-content/uploads/2020/03/Bulletin-20-01.pdf.) In
OMB Bulletin No. 20-01, OMB announced one new Micropolitan Statistical
Area, one new component of an existing Combined Statistical Area (CSA),
and changes to New England City and Town Area (NECTA) delineations. In
the FY 2021 Hospice Wage Index final rule (85 FR 47070) we stated that
if appropriate, we would propose any updates from OMB Bulletin No. 20-
01 in future rulemaking. After reviewing OMB Bulletin No. 20-01, we
determined that the changes in Bulletin 20-01 encompassed delineation
changes that would not affect the Medicare wage index for FY 2022.
Specifically, the updates consisted of changes to NECTA delineations
and the redesignation of a single rural county into a newly created
Micropolitan Statistical Area. The Medicare wage index does not utilize
NECTA definitions, and, as most recently discussed in the FY 2021
Hospice Wage Index final rule (85 FR 47070), we include hospitals
located in Micropolitan Statistical areas in each state's rural wage
index. Therefore, in the FY 2022 Hospice Wage Index final rule (86 FR
42528) we adopted the updates set forth in OMB Bulletin No. 20-01
consistent with our longstanding policy of adopting OMB delineation
updates.
In the FY 2020 Hospice Wage Index final rule (84 FR 38484), we
finalized the proposal to use the current FY's hospital wage index data
to calculate the hospice wage index values. In the FY 2021 Hospice Wage
Index final rule (85 FR 47070), we adopted the revised OMB delineations
with a 5-percent cap on wage index decreases, where the estimated
reduction in a geographic area's wage index would be capped at 5-
percent in FY 2021 and no cap would be applied to wage index decreases
for the second year (FY 2022). For FY 2023, the proposed hospice wage
index would be based on the FY 2023 hospital pre-floor, pre-
reclassified wage index for hospital cost reporting periods beginning
on or after October 1, 2018 and before October 1, 2019 (FY 2019 cost
report data). The proposed FY 2023 hospice wage index would not take
into account any geographic reclassification of hospitals, including
those in accordance with section 1886(d)(8)(B) or 1886(d)(10) of the
Act. The proposed FY 2023 hospice wage index would include a 5-percent
cap on wage index decreases as discussed later in this section. The
appropriate wage index value would be applied to the labor portion of
the hospice payment rate based on the geographic area in which the
beneficiary resides when receiving RHC or CHC. The appropriate wage
index value is applied to the labor portion of the payment rate based
on the geographic location of the facility for beneficiaries receiving
GIP or IRC.
In the FY 2006 Hospice Wage Index final rule (70 FR 45135), we
adopted the policy that, for urban labor markets without a hospital
from which hospital wage index data could be derived, all of the CBSAs
within the state would be used to calculate a statewide urban average
pre-floor, pre-reclassified hospital wage index value to use as a
reasonable proxy for these areas. For FY 2023, the only CBSA without a
hospital from which hospital wage data can be derived is 25980,
Hinesville-Fort Stewart, Georgia. The FY 2023 wage index value for
Hinesville-Fort Stewart, Georgia is 0.8620.
There exist some geographic areas where there were no hospitals,
and thus, no hospital wage data on which to base the calculation of the
hospice wage index. In the FY 2008 Hospice Wage Index final rule (72 FR
50217 through 50218), we implemented a methodology to update the
hospice wage index for rural areas without hospital wage data. In cases
where there was a rural area without rural hospital wage data, we use
the average pre-floor, pre-reclassified hospital wage index data from
all contiguous CBSAs, to represent a reasonable proxy for the rural
area. The term ``contiguous'' means sharing a border (72 FR 50217).
Currently, the only rural area without a hospital from which hospital
wage data could be derived is Puerto Rico. However, for rural Puerto
Rico, we would not apply this methodology due to the distinct economic
circumstances that exist there (for example, due to the close proximity
of almost all of Puerto Rico's various
[[Page 19447]]
urban areas to non-urban areas, this methodology would produce a wage
index for rural Puerto Rico that is higher than that in half of its
urban areas); instead, we would continue to use the most recent wage
index previously available for that area. For FY 2023, we propose to
continue using the most recent pre-floor, pre-reclassified hospital
wage index value available for Puerto Rico, which is 0.4047,
subsequently adjusted by the hospice floor.
As described in the August 8, 1997 Hospice Wage Index final rule
(62 FR 42860), the pre-floor and pre-reclassified hospital wage index
is used as the raw wage index for the hospice benefit. These raw wage
index values are subject to application of the hospice floor to compute
the hospice wage index used to determine payments to hospices. As
previously discussed, the pre-floor, pre-reclassified hospital wage
index values below 0.8 will be further adjusted by a 15 percent
increase subject to a maximum wage index value of 0.8. For example, if
County A has a pre-floor, pre-reclassified hospital wage index value of
0.3994, we would multiply 0.3994 by 1.15, which equals 0.4593. Since
0.4593 is not greater than 0.8, then County A's hospice wage index
would be 0.4593. In another example, if County B has a pre-floor, pre-
reclassified hospital wage index value of 0.7440, we would multiply
0.7440 by 1.15, which equals 0.8556. Because 0.8556 is greater than
0.8, County B's hospice wage index would be 0.8.
The proposed hospice wage index applicable for FY 2023 (October 1,
2022 through September 30, 2023) is available on the CMS website at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Wage-Index.html.
2. Proposed Permanent Cap on Wage Index Decreases
As discussed in section III.A.1, we have proposed and finalized
temporary transition policies in the past to mitigate significant
changes to payments due to changes to the hospice wage index.
Specifically, in the FY 2016 Hospice Wage Index and Payment Rate Update
final rule (80 FR 47142) we implemented a 50/50 blend for all
geographic areas consisting of the wage index values using the then-
current OMB area delineations and the wage index values using OMB's new
area delineations based on OMB Bulletin No. 13-01. In the FY 2021
Hospice Wage Index final rule (85 FR 47070), we adopted the revised OMB
delineations with a 5-percent cap on wage index decreases, where the
estimated reduction in a geographic area's wage index would be capped
at 5-percent in FY 2021 and no cap would be applied to wage index
decreases for the second year (FY 2022). As explained, we believed the
5-percent cap would provide greater transparency and be
administratively less complex than the prior methodology of applying a
50/50 blended wage index. We noted that this transition approach struck
an appropriate balance by providing a transition period to mitigate the
resulting -short-term instability and negative impacts on providers and
time for them to adjust to their new labor market area delineations and
wage index values.
In the FY 2022 Hospice Wage Index and Payment Rate Update final
rule (86 FR 42541), a few commenters stated that providers should be
protected against substantial payment reductions due to dramatic
reductions in wage index values from one year to the next. Because we
did not propose to modify the transition policy that was finalized in
the FY 2021 Hospice final rule, we did not extend the transition period
for FY 2022. In the FY 2022 Hospice final rule, we stated that we
continued to believe that applying the 5-percent cap transition policy
in year one provided an adequate safeguard against any significant
payment reductions associated with the adoption of the revised CBSA
delineations in FY 2021, allowed for sufficient time to make
operational changes for future FYs, and provided a reasonable balance
between mitigating some short-term instability in hospice payments and
improving the accuracy of the payment adjustment for differences in
area wage levels. However, we acknowledged that certain changes to wage
index policy may significantly affect Medicare payments. In addition,
we reiterated that our policy principles with regard to the wage index
include generally using the most current data and information available
and providing that data and information, as well as any approaches to
addressing any significant effects on Medicare payments resulting from
these potential scenarios, in notice and comment rulemaking. With these
policy principles in mind, we considered for this FY 2023 Hospice
proposed rule how best to address the potential scenarios, which
commenters raised concerns; that is, scenarios in which changes to wage
index policy may significantly affect Medicare payments.
In the past, we have established transition policies of limited
duration to phase in significant changes to labor market areas. In
taking this approach in the past, we sought to mitigate short term
instability and fluctuations that can negatively impact providers due
to wage index changes. In accordance with the requirement of our
regulations at Sec. 418.306(c) each labor market is established using
the most current hospital wage data available, including any changes
made by the OMB to the Metropolitan Statistical Areas (MSAs)
definitions. We have previously stated that, because the wage index is
a relative measure of the value of labor in prescribed labor market
areas, we believe it is important to implement new labor market area
delineations with as minimal a transition as is reasonably possible.
However, we recognize that changes to the wage index have the potential
to create instability and significant negative impacts on certain
providers even when labor market areas do not change. In addition,
year-to-year fluctuations in an area's wage index can occur due to
external factors beyond a provider's control, such as the COVID-19 PHE,
and for an individual provider, these fluctuations can be difficult to
predict. We also recognize that predictability in Medicare payments is
important to enable providers to budget and plan their operations.
In light of these considerations, we are proposing a permanent
approach to smooth year-to-year changes in providers' wage indexes. We
are proposing a policy that increases the predictability of hospice
payments for providers, and mitigates instability and significant
negative impacts to providers resulting from changes to the wage index.
As previously discussed, we believed that applying a 5-percent cap
on wage index decreases for FY 2021 provided greater transparency and
was administratively less complex than prior transition methodologies.
In addition, we believed this methodology mitigated short term
instability and fluctuations that can negatively impact providers due
to wage index changes. Lastly, we believed the 5-percent cap applied to
all wage index decreases for FY 2021 provided an adequate safeguard
against significant payment reductions related to the adoption of the
revised CBSAs. However, as discussed earlier in this section of the
proposed rule, we recognize there are circumstances that a one-year
mitigation policy, like the one adopted for FY 2021, would not
effectively address future years in which providers continue to be
negatively affected by significant wage index decreases.
Typical year-to-year variation in the hospice wage index has
historically been within 5-percent, and we expect
[[Page 19448]]
this will continue to be the case in future years. Therefore, we
believe that applying a 5-percent cap on all wage index decreases in
future years, regardless of the reason for the decrease, would
effectively mitigate instability in hospice payments due to any
significant wage index decreases that may affect providers in any year
that commenters raised in the FY 2022 Hospice final rule. In addition,
we believe that applying a 5-percent cap on all wage index decreases
would increase the predictability of hospice payments for providers,
enabling them to more effectively budget and plan their operations.
Lastly, we believe that applying a 5-percent cap on all wage index
decreases, from the prior year, would have a small overall impact on
the labor market area wage index system. As discussed in further detail
in section III.A.4. of this proposed rule, we estimate that applying a
5-percent cap on all wage index decreases, from the prior year, will
have a very small effect on the wage index budget standardization
factors for FY 2023. Because the wage index is a measure of the value
of labor (wage and wage-related costs) in a prescribed labor market
area relative to the national average, we anticipate that most
providers will not experience year-to-year wage index declines greater
than 5-percent in any given year. We believe that applying a 5-percent
cap on all wage index decreases, from the prior year, would continue to
maintain the accuracy of the overall labor market area wage index
system.
Therefore, for FY 2023 and subsequent years, we are proposing to
apply a permanent 5-percent cap on any decrease to a geographic area's
wage index from its wage index in the prior year, regardless of the
circumstances causing the decline. That is, we are proposing that a
geographic area's wage index for FY 2023 would not be less than 95
percent of its final wage index for FY 2022, regardless of whether the
geographic area is part of an updated CBSA, and that for subsequent
years, a geographic area's wage index would not be less than 95 percent
of its wage index calculated in the prior FY. We further propose that
if a geographic area's prior FY wage index is calculated based on the
5-percent cap, then the following year's wage index would not be less
than 95 percent of the geographic area's capped wage index in the prior
FY. For example, if a geographic area's wage index for FY 2023 is
calculated with the application of the 5-percent cap, then its wage
index for FY 2024 would not be less than 95 percent of its capped wage
index in FY 2023. Likewise, we are proposing to make the corresponding
regulations text changes at Sec. 418.306(c) as follows: Starting on
October 1, 2022, CMS applies a cap on decreases to the hospice wage
index such that the wage index applied to a geographic area is not less
than 95 percent of the wage index applied to that geographic area in
the prior FY. This 5-percent cap on negative wage index changes would
be implemented in a budget neutral manner through the use of wage index
standardization factors. Furthermore, the 5-percent cap would be
applied after the application of the hospice wage index floor.
Therefore, pre-floor, pre-reclassified hospital wage index values below
0.8 would be adjusted by the 15 percent increase, subject to a maximum
wage index value of 0.8. If there is a 5 percent decrease from the
previous FY's wage index value after the application of the hospice
wage index floor, then the 5-percent cap on wage index decreases would
also be applied.
In section III.A.4 of this proposed rule, we estimate the impact to
payments for providers in FY 2023 based on this proposed policy. We
also note that we would examine the effects of this policy on an
ongoing basis in the future in order to assess its appropriateness.
3. Proposed FY 2023 Hospice Payment Update Percentage
Section 4441(a) of the BBA (Pub. L. 105-33) amended section
1814(i)(1)(C)(ii)(VI) of the Act to establish updates to hospice rates
for FYs 1998 through 2002. Hospice rates were to be updated by a factor
equal to the inpatient hospital market basket percentage increase set
out under section 1886(b)(3)(B)(iii) of the Act, minus 1 percentage
point. Payment rates for FYs since 2002 have been updated according to
section 1814(i)(1)(C)(ii)(VII) of the Act, which states that the update
to the payment rates for subsequent FYs must be the inpatient market
basket percentage increase for that FY. In the FY 2022 IPPS final rule
CMS finalized the proposal to rebase and revise the IPPS market baskets
to reflect a 2018 base year. We refer readers to the FY 2022 IPPS final
rule for further information (86 FR 45194 through 45208).
Section 3401(g) of the Affordable Care Act mandated that, starting
with FY 2013 (and in subsequent FYs), the hospice payment update
percentage would be annually reduced by changes in economy-wide
productivity as specified in section 1886(b)(3)(B)(xi)(II) of the Act.
The statute defines the productivity adjustment to be equal to the 10-
year moving average of changes in annual economy-wide private nonfarm
business multifactor productivity (MFP) as projected by the Secretary
for the 10-year period ending with the applicable FY, year, cost
reporting period, or other annual period) (the ``productivity
adjustment''). The United States Department of Labor's Bureau of Labor
Statistics (BLS) publishes the official measures of productivity for
the United States economy. We note that previously the productivity
measure referenced in section 1886(b)(3)(B)(xi)(II) was published by
BLS as private nonfarm business multifactor productivity. Beginning
with the November 18, 2021 release of productivity data, BLS replaced
the term ``multifactor productivity'' with ``total factor
productivity'' (TFP). BLS noted that this is a change in terminology
only and will not affect the data or methodology. As a result of the
BLS name change, the productivity measure referenced in section
1886(b)(3)(B)(xi)(II) of the Act is now published by BLS as ``private
nonfarm business total factor productivity''. However, as mentioned,
the data and methods are unchanged. We refer readers to http://www.bls.gov for the BLS historical published TFP data. A complete
description of IGI's TFP projection methodology is available on the CMS
website at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareProgramRatesStats/MarketBasketResearch. In addition, in the FY 2022 IPPS final rule (86
FR 45214), we noted that beginning with FY 2022, CMS changed the name
of this adjustment to refer to it as the ``productivity adjustment''
rather than the ``MFP adjustment''.
The proposed hospice payment update percentage for FY 2023 is based
on the proposed inpatient hospital market basket update of 3.1 percent
(based on IHS Global Inc.'s fourth quarter 2021 forecast with
historical data through the third quarter 2021). Due to the
requirements at sections 1886(b)(3)(B)(xi)(II) and 1814(i)(1)(C)(v) of
the Act, the proposed inpatient hospital market basket update for FY
2023 of 3.1 percent must be reduced by a productivity adjustment as
mandated by the Affordable Care Act (currently estimated to be 0.4
percentage point for FY 2023). In effect, the proposed hospice payment
update percentage for FY 2023 would be 2.7 percent. We also propose
that if more recent data become available after the publication of this
proposed rule and before the publication of the final rule (for
[[Page 19449]]
example, more recent estimates of the inpatient hospital market basket
update and productivity adjustment), we would use such data, if
appropriate, to determine the hospice payment update percentage for FY
2023 in the final rule. We continue to believe it is appropriate to
routinely update the hospice payment system so that it reflects the
best available data about differences in patient resource use and costs
among hospices as required by the statute. Therefore, we are proposing
to: (1) Update hospice payments using the methodology outlined and
apply the 2018-based IPPS market basket update for FY 2023 of 3.1
percent, reduced by the statutorily required productivity adjustment of
0.4 percentage point along with the wage index budget neutrality
adjustment to update the payment rates; and (2) use the FY 2023 hospice
wage index which uses the FY 2023 pre-floor, pre-reclassified IPPS
hospital wage index as its basis.
In the FY 2022 Hospice Wage Index final rule (86 FR 42532 through
42539), we rebased and revised the labor shares for RHC, CHC, GIP and
IRC using MCR data for freestanding hospices (CMS Form 1984-14, OMB
Control Number 0938-0758) from 2018. The current labor portion of the
payment rates are: For RHC, 66.0 percent; for CHC, 75.2 percent; for
GIP, 63.5 percent; and for IRC, 61.0 percent. The non-labor portion is
equal to 100 percent minus the labor portion for each level of care.
The non-labor portion of the payment rates are as follows: For RHC,
34.0 percent; for CHC, 24.8 percent; for GIP, 36.5 percent; and for
IRC, 39.0 percent.
4. Proposed FY 2023 Hospice Payment Rates
There are four payment categories that are distinguished by the
location and intensity of the hospice services provided. The base
payments are adjusted for geographic differences in wages by
multiplying the labor share, which varies by category, of each base
rate by the applicable hospice wage index. A hospice is paid the RHC
rate for each day the beneficiary is enrolled in hospice, unless the
hospice provides CHC, IRC, or GIP. CHC is provided during a period of
patient crisis to maintain the patient at home; IRC is short-term care
to allow the usual caregiver to rest and be relieved from caregiving;
and GIP is to treat symptoms that cannot be managed in another setting.
As discussed in the FY 2016 Hospice Wage Index and Rate Update
final rule (80 FR 47172), we implemented two different RHC payment
rates, one RHC rate for the first 60 days and a second RHC rate for
days 61 and beyond. In addition, in that final rule, we implemented an
SIA payment for RHC when direct patient care is provided by an RN or
social worker during the last 7 days of the beneficiary's life. The SIA
payment is equal to the CHC hourly rate multiplied by the hours of
nursing or social work provided (up to 4 hours total) that occurred on
the day of service, if certain criteria are met. In order to maintain
budget neutrality, as required under section 1814(i)(6)(D)(ii) of the
Act, the new RHC rates were adjusted by a service intensity add-on
budget neutrality factor (SBNF). The SBNF is used to reduce the overall
RHC rate in order to ensure that SIA payments are budget-neutral. At
the beginning of every FY, SIA utilization is compared to the prior
year in order calculate a budget neutrality adjustment. In the FY 2017
Hospice Wage Index and Rate Update final rule (81 FR 52156), we
initiated a policy of applying a wage index standardization factor to
hospice payments in order to eliminate the aggregate effect of annual
variations in hospital wage data. Typically, the wage index
standardization factor is calculated using the most recent, complete
hospice claims data available. However, due to the COVID-19 PHE, in the
FY 2022 Hospice Wage Index and Payment Rate Update proposed rule we
looked at using hospice claims data before the declaration of the
COVID-19 PHE (FY 2019) to determine if there were significant
differences between utilizing 2019 and 2020 claims data. The difference
between using FY 2019 and FY 2020 hospice claims data was minimal.
Therefore, in the FY 2022 Hospice Wage Index and Payment Rate Update
final rule (86 FR 42543), we stated that we would continue our practice
of using the most recent, complete hospice claims data available. For
FY 2023 hospice rate setting, we saw minimal differences in using the
updated data; therefore, we are continuing our longstanding policy of
using the most recent data available. Specifically, we are using FY
2021 claims data with the FY 2023 payment rate updates. In order to
calculate the wage index standardization factor, we simulate total
payments using FY 2021 hospice utilization claims data with the FY 2022
wage index (pre-floor, pre-reclassified hospital wage index with the
hospice floor, without the 5-percent cap on wage index decreases) and
FY 2022 payment rates and compare it to our simulation of total
payments using the FY 2023 hospice wage index (pre-floor, pre-
reclassified hospital wage index with hospice floor, with the 5-percent
cap on wage index decreases) and FY 2022 payment rates. By dividing
payments for each level of care (RHC days 1 through 60, RHC days 61+,
CHC, IRC, and GIP) using the FY 2022 wage index and payment rates for
each level of care by the FY 2023 wage index and FY 2022 payment rates,
we obtain a wage index standardization factor for each level of care.
The wage index standardization factors for each level of care are shown
in the Tables 1 and 2.
The proposed FY 2023 RHC rates are shown in Table 1. The proposed
FY 2023 payment rates for CHC, IRC, and GIP are shown in Table 2.
Table 1--Proposed FY 2023 Hospice RHC Payment Rates
--------------------------------------------------------------------------------------------------------------------------------------------------------
SIA budget Wage index Proposed FY Proposed FY
Code Description FY 2022 neutrality standardization 2023 hospice 2023 payment
payment rates factor factor payment update rates
--------------------------------------------------------------------------------------------------------------------------------------------------------
651.............................. Routine Home Care (days 1-60)..... $203.40 1.0004 1.0008 1.027 $209.14
651.............................. Routine Home Care (days 61+)...... 160.74 1.0003 1.0007 1.027 165.25
--------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 19450]]
Table 2--Proposed FY 2023 Hospice CHC, IRC, and GIP Payment Rates
----------------------------------------------------------------------------------------------------------------
Proposed FY
FY 2022 payment Wage index 2023 hospice Proposed FY
Code Description rates standardization payment 2023 payment
factor update rates
----------------------------------------------------------------------------------------------------------------
652................ Continuous Home $1,462.52 ($60.94 1.0024 1.027 $1,505.61
Care Full Rate = per hour).
24 hours of care.
655................ Inpatient Respite 473.75............. 1.0007 1.027 486.88
Care.
656................ General Inpatient 1,068.28........... 1.0016 1.027 1,098.88
Care.
----------------------------------------------------------------------------------------------------------------
Sections 1814(i)(5)(A) through (C) of the Act require that hospices
submit quality data, based on measures to be specified by the
Secretary. In the FY 2012 Hospice Wage Index and Rate Update final rule
(76 FR 47320 through 47324), we implemented a HQRP as required by those
sections. Hospices were required to begin collecting quality data in
October 2012 and submit those quality data in 2013. Section
1814(i)(5)(A)(i) of the Act requires that beginning with FY 2014 and
each subsequent FY, the Secretary shall reduce the market basket update
by 2 percentage points for any hospice that does not comply with the
quality data submission requirements with respect to that FY. The
proposed FY 2023 rates for hospices that do not submit the required
quality data would be updated by the proposed FY 2023 hospice payment
update percentage of 2.7 percent minus 2 percentage points. These rates
are shown in Tables 3 and 4.
Table 3--Proposed FY 2023 Hospice RHC Payment Rates for Hospices That DO NOT Submit the Required Quality Data
--------------------------------------------------------------------------------------------------------------------------------------------------------
Proposed FY
2023 hospice
SIA budget Wage index payment Proposed FY
Code Description FY 2022 neutrality standardization update of 2023 payment
payment rates factor factor 2.7% minus 2 rates
percentage
points = +0.7%
--------------------------------------------------------------------------------------------------------------------------------------------------------
651.............................. Routine Home Care (days 1-60)..... $203.40 1.0004 1.0008 1.007 $205.07
651.............................. Routine Home Care (days 61+)...... 160.74 1.0003 1.0007 1.007 162.03
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 4--Proposed FY 2023 Hospice CHC, IRC, and GIP Payment Rates for Hospices That DO NOT Submit the Required
Quality Data
----------------------------------------------------------------------------------------------------------------
Proposed FY
2023 hospice
Wage index payment Proposed FY
Code Description FY 2022 payment standardization update of 2023 payment
rates factor 2.7% minus 2 rates
percentage
points = +0.7%
----------------------------------------------------------------------------------------------------------------
652................ Continuous Home $1,462.52 ($60.94 1.0024 1.007 $1,476.29
Care. per hour).
Full Rate= 24 hours
of care.
655................ Inpatient Respite $473.75............ 1.0007 1.007 $477.40
Care.
656................ General Inpatient 1,068.28........... 1.0016 1.007 1,077.48
Care.
----------------------------------------------------------------------------------------------------------------
5. Proposed Hospice Cap Amount for FY 2023
As discussed in the FY 2016 Hospice Wage Index and Rate Update
final rule (80 FR 47183), we implemented changes mandated by the IMPACT
Act of 2014 (Pub. L. 113-185). Specifically, we stated that for
accounting years that end after September 30, 2016 and before October
1, 2025, the hospice cap is updated by the hospice payment update
percentage rather than using the CPI-U. Division CC, section 404 of the
CAA 2021 extended the accounting years impacted by the adjustment made
to the hospice cap calculation until 2030. In the FY 2022 Hospice Wage
Index final rule (86 FR 42539), we finalized conforming regulations
text changes at Sec. 418.309 to reflect the provisions of the CAA
2021. Therefore, for accounting years that end after September 30, 2016
and before October 1, 2030, the hospice cap amount is updated by the
hospice payment update percentage rather than using the CPI-U.
The proposed hospice cap amount for the FY 2023 cap year is
$32,142.65, which is equal to the FY 2022 cap amount ($31,297.61)
updated by the proposed FY 2023 hospice payment update percentage of
2.7 percent.
B. Proposed Updates to the Hospice Quality Reporting Program
1. Background and Statutory Authority
The Hospice Quality Reporting Program (HQRP) specifies reporting
requirements for the Hospice Item Set (HIS), administrative data, and
Consumer Assessment of Healthcare Providers and Systems (CAHPS[supreg])
Hospice Survey. Section 1814(i)(5) of the Act requires the Secretary to
establish and maintain a quality
[[Page 19451]]
reporting program for hospices. Section 1814(i)(5)(A)(i) of the Act was
amended by section 407(b) of Division CC, Title IV of the CAA 2021
(Pub. L. 116-260) to change the payment reduction for failing to meet
hospice quality reporting requirements from 2 to 4 percentage points.
This policy will apply beginning with FY 2024 annual payment update
(APU) that is based on CY 2022 quality data. Specifically, the Act
requires that, beginning with FY 2014 through FY 2023, the Secretary
shall reduce the market basket update by 2 percentage points and
beginning with the FY 2024 APU and for each subsequent year, the
Secretary shall reduce the market basket update by 4 percentage points
for any hospice that does not comply with the quality data submission
requirements for that FY.
Depending on the amount of the annual update for a particular year,
a reduction of 2 percentage points through FY 2023 or 4 percentage
points beginning in FY 2024 could result in the annual market basket
update being less than zero percent for a FY and may result in payment
rates that are less than payment rates for the preceding FY. Any
reduction based on failure to comply with the reporting requirements,
as required by section 1814(i)(5)(B) of the Act, would apply only for
the specified year.
In the FY 2022 Hospice Wage Index and Payment Rate Update final
rule (86 FR 42552), we finalized two new measures using claims data:
(1) Hospice Visits in the Last Days of Life (HVLDL); and (2) Hospice
Care Index (HCI). We also finalized a policy that claims-based measures
will use 8 quarters of data in order to report on more hospices. In
addition, we removed the seven Hospice Item Set (HIS) Process Measures
from the program as individual measures and public reporting because
the HIS Comprehensive Assessment Measure (NQF#3235) is sufficient for
measuring care at admission without the seven individual process
measures. For a detailed discussion of the historical use for measure
selection and removal for the HQRP quality measures, we refer readers
to the FY 2016 Hospice Wage Index and Rate Update final rule (80 FR
47142) and the FY 2019 Hospice Wage Index and Rate Update final rule
(83 FR 38622). In the FY 2022 Hospice Wage Index and Rate Update final
rule (86 FR 42553), we finalized Sec. 418.312(b)(2); this new
provision requires hospices to provide administrative data, including
claims-based measures, as part of the HQRP requirements for Sec.
418.306(b). In that same final rule, we provided CAHPS Hospice Survey
updates. We finalized temporary changes to our public reporting
policies based on the March 27, 2020 memorandum \3\ and provided
another tip sheet, referred to as the Second Edition HRQP Public
Reporting Tip Sheet (https://www.cms.gov/files/document/second-edition-hqrp-public-reporting-tip-sheetpdf.pdf) on the HQRP Requirements and
Best Practices web page (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/HQRP-Requirements-and-Best-Practices).
---------------------------------------------------------------------------
\3\ Exceptions and Extensions for Quality Reporting Requirements
for Acute Care Hospitals, PPS-Exempt Cancer Hospitals, Inpatient
Psychiatric Facilities, Skilled Nursing Facilities, Home Health
Agencies, Hospices, Inpatient Rehabilitation Facilities, Long-Term
Care Hospitals, Ambulatory Surgical Centers, Renal Dialysis
Facilities, and MIPS Eligible Clinicians Affected by COVID-19.
Available at: https://www.cms.gov/files/document/guidance-memo-exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf
---------------------------------------------------------------------------
As finalized in the FY 2022 Hospice Wage Index and Payment Rate
Update final rule (86 FR 42552), CMS is targeting the May 2022 refresh
of Care Compare/Provider Data Catalogue (PDC) for the inaugural display
of the two new claims-based quality measures (QMs), the Hospice Visits
in Last Days of Life (HVLDL) and the Hospice Care Index (HCI). This
rule proposes no new quality measures but proposes updates on already-
adopted measures. Table 5 shows all quality measures finalized in the
FY 2022 Hospice Wage Index and Payment Rate Update final rule and in
effect for the FY 2023 HQRP.
Table 5--Quality Measures Finalized in the FY 2022 Hospice Wage Index
Final Rule and in Effect for FY 2023 for the Hospice Quality Reporting
Program
------------------------------------------------------------------------
Hospice quality reporting program
-------------------------------------------------------------------------
NQF# Hospice item set
------------------------------------------------------------------------
3235............................ Hospice and Palliative Care Composite
Process Measure--HIS-Comprehensive
Assessment Measure at Admission
includes:
1. Patients Treated with an Opioid
who are Given a Bowel Regimen (NQF
#1617).
2. Pain Screening.
3. Pain Assessment.
4. Dyspnea Treatment.
5. Dyspnea Screening.
6. Treatment Preferences.
7. Beliefs/Values Addressed (if
desired by the patient).
------------------------------------------------------------------------
Administrative Data, including Claims-based Measures
------------------------------------------------------------------------
3645 Hospice Visits in Last Days of Life
(HVLDL).
Pending NQF endorsement......... Hospice Care Index (HCI).
[[Page 19452]]
1. Continuous Home Care (CHC) or
General Inpatient (GIP) Provided.
2. Gaps in Skilled Nursing Visits.
3. Early Live Discharges.
4. Late Live Discharges.
5. Burdensome Transitions (Type 1)--
Live Discharges from Hospice Followed
by Hospitalization and Subsequent
Hospice Readmission.
6. Burdensome Transitions (Type 2)--
Live Discharges from Hospice Followed
by Hospitalization with the Patient
Dying in the Hospital.
7. Per-beneficiary Medicare Spending.
8. Skilled Nursing Care Minutes per
Routine Home Care (RHC) Day.
9. Skilled Nursing Minutes on Weekends
10. Visits Near Death.
------------------------------------------------------------------------
CAHPS Hospice Survey
------------------------------------------------------------------------
2651............................ CAHPS Hospice Survey.
1. Communication with Family.
2. Getting timely help.
3. Treating patient with respect.
4. Emotional and spiritual support.
5. Help for pain and symptoms.
6. Training family to care for the
patient.
7. Rating of this hospice.
8. Willing to recommend this hospice.
------------------------------------------------------------------------
2. Hospice Outcomes & Patient Evaluation (HOPE) Update
As finalized in the FY 2020 Hospice Wage Index and Payment Rate
Update and Hospice Quality Reporting Requirements final rule (84 FR
38484), we are developing a hospice patient assessment instrument
identified as HOPE. HOPE contributes to the patient's plan of care
through on-going patient assessments throughout the hospice stay. HOPE
is designed to support the hospice conditions of participation (CoPs),
including hospices' quality assessment and performance improvement
(QAPI) and provide quality data to calculate outcome and other types of
quality measures. Our primary objectives for HOPE are to provide
quality data for the HQRP requirements through standardized data
collection; support survey and certification processes; and provide
additional clinical data that could inform future payment refinements.
HOPE is an on-going patient assessment instrument designed to
capture patient and family care needs throughout the hospice stay. HOPE
supports care planning, quality improvement efforts, and health and
safety of patients enrolled in Medicare-certified hospices. HOPE will
include key items from the HIS and demographics like gender and race.
Some HIS items will be modified for inclusion in HOPE to increase
specificity. This approach to include key demographic information
reflects stakeholder feedback discussed in the FYs 2017 and 2018
Hospice Wage Index and Payment Rate Update final rules (81 FR 52171 and
82 FR 36669, respectively).
HOPE is multidisciplinary, with the assessment instrument to be
completed by nursing, social work, and spiritual care staff. We are
undergoing testing with three distinct disciplinary assessments in beta
field testing described in this section. We stated in the FY 2022
Hospice Wage Index and Payment Update final rule (86 FR 42528) that
while the standardized patient assessment data elements for certain
post-acute care providers required under the IMPACT Act of 2014 are not
applicable to hospices, it is reasonable to include some of those
standardized elements that appropriately and feasibly apply to hospice.
Some patients may move through the healthcare system to hospice.
Therefore, tracking key demographic and social risk factor items that
apply to hospice support our goals for continuity of care, overall
patient care and well-being, interoperability, and health equity that
is also discussed in this rule.
The draft of HOPE has undergone cognitive, pilot, and alpha
testing, and is undergoing national beta field testing to establish
reliability, validity, and feasibility of the assessment instrument.
The purpose of the alpha test was to establish preliminary reliability
and validity of the draft assessment items, and feasibility of the HOPE
assessment. Specifically, the objectives were to:
Establish inter-rater reliability (IRR) of the assessment
items.
Demonstrate validity of the assessment items.
Demonstrate feasibility of the assessment and time points
for data collection.
HOPE alpha testing completed at the end of January 2021. Based on
the quantitative data analyses and feedback from assessors in alpha
testing, the items generally support the feasibility of collecting the
data items. Alpha testing also showed that HOPE exhibited acceptable
inter-rater reliability ranging from moderate to very good with few
exceptions and demonstrated evidence of convergent validity. We used
findings of the alpha test to inform decisions about the next draft of
the HOPE assessment, which are being tested in the national beta test
that began in late fall 2021 and continuing through 2022.
National beta testing allows us to obtain input from participating
hospice teams about the assessment instrument and field testing to
refine and support the final draft items and assessment time points for
HOPE. It also allows us to estimate the time to complete the HOPE data
items. We anticipate proposing HOPE in future rulemaking after testing
and analyses are complete.
[[Page 19453]]
We continue HOPE development in accordance with the Blueprint for
the CMS Measures Management System. HOPE development is grounded in
information gathering activities to identify and refine hospice
assessment domains and candidate assessment items. We appreciate the
industry's and national associations' engagement in providing input
through information sharing activities, including listening sessions,
expert interviews, key stakeholder interviews, and focus groups to
support HOPE development. As CMS proceeds with field testing HOPE, we
will continue to engage with stakeholders through sub-regulatory
channels. In particular, we will continue to host HQRP Forums to allow
hospices and other interested parties to engage with us on the latest
updates and ask questions on the development of HOPE and related
quality measures. We also have a dedicated email account,
[email protected], for comments about HOPE.
We will use field test results to create a final version of HOPE to
propose in future rulemaking for national implementation. We will
continue to engage all stakeholders throughout this process that
includes a variety of sub-regulatory channels and regular HQRP
communication strategies, such as Open Door Forums, Medicare Learning
Network (MLN), CMS.gov website announcements, listserv messaging, and
other ad hoc publicly announced opportunities. We appreciate the
support for HOPE and reiterate our commitment to providing updates and
engaging stakeholders through sub-regulatory means. HOPE updates can be
found at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/HOPE and engagement
opportunities, including those regarding HOPE are at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-QRP-Provider-Engagement-Opportunities.
3. Update on Future Quality Measure (QM) Development
In the FY 2020 Hospice Wage Index and Payment Rate Update final
rule (84 FR 38484), we provided updates related to CMS's process for
identifying high priority areas of quality measurement and improvement
and for developing quality measures that address those priorities.
Information on the current HQRP quality measures can be found at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures. In this
proposed rule, we provide contemplated updates for hospice quality
measure concepts based on future use of HOPE and administrative data.
In section III.B.6 of this proposed rule, we are seeking public comment
from hospices on their health equity initiatives and a structural
composite measure concept to inform future measure development.
To support new measure development, our contractor convened two
technical expert panel (TEP) meetings in 2021. The TEP considered HOPE-
based process measures that may be proposed with HOPE in future
rulemaking. The TEP meetings in 2021 included HOPE-based process
measures intended to (1) evaluate the rate at which hospices' use
specific processes of care; (2) assist in reducing variation in care
delivery; and (3) determine hospices' compliance with practices that
are expected to improve outcomes. The TEP also considered potential
areas for future quality measure development. We refer the public to
the ``2021 Technical Expert Panel Meetings: Hospice Quality Reporting
Program Summary Report'' available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-QRP-Provider-Engagement-Opportunities.
As stated in the FY 2022 Hospice Wage Index and Rate Update final
rule (86 FR 42528), we continue to consider developing hybrid quality
measures that could be calculated from multiple data sources: for
example, claims, assessments (HOPE), or other data sources. Hybrid
quality measures allow for a more comprehensive set of information
about care processes and outcomes than can be calculated using claims
data alone. As described in the ``2021 Technical Expert Panel Meetings:
Hospice Quality Reporting Program Summary Report,'' the TEP discussed
hybrid concepts such as hospitalizations during a hospice election and
patterns of live discharge using claims data and HOPE data elements.
4. Updates to the CAHPS Hospice Survey Participation Requirements for
the FY 2023 APU and Subsequent Years
a. Background and Description of the CAHPS Hospice Survey
The CAHPS Hospice Survey is a component of the CMS HQRP, which is
used to collect data on the experiences of hospice patients and the
primary caregivers listed in their hospice records. Readers who want
more information about the development of the survey, originally called
the Hospice Experience of Care Survey, may refer to 79 FR 50452 and 78
FR 48261.
b. Overview of the ``CAHPS Hospice Survey Measures''
The CAHPS Hospice Survey measures were re-endorsed by NQF on
November 20, 2020. The re-endorsement can be found on the NQF website
at: https://www.qualityforum.org/Measures_Reports_Tools.aspx. The
survey received its initial NQF endorsement on October 26, 2016 (NQF
#2651). We adopted 8 survey-based measures for the CY 2018 data
collection period and for subsequent years. These eight measures are
publicly reported on a designated CMS website, Care Compare, https://www.medicare.gov/care-compare/.
c. CAHPS Hospice Survey Mode Experiment
CMS recently conducted a mode experiment with the goal of testing
the effects of adding a web-based mode to the CAHPS Hospice Survey. We
are examining the impact of a web-based mode on survey response rates
and scores. The survey currently has three approved modes without any
web component (mail, telephone, and mail with telephone follow-up.). In
addition, the test will allow for examination of the effects of a
shortened survey (that is, removing existing survey items) on response
rate and scores; assessment of the measure properties of a limited
number of supplemental survey items suggested by stakeholders; and
calculation of item-level mode adjustments for the shortened survey in
the currently-approved modes of CAHPS Hospice Survey administration, as
well as the proposed new web-based mode.
The mode experiment design applied all of the existing CAHPS
Hospice Survey eligibility criteria, and sampled patients/caregivers
across five arms. The first arm tested a new web-mail mode, in which
invitations to the web survey were sent by email to those with email
addresses. The email was personalized to the respondent and included a
link to the web version of the survey, which can be completed on either
a computer or a mobile device such as a smartphone or tablet. If the
respondent did not complete the web survey after one week, or did not
have a valid email address in which to send an email, up to two surveys
were sent by mail. This arm used a shortened version of the CAHPS
Hospice Survey.
In the next three arms, the shortened version of the CAHPS Hospice
Survey instrument was administered in the three currently-approved
modes: Mail only; telephone-only; and mixed mode
[[Page 19454]]
(mail with telephone follow up). The fifth arm, in which the current
survey instrument was administered via mail only served as a comparison
for all other arms. Across all arms, half of sampled caregivers
received a pre-notification letter to examine the effects of such a
letter on response rates.
Overall (across the five arms), CMS sampled 15,000 eligible
caregivers from around 50 hospices over a six- to seven-month period.
Caregivers were randomized within each hospice to one of the five arms.
We continue to analyze the results of the mode experiment and will
keep stakeholders informed on any plans for changes to the survey
content or administration options through our regular stakeholder
communication channels. In this proposed rule, there are no changes to
the administration procedures or content for the CAHPS Hospice Survey.
Any changes to the CAHPS Hospice Survey will be proposed in future
rulemaking.
d. Data Sources
In the FY 2020 Hospice Wage Index and Rate Update final rule (84 FR
38484), we finalized the participation requirements for the CAHPS
Hospice Survey. To meet the CAHPS Hospice Survey requirements for the
HQRP, hospice facilities must contract with a CMS-approved vendor to
collect survey data for eligible patients on a monthly basis and report
that data to CMS on the hospice's behalf by the quarterly deadlines
established for each data collection period.
e. Public Reporting of CAHPS Hospice Survey Results
We began public reporting of the results of the CAHPS Hospice
Survey on Hospice Compare as of February 2018. Before the COVID-19 PHE,
we reported the most recent 8 quarters of data on the basis of a
rolling average, with the most recent quarter of data being added and
the oldest quarter of data removed from the averages for each data
refresh. As finalized in the FY 2022 Hospice Wage Index and Payment
Rule Update (86 FR 42528), we are not reporting Q1 2020 and Q2 2020
data due to the COVID-19 PHE. Therefore, we have publicly reported the
most recently available 8 quarters of CAHPS data that excluded Q1 2020
and Q2 2020 data. These data were publicly reported starting with the
February 2022 refresh and will continue through the May 2023 refresh on
Care Compare. The Second Edition HQRP Public Reporting Tip Sheet dated
Dec. 2021 on the HQRP Requirements and Best Practices web page (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/HQRP-Requirements-and-Best-Practices) summarizes CMS' approach to the HQRP as public reporting has
resumed in February 2022. It also explains the HQRP public reporting
changes associated with the FY 2022 Hospice Wage Index and Payment Rule
Update final rule and provides a summary of the data refreshes.
f. Volume-Based Exemption for CAHPS Hospice Survey Data Collection and
Reporting Requirements
In the FY 2020 Hospice Wage Index and Rate Update final rule (84 FR
38526), we finalized a policy making a volume-based exemption for CAHPS
Hospice Survey Data Collection and Reporting requirements for FY 2021
and every year thereafter.
In this proposed rule, there would be no changes to this exemption.
The exemption request form is available on the official CAHPS Hospice
Survey website: http://www.hospiceCAHPSsurvey.org. Hospices that intend
to claim the size exemption are required to submit to CMS their
completed exemption request form by December 31, of the data collection
year.
Hospices that served a total of fewer than 50 survey-eligible
decedent/caregiver pairs in the year before the data collection year
are eligible to apply for the size exemption. Hospices may apply for a
size exemption by submitting the size exemption request form. The size
exemption is only valid for the year on the size exemption request
form. If the hospice remains eligible for the size exemption, the
hospice must complete the size exemption request form for every
applicable FY APU period, as shown in Table 6.
Table 6--Size Exemption Key Dates FY 2023 Through FY 2026
----------------------------------------------------------------------------------------------------------------
Size exemption form
Fiscal year Data collection year Reference year submission deadline
----------------------------------------------------------------------------------------------------------------
FY 2023.............................. CY 2021................ CY 2020................ December 31, 2021.
FY 2024.............................. CY 2022................ CY 2021................ December 31, 2022.
FY 2025.............................. CY 2023................ CY 2022................ December 31, 2023.
FY 2026.............................. CY 2024................ CY 2023................ December 31, 2024.
----------------------------------------------------------------------------------------------------------------
g. Newness Exemption for CAHPS Hospice Survey Data Collection and
Public Reporting Requirements
We previously finalized a one-time newness exemption for hospices
that meet the criteria as stated in the FY 2017 Hospice Wage Index and
Payment Rate Update final rule (81 FR 52181). In the FY 2019 Hospice
Wage Index and Payment Rate Update final rule (83 FR 38642), we
continued the newness exemption for FY 2023, and all subsequent years.
We encourage hospices to keep the letter they receive providing them
with their CMS Certification Number (CCN). The letter can be used to
show when you received your number.
h. Survey Participation Requirements
We previously finalized survey participation requirements for FY
2022 through FY 2025 as stated in the FY 2018 and FY 2019 Hospice Wage
Index and Payment Rate Update final rules (82 FR 36670 and 83 FR 38642
through 38643). We also continued those requirements in all subsequent
years (84 FR 38526). Table 7 restates the data submission dates for FY
2023 through FY 2025.
Table 7--CAHPS Hospice Survey Data Submission Dates for the APU in FY
2023, FY 2024, and FY 2025
------------------------------------------------------------------------
CAHPS quarterly data
Sample months (month of death) * submission deadlines
**
------------------------------------------------------------------------
FY 2023 APU
[[Page 19455]]
CY January-March 2021 (Quarter 1)........... August 11, 2021.
CY April-June 2021 (Quarter 2).............. November 10, 2021.
CY July-September 2021 (Quarter 3).......... February 9, 2022.
CY October-December 2021 (Quarter 4)........ May 11, 2022.
FY 2024 APU
CY January-March 2022 (Quarter 1)........... August 10, 2022.
CY April-June 2022 (Quarter 2).............. November 9, 2022.
CY July-September 2022 (Quarter 3).......... February 8, 2023.
CY October-December 2022 (Quarter 4)........ May 10, 2023.
FY 2025 APU
CY January-March 2023 (Quarter 1)........... August 9, 2023.
CY April-June 2023 (Quarter 2).............. November 8, 2023.
CY July-September 2023 (Quarter 3).......... February 14, 2024.
CY October-December 2023 (Quarter 4)........ May 8, 2024.
------------------------------------------------------------------------
* Data collection for each sample month initiates 2 months following the
month of patient death (for example, in April for deaths occurring in
January).
** Data submission deadlines are the second Wednesday of the submission
months, which are the months August, November, February, and May.
For further information about the CAHPS Hospice Survey, we
encourage hospices and other entities to visit: https://www.hospiceCAHPSsurvey.org. For direct questions, contact the CAHPS
Hospice Survey Team at [email protected] or call 1-(844)
472-4621.
i. CAHPS Hospice Survey Star Ratings
We previously finalized a policy requiring us to display Hospice
CAHPS Survey Star Ratings no sooner than FY 2022 as stated in the FY
2022 Hospice Wage Index and Payment Rule Update rule (86 FR 42528).
Star Ratings will be publicly reported on Care Compare on Medicare.gov
beginning with the August 2022 refresh. This start date allowed CMS to
conduct a dry run of the Star Ratings with reporting to hospices via
preview reports. Hospices first saw their Star Ratings in their preview
reports during the November 2021 and March 2022 preview periods for the
February 2022 and May 2022 updates of Care Compare on Medicare.gov.
However, the CAHPS Hospice Survey Star Ratings will not be publicly
reported in February or May 2022. The reporting period for the dry run
covers data from Q4 2018 through Q4 2019 and Q3 2020 through Q1 2021.
Detailed information about the calculation and display of Hospice CAHPS
Survey Star Ratings can be found on the official CAHPS Hospice Survey
website: http://www.hospiceCAHPSsurvey.org. There are no changes to the
Hospice CAHPS Survey Star Ratings for FY 2023.
5. Form, Manner, and Timing of Quality Data Submission
a. Statutory Penalty for Failure To Report
Section 1814(i)(5)(C) of the Act requires that each hospice submit
data to the Secretary on quality measures specified by the Secretary.
Such data must be submitted in a form and manner, and at a time
specified by the Secretary. Section 1814(i)(5)(A)(i) of the Act was
amended by the CAA 2021 and the payment reduction for failing to meet
hospice quality reporting requirements is increased from 2 percent to 4
percent beginning with FY 2024. The Act requires that, beginning with
FY 2014 through FY 2023, the Secretary shall reduce the market basket
update by 2 percentage points and then beginning in FY 2024 and for
each subsequent year, the Secretary shall reduce the market basket
update by 4 percentage points for any hospice that does not comply with
the quality data submission requirements for that fiscal year. Last
year, we revised our rule at Sec. 418.306(b)(2) in accordance with
this statutory change (86 FR 42605).
b. Compliance
HQRP Compliance requires understanding three timeframes for both
HIS and CAHPS; (1) The relevant Reporting Year, payment FY and the
Reference Year. The ``Reporting Year'' (HIS)/``Data Collection Year''
(CAHPS). This timeframe is based on the calendar year. It is the same
calendar year for both HIS and CAHPS. If the CAHPS Data Collection year
is CY 2023, then the HIS reporting year is also CY 2023. (2) The APU is
subsequently applied to FY payments based on compliance in the
corresponding Reporting Year/Data Collection Year; and (3) For the
CAHPS Hospice Survey, the Reference Year is the CY prior to the Data
Collection Year. The Reference Year applies to hospices submitting a
size exemption from the CAHPS survey (there is no similar exemption for
HIS). For example, for the CY 2023 data collection year, the Reference
Year, is CY 2022. This means providers seeking a size exemption for
CAHPS in CY 2023 would base it on their hospice size in CY 2022.
Submission requirements are codified in Sec. 418.312.
For every CY all Medicare-certified hospices are required to submit
HIS and CAHPS data according to the requirements in Sec. 418.312.
Table 8 summarizes the three timeframes. It illustrates how the CY
interacts with the FY payments, covering the CY 2021 through CY 2024
data collection periods and the corresponding APU application from FY
2023 through FY 2026.
Table 8--HQRP Reporting Requirements and Corresponding Annual Payment
Updates
------------------------------------------------------------------------
Annual payment Reference year for
Reporting year for HIS and data update impacts CAHPS size
collection year for CAHPS data payments for the exemption (CAHPS
(calendar year) FY only)
------------------------------------------------------------------------
CY 2021......................... FY 2023 APU....... CY 2020.
CY 2022......................... FY 2024 APU *..... CY 2021.
CY 2023......................... FY 2025 APU....... CY 2022.
[[Page 19456]]
CY 2024......................... FY 2026 APU....... CY 2023.
------------------------------------------------------------------------
* Beginning in FY 2024 and all subsequent years, the payment penalty is
4 percent. Prior to FY 2024, the payment penalty is 2 percent.
As illustrated in Table 8, CY 2021 data submissions compliance
impacts the FY 2023 APU. CY 2022 data submissions compliance impacts
the FY 2024 APU. CY 2023 data submissions compliance impacts FY 2025
APU. This CY data submission impacting FY APU pattern follows for
subsequent years.
c. Submission Data and Requirements
As finalized in the FY 2016 Hospice Wage Index and Payment Rate
Update final rule (80 FR 47192), hospices' compliance with HIS
requirements beginning with the FY 2020 APU determination (that is,
based on HIS- Admission and Discharge records submitted in CY 2018) are
based on a timeliness threshold of 90 percent. This means CMS requires
that hospices submit 90 percent of all required HIS records within 30-
days of the event (that is, patient's admission or discharge). The 90-
percent threshold is hereafter referred to as the timeliness compliance
threshold. Ninety percent of all required HIS records must be submitted
and accepted within the 30-day submission deadline to avoid the
statutorily-mandated payment penalty. Hospice compliance with claims
data requirements is based on administrative data collection. Since
Medicare claims data are already collected from claims, hospices are
considered 100 percent compliant with the submission of these data for
the HQRP. There is no additional submission requirement for
administrative data.
To comply with CMS' quality reporting requirements for CAHPS,
hospices are required to collect data monthly using the CAHPS Hospice
Survey. Hospices comply by utilizing a CMS-approved third-party vendor.
Approved Hospice CAHPS vendors must successfully submit data on the
hospice's behalf to the CAHPS Hospice Survey Data Center. A list of the
approved vendors can be found on the CAHPS Hospice Survey website:
www.hospicecahpssurvey.org. Table 9. HQRP Compliance Checklist
illustrates the APU and timeliness threshold requirements.
Table 9--HQRP Compliance Checklist
------------------------------------------------------------------------
Annual payment update HIS CAHPS
------------------------------------------------------------------------
FY 2023..................... Submit at least 90 Ongoing monthly
percent of all HIS participation in
records within 30 the Hospice CAHPS
days of the event survey 1/1/2021-12/
date (patient's 31/2021.
admission or
discharge) for
patient admissions/
discharges
occurring 1/1/21-12/
31/21.
FY 2024..................... Submit at least 90 Ongoing monthly
percent of all HIS participation in
records or its the Hospice CAHPS
successor survey 1/1/2022-12/
instrument within 31/2022.
30 days of the
event date
(patient's
admission or
discharge) for
patient admissions/
discharges
occurring 1/1/22-12/
31/22.
FY 2025..................... Submit at least 90 Ongoing monthly
percent of all HIS participation in
records or its the Hospice CAHPS
successor survey 1/1/2023-12/
instrument within 31/2023.
30 days of the
event date
(patient's
admission or
discharge) for
patient admissions/
discharges
occurring 1/1/23-12/
31/23.
------------------------------------------------------------------------
Note: The data source for the claims-based measures will be Medicare
claims data that are already collected and submitted to CMS. There is
no additional submission requirement for administrative data (Medicare
claims), and hospices with claims data are 100-percent compliant with
this requirement.
Most hospices that fail to meet HQRP requirements do so because
they miss the 90 percent threshold. We offer many training and
education opportunities through our website, which are available 24/7,
365 days per year, to enable hospice staff to learn at the pace and
time of their choice. We want hospices to be successful with meeting
the HQRP requirements. We encourage hospices to use this website at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Quality-Reporting-Training-Training-and-Education-Library. For more information about
HQRP Requirements, we refer readers to visit the frequently-updated
HQRP website and especially the Best Practice, Education and Training
Library, and Help Desk web pages at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting. We also encourage readers to visit the HQRP web page and
sign-up for the Hospice Quality ListServ to stay informed about HQRP.
6. Request for Information Related to the HQRP Health Equity Initiative
CMS defines health equity as ``the attainment of the highest level
of health for all people, where everyone has a fair and just
opportunity to attain their optimal health regardless of race,
ethnicity, disability, sexual orientation, gender identity,
socioeconomic status, geography, preferred language, or other factors
that affect access to care and health outcomes.'' CMS is working to
advance health equity by designing, implementing, and operationalizing
policies and programs that support health for all the people served by
our programs, eliminating avoidable differences in health outcomes
experienced by people who are disadvantaged or underserved, and
providing the care and support that our enrollees need to thrive. CMS'
goals are in line with Executive Order 13985, on the Advancement of
Racial Equity and Support for the Underserved Communities, which can be
found at: https://www.whitehouse.gov/briefing-room/presidential-actions/2021/06/25/executive-order-on-diversity-equity-inclusion-and-accessibility-in-the-federal-workforce/.
Belonging to an underserved community is often associated with
worse health outcomes.4 5 6 7 8 9 10 11 Such
[[Page 19457]]
disparities in health outcomes are the result of multiple factors.
Although not the sole determinants, poor access to care and provision
of lower quality health care are important contributors to health
disparities notable for CMS programs. Health inequities persist in
hospice and palliative care, where Black and Hispanic populations are
less likely to utilize care and over 80 percent of patients are
White.12 13 14 15 After hospice admission, racial and ethnic
disparities appear to impact quality of care and health outcomes.\16\
Black patients may receive fewer supportive care medications despite
higher symptom burdens, experience care less consistent with their
expressed preferences, and encounter worse end-of-life
communication.17 18 19 20 21 In response to these
disparities, 70 percent of home health organizations, including 22
percent that are hospices, indicated they would increase the resources
dedicated to diversity, equity, and inclusion in 2021.\22\ One
important strategy for addressing these disparities is improving data
collection to allow for better measurement and reporting on equity
across our programs and policies.23 24
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\4\ Joynt KE, Orav E, Jha AK. Thirty-Day Readmission Rates for
Medicare Beneficiaries by Race and Site of Care. JAMA. 2011;
305(7):675-681.
\5\ Lindenauer PK, Lagu T, Rothberg MB, et al. Income Inequality
and 30 Day Outcomes After Acute Myocardial Infarction, Heart
Failure, and Pneumonia: Retrospective Cohort Study. British Medical
Journal. 2013; 346.
\6\ Trivedi AN, Nsa W, Hausmann LRM, et al. Quality and Equity
of Care in U.S. Hospitals. New England Journal of Medicine. 2014;
371(24):2298- 2308.
\7\ Polyakova, M., et al. Racial Disparities In Excess All-Cause
Mortality During The Early COVID-19 Pandemic Varied Substantially
Across States. Health Affairs. 2021; 40(2): 307-316.
\8\ Rural Health Research Gateway. Rural Communities: Age,
Income, and Health Status. Rural Health Research Recap. November
2018.
\9\ https://www.minorityhealth.hhs.gov/assets/PDF/Update_HHS_Disparities_Dept-FY2020.pdf.
\10\ www.cdc.gov/mmwr/volumes/70/wr/mm7005a1.htm.
\11\ Poteat TC, Reisner SL, Miller M, Wirtz AL. COVID-19
Vulnerability of Transgender Women With and Without HIV Infection in
the Eastern and Southern U.S. Preprint. medRxiv.
2020;2020.07.21.20159327. Published 2020 Jul 24. doi:10.1101/
2020.07.21.20159327.
\12\ Addressing Disparities in Hospice & Palliative Care.
Nalley, Catlin. Oncology Times: March 20, 2021-Volume 43-Issue 6-p
1,10doi: 10.1097/01.COT.0000741732.73529.bb.
\13\ https://journalofethics.ama-assn.org/article/racial-disparities-hospice-moving-analysis-intervention/2006-09.
\14\ Capital Caring, Seasons Execs: Improving Hospice Diversity
Starts from the Inside Out. 11/17/21. Holly Vossel. Capital Caring,
Seasons Execs: Improving Hospice Diversity Starts from the Inside
Out--Hospice & Palliative Care Network of Maryland https://hospicenews.com/2021/11/17/capital-caring-seasons-execs-improving-hospice-diversity-starts-from-the-inside-out/.
\15\ Disparities in Palliative and Hospice Care and Completion
of Advance Care Planning and Directives Among Non-Hispanic Blacks: A
Scoping Review of Recent Literature (nih.gov).
\16\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3822363/.
\17\ Naming the Problem: A Structural Racism Framework to
Examine Disparities in Palliative Care--ScienceDirect.
\18\ Johnson KS. Racial and ethnic disparities in palliative
care. J Palliat Med 2013;16:1329-1334.
\19\ Elk R, Felder TM, Cayir E, Samuel CA. Social inequalities
in palliative care for cancer patients in the United States:
astructured review. Semin Oncol Nurs 2018;34:303-315.
\20\ Elliott AM, Alexander SC, Mescher CA, Mohan D, Bar-nato AE.
Differences in physicians' verbal and nonverbal communication with
black and white patients at the end of life. J Pain Symptom Manage
2016;51:1-8.
\21\ Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/
ethnicity and quality of patient-physician communication during
medical visits. Am J Public Health 2004;94:2084-2090.
\22\ Capital Caring, Seasons Execs: Improving Hospice Diversity
Starts from the Inside Out. 11/17/21. Holly Vossel. Capital Caring,
Seasons Execs: Improving Hospice Diversity Starts from the Inside
Out--Hospice & Palliative Care Network of Maryland https://hospicenews.com/2021/11/17/capital-caring-seasons-execs-improving-hospice-diversity-starts-from-the-inside-out/.
\23\ https://hospicenews.com/2021/05/27/hospice-providers-leverage-data-to-reach-the-underserved/.
\24\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3822363/.
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We are committed to achieving equity in health care outcomes for
our beneficiaries by supporting providers in quality improvement
activities to reduce health inequities, enabling beneficiaries to make
more informed decisions, and promoting provider accountability for
health care disparities.25 26 CMS is committed to closing
the equity gap in CMS quality programs. For more information on the
portfolio of programs aimed at making information on the quality of
health care providers and services, including disparities, more
transparent, we refer readers to the FY 2022 Hospice Wage Index and
Rate Update proposed rule (86 FR 19700).
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\25\ https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality-Strategy.pdf.
\26\ Report to Congress: Improving Medicare PostAcute Care
Transformation (IMPACT) Act of 2014 Strategic Plan for Accessing
Race and Ethnicity Data. January 5, 2017. Available at https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Research-Reports-2017-Report-to-Congress-IMPACT-ACT-of-2014.pdf.
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In the FY 2022 Hospice Wage Index and Rate Update final rule, we
received comments supportive of gathering standardized patient
assessment data elements and additional SDOH data to improve health
equity. In parallel, commenters advocated for education efforts for
beneficiaries, providers, and stakeholders on the benefits of
collecting and reporting demographic and social risk factor data. We
received many comments about the use of standardized patient assessment
data elements in the hospice setting to assess health equity and SDOH,
some of which raised concerns there may be unintended consequences.
Many commenters noted that hospice patients have different goals of
care than non-hospice patients, which does not align with standardized
data elements for patient assessment. Commenters encouraged CMS to only
utilize certain aspects of standardized data elements for patient
assessment (specifically, Z-codes 55-65) in collecting health equity
data. We refer the readers to review the summary of public comments
received in the FY 2022 Hospice Wage Index and Rate Update final rule
(86 FR 42528).
We will continue to take all comments and suggestions into account
as we work to develop policies on this important topic. We appreciate
hospices and national organizations sharing their support and
commitment to addressing health disparities and offering meaningful
comments for consideration in the FY 2022 Hospice Wage Index and Rate
Update final rule (86 FR 42528). Given the value of the comments thus
far and the ongoing development of activities to improve health equity,
we solicit public comment on the following questions:
What efforts does your hospice employ to recruit staff,
volunteers, and board members from diverse populations to represent and
serve underserved populations? How does your hospice attempt to bridge
any cultural gaps between your personnel and beneficiaries/clients? How
does your hospice measure whether this has an impact on health equity?
How does your hospice currently identify barriers to
access in your community or service area? What are barriers to
collecting data related to disparities, social determinants of health,
and equity? What steps does your hospice take to address these
barriers?
How does your hospice collect self-reported data such as
race/ethnicity, veteran status, socioeconomic status, housing, food
security, access to interpreter services, caregiving status, and
marital status used to inform its health equity initiatives?
How is your hospice using qualitative data collection and
analysis methods to measure the impact of its health equity
initiatives?
In addition, we are considering a structural composite measure
based on information already collected by hospices. Specifically, the
structural composite measure could include organizational activities to
address access to and quality of hospice care for underserved
populations. The composite structural measure concept could include
hospice reported data on hospice activities to address
[[Page 19458]]
underserved populations' access to hospice care. For example, a hospice
could receive a point for each domain where data are submitted to a CMS
portal, regardless of the hospice's action in that domain (such as,
reporting whether or not the hospice provided training for board
members, leaders, staff and volunteers in culturally and linguistically
appropriate services (CLAS), health equity, and implicit bias). The
data could reflect the hospice's completed actions for each
corresponding domain (for a total of three points) in a reporting year.
A hospice could submit information such as documentation, examples, or
narratives to qualify for the measure numerator. We are also seeking
comment on how to score a domain for a hospice that submitted data
reflecting no actions or partial actions in the given domain.
Examples of the domains we are considering are described in the
following outline. We seek comment on each of these domains, including
specific suggestions on items that should be added, removed, or
revised.
Domain 1: Hospice commitment to reducing disparities is
strengthened when equity is a key organizational priority. Candidate
domain 1 could be satisfied when a hospice submits data on their
actions regarding the role of health equity and community engagement in
their strategic plan. Hospices could self-report data in the reporting
year about their actions in each of the following areas, and submission
of data for all elements could be required to qualify for the measure
numerator.
Hospice attests whether its strategic plan includes
approaches to address health equity in the reporting year.
Hospice reports community engagement and key stakeholder
activities in the reporting year.
Hospice reports on any attempts to measure input from
patients and caregivers about care disparities they may experience and
recommendations or suggestions.
Domain 2: Training board members, leaders, staff and volunteers in
culturally and linguistically appropriate services (CLAS),\27\ health
equity, and implicit bias is an important step hospices take to provide
quality care to diverse populations. Candidate domain 2 could focus on
hospices' diversity, equity, inclusion and CLAS training for board
members, employed staff, and volunteers by capturing the following
self-reported actions in the reporting year. Submission of relevant
data for all elements could be required to qualify for the measure
numerator.
---------------------------------------------------------------------------
\27\ https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/CLAS-Toolkit-12-7-16.pdf.
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Hospice attests whether employed staff were trained in
CLAS and culturally sensitive care mindful of social determinants of
health (SDOH) in the reporting year. Example data include specific
training programs or training requirements for staff.
Hospice attests whether it provided resources to staff and
volunteers about health equity, SDOH, and equity initiatives in the
reporting year. Examples include the materials provided, webinars, or
learning opportunities.
Domain 3: Leaders and staff could improve their capacity to address
disparities by demonstrating routine and thorough attention to equity
and setting an organizational culture of equity. This candidate domain
could capture activities related to organizational inclusion
initiatives and capacity to promote health equity. Examples of equity-
focused factors include proficiency in languages other than English,
experience working with populations in the service area, experience
working on health equity issues, and experience working with
individuals with disabilities.
Submission of relevant data for all elements could be required to
qualify for the measure numerator.
Hospice attests whether equity-focused factors were
included in the hiring of hospice senior leadership, including chief
executives and board of trustees, in the previous reporting year.
Hospice attests whether equity-focused factors were
included in the hiring of hospice senior leadership, including chief
executives and board of trustees, is more reflective of the services
area patient than in the previous reporting year.
Hospice attests whether equity-focused factors were
included in the hiring of direct patient care staff (for example, RNs,
medical social workers, aides, volunteers, chaplains, or therapists) in
the previous reporting year.
Hospice attests whether equity focused factors were
included in the hiring of indirect care or support staff (for example.
administrative, clerical, or human resources) in the previous reporting
year.
We are interested in developing health equity measures based on
information collected by hospices not currently available on claims,
assessments, or other publicly available data sources to support
development of future quality measures. We are soliciting public
comment on the conceptual domains and quality measures described in
this section. Furthermore, we are soliciting public comments on
publicly reporting a composite structural health equity quality
measure; displaying descriptive information on Care Compare from the
data hospices provide to support health equity measures; and the impact
of the domains and quality measure concepts on organizational culture
change.
7. Advancing Health Information Exchange Update
The Department of Health and Human Services (HHS) has a number of
initiatives designed to encourage and support the adoption of
interoperable health information technology and to promote nationwide
health information exchange to improve health care and patient access
to their digital health information.
To further interoperability in post-acute care settings, CMS and
the Office of the National Coordinator for Health Information
Technology (ONC) participate in the Post-Acute Care Interoperability
Workgroup (PACIO) to facilitate collaboration with industry
stakeholders to develop Health Level Seven International[supreg] (HL7)
Fast Healthcare Interoperability Resources[supreg] (FHIR)
standards.\28\ These standards could support the exchange and reuse of
patient assessment data derived from the Minimum Data Set (MDS),
Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-
PAI), LTCH Continuity Assessment Record and Evaluation (CARE) Data Set
(LCDS), Outcome and Assessment Information Set (OASIS), and other
sources. The PACIO Project has focused on HL7 FHIR implementation
guides for functional status, cognitive status and new use cases on
advance directives, re-assessment timepoints, and Speech Language,
Swallowing, Cognitive communication and Hearing (SPLASCH) pathology. We
encourage PAC provider and health (IT) vendor participation as the
efforts advance.
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\28\ http://pacioproject.org/.
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The CMS Data Element Library (DEL) continues to be updated and
serves as a resource for PAC assessment data elements and their
associated mappings to health IT standards, such as Logical Observation
Identifiers Names and Codes (LOINC) and Systematized Nomenclature of
Medicine Clinical Terms (SNOMED). The DEL furthers CMS' goal of data
standardization and interoperability. Standards in the DEL (https://del.cms.gov/DELWeb/pubHome) can be referenced on the CMS website
[[Page 19459]]
and in the ONC Interoperability Standards Advisory (ISA). The 2022 ISA
is available at https://www.healthit.gov/isa.
The 21st Century Cures Act (Cures Act) (Pub. L. 114-255, enacted
December 13, 2016) required HHS and ONC to take steps to further
interoperability for providers and settings across the care continuum.
Section 4003(b) of the Cures Act required ONC to take steps to advance
interoperability through the development of a trusted exchange
framework and common agreement aimed at establishing a universal floor
of interoperability across the country. On January 18, 2022, ONC
announced a significant milestone by releasing the Trusted Exchange
Framework \29\ and Common Agreement Version 1 \30\. The Trusted
Exchange Framework is a set of non-binding principles for health
information exchange, and the Common Agreement is a contract that
advances those principles. The Common Agreement and the incorporated by
reference Qualified Health Information Network Technical Framework
Version 1 \31\ establish the technical infrastructure model and
governing approach for different health information networks and their
users to securely share clinical information with each other--all under
commonly agreed to terms. The technical and policy architecture of how
exchange occurs under the Trusted Exchange Framework and the Common
Agreement follows a network-of-networks structure, which allows for
connections at different levels and is inclusive of many different
types of entities at those different levels, such as health information
networks, healthcare practices, hospitals, public health agencies, and
Individual Access Services (IAS) For more information, we refer readers
to https://www.healthit.gov/topic/interoperability/trusted-exchange-framework-and-common-agreement.
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\29\ The Trusted Exchange Framework (TEF): Principles for
Trusted Exchange (Jan. 2022), https://www.healthit.gov/sites/default/files/page/2022-01/Trusted_Exchange_Framework_0122.pdf.
\30\ Common Agreement for Nationwide Health Information
Interoperability Version 1 (Jan. 2022), https://www.healthit.gov/sites/default/files/page/2022-01/Common_Agreement_for_Nationwide_Health_Information_Interoperability_Version_1.pdf.
\31\ Qualified Health Information Network (QHIN) Technical
Framework (QTF) Version 1.0 (Jan. 2022), https://rce.sequoiaproject.org/wp-content/uploads/2022/01/QTF_0122.pdf.
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We invite readers to learn more about these important developments
and how they are likely to affect hospices.
C. CAA 2021, Section 407. Establishing Hospice Program Survey and
Enforcement Procedures Under the Medicare Program; Provisions Update
Division CC, section 407 of the CAA 2021, amended Part A of Title
XVIII of the Act to add a new section 1822, and amended sections
1864(a) and 1865(b) of the Act, establishing new hospice program survey
and enforcement requirements, required public reporting of survey
information, and a new hospice hotline.
The law requires public reporting of hospice program surveys
conducted by both State Agencies (SAs) and Accrediting Organizations
(AOs), as well as enforcement actions taken as a result of these
surveys, on the CMS website in a manner that is prominent, easily
accessible, searchable, and presented in a readily understandable
format. It removes the prohibition at section 1865(b) of the Act of
public disclosure of hospice surveys performed by AOs, and requires
that AOs use the same survey deficiency reports as SAs (Form CMS-2567,
``Statement of Deficiencies'' or a successor form) to report survey
findings.
The law also requires hospice programs to measure and reduce
inconsistency in the application of survey results among all surveyors,
and requires the Secretary to provide comprehensive training and
testing of SA and AO hospice program surveyors, including training with
respect to review of written plans of care. The statute prohibits SA
surveyors from surveying hospice programs for which they have worked in
the last 2 years or in which they have a financial interest, requires
hospice program SAs and AOs to use a multidisciplinary team of
individuals for surveys conducted with more than one surveyor to
include at least one registered nurse, and provides that each SA must
establish a dedicated toll-free hotline to collect, maintain, and
update information on hospice programs and to receive complaints.
The provisions in the CAA 2021 also direct the Secretary to create
a Special Focus Program (SFP) for poor-performing hospice programs,
sets out authority for imposing enforcement remedies for noncompliant
hospice programs, and requires the development and implementation of a
range of remedies as well as procedures for appealing determinations
regarding these remedies. These remedies can be imposed instead of, or
in addition to, termination of the hospice programs' participation in
the Medicare program. The remedies include civil money penalties
(CMPs), suspension of all or part of payments, and appointment of
temporary management to oversee operations.
In the CY 2022 Home Health Prospective Payment System (HH PPS)
final rule (86 FR 62240), we addressed provisions related to the
hospice survey enforcement and other activities described in this
section. A summary of the finalized CAA provisions can be found in the
CY 2022 HH PPS final rule: https://www.govinfo.gov/content/pkg/FR-2021-11-09/pdf/2021-23993.pdf. We finalized all the CAA provisions in CY
2022 rulemaking except for the special focus program (SFP). As outlined
in the CY 2022 HH PPS final rule, we stated that we would take into
account comments that we received and work on a revised proposal,
seeking additional collaboration with stakeholders to further develop
the methodology for the SFP Since the publication of the CY 2022 HH PPS
final rule, we have decided to initiate a hospice Technical Expert
Panel (TEP) in CY 2022. Accordingly, CMS plans to use the TEP findings
to further develop a proposal on the methodology for establishing the
hospice SFP, and we plan to include a proposal implementing a SFP in
the FY 2024 Hospice rulemaking proposed rule.
IV. Response to Comments
Because of the large number of public comments, we normally receive
on Federal Register documents, we are not able to acknowledge or
respond to them individually. We will consider all comments we receive
by the date and time specified in the DATES section of this preamble,
and, when we proceed with a subsequent document, we will respond to the
comments in the preamble to that document.
V. Collection of Information
This document does not impose information collection requirements,
that is, reporting, recordkeeping or third-party disclosure
requirements. Consequently, there is no need for review by the Office
of Management and Budget under the authority of the Paperwork Reduction
Act of 1995 (44 U.S.C. 3501 et seq.).
VI. Regulatory Impact Analysis
A. Statement of Need
This proposed rule meets the requirements of our regulations at
Sec. 418.306(c) and (d), which require annual issuance, in the Federal
Register, of the hospice wage index based on the most current available
CMS hospital wage data, including any changes to the definitions of
CBSAs or previously used MSAs, as well as any
[[Page 19460]]
changes to the methodology for determining the per diem payment rates.
This proposed rule would also update payment rates for each of the
categories of hospice care, described in Sec. 418.302(b), for FY 2023
as required under section 1814(i)(1)(C)(ii)(VII) of the Act. The
payment rate updates are subject to changes in economy-wide
productivity as specified in section 1886(b)(3)(B)(xi)(II) of the Act.
Lastly, section 3004 of the Affordable Care Act amended the Act to
authorize a quality reporting program for hospices, and this rule does
not change the requirements for the HQRP in accordance with section
1814(i)(5) of the Act.
B. Overall Impacts
We estimate that the aggregate impact of the payment provisions in
this proposed rule would result in an estimated increase of $580
million in payments to hospices, resulting from the hospice payment
update percentage of 2.7 percent for FY 2023. The impact analysis of
this proposed rule represents the projected effects of the changes in
hospice payments from FY 2022 to FY 2023. Using the most recent
complete data available at the time of rulemaking, in this case FY 2021
hospice claims data as of January 21, 2022, we apply the current FY
2022 wage index with the current labor shares. Using the same FY 2021
data, we apply the FY 2023 wage index and the current labor share
values to simulate FY 2022 payments. We then apply a budget neutrality
adjustment so that the aggregate simulated payments do not increase or
decrease due to changes in the wage index.
Certain events may limit the scope or accuracy of our impact
analysis, because such an analysis is susceptible to forecasting errors
due to other changes in the forecasted impact time period. The nature
of the Medicare program is such that the changes may interact, and the
complexity of the interaction of these changes could make it difficult
to predict accurately the full scope of the impact upon hospices.
We have examined the impacts of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993),
Executive Order 13563 on Improving Regulation and Regulatory Review
(January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act,
section 202 of the Unfunded Mandates Reform Act of 1995 (March 22,
1995; Pub. L. 104-4), Executive Order 13132 on Federalism (August 4,
1999), and the Congressional Review Act (5 U.S.C. 804(2)).
Executive Orders 12866 and 13563 direct agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). Section
3(f) of Executive Order 12866 defines a ``significant regulatory
action'' as an action that is likely to result in a rule: (1) (Having
an annual effect on the economy of $100 million or more in any 1 year,
or adversely and materially affecting a sector of the economy,
productivity, competition, jobs, the environment, public health or
safety, or state, local or tribal governments or communities (also
referred to as ``economically significant''); (2) creating a serious
inconsistency or otherwise interfering with an action taken or planned
by another agency; (3) materially altering the budgetary impacts of
entitlement grants, user fees, or loan programs or the rights and
obligations of recipients thereof; or (4) raising novel legal or policy
issues arising out of legal mandates, the President's priorities, or
the principles set forth in the Executive Order.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
A regulatory impact analysis (RIA) must be prepared for major rules
with economically significant effects ($100 million or more in any 1
year). We estimate that this rulemaking is ``economically significant''
as measured by the $100 million threshold, and hence also a major rule
under the Congressional Review Act. Accordingly, we have prepared a RIA
that, to the best of our ability presents the costs and benefits of the
rulemaking.
C. Detailed Economic Analysis
1. Proposed Hospice Payment Update for FY 2023
The FY 2023 hospice payment impacts appear in Table 10. We tabulate
the resulting payments according to the classifications (for example,
provider type, geographic region, facility size), and compare the
difference between current and future payments to determine the overall
impact. The first column shows the breakdown of all hospices by
provider type and control (non-profit, for-profit, government, other),
facility location, facility size. The second column shows the number of
hospices in each of the categories in the first column. The third
column shows the effect of using the FY 2023 updated wage index data
with a 5-percent cap on wage index decreases. This represents the
effect of moving from the FY 2022 hospice wage index to the FY 2023
hospice wage index with a 5-percent cap on wage index decreases. The
aggregate impact of the changes in column three is zero percent, due to
the hospice wage index standardization factor. However, there are
distributional effects of the FY 2023 hospice wage index. The fourth
column shows the effect of the hospice payment update percentage as
mandated by section 1814(i)(1)(C) of the Act, and is consistent for all
providers. The proposed hospice payment update percentage of 2.7
percent is based on the proposed 3.1 percent inpatient hospital market
basket update, reduced by a proposed 0.4 percentage point productivity
adjustment. The fifth column shows the effect of all the proposed
changes on FY 2023 hospice payments. It is projected aggregate payments
would increase by 2.7 percent; assuming hospices do not change their
billing practices. As illustrated in Table 10, the combined effects of
all the proposals vary by specific types of providers and by location.
We note that simulated payments are based on utilization in FY 2021 as
seen on Medicare hospice claims (accessed from the CCW in January 21,
2022) and only include payments related to the level of care and do not
include payments related to the service intensity add-on.
As illustrated in Table 10, the combined effects of all the
proposals vary by specific types of providers and by location.
[[Page 19461]]
Table 10--Projected Impact to Hospices for FY 2023
----------------------------------------------------------------------------------------------------------------
FY 2023 updated FY 2023 proposed Overall total
Hospice subgroup Hospices wage data >with hospice payment impact for FY
cap update (%) 2023
----------------------------------------------------------------------------------------------------------------
All Hospices............................ 5,186 0.0% 2.7% 2.7%
Hospice Type and Control:
Freestanding/Non-Profit............. 581 -0.1 2.7 2.6
Freestanding/For-Profit............. 3,508 0.1 2.7 2.8
Freestanding/Government............. 42 0.1 2.7 2.8
Freestanding/Other.................. 352 -0.1 2.7 2.6
Facility/HHA Based/Non-Profit....... 347 -0.2 2.7 2.5
Facility/HHA Based/For-Profit....... 200 -0.1 2.7 2.6
Facility/HHA Based/Government....... 79 -0.1 2.7 2.6
Facility/HHA Based/Other............ 77 -0.3 2.7 2.4
Subtotal: Freestanding Facility 4,483 0.0 2.7 2.7
Type...........................
-----------------------------------------------------------------------
Subtotal: Facility/HHA Based 703 -0.2 2.7 2.5
Facility Type..................
-----------------------------------------------------------------------
Subtotal: Non-Profit............ 928 -0.1 2.7 2.6
-----------------------------------------------------------------------
Subtotal: For Profit............ 3,708 0.1 2.7 2.8
-----------------------------------------------------------------------
Subtotal: Government............ 121 0.0 2.7 2.7
-----------------------------------------------------------------------
Subtotal: Other................. 429 -0.1 2.7 2.6
Hospice Type and Control: Rural:
Freestanding/Non-Profit............. 132 -0.1 2.7 2.6
Freestanding/For-Profit............. 351 0.0 2.7 2.7
Freestanding/Government............. 24 -0.6 2.7 2.1
Freestanding/Other.................. 49 0.0 2.7 2.7
Facility/HHA Based/Non-Profit....... 135 -0.2 2.7 2.5
Facility/HHA Based/For-Profit....... 47 -0.7 2.7 2.0
Facility/HHA Based/Government....... 62 -0.2 2.7 2.5
Facility/HHA Based/Other............ 46 -0.1 2.7 2.6
Facility Type and Control: Urban:
Freestanding/Non-Profit............. 449 -0.1 2.7 2.6
Freestanding/For-Profit............. 3,157 0.1 2.7 2.8
Freestanding/Government............. 18 0.3 2.7 3.0
Freestanding/Other.................. 303 -0.1 2.7 2.6
Facility/HHA Based/Non-Profit....... 212 -0.2 2.7 2.5
Facility/HHA Based/For-Profit....... 153 -0.1 2.7 2.6
Facility/HHA Based/Government....... 17 -0.1 2.7 2.6
Facility/HHA Based/Other............ 31 -0.3 2.7 2.4
Hospice Location: Urban or Rural:
Rural............................... 846 -0.1 2.7 2.6
Urban............................... 4,340 0.0 2.7 2.7
Hospice Location: Region of the Country
(Census Division):
New England......................... 149 -0.5 2.7 2.2
Middle Atlantic..................... 282 0.0 2.7 2.7
South Atlantic...................... 588 -0.2 2.7 2.5
East North Central.................. 559 -0.4 2.7 2.3
East South Central.................. 256 -0.1 2.7 2.6
West North Central.................. 410 -0.5 2.7 2.2
West South Central.................. 1,015 0.3 2.7 3.0
Mountain............................ 538 -0.2 2.7 2.5
Pacific............................. 1,340 0.7 2.7 3.4
Outlying............................ 49 -0.3 2.7 2.4
Hospice Size:
0-3,499 RHC Days (Small)............ 1,076 0.3 2.7 3.0
3,500-19,999 RHC Days (Medium)...... 2,457 0.2 2.7 2.9
20,000+ RHC Days (Large)............ 1,653 0.0 2.7 2.7
----------------------------------------------------------------------------------------------------------------
Source: FY 2021 hospice claims data from CCW accessed on January 21, 2022.
Note: The overall total impact reflects the addition of the individual impacts, which includes the overall wage
index impact of updating the wage data with a 5-percent cap on wage index decreases, as well as the proposed
2.7 percent hospice payment update percentage.
Region Key:
New England=Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont.
Middle Atlantic Pennsylvania, New Jersey, New York;
South Atlantic Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina,
Virginia, West Virginia.
East North Central Illinois, Indiana, Michigan, Ohio, Wisconsin.
East South Central Alabama, Kentucky, Mississippi, Tennessee.
West North Central Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota.
West South Central Arkansas, Louisiana, Oklahoma, Texas.
Mountain=Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming Pacific= Alaska, California,
Hawaii, Oregon, Washington.
Outlying=Guam, Puerto Rico, Virgin Islands.
[[Page 19462]]
2. Regulatory Review Cost Estimation
If regulations impose administrative costs on private entities,
such as the time needed to read and interpret this proposed rule, we
should estimate the cost associated with regulatory review. Due to the
uncertainty involved with accurately quantifying the number of entities
that will review the rule, we assume that the total number of unique
commenters on last year's proposed rule will be the number of reviewers
of this proposed rule. We acknowledge that this assumption may
understate or overstate the costs of reviewing this proposed rule. It
is possible that not all commenters reviewed last year's rule in
detail, and it is also possible that some reviewers chose not to
comment on the proposed rule. For these reasons we thought that the
number of past commenters would be a fair estimate of the number of
reviewers of this proposed rule. We welcome any comments on the
approach in estimating the number of entities which will review this
proposed rule. We also recognize that different types of entities are
in many cases affected by mutually exclusive sections of this proposed
rule, and therefore for the purposes of our estimate we assume that
each reviewer reads approximately 50 percent of the rule. We are
soliciting public comments on this assumption.
Using the occupational wage information from the BLS for medical
and health service managers (Code 11-9111) from May 2020; we estimate
that the cost of reviewing this rule is $114.24 per hour, including
overhead and fringe benefits (https://www.bls.gov/oes/current/oes_nat.htm). This proposed rule consists of approximately 20,000
words. Assuming an average reading speed of 250 words per minute, it
would take approximately 0.67 hours for the staff to review half of it.
For each hospice that reviews the rule, the estimated cost is $76.16
(0.67 hours x $114.24). Therefore, we estimate that the total cost of
reviewing this regulation is $4,036.48 ($76.16 x 53 reviewers).
D. Alternatives Considered
Since the hospice payment update percentage is determined based on
statutory requirements, we only considered not updating hospice payment
rates by the payment update percentage. Payment rates since FY 2002
have been updated according to section 1814(i)(1)(C)(ii)(VII) of the
Act, which states that the update to the payment rates for subsequent
years must be the market basket percentage for that FY. Section 3401(g)
of the Affordable Care Act also mandates that, starting with FY 2013
(and in subsequent years), the hospice payment update percentage will
be annually reduced by changes in economy-wide productivity as
specified in section 1886(b)(3)(B)(xi)(II) of the Act. For FY 2023,
since the hospice payment update percentage is determined based on
statutory requirements at section 1814(i)(1)(C) of the Act, we cannot
consider not updating the hospice payment rates by the hospice payment
update percentage, nor can we consider updating the hospice payment
rates by the hospice payment update percentage.
E. Accounting Statement
As required by OMB Circular A-4 (available at https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/circulars/A4/a-4.pdf), in Table 11, we have prepared an accounting statement showing
the classification of the expenditures associated with the provisions
of this proposed rule. Table 11 provides our best estimate of the
possible changes in Medicare payments under the hospice benefit as a
result of the policies in this proposed rule. This estimate is based on
the data for 4,957 hospices in our impact analysis file, which was
constructed using FY 2021 claims available in January 2022. All
expenditures are classified as transfers to hospices.
Table 11--Accounting Statement: Classification of Estimated Transfers
and Costs, From FY 2022 to FY 2023
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............ $ 580 million\*\.
From Whom to Whom?........................ Federal Government to
Medicare Hospices.
------------------------------------------------------------------------
*The increase of $580 million in transfer payments is a result of the
2.7 percent hospice payment update compared to payments in FY 2022.
F. Regulatory Flexibility Act (RFA)
The RFA requires agencies to analyze options for regulatory relief
of small businesses if a rule has a significant impact on a substantial
number of small entities. The great majority of hospitals and most
other health care providers and suppliers are small entities by meeting
the Small Business Administration (SBA) definition of a small business
(in the service sector, having revenues of less than $8.0 million to
$41.5 million in any 1 year), or being nonprofit organizations.
For purposes of the RFA, we consider all hospices as small entities
as that term is used in the RFA. The Department of Health and Human
Services practice in interpreting the RFA is to consider effects
economically ``significant'' only if greater than 5 percent of
providers reach a threshold of 3 to 5 percent or more of total revenue
or total costs. The effect of the FY 2023 hospice payment update
percentage results in an overall increase in estimated hospice payments
of 2.7 percent, or $580 million. The distributional effects of the
proposed FY 2023 hospice wage index do not result in a greater than 5
percent of hospices experiencing decreases in payments of 3 percent or
more of total revenue. Therefore, the Secretary has determined that
this rule will not create a significant economic impact on a
substantial number of small entities.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 603 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a MSA and has fewer
than 100 beds. This rule will only affect hospices. Therefore, the
Secretary has determined that this rule will not have a significant
impact on the operations of a substantial number of small rural
hospitals (see Table 10).
G. Unfunded Mandates Reform Act (UMRA)
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2022, that
threshold is approximately $165 million. This rule is not anticipated
to have an effect on state, local, or tribal governments, in the
aggregate, or on the private sector of $165 million or more in any 1
year.
H. Federalism
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a
[[Page 19463]]
proposed rule (and subsequent final rule) that imposes substantial
direct requirement costs on state and local governments, preempts state
law, or otherwise has Federalism implications. We have reviewed this
rule under these criteria of Executive Order 13132, and have determined
that it will not impose substantial direct costs on state or local
governments.
I. Conclusion
We estimate that aggregate payments to hospices in FY 2023 will
increase by $580 million as a result of the market basket update,
compared to payments in FY 2022. We estimate that in FY 2023, hospices
in urban areas will experience, on average, a 2.7 percent increase in
estimated payments compared to FY 2022; while hospices in rural areas
will experience, on average, a 2.6 percent increase in estimated
payments compared to FY 2022. Hospices providing services in the
Pacific and West South Central regions would experience the largest
estimated increases in payments of 3.4 percent and 3.0 percent,
respectively. Hospices serving patients in areas in the New England and
West North Central regions would experience, on average, the lowest
estimated increase of 2.2 percent in FY 2023 payments.
Chiquita Brooks-LaSure, Administrator of the Centers for Medicare &
Medicaid Services, approved this document on March 29, 2022.
List of Subjects in 42 CFR Part 418
Health facilities, Hospice care, Medicare, Reporting and
recordkeeping requirements.
For the reasons set forth in the preamble, the Centers for Medicare
& Medicaid Services proposes to amend 42 CFR part 418 as set forth
below.
PART 418--HOSPICE CARE
0
1. The authority citation for part 418 continues to read as follows:
Authority: 42 U.S.C. 1302 and 1395hh.
0
2. Section Sec. 418.306 is amended by revising paragraph (c) to read
as follows:
Sec. 418.306 Annual update of the payment rates and adjustment for
area wage differences.
* * * * *
(c) Adjustment for wage differences. (1) Each hospice's labor
market is determined based on definitions of Metropolitan Statistical
Areas (MSAs) issued by OMB. CMS will issue annually, in the Federal
Register, a hospice wage index based on the most current available CMS
hospital wage data, including changes to the definition of MSAs. The
urban and rural area geographic classifications are defined in Sec.
412.64(b)(1)(ii)(A) through (C) of this chapter. The payment rates
established by CMS are adjusted by the Medicare contractor to reflect
local differences in wages according to the revised wage data.
(2) Beginning on October 1, 2022, CMS applies a cap on decreases to
the hospice wage index such that the wage index applied to a geographic
area is not less than 95 percent of the wage index applied to that
geographic area in the prior fiscal year.
* * * * *
Dated: March 29, 2022.
Xavier Becerra,
Secretary, Department of Health and Human Services.
[FR Doc. 2022-07030 Filed 3-30-22; 4:15 pm]
BILLING CODE 4120-01-P