No official summary available for this bill.
[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 9803 Introduced in House (IH)]
<DOC>
118th CONGRESS
2d Session
H. R. 9803
To amend title XVIII of the Social Security Act to ensure the integrity
of hospice care furnished under the Medicare program, and for other
purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 25, 2024
Mr. Blumenauer introduced the following bill; which was referred to the
Committee on Ways and Means, and in addition to the Committee on Energy
and Commerce, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall
within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend title XVIII of the Social Security Act to ensure the integrity
of hospice care furnished under the Medicare program, and for other
purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Hospice Care Accountability, Reform,
and Enforcement Act of 2024'' or the ``Hospice CARE Act of 2024''.
SEC. 2. ENSURING THE INTEGRITY OF HOSPICE CARE FURNISHED UNDER THE
MEDICARE PROGRAM.
(a) Mandatory Temporary Moratorium on Enrollment.--
(1) In general.--Section 1866(j) of the Social Security Act
(42 U.S.C. 1395cc(j)) is amended by adding at the end the
following new paragraph:
``(10) Mandatory temporary moratorium on enrollment of
hospice programs.--
``(A) In general.--Except as provided in
subparagraphs (B) and (C), the Secretary shall impose a
nationwide temporary moratorium on the enrollment of
new hospice programs under this title for the 5-year
period beginning on the date of the enactment of this
paragraph.
``(B) Exemption for certain hospices.--
``(i) In general.--The Secretary may exempt
a hospice program seeking to enroll under this
title from the moratorium described in
subparagraph (A) if the Secretary determines
that such program will furnish hospice care to
individuals entitled to benefits under part A
in an area with insufficient access to such
care (as specified by the Secretary, taking
into account the considerations described in
clause (ii)).
``(ii) Considerations described.--For
purposes of clause (i), the considerations
described in this clause are, with respect to a
hospice program seeking to enroll under this
title, the following:
``(I) The specific geographic area
that such program intends to serve.
``(II) The current availability of
hospice care in such area.
``(III) Any evidence of unmet need
for hospice care in such area (such as
wait times for such care, the extent to
which such area (or a population in
such area) is considered underserved,
and evidence that existing hospice
programs are provided a substandard
quality of care in such area).
``(IV) The program's plan to
address any identified gaps in the
provision of hospice care in such area.
``(C) Authority to lift moratorium.--The Secretary
may lift the moratorium imposed under subparagraph (A)
within a State (or geographic region of a State)
specified by the Secretary in the same manner as the
Secretary may lift a temporary moratorium (as described
in paragraph (7)) under section 424.570(d) of title 42,
Code of Federal Regulations (or a successor
regulation).
``(D) Application of prepayment medical review
during the temporary moratorium in certain
circumstances.--
``(i) In general.--Subject to clause (ii),
the Secretary shall apply prepayment medical
review to hospice care consisting of routine
home care furnished during the 5-year period
beginning on the date of the enactment of this
paragraph by an applicable hospice program to a
covered individual.
``(ii) Termination of application of
prepayment medical review.--
``(I) In general.--The Secretary
shall terminate the application of
prepayment medical review under clause
(i) with respect to hospice care
furnished by an applicable hospice
program to a covered individual if the
Secretary determines that, during the
period in which such care so furnished
by such program was subject to such
review, such care was subject to a low
rate of denial (as specified by the
Secretary) under such review.
``(II) Revocation of termination.--
The Secretary may revoke any
termination of prepayment medical
review under subclause (I) if
determined appropriate by the
Secretary.
``(iii) Definitions.--For purposes of this
subparagraph:
``(I) Applicable hospice program.--
The term `applicable hospice program'
means a hospice program with a history
of claim submissions with respect to
hospice care furnished under this title
that is aberrant (such as by
demonstrating that such program is an
outlier with respect to live
discharges) compared to such history of
claim submissions of similarly situated
hospice programs, as determined by the
Secretary.
``(II) Covered individual.--The
term `covered individual' means an
individual receiving hospice care under
this title during the second 90-day
period described in section 1812(d)(1)
(or during any subsequent period)
applicable to such individual.
``(E) Revalidation of enrollment information.--
``(i) In general.--During the 6-month
period beginning on the date of the enactment
of this paragraph and notwithstanding any
applicable revalidation cycle under section
424.515 of title 42, Code of Federal
Regulations (or a successor regulation), the
Secretary shall revalidate the enrollment
information of each hospice program enrolled
under this title in accordance with the
requirements applicable to revalidations of
such information under such section.
``(ii) Publication of ownership
information.--Not later than 1 year after the
date of the enactment of this paragraph, the
Secretary shall publish on a public website of
the Centers for Medicare & Medicaid Services
ownership interest and managing control
information collected pursuant to revalidations
described in clause (i) for each hospice
program enrolled under this title.
``(iii) Report.--Not later than January 1,
2027, the Secretary, acting through the
Assistant Secretary for Planning and
Evaluation, shall submit to Congress a report
on hospice ownership and control trends and the
role of private equity in ownership and control
of hospice programs. Such report shall
include--
``(I) validation, to the extent
feasible, of the ownership and control
information reported on form CMS-855A
(or any successor form);
``(II) an analysis of hospice cost
report data by ownership type;
``(III) recommendations on ways to
improve the integrity of the ownership
and control information reported by
hospices during the enrollment process
under this title; and
``(IV) to the extent practicable,
recommendations on policies to promote
health care competition.
``(F) Implementation.--The Secretary shall
implement this paragraph through program instruction or
other forms of subregulatory guidance.''.
(2) Authority to provide exemptions to temporary
moratoria.--Section 1866(j)(7) of the Social Security Act (42
U.S.C. 1395cc(j)(7)) is amended--
(A) in subparagraph (A), by adding at the end the
following new sentence: ``The Secretary may exempt a
provider of services or supplier that would otherwise
be subject to a moratorium imposed under the preceding
sentence from such moratorium if determined appropriate
by the Secretary.''; and
(B) in subparagraph (C)(iii)--
(i) in subclause (I), by striking ``and''
at the end;
(ii) in subclause (II), by striking the
period and inserting ``; and''; and
(iii) by adding at the end the following
new subclause:
``(III) is not subject to an
exemption described in such
subparagraph.''.
(b) Extension of Oversight of Newly-Enrolled Hospice Programs.--
(1) In general.--Section 1866(j)(3)(A) of the Social
Security Act (42 U.S.C. 1395cc(j)(3)(A)) is amended by
inserting ``(or, in the case of a hospice program, not more
than 2 years)'' after ``1 year''.
(2) Mandatory application of enhanced oversight for certain
hospice programs.--Section 1866(j)(3) of the Social Security
Act (42 U.S.C. 1395cc(j)(3)) is amended--
(A) by redesignating subparagraph (B) as
subparagraph (C); and
(B) by inserting after subparagraph (A) the
following new subparagraph:
``(B) Mandatory application to certain hospice
programs.--The procedures established by the Secretary
under subparagraph (A) shall provide that any hospice
program enrolling under this title that would, but for
application of subparagraph (B) or (C) of paragraph
(10), have been prohibited from so enrolling be subject
to the enhanced oversight described in such
subparagraph for a period of not less than 30 days.''.
(c) Increase in Survey Frequency for Certain Hospice Programs.--
Section 1822(a) of the Social Security Act (42 U.S.C. 1395i-6(a)) is
amended--
(1) in paragraph (1)--
(A) by inserting ``, with respect to such a survey
conducted with respect to a hospice program that is not
included on the list established under paragraph (5),''
after ``local survey agency, or''; and
(B) by inserting ``(or, in the case of a hospice
program that is included on the list established under
paragraph (5), not less frequently than once every 18
months)'' after ``36 months'';
(2) by redesignating paragraph (5) as paragraph (6);
(3) by inserting after paragraph (4) the following new
paragraph:
``(5) Hospice programs subject to increased survey
frequency.--
``(A) In general.--The Secretary shall establish a
list of hospice programs subject to increased survey
frequency under paragraph (1) in accordance with the
provisions of this paragraph.
``(B) Inclusion on list.--
``(i) In general.--The Secretary shall
include a hospice program on the list
established under subparagraph (A) if such
program is not participating in the special
focus program under subsection (b) and such
hospice program meets either of the following
criteria:
``(I) The program first submitted a
claim for an item or service under this
title during the 5-year period ending
on the date of the enactment of this
paragraph.
``(II) The program first submits a
claim for an item or service under this
title on or after such date of
enactment.
``(ii) Discretionary inclusion.--The
Secretary may include a hospice program on the
list established under subparagraph (A)--
``(I) if claims data submitted by
such program indicates that such
program is not providing the full scope
of hospice care services payable under
this title;
``(II) if the Secretary determines
that such program is an outlier with
respect to live discharges; or
``(III) for any other reason
determined appropriate by the
Secretary.
``(C) Removal from list.--The Secretary shall
remove a hospice program included in the list
established under subparagraph (A)--
``(i) if--
``(I) such program has been subject
to 2 surveys under this subsection
while included on such list; and
``(II) neither such survey resulted
in such program being cited for a
deficiency for failure to comply with a
condition of participation relating to
quality of care; or
``(ii) if such program is placed in the
special focus program established under
subsection (b).''; and
(4) in paragraph (6), as so redesignated, by striking
``each fiscal year (beginning with fiscal year 2022)'' and
inserting ``each of fiscal years 2022 through 2025, and of
$15,000,000 for fiscal year 2026 and for each subsequent fiscal
year,''.
(d) Prohibition on Payment for Failure To Meet Quality Data
Reporting Requirements.--Section 1814(i)(5) of the Social Security Act
(42 U.S.C. 1395f(i)(5)) is amended--
(1) in subparagraph (A)--
(A) in the header, by striking ``Reduction in
update for'';
(B) in clause (i)--
(i) in the header, by striking ``In
general'' and inserting ``Fiscal years 2014
through 2026'';
(ii) by inserting ``through fiscal year
2026'' after ``each subsequent fiscal year'';
and
(iii) by adding at the end the following
new sentence: ``The application of the
preceding sentence may result in the market
basket percentage increase under paragraph
(1)(C)(ii)(VII) or paragraph (1)(C)(iii), as
applicable, being less than 0.0 for a fiscal
year, and may result in payment rates under
this subsection for a fiscal year being less
than such payment rates for the preceding
fiscal year.''; and
(C) by amending clause (ii) to read as follows:
``(ii) Subsequent fiscal years.--For
purposes of fiscal year 2027 and each
subsequent fiscal year, no payment may be made
under this title to a hospice program that does
not submit data to the Secretary in accordance
with subparagraph (C) with respect to such
fiscal year.''; and
(2) in subparagraph (B), by striking ``subparagraph (A)''
and inserting ``subparagraph (A)(i)''.
(e) Ensuring Independence of Physician Certifications of Terminal
Illness.--Section 1814(a)(7)(A)(i) of the Social Security Act (42
U.S.C. 1395f(a)(7)(A)(i)) is amended--
(1) in subclause (I), by inserting ``or, with respect to
certifications under this clause occurring on or after October
1, 2026, in the case such individual fails to designate such an
attending physician (or in the case such attending physician is
employed by the hospice program at which such individual will
receive such care or otherwise has a significant ownership
interest in, or a significant financial relationship with, such
program (as determined by the Secretary)), by a physician,
physician assistant, or nurse practitioner that does not have
such a significant ownership interest in, or such a significant
financial relationship with, such program (as determined by the
Secretary)'' before ``, and''; and
(2) in the matter following subclause (II), by striking
``physician's'' and inserting ``physician's, physician
assistant's, nurse practitioner's,''.
(f) Allowing Additional Providers To Certify Terminal Illness.--
(1) In general.--Section 1814(a)(7)(A)(i)(I) of the Social
Security Act (42 U.S.C. 1395f(a)(7)(A)(i)(I)) is amended by
striking ``(which for purposes of this subparagraph does not
include a nurse practitioner or a physician assistant)''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply with respect to certifications of terminal
illnesses made on or after October 1, 2026.
(g) Allowable Use of Supporting Material in Medical Review of
Hospice Care.--Section 1814(a) of the Social Security Act (42 U.S.C.
1395f(a)) is amended by adding at the end the following new sentence:
``For purposes of conducting medical review of hospice care furnished
to an individual, in addition to using documentation in the medical
record of such individual's attending physician (as defined in section
1861(dd)) or of the physician, physician assistant, or nurse
practitioner otherwise making the certification described in paragraph
(7)(A)(i)(I) with respect to such individual, the Secretary may use
documentation in the medical record of the hospice program furnishing
such care as supporting material, as determined appropriate by the
Secretary.''.
(h) Prohibition on Certain Changes in Majority Ownership.--With
respect to any change in the majority ownership of a hospice program
occurring during the 5-year period beginning on the date of the
enactment of this Act, the Secretary of Health and Human Services shall
apply section 424.550(b) of title 42, Code of Federal Regulations (or a
successor regulation) as if the references to ``36 months'' in
paragraph (1) of such section were references to ``60 months''.
(i) Advanced Notice of Changes in Ownership or Control.--Section
1822 of the Social Security Act (42 U.S.C. 1395i-6) is amended by
adding at the end the following new subsection:
``(d) Advanced Notice of Changes in Ownership or Control.--
``(1) In general.--Beginning January 1, 2027, in the case a
change occurs in--
``(A) the persons with an ownership or control
interest (as defined in section 1124(a)(3)) in the
hospice program;
``(B) the persons who are officers, directors,
agents, or managing employees (as defined in section
1126(b)) of the hospice program;
``(C) the corporation, association, or other
company responsible for the management of the hospice
program; or
``(D) the individual who is the administrator of
the hospice program, or (v) the individual who is the
medical director of the hospice program;
such program shall provide notice at the time of the change
(or, in the case such change is with respect to a person
described in subparagraph (A), at least 90 days before the
effective date of the change) to the Secretary, the appropriate
State or local survey agency, or appropriate approved
accreditation agency of the change and of the identity of each
new person, company, or individual described in the respective
subparagraph.
``(2) Enforcement.--
``(A) In general.--In the case that the Secretary
determines that a hospice program has violated
paragraph (1), the Secretary may--
``(i) impose a civil monetary penalty in an
amount not to exceed $1,000,000 per violation;
and
``(ii) if determined appropriate by the
Secretary, terminate such program's enrollment
under this title.
``(B) Procedures.--The provisions of section 1128A
(other than subsections (a) and (b) of such section)
shall apply to a civil monetary penalty imposed under
subparagraph (A) in the same manner as such provisions
apply to a penalty or proceeding under such section.''.
(j) Required Provision of Addendum of Noncovered Services.--Section
1812(d)(1) of the Social Security Act (42 U.S.C. 1395d(d)(1)) is
amended by adding at the end the following new sentence: ``With respect
to such an election made on or after October 1, 2026, in the case such
program determines that there are items and services being furnished to
such individual that are not related to the treatment of the
individual's condition with respect to which a diagnosis of terminal
illness has been made, such election shall include an addendum that
specifies such items and services and includes such additional
information as may be specified by the Secretary. Such program shall
provide an updated addendum described in the preceding sentence to such
individual if, while such election is in effect with respect to such
individual, such program makes any alteration to the addendum provided
to such individual at the time of such election.''.
(k) Medical Review of Hospice Outliers and Care Unrelated to
Terminal Condition.--
(1) In general.--
(A) Medical review.--Section 1814(a)(7) of the
Social Security Act (42 U.S.C. 1395f(a)(7)) is
amended--
(i) in subparagraph (D), by striking
``and'' at the end;
(ii) in subparagraph (E), by inserting
``before the date of the enactment of
subparagraph (F),'' after ``subparagraph,'';
and
(iii) by adding at the end the following
new subparagraph:
``(F) beginning on the date that is 5 years after
the date of the enactment of this subparagraph, in the
case of hospice care provided an individual for more
than 90 days by a hospice program with aberrant billing
patterns (as determined by the Secretary), the hospice
care provided to such individual is subject to
prepayment medical review (in accordance with
procedures established by the Secretary); and''.
(B) Technical expert panel.--
(i) In general.--The Secretary of Health
and Human Services shall establish a technical
expert panel for purposes of establishing
standards for identifying a hospice program
with a history of aberrant billing patterns
under section 1814(a)(7)(F) of the Social
Security Act, as added by subparagraph (A). In
making recommendations with respect to such
standards, such panel shall take into account
the results of prepayment medical reviews
conducted under section 1866(j)(10)(D) of such
Act, as added by subsection (a).
(ii) FACA waiver.--The provisions of
chapter 10 of title 5, United States Code,
shall not apply to the panel established under
clause (i).
(2) Prepayment medical review requirement.--Section
1812(d)(2) of the Social Security Act (42 U.S.C. 1395d(d)(2))
is amended by adding at the end the following new subparagraph:
``(E) Notwithstanding any other provision of this title, in the
case of items and services (other than items and services described in
the matter following clause (ii)(II) of subparagraph (A)) furnished on
or after October 1, 2026, to an individual with an election in effect
under paragraph (1) by a provider of services or supplier, if such
provider of services or supplier indicates that such items and services
are unrelated to the individual's condition with respect to which a
diagnosis of terminal illness has been made, no payment may be made
under this title for such items and services before the Secretary has
conducted a medical review of such items and services to determine
whether such items and services are unrelated to such condition. Such
review shall include a review of any addendum described in paragraph
(1) included in such election.''.
(3) Funding.--The Secretary of Health and Human Services
shall provide for the transfer, from the Federal Hospital
Insurance Trust Fund established under section 1817 of the
Social Security Act (42 U.S.C. 1395i) to the Centers for
Medicare & Medicaid Services Program Management Account, of
$20,000,000 for fiscal year 2026, to remain available until
expended, for purposes of carrying out the amendments made by
this subsection.
(l) Provision of Explanation of Benefits Upon Hospice Election.--
(1) In general.--Section 1806 of the Social Security Act
(42 U.S.C. 1395b-7) is amended by adding at the end the
following new subsection:
``(d) Provision of Explanation of Benefits Upon Hospice Election.--
The Secretary shall furnish to each individual who makes an election
described in section 1812(d)(1), not later than 15 days after such
individual makes such election, a notice that--
``(1) specifies--
``(A) the effective date of such election;
``(B) the hospice program that will be furnishing
hospice care to such individual;
``(C) the telephone number and address of such
program;
``(D) the physician, physician assistant, or nurse
practitioner who made the certification described in
section 1814(a)(7)(A)(i)(I) with respect to such
individual;
``(E) the toll-free telephone number of the
medicare administrative contractor responsible for
processing claims for such care;
``(2) informs such individual of the waiver of rights
described in section 1812(d)(2)(A);
``(3) includes a statement which indicates that, because
errors do occur and because Medicare waste, fraud, and abuse is
a significant problem, such individual should carefully check
the individual's hospice election information and if such
individual suspects Medicare waste, fraud, or abuse with
respect to the provision of such care, the individual should
contact the toll-free phone number 1-800-MEDICARE and a toll-
free phone number maintained by the Inspector General of the
Department of Health and Human Services for the receipt of
complaints and information about waste, fraud, and abuse in the
provision or billing of services under this title; and
``(4) includes any other information determined appropriate
by the Secretary.''.
(2) Funding.--The Secretary of Health and Human Services
shall provide for the transfer from the Federal Hospital
Insurance Trust Fund established under section 1817 of the
Social Security Act (42 U.S.C. 1395i) to the Centers for
Medicare & Medicaid Services Program Management Account of
$10,000,000 for fiscal year 2026, to remain available until
expended, for purposes of carrying out the amendment made by
paragraph (1).
(3) Effective date.--The amendment made by paragraph (1)
shall apply to individuals making elections described in
section 1812(d)(1) of the Social Security Act (42 U.S.C.
1395d(d)(1)) on or after the date that is 1 year after the date
of the enactment of this Act.
(m) Medical Review of Hospice Care Contractor Requirements.--
(1) In general.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
require any entity performing medical review under contract
with Secretary of hospice care furnished under part A of title
XVIII of the Social Security Act (42 U.S.C. 1395c et seq.) to,
with respect to such reviews performed on or after January 1,
2027, utilize only individuals who have received specialized
instruction on the philosophy behind hospice care and medical
prognostication (as specified by the Secretary) in performing
such reviews. In so specifying such instruction and in updating
such instruction, the Secretary shall consult with hospice
programs as to the content of such instruction.
(2) Publication.--The Secretary shall make any instruction
specified for purposes of paragraph (1) publicly available on
the website of the Centers for Medicare & Medicaid Services.
(3) Report.--Not later than October 1, 2027, the Secretary
shall submit to Congress a report on activities relating to the
medical review of hospice care furnished under part A of title
XVIII of the Social Security Act (42 U.S.C. 1395c et seq.).
Such report shall include--
(A) with respect to the medical review of hospice
care performed during the period beginning on January
1, 2019, and ending on December 31, 2024, the accuracy
rates of such reviews when performed by--
(i) medicare administrative contractors;
(ii) recovery audit contractors;
(iii) supplemental medical review
contractors; and
(iv) uniform program integrity contractors;
(B) the total number of hospice claims submitted
during the period described in subparagraph (A) subject
to medical review;
(C) the percentage of such claims that were denied
and appealed and the percentage of such claims so
appealed that were overturned on appeal, broken down by
the type of contractor conducing review of such claims
and by each level of appeal;
(D) a list of medical review projects relating to
hospice care undertaken by contractors described in
subparagraph (A); and
(E) actions the Secretary will take to reduce the
audit burden on hospice programs with claims selected
for medical review under multiple projects described in
subparagraph (D) and to minimize the number of denials
of claims for hospice care that are overturned on
appeal.
(n) Requiring Face-to-Face Encounters Before Recertifications of
Terminal Illness.--Section 1814(a)(7) of the Social Security Act (42
U.S.C. 1395f(a)(7)) is amended--
(1) in subparagraph (D)--
(A) by inserting ``, and before October 1, 2026''
after ``2011''; and
(B) by striking ``and'' at the end; and
(2) by adding at the end the following new subparagraph:
``(F) on and after October 1, 2026, not more than
30 days before each recertification described in
subparagraph (A)(ii) is made with respect to an
individual, a hospice physician, hospice nurse
practitioner, or hospice physician assistant has a
face-to-face encounter (which may, with respect to any
such recertification made for a 60-day period described
in such subparagraph, be conducted via telehealth, but
only if a registered nurse, licensed practical nurse,
or home health aide employed by the hospice program
furnishing hospice care to such individual is
physically present with such individual during such
encounter) with such individual to gather clinical
findings to determine such individual's continue
eligibility for hospice care; and''.
(o) Ensuring Medical Director and Physician Availability.--
(1) In general.--Section 1861(dd) of the Social Security
Act (42 U.S.C. 1395x(dd)) is amended--
(A) in paragraph (2)--
(i) in subparagraph (F), by striking
``and'' at the end;
(ii) by redesignating subparagraph (G) as
subparagraph (I); and
(iii) by inserting after subparagraph (F)
the following new subparagraphs:
``(G) has a medical director responsible for the
medical component of hospice care provided by such
program who--
``(i) is a doctor of medicine or osteopathy
licensed to practice in the State in which such
program is located; and
``(ii) subject to paragraph (6), is not the
medical director of more than 1 other hospice
program;
``(H) ensures that the medical director described
in subparagraph (G) or a physician member of the group
described in subparagraph (B) is available for
immediate consultation (which may be through
telehealth) when hospice care is provided in an
individual's home; and''; and
(B) by adding at the end the following new
paragraph:
``(6) The Secretary may waive the requirement described in
paragraph (2)(G)(ii) with respect to the medical director of a hospice
program if determined appropriate by the Secretary on a case-by-case
basis. In determining whether to grant a waiver under the preceding
sentence, the Secretary shall take into consideration--
``(A) the average daily census for each hospice program
with respect to which such director is medical director;
``(B) the geographic areas served by such programs; and
``(C) any other information determined appropriate by the
Secretary.''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply beginning January 1, 2028.
(p) Report on Hospice Accrediting Organizations.--Not later than 2
years after the date of the enactment of this Act, the Comptroller
General of the United States shall submit to Congress a report on the
Secretary of Health and Human Services' (in this subsection referred to
as the ``Secretary'') oversight of hospice program accrediting
organizations. Such report shall include the following:
(1) An analysis of deficiencies relating to quality of care
found pursuant to surveys conducted under section 1822(a) of
the Social Security Act (42 U.S.C. 1395i-6(a)) following
complaints when such surveys were of hospice programs
accredited by such an organization and such surveys were
conducted by such an organization compared to such deficiencies
so found following such complaints when such surveys were of
hospice programs certified by State or local survey agencies
and such surveys were conducted by such agencies.
(2) A list of hospice programs determined by the Secretary
not to be in compliance with all requirements applicable to
such programs, along with a list of the accrediting
organization of each such program.
(3) A list of hospice programs that have been deactivated,
terminated, or investigated due to concerns relating to waste,
fraud, or abuse, along with a list of the accrediting
organization of each such program.
(4) An analysis of any conflicts of interest of hospice
program accrediting organizations.
(5) Performance data for hospice program accrediting
organizations.
SEC. 3. PAYMENT REFORMS FOR HOSPICE CARE FURNISHED UNDER THE MEDICARE
PROGRAM.
(a) Adjusting Payments for Hospice Care.--
(1) In general.--Section 1814(i)(1)(C) of the Social
Security Act (42 U.S.C. 1395f(i)(1)(C)) is amended--
(A) in clause (iii)--
(i) by moving such clause 6 ems to the
left;
(ii) by striking ``With respect to'' and
inserting ``Except as provided under clauses
(viii) through (x), with respect to'';
(iii) by inserting ``in a setting (as
specified by the Secretary for purposes of
clause (vii))'' after ``hospice care
furnished'';
(iv) by inserting ``for such setting''
after ``payment rates in effect''; and
(v) by striking ``under this clause'' and
inserting ``under this subparagraph'';
(B) in clause (iv), by striking ``clause (ii)(VII)
or (iii)'' each place such phrase appears and inserting
``clause (iii) or (iv) of paragraph (2)(D) or clause
(ii)(VII), (iii), (viii), (ix), or (x)'' in each such
place; and
(C) by adding at the end the following new clauses:
``(vii) Prior to the beginning of a specified fiscal year (as
defined in clause (xi)), the Secretary shall specify percentages by
which the payment rates for hospice care consisting of services other
than routine home care (and, for specified years beginning on or after
October 1, 2033, for hospice care consisting of routine home care and
other services included in hospice care) in effect for the preceding
fiscal year shall be adjusted in such specified fiscal year to align
such rates with the costs of such care. In specifying such
percentages--
``(I) the Secretary shall take into account changes in the
average cost of such care and such other factors as determined
appropriate by the Secretary; and
``(II) the Secretary may specify different percentages for
such care based on the setting (as specified by the Secretary)
in which such care is furnished.
``(viii)(I) With respect to routine home care furnished during
fiscal year 2029, the payment rates for such care shall be equal to the
sum of--
``(aa) a per diem amount (which may include an a case mix
adjustment to account for variations in cost among different
units of service) reflecting the cost of routine home care not
consisting of direct patient care for nursing care, physical
therapy, occupational therapy, speech-language pathology
services, medical social services (other than counseling
services), home health aide services, and physician services
(other than such services that are considered administrative
services); and
``(bb) subject to such frequency limits as may be specified
by the Secretary, a per visit amount (which may vary depending
on the type and duration of the visit, as determined
appropriate by the Secretary) reflecting the cost of routine
home care consisting of direct patient care excluded from the
per diem amount established under item (aa) (other than, in the
case of such care furnished at a skilled nursing facility or
nursing facility (as defined in section 1919(a)), the component
of such rates attributable to home health aide services).
``(II) With respect to routine home care furnished during fiscal
year 2030 or a subsequent fiscal year, the payment rates for such care
shall be equal to the sum of--
``(aa) the per diem amount attributable to hospice care
described in subclause (I)(aa) in effect under this clause for
the preceding fiscal year, adjusted, in the case of a specified
fiscal year, by the percentages specified pursuant to clause
(vii) for such specified fiscal year, increased by the market
basket percentage increase (as defined in section
1886(b)(3)(B)(iii)) for the fiscal year (reduced in accordance
with clause (iv)); and
``(bb) the per visit amount for hospice care described in
subclause (I)(bb) in effect under this clause for the preceding
fiscal year, adjusted, in the case of a specified fiscal year,
by the percentages specified pursuant to clause (vii) for such
specified fiscal year, increased by such market basked
percentage increase for the fiscal year (reduced in accordance
with clause (iv)).
``(III) For purposes of this clause, the term `visit' means, with
respect to an individual receiving hospice care from a hospice program,
in-person contact with such individual by staff of such program (or by
others under arrangements with such program), not including any such
contact conducted via telehealth or any other form of
telecommunications technology.
``(ix)(I) With respect to routine home care consisting of specified
hospice care (as defined in subclause (II)) furnished by, or under
arrangements made by, a hospice program during the period beginning on
October 1, 2026, and ending on September 30, 2031, in lieu of the rates
otherwise payable under this subparagraph for such routine home care,
the Secretary shall pay to the hospice program furnishing such care an
amount equal to 400 percent of the amount payable for routine home care
furnished in fiscal year 2026, increased by the market basket
percentage increase (as defined in section 1886(b)(3)(B)(iii)) for the
fiscal year (reduced in accordance with clause (iv)), or such other
amount determined appropriate by the Secretary (which may vary based on
the type of service furnished) for each day during which such specified
hospice care was furnished.
``(II) For purposes of subclause (I), the term `specified hospice
care' means any of the following items and services:
``(aa) Palliative chemotherapy or radiation furnished under
the supervision of an oncologist and in accordance with
accepted clinical guidelines.
``(bb) Palliative radiation therapy furnished under the
supervision of an oncologist and in accordance with accepted
clinical guidelines.
``(cc) Subject to such frequency limitations as the
Secretary may establish, palliative blood transfusions
furnished to an individual diagnosed with a blood cancer and
furnished under the supervision of an oncologist and in
accordance with accepted clinical guidelines.
``(dd) Palliative dialysis furnished under the supervision
of a nephrologist, but only if--
``(AA) the individual receiving such palliative
dialysis was receiving dialysis treatments prior to
making the election under section 1812(d); and
``(BB) such individual has received fewer than 10
sessions of such palliative in-center or home
hemodialysis or the equivalent for peritoneal dialysis
or other modalities (or, in the case such individual
has received 10 or more such sessions or the equivalent
of such sessions, such session or equivalent of such
session is subject to prior authorization).
``(x) With respect to hospice care consisting of services other
than routine home care furnished during 2029 or a subsequent fiscal
year, the payment rates for such care shall be equal to the rates in
effect for such care for the preceding fiscal year, adjusted, in the
case of a specified fiscal year, by the percentages specified pursuant
to clause (vii) for such specified fiscal year, increased by the market
basket percentage increase (as defined in section 1886(b)(3)(B)(iii))
for the fiscal year (reduced in accordance with clause (iv)).
``(xi) For purposes of this subparagraph, the term `specified
fiscal year' means fiscal years 2029, 2034, and 2039.
``(xii)(I) The Secretary shall, with respect to cost reporting
periods beginning during an applicable fiscal year (as defined in
subclause (III)), conduct an audit of a representative sample of cost
reports submitted by hospice programs.
``(II) The Secretary shall, for each applicable fiscal year,
convene a technical expert panel for purposes of reviewing the
methodology and results of the audit conducted under subclause (I) with
respect to such applicable fiscal year.
``(III) For purposes of this clause, the term `applicable fiscal
year' means fiscal years 2025, 2030, and 2035.
``(IV) The provisions of chapter 10 of title 5, United States Code,
shall not apply to the panel established under subclause (II).
``(V) The Secretary shall provide for the transfer, from the
Federal Hospital Insurance Trust Fund established under section 1817 to
the Centers for Medicare & Medicaid Services Program Management
Account, of $10,000,000 for each of fiscal years 2026, 2031, and 2036,
to remain available until expended, for purposes of carrying out this
clause.''.
(2) Outlier payments.--Section 1814(i) of the Social
Security Act (42 U.S.C. 1395f(i)) is amended--
(A) by redesignating paragraph (7) as paragraph
(8); and
(B) by inserting after paragraph (6) the following
new paragraph:
``(7)(A) Subject to subparagraph (B), with respect to routine home
care furnished during a fiscal year beginning on or after October 1,
2031, the Secretary may, if determined appropriate by the Secretary,
provide an additional payment for types of such care (such as specified
hospice care (as defined in paragraph (1)(C)(ix))) specified by the
Secretary to account for unusual variations in the type or amount of
such routine home care.
``(B)(i) The total amount of additional payments estimated to be
made under subparagraph (A) for routine home care furnished during a
fiscal year may not exceed 5 percent of the total amount of payments
estimated to be made for such care furnished during such fiscal year
without application of this paragraph for such fiscal year.
``(ii) The total amount of additional payments estimated to be made
under subparagraph (A) for routine home care furnished during a fiscal
year to an individual hospice program may not exceed 10 percent of the
total amount of payments estimated to be made for such care furnished
during such fiscal year by such program without application of this
paragraph for such fiscal year.
``(C) The Secretary shall reduce any per diem rate applicable under
paragraph (1) to routine home care furnished during the first fiscal
year for which payments are made under subparagraph (A) by such
proportion as will result, not taking into account any additional
payments made under subparagraph (A) for such care furnished during
such fiscal year, in an aggregate reduction of 5 percent in payment for
such care furnished during such fiscal year.''.
(3) Plan of care requirements.--
(A) In general.--Section 1814(a)(7)(B) of the
Social Security Act (42 U.S.C. 1395f(a)(7)(B)) is
amended by inserting ``and, with respect to the
establishment of such plan, in the case such plan
includes the furnishing of specified hospice care (as
defined in subsection (i)(1)(C)(x)(II)), by a
nephrologist (if such care is care described in item
(dd) of such subsection) or by an oncologist (if such
care is care described in any of items (aa) through
(cc) of such subsection) who does not have a
significant ownership interest in, or a significant
financial relationship with, such hospice program, as
determined by the Secretary, and, with respect to the
periodic review of such plan, in the case such plan
includes the furnishing of specified hospice care (as
defined in subsection (i)(1)(C)(x)(II)), by the
nephrologist supervising the furnishing of such care
(if such care is described in item (dd) of such
subsection) or by the oncologist supervising the
furnishing of such care (if such care is described in
any of items (aa) through (cc) of such subsection)''
after ``of the hospice program''.
(B) Effective date.--The amendment made by
subparagraph (A) shall apply with respect to written
plans for providing hospice care developed or reviewed
on or after October 1, 2026.
(4) Excluding home health aide services and homemaker from
the definition of hospice care in certain circumstances.--
(A) In general.--Section 1861(dd)(1)(D)(i) of the
Social Security Act (42 U.S.C. 1395x(dd)(1)(D)(i)) is
amended by inserting ``in the case such individual is
not residing in a skilled nursing facility or a nursing
facility,'' before ``services of a''.
(B) Homemaker services.--Section 1861(dd)(1)(D)(ii)
of the Social Security Act (42 U.S.C.
1395x(dd)(1)(D)(ii)) is amended by inserting ``(but
only if such individual is not residing in a skilled
nursing facility or a nursing facility (as defined in
section 1919(a)) or, if such individual is residing in
such a skilled nursing facility or nursing facility,
only if such services are provided on a volunteer basis
in accordance with paragraph (2)(E))'' after
``homemaker services''.
(C) Effective date.--The amendments made by
subparagraphs (A) and (B) shall apply to items and
services furnished on or after October 1, 2028.
(5) Conforming adjustment to payment cap.--Section
1814(i)(2)(B) of the Social Security Act (42 U.S.C.
1395f(i)(2)(B)) is amended--
(A) in clause (i), by striking ``clause (ii)'' and
inserting ``clauses (ii) through (iv)'';
(B) in clause (ii), by inserting ``, subject to
clause (iii),'' after ``subparagraph (A)'';
(C) by striking clause (iii) and inserting the
following new clause:
``(iii) For purposes of subparagraph (A), in the case of a
specified fiscal year (as defined in paragraph (1)(C)(xi)), the `cap
amount' for such year is the cap amount under this subparagraph for the
preceding fiscal year, adjusted by the estimated percentage change in
the total amount of payment made under this part for hospice care
attributable to application of the amendments made by section 3(a)(1)
of the Hospice CARE Act of 2024 for such specified fiscal year and then
increased by the market basket percentage increase (as defined in
section 1886(b)(3)(B)(iii)) for such specified fiscal year (reduced in
accordance with paragraph (1)(C)(iv)).''; and
(D) by adding at the end the following new clause:
``(iv) For purposes of subparagraph (A), subject to clause (iii),
for a fiscal year beginning on or after October 1, 2034, the `cap
amount' for such year is the cap amount under this subparagraph for the
preceding fiscal year, increased by the market basket percentage
increase (as defined in section 1886(b)(3)(B)(iii)) for such fiscal
year (reduced in accordance with paragraph (1)(C)(iv)).''.
(b) Wage Adjusting Caps.--
(1) In general.--Section 1814(i)(2) of the Social Security
Act (42 U.S.C. 1395f(i)(2)), as amended by subsection (a), is
further amended--
(A) in subparagraph (A)--
(i) by striking ```cap amount' for the year
(computed under subparagraph (B))'' and
inserting ``wage-adjusted cap (as defined in
subparagraph (B)) for such program and year'';
and
(ii) by striking ``subparagraph (C)'' and
inserting ``subparagraph (E)'';
(B) by redesignating subparagraphs (B) through (D)
as subparagraphs (D) through (F), respectively;
(C) by inserting after subparagraph (A) the
following new subparagraphs:
``(B) For purposes of subparagraph (A), the term `wage-adjusted
cap' means, with respect to a hospice program and a year, the product
of--
``(i) the wage index ratio (as computed under subparagraph
(C)) for such program and year; and
``(ii) the cap amount for such year (as computed under
subparagraph (D)).
``(C) For purposes of subparagraph (B), the wage index ratio for a
hospice program and a year is the ratio of--
``(i) the aggregate payments to such program for such year
under paragraph (1); to
``(ii) the aggregate payments to such program for such year
under such paragraph that would have been made had such
payments not been subject to any wage adjustment.'';
(D) in subparagraph (D), as so redesignated--
(i) by striking ``subparagraph (A)'' each
place it appears and inserting ``subparagraph
(B)'' in each such place; and
(ii) by adding at the end the following new
clause:
``(v) Notwithstanding the preceding provisions of this
subparagraph, for a fiscal year beginning on or after October 1, 2025,
the cap amount otherwise determined under this subparagraph for such
fiscal year shall be decreased by the same percentage reduction (if
any) applied to the amount of payment made under this part for such
fiscal year under an order issued pursuant to section 251 of the
Balanced Budget and Emergency Deficit Control Act of 1985. Any
reduction to the cap amount for a fiscal year under the preceding
sentence shall not be taken into account for purposes of determining
the cap amount for any succeeding fiscal year.''; and
(E) by adding at the end the following new
subparagraph:
``(G) Not later than 1 year after the date of the enactment of this
subparagraph, and annually thereafter, the Secretary shall submit to
Congress and make public on the website of the Centers for Medicare &
Medicaid Services a report on the calculation of hospice programs' cap
amounts under this paragraph. Such report shall contain, with respect
to each of the 5 most recent accounting years for which data is
available and each hospice program receiving payments under this
section for hospice care furnished during such year, the following:
``(i) Such program's cap amount determined under such
section.
``(ii) The percentage of such program's cap amount paid to
such program for such care.
``(iii) In the case payments to such program exceeded such
cap, any amount recouped by the Secretary with respect to such
program.
``(iv) The live discharge rate of such program.''.
(2) Implementation.--Notwithstanding any other provision of
law, the Secretary of Health and Human Services may implement
the amendments made by paragraph (1) by program instruction or
otherwise.
(3) Effective date.--The amendments made by subparagraphs
(A) through (C) of paragraph (1) shall apply with respect to
payment for hospice care furnished during fiscal years
beginning on or after October 1, 2026.
(c) Modification of Requirements Relating to Short-Term Inpatient
Care.--
(1) In general.--Section 1861(dd) of the Social Security
Act (42 U.S.C. 1395x(dd)) is amended--
(A) in paragraph (1)--
(i) in subparagraph (G), by striking
``consecutively over longer than five days''
and inserting ``for more than 5 days during any
90-day election period (or 60-day election
period, as applicable) described in section
1812(d)(1)''; and
(ii) in the flush matter following
subparagraph (I), by adding at the end the
following new sentence: ``In the case of an
individual who receives short-term inpatient
care described in subparagraph (G) consisting
of respite care during an election period and
the furnishing of such care is immediately
preceded by a hospital stay (which may include
a stay for observation) during which such
individual made an election described in
section 1812(d)(1) for the first time during
such individual's lifetime (or if such care is
immediately preceded by the furnishing of
hospice care consisting of general inpatient
care and such general inpatient care is
immediately preceded by such a hospital stay),
the first continuous 15 days of such care shall
not be taken into account for purposes of
applying the limitation on the number of days
during which such care may be furnished during
an election period under such subparagraph, but
only if such individual does not have
sufficient caregiver support to be discharged
to the individual's home.''; and
(B) in paragraph (2)--
(i) in subparagraph (A)(iii)--
(I) by striking ``provides
assurances satisfactory to the
Secretary that'' and inserting
``ensures that the sum of''; and
(II) by striking ``20 percent'' and
inserting ``10 percent (or a higher
percent (not to exceed 20 percent)
specified by the Secretary if
determined necessary by the Secretary
to ensure sufficient access to such
inpatient care)''; and
(ii) by adding at the end the following
flush sentence:
``For purposes of subparagraph (A)(iii), the Secretary shall
ensure that the limitation described in such subparagraph is
applied, to the extent practicable, on a real-time basis.''.
(2) Allowing respite care to be furnished in residential
care facilities.--Not later than October 1, 2026, the Secretary
of Health and Human Services (in this paragraph referred to as
the ``Secretary'') shall revise section 418.108 of title 42,
Code of Federal Regulations (or a successor regulation) to
allow short-term inpatient care consisting of respite care (as
described in section 1861(dd)(1)(G) of the Social Security Act
(42 U.S.C. 1395x(dd)(1)(G))) to be furnished in residential
care facilities (as defined by the Secretary) that only provide
care to individuals receiving hospice care (as specified by the
Secretary) and that meet such standards relating to health and
safety as the Secretary may specify (which may be based on
State licensure requirements applicable to such facilities).
(3) Effective date.--The amendments made by paragraph (1)
shall apply to hospice care furnished on or after October 1,
2026.
(d) Hospital Discharge Planning Requirements.--
(1) In general.--Section 1861(ee)(2)(D) of the Social
Security Act (42 U.S.C. 1395x(ee)(2)(D)) is amended--
(A) by inserting ``, home health services,'' after
``including hospice care'';
(B) by striking ``including the availability of
home health services through individuals and entities''
and inserting the following: ``including--
``(i) in the case of individuals who are likely to
need home health services, the availability of such
services through home health agencies'';
(C) by striking ``listed by the hospital as
available and, in the case of individuals who are
likely to need post-hospital extended care services,''
and inserting the following: ``listed by the hospital
as available;
``(ii) in the case of individuals who are likely to
need post-hospital extended care services,'';
(D) by striking the period and inserting ``; and'';
and
(E) by adding at the end the following new clause:
``(iii) in the case of individuals who are
likely eligible for hospice care, the
availability of such care (including the
availability of respite care described in
subsection (dd)(1)(G)) through hospice programs
that participate in the program under this
title and that serve the area in which the
patient resides.''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply with respect to discharges occurring on or after
October 1, 2026.
(e) Payment for Respite Care Furnished in the Home.--
(1) In general.--Section 1861(dd)(1) of the Social Security
Act (42 U.S.C. 1395x(dd)(1)) is amended--
(A) in subparagraph (H), by striking ``and'' at the
end;
(B) by redesignating subparagraph (I) as
subparagraph (J); and
(C) by inserting after subparagraph (H) the
following new subparagraph:
``(I) short-term home respite care furnished to an
individual on or after October 1, 2028, that--
``(i) is furnished in the place of residence used
as such individual's home (other than a skilled nursing
facility, a nursing facility (as defined in section
1919(a)), an assisted living facility (as defined by
the Secretary), or another facility specified by the
Secretary);
``(ii) is furnished on an intermittent, nonroutine,
and occasional basis;
``(iii) is furnished for not more than 120 hours
during any 90-day period described in section
1812(d)(1) (or, in the case such individual is 60-day
period described in such section, for not more than 80
hours during such period); and
``(iv) meets such other requirements as the
Secretary may specify.''.
(2) Payment rates.--Section 1814(i)(1)(C) of the Social
Security Act (42 U.S.C. 1395f(i)(1)(C)), as amended by
subsection (a), is further amended--
(A) in clause (iii), by striking ``through (x)''
and inserting ``through (x) and clause (xiii)''; and
(B) by adding at the end the following new clause:
``(xiii) With respect to short-term home respite care furnished to
an individual during fiscal year 2029 or a subsequent fiscal year, the
rates payable for such care shall be equal to the sum of the per diem
rate established for routine home care for such fiscal year and an
hourly rate established by the Secretary, except that in no case may
such rate payable for such short-term home respite care furnished in a
24-hour period exceed the rate of payment for general inpatient care
furnished during such a period.''.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Health.
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