Federal Funding Deal Includes Important Telehealth, Other Health Care Provisions

  • Text of the bill is HERE.
  • A summary of the entire bill is HERE

Late in the evening on Tuesday, March 8, the House of Representatives’ Appropriations Committee released the text of the FY2022 Omnibus government spending legislation. The situation is very fluid right now and the details of the bill could change. For example, after a dispute among lawmakers, $15 billion in Covid-19 relief funding was pulled out of the $1.5 trillion omnibus package leaving the federal government with only a few months’ supply of coronavirus therapeutics.

It is possible the text of the bill could change, but as of Wednesday afternoon, this is what is in the legislation that matters for hospice.

Importantly, the funding package does not include any relief from impending Medicare sequester payment cuts. As a reminder, a one percent across-the-board reduction in Medicare payments is set to take effect April 1, 2022, lasting through June 30, 2022. The full two percent cuts will begin July 2022, lasting through the end of the calendar year. NAHC continues to advocate strongly for a further delay of the sequester reductions. Even as the pandemic enters a more stable phase, the current labor crisis in health care has increased costs for providers of all kinds, and a Medicare rate cut will only exacerbate the already dire workforce situation.

“We are very pleased to see the extension of the telehealth waivers in the bill as they have proven extremely valuable during the pandemic,” said NAHC President William A. Dombi. “Our hope is to see these become permanent parts of Medicare in the future. Also, we anticipate further legislative opportunities this year to deal with sequestration as well as our Choose Home bill among other crucial matters.”

A summary of the Labor-Health and Human Services portion of the bill (where most of the health care provisions are included) is HERE.

Included in the massive bill are a number of provisions relevant to home-based care providers, including:

Telehealth (Sec. 301-309)

  • An extension of the Medicare flexibility allowing hospices to perform the face-to-face (F2F) recertification visit via telehealth (Sec. 306). This flexibility will be extended for 5 months (151 days) after the end of the COVID-19 public health emergency (PHE). The current PHE declaration is in place until April 16, 2022, but it may be extended further till at least the middle of July 2022.
    • The inclusion of this specific extension is an advocacy win for NAHC and the hospice community. In recent days, intel from Capitol Hill indicated that the F2F fix was not being considered for extension. NAHC, our members, and other hospice stakeholders ramped up our advocacy to Congress to press for the F2F’s inclusion, and we are pleased to see it in the omnibus. We will continue to fight for a permanent extension.
  • Like the F2F telehealth extension, many other pandemic-era telehealth flexibilities are being extended for the same 5-months post-PHE timeframe. This includes the changes to the geographic and originating site requirements (Sec. 301), which are allowing patients to receive telehealth services in their own homes and in non-rural parts of the country. It also includes the flexibility to use audio-only telehealth (Sec. 305) It is through this provision that authorization for using telehealth to conduct the home health face-to-face results.
    • There is also a provision that will require both a MedPAC and an HHS OIG report on the expansion of telehealth as a result of the PHE, to inform future payment and program integrity policy (Sec. 308)
    • Additionally, beginning July 1, 2022, CMS will be required to publicly post, on a quarterly basis, data on Medicare claims for telemedicine services, including data on utilization and beneficiary characteristics (Sec. 308).
    • It is important to note that this legislation does not cover extensions for every single Medicare service that has been allowed to be delivered via telehealth during the pandemic. For example, the current flexibility provided hospices to deliver routine home care (RHC) using telehealth and telephone technology would not be extended by this bill. Likewise, a number of specific interventions that have been added to the Medicare Telehealth Code List only for the duration of the PHE would also not be extended by the omnibus. This includes certain Medicare Part B services that have been used by palliative care providers during the pandemic, such as CPT codes 99341-99345, which are evaluation and management (E&M) codes for home visits to new patients. (The current list of Medicare Telehealth Codes can be found HERE). NAHC believes that it will be up to CMS to determine extension policy for those telehealth services not covered by these legislative expansions.

Hospice Cap Methodology Extension (Sec. 312)

  • Included is an extension by one year, until 2031, of the current methodology used to update the Medicare hospice aggregate cap by the annual hospice payment update (APU), as opposed to the Consumer Price Index for Urban areas (CPI-U). This methodology of using the APU to update the cap has been in place since 2016 (as a result of the IMPACT Act of 2014) and was already set to remain effective until 2030 (as a result of the Consolidated Appropriations Act, 2021). The provision in this omnibus package simply extends this methodology to 2031. A one-year extension is expected to save the government ~$55-60 million dollars, so when applied across the nearly 5000 Medicare-certified hospices, this provision does not represent a major impact for providers.

CMS Report on Hospice Respite Care (Included in the Joint Explanatory Statement)

  • A congressional request to CMS, in consultation with the Office of the Assistant Secretary for Planning and Evaluation (ASPE), to provide, within 180 days of the enactment of the omnibus bill, a report to the relevant congressional committees on the current capacity and best practices for the provision of hospice respite care, including in the home.

Other important elements of the bill include:

  • Health workforce: $1.3 billion, an increase of $72 million above the FY 2021 enacted level, for the Health Resources and Services Administration’s (HRSA) Bureau of Health Professions programs to support health workforce development.
  • Program integrity funding: Roughly $659 million for CMS’ program integrity efforts; $102 million for HHS OIG program integrity activity; and $112 million for Department of Justice program integrity work within the health care industry.

Additional summary and explanatory documents related to the bill can be found on the House Appropriation Committee’s press release page HERE.

In addition to the omnibus funding package, the House of Representatives also released a very short-term “continuing resolution” bill that will fund the government for four additional days beyond the current funding expiration date of Friday, March 11, 2022. These four extra days will give the Senate time to review and pass the funding package by the new deadline of Tuesday, March 15, 2022.

Federal Funding Deal Includes Important Telehealth, Other Health Care Provisions

Text of the bill is HERE. A summary of the entire bill is HERE Late in the evening on Tuesday, March 8, the House of Representatives’ Appropriations Committee released the text of the FY2022 Omnibus government spending legislation. The situation is very fluid right now and the details of the bill could change. For example,…

Advocacy Alert: Ask Congress to Extend a Critical Telehealth Policy for Hospices

The National Association for Home Care & Hospice (NAHC) is calling on home-based care advocates to reach out to your members of congress now and ask that, as part of any forthcoming omnibus government spending legislation, they include an extension of the COVID-related flexibility that is allowing hospices to perform the face-to-face (F2F) recertification via telehealth. We need your voices on this issue now, as it is expected that congress will pass an omnibus bill before the current stopgap funding measure expires next Friday, March 11, 2022.

Temporary expansions of some other pandemic telehealth flexibilities are being considered for an omnibus package, but the hospice F2F allowance is not currently a part of those discussions. Reach out and tell your lawmakers how critical this flexibility has been, and how it will continue to positively impact patients, families, and hospices if extended.

Use NAHC’s grassroots outreach campaign to send a note to your elected officials about this issue HERE.

NAHC recently joined other major national associations representing hospices to send a letter to key Congressional leaders, urging them to extend the F2F telehealth flexibility. The letter requests that Congress, as part of any broader legislative effort to expand COVID-related Medicare telehealth flexibilities beyond the end of the PHE, make sure to explicitly extend the waiver that is allowing hospices to perform the (F2F eligibility recertification via telehealth. Our hospice members have reported that being able to perform the F2F virtually has been a major success and should be permanently, or at least temporarily, expanded beyond the pandemic. Hospices are able to collect all necessary clinical information for recertification, follow patient and family wishes for fewer visits during the pandemic, and allocate staff more effectively due to this flexibility.

However, unlike many of the other pandemic telehealth flexibilities that are authorized in a blanket fashion under HHS’ expanded Section 1135 waiver authority, the hospice recertification flexibility is a separate, standalone statutory provision. Any future broad-based legislative extension of telehealth flexibilities implemented under the 1135 waiver authority would not address the hospice telehealth recertification allowance, so separate legislative action would help ensure this particular flexibility can be continued post-PHE. Importantly, a number of popular bipartisan and bicameral bills do call for a permanent extension of the hospice F2F telehealth flexibility, including the Connect for Health Act of 2021 (S.1512/H.R. 2903), the Telehealth Modernization Act (S. 378/H.R. 1332), and the CURES 2.0 Act (H.R. 6000).

NAHC believes that absent specific congressional action on extending the F2F flexibility, CMS itself does have authority on its own to keep the allowance in place after the PHE ends. In the 2020 Interim Final Rule (IFR) implementing various COVID-19 flexibilities, CMS stated, as rationale for its decision to implement the F2F telehealth flexibility, “The statute is silent as to whether a face-to-face encounter solely for the purpose of Medicare hospice recertification (meaning there is no direct patient care) could be conducted via telecommunications technology by the hospice physician or NP”. We will work hard to engage CMS on this issue in parallel to our congressional advocacy.

As we have done throughout the pandemic, NAHC will continue to work with both Congress and CMS to ensure COVID’s lessons-learned and best-practices are institutionalized into policy that supports home-based care providers across the country.

Advocacy Alert: Ask Congress to Extend a Critical Telehealth Policy for Hospices

Tell Congress to Extend the Hospice Face-to-Face Telehealth Flexibility Act now before the March 11 deadline! The National Association for Home Care & Hospice (NAHC) is calling on home-based care advocates to reach out to your members of congress now and ask that, as part of any forthcoming omnibus government spending legislation, they include an extension of…

NAHC to Congress: Sequester Relief and Telehealth Extension

The National Association for Home Care & Hospice (NAHC) has written a letter to Congressional leaders urging them to work to enact legislative proposals that will prevent billions of dollars in harmful sequestration-related Medicare rate cuts, as well as extend a key PHE-related hospice telehealth flexibility.

Online advocacy outreach campaigns have also been set up so that stakeholders can reach out directly to their congressional delegations and echo these requests to stop the looming cuts and ensure hospices can continue to perform the face-to-face recertification via telehealth after the public health emergency ends.

The letter, which was sent to Senate Majority Leader Chuck Schumer (D-NY), Senate Minority Leader Mitch McConnell (R-KY), Speaker of the House Nancy Pelosi (D-CA), and House Minority Leader Kevin McCarthy (R-CA), asks Congress to take steps soon to delay or avert scheduled cuts to Medicare that are set to take effect starting April 1, 2022. Absent congressional action, a three-month, one percent reduction in Medicare sequester payment reductions will be in place from April 1, 2022 – June 30, 2022, and the full two percent cuts will be in place from July 1, 2022 through the end of the year.

Joining NAHC on the letter are other major national associations representing hospices.

America’s front line health care providers continue to struggle through the COVID-19 pandemic, as well as a historically challenging workforce shortage, both of which have placed unprecedented stress on the entire health care system. Home health and hospice providers are working tirelessly to deliver the best care for patients, families and communities, despite battling major operational pressures. Ongoing financial challenges for home care providers include higher expenses for labor and supplies, lost revenues due to forgone routine visits, and increased emergency costs associated with new COVID-19 surges, among others. Allowing the scheduled Medicare cuts to take effect in April would reduce access to high-quality home-based medical and social services for those individuals and families who have never needed them more.

The letter also requests that Congress, as part of any broader legislative effort to expand COVID-related Medicare telehealth flexibilities beyond the end of the PHE, make sure to explicitly extend the waiver that is allowing hospices to perform the face-to-face (F2F) eligibility recertification via telehealth. Our hospice members have reported that being able to perform the F2F virtually has been a major success and should be permanently, or at least temporarily, expanded beyond the pandemic. Hospices are able to collect all necessary clinical information for recertification, follow patient and family wishes for fewer visits during the pandemic, and allocate staff more effectively due to this flexibility.

However, unlike many of the other pandemic telehealth flexibilities that are authorized in a blanket fashion under HHS’ expanded Section 1135 waiver authority, the hospice recertification flexibility is a separate, standalone statutory provision. Any future broad-based legislative extension of telehealth flexibilities implemented under the 1135 waiver authority would not address the hospice telehealth recertification allowance, so separate legislative action is required for this particular flexibility to be continued post-PHE.

Importantly, a number of popular bipartisan and bicameral bills do call for a permanent extension of the hospice F2F telehealth flexibility, including the Connect for Health Act of 2021 (S.1512/H.R. 2903), the Telehealth Modernization Act (S. 378/H.R. 1332), and the CURES 2.0 Act (H.R. 6000).

NAHC will continue to advocate for inclusion of important home-based care provisions in any forthcoming major legislative vehicles, including the omnibus government funding package currently being negotiated on Capitol Hill.

NAHC Urges CMS to Collect Data on Technology-based and Chaplain Visits

Prior to the COVID-19 Public Health Emergency (PHE) many hospice providers had significant success with use of technology-based visits; however, there were a number of hospices that did not utilize technologies to their fullest extent because they believed they were required to provide all visits in-person. Early in the PHE, the Centers for Medicare & Medicaid Services (CMS) communicated that hospices are permitted to use telecommunications technologies to deliver hospice visits provided that such visits and technologies are specified by the Interdisciplinary Team (IDT) on the plan of care and that the goals of care (as outlined) are met.

In response to CMS’ clarification, hospice providers throughout the nation began to utilize technology more broadly in hospice care delivery, and found that, when used appropriately, this mode of care can provide substantial benefits to patients, family members, and hospice staff. However, CMS instructed hospices to not report these visits on hospice claims, which raised significant concern that CMS would not have accurate information on the full scope of services being provided to hospice patients, and that CMS and others would have no way of determining the impact that use of telecommunications technologies has on the quality of hospice care. The National Association for Home Care & Hospice (NAHC) has communicated to CMS a number of times since the start of the PHE that data on hospice “virtual” visits should be collected.

On a related matter, CMS has never required collection of data on chaplain visits on hospice claims, although previously, when the Hospice Item Set (HIS) data was directly submitted by hospice organizations and CMS gathered date for the Hospice Visits When Death is Imminent (HVDII) measure pair, the number of chaplain visits delivered during the last seven days of life was collected. The HVDII measure pair has been replaced with a claims-based measure (Hospice Visits in the Last Days of Life), which does not assess chaplain visits. As chaplains are essential members of the hospice IDT and the provision of chaplain services is a distinguishing element of the hospice benefit, NAHC and others have strongly urged CMS to collect data on chaplain visits on claims.

During the January 2022 meeting of the Medicare Payment Advisory Commission (MedPAC), the Commission approved a recommendation that the Secretary of Health & Human Services collect data on telehealth visits going forward as long as the agency permits telehealth visits in hospice. In putting forth the recommendation for the MedPAC March 2022 Report to Congress, Commission staff noted that, “Requiring hospices to report telehealth visits would increase the program’s ability to monitor beneficiary access to care.”  MedPAC’s recent action prompted the national hospice associations  (NAHC, NHPCO, LeadingAge, and NPHI) to join together in a letter to CMS Administrator Chiquita Brooks-LaSure urging that CMS:

  • Implement a modifier or HCPCS code and create a field on the hospice claim for telehealth visits from any discipline, to more accurately represent the full range of visits that hospices provide
  • Take the necessary steps to establish a HCPCS code specifically for chaplains in hospice and require reporting of chaplain visits on claims

The full letter to Administrator Brooks-LaSure is available HERE.  NAHC will provide updates on this and related issues in future issues of NAHC Report.

NAHC to Congress: Sequester Relief and Telehealth Extension

The National Association for Home Care & Hospice (NAHC) has written a letter to Congressional leaders urging them to work to enact legislative proposals that will prevent billions of dollars in harmful sequestration-related Medicare rate cuts, as well as extend a key PHE-related hospice telehealth flexibility. Online advocacy outreach campaigns have also been set up so…

NAHC Urges CMS to Collect Data on Technology-based and Chaplain Visits

Prior to the COVID-19 Public Health Emergency (PHE) many hospice providers had significant success with use of technology-based visits; however, there were a number of hospices that did not utilize technologies to their fullest extent because they believed they were required to provide all visits in-person. Early in the PHE, the Centers for Medicare &…

MedPAC Votes for Payment Cuts, Telehealth Reporting

The Medicare Payment Advisory Commission (MedPAC) met Thursday, January 13, to vote on their annual recommendations to Congress regarding payment policy and reporting requirements. This session served as a formality following presentation and discussion of the same recommendations that were put forward at the commission’s December 2021 meeting. The proposed recommendations voted on at this…

MedPAC Recommends 20 Percent Cut to Hospice Aggregate Cap

  • Payment Freeze, Aggregate Cap and Telehealth Visit Reporting Highlighted

Late last week, the Medicare Payment Advisory Commission (MedPAC), an advisory body to the U.S. Congress, verbally approved the following recommendations:

  • For fiscal year (FY) 2023, the Congress should eliminate the update to the 2022 Medicare base payment rates for hospice and wage adjust and reduce the hospice aggregate cap by 20 percent; and
  • The Secretary of Health and Human Services should require that hospices report telehealth services on Medicare claims.

A formal vote will be taken at a January 2022 meeting.

On an annual basis, MedPAC reviews draft policy recommendations for inclusion in its annual Report to Congress: Medicare Payment Policy issued each March. The Commissioners met to discuss a wide array of preliminary recommendations that included discussion of hospice payment and related issues.

The first recommendation is a repeat of recommendations from the previous two reports; MedPAC staff indicated that based on existing analysis they do not believe these changes would negatively impact access to hospice care or willingness or ability of hospice providers to care for beneficiaries.

The second recommendation regarding telehealth services was motivated by the expanded use of telecommunications-based visits during the public health emergency (PHE) and the need to know the extent to which telehealth visits are being conducted and access to care during the PHE.

The National Association for Home Care & Hospice (NAHC) has strongly urged the Centers for Medicare & Medicaid Services (CMS) to begin collection of data related to telecommunications-based visits to ensure more complete knowledge of services that are being provided as part of the hospice benefit.

In arriving at these recommendations MedPAC examined a great deal of data regarding the Medicare hospice program that provides insights into existing hospice payment adequacy as viewed through four separate lenses:

  • Beneficiaries’ access to care, including the supply of providers; use, length of stay, and visits; and marginal profit
  • Quality of care, including findings of the CAHPS Hospice Survey and visits at the end of life – while quality data were not available due to the PHE, there was a slight improvement in the share of patients receiving at least one visit from a nurse or other clinician in last three days of life in 2019. MedPAC also indicated that while in-person visits declined during 2020 that does not necessarily reflect a reduction in quality but more likely was due to the PHE
  • Hospices’ access to capital, including provider entry and financial reports and mergers and acquisition activity – continued growth in the number of for-profit providers (7 percent increase) and continued favorable perspectives on the sector by investors indicates positive access to capital
  • Medicare payments and hospices’ costs, including overall Medicare margins in 2019 and the projected overall Medicare hospice margin in 2022 – the 2019 Medicare hospice margin was 13.4 percent, and four of five provider quintiles average margins of over 10 percent. Non-profit hospices and provider-based hospices generally experience lower margins.

Following are some key data provided during the meeting:

  • Medicare hospice outlays grew to $22.4 Billion in 2020;
  • In 2020, over 5,000 providers served over 1.7 million beneficiaries;
  • The number of hospice providers grew by 4.5 percent during 2020, largely driven by the growth in for-profit hospice providers;
  • Hospice deaths in 2020 increased by 18 percent;
  • The number of decedents using hospice increased by 9 percent;
  • The share of decedents using hospice declined to 47.8 percent in 2020 (from 51.6 percent in 2019;
  • Total number of hospice users increased by 6.6 percent between 2019 and 2020;
  • The number of hospice days increased by 4.9 percent in 2020;
  • During 2020 more hospice patients were cared for at home, in assisted living facilities, and in hospitals, while fewer were cared for in nursing facilities and hospice facilities;
  • Average length of stay increased from 92.5 days in 2019 to 97.0 days in 2020, while the median length of stay remained stable at 18 days;
  • Average in-person visits per week decreased from 4.3 visits in 2019 to 3.5 in 2020, with aide visits experiencing the largest decline, although nursing visits also declined (likely offset to some extent by use of telehealth visits);
  • Marginal profit in 2019 was 17 percent; and
  • During 2019, 19 percent of hospices exceeded the aggregate cap (margin prior to recoupment was 22.5 percent and 10 percent afterward).

While time for general discussion was limited, Commissioners expressed a great deal of interest in this sector, including the status of the Medicare Advantage VBID Hospice Component Model (a CMS demonstration model under which hospice is being covered as part of the MA benefit package), concerns about access to care in rural areas, concerns about the impact of the workforce shortage on hospice care, request for further exploration of live discharges in hospice care, and the degree to which the hospice population has changed and reflects a higher proportion of patients with cognitive disease.

A copy of the slides used during the staff presentation is available HERE.  In the coming days, a copy of the full transcript of the meeting will be posted HERE.