This document summarizes the hospice network requirements outlined in the VBID Request for Applications. More importantly, we offer guidance on what it may mean to hospice and palliative care organizations and some recommendations for engaging Medicare Advantage Organizations (MAOs) in their markets.

All hospices are covered, initially, but networks will get more restrictive each year

In 2021 and 2022, MAOs must cover all certified hospices and pay them at standard rates. They cannot negotiate fee schedules with out-of-network providers. (page 4)

CMS expects plans to steer members to use in-network providers. While this won’t be a prior authorization process, MAOs must provide a 24/7 support line, staffed by care managers, that can help members understand the benefits of using in-network providers. (page 22)

By 2023, MAOs can establish a traditional network (some providers will be truly out-of-network) as long as there is sufficient coverage and range of services in each county. (page 23)

Palliative care, transitional concurrent care, and other supplemental benefits will be available but limited to in-network providers

MAOs will be expected to cover “comprehensive” palliative care (page 14) for members that aren’t eligible or choose not to elect hospice. (page 4)

MAOs must also provide transitional concurrent care services. (page 4)

Other supplemental benefits are optional such as room and board, home and bathroom safety devices/modifications, over-the-counter (OTC) benefits, support for caregivers, meals and transportation. (page 33)

However, it is important to note that these supplemental benefits will likely be limited to in-network providers. (page 4, 18, 23)

MAOs are encouraged to establish innovative payment arrangements for palliative care

CMS is encouraging MAOs to establish innovative payment arrangements for palliative care services, likely resulting in a Per Member Per Month (PMPM) model versus fee for service. (page 28)

In preparation for negotiating a sufficient PMPM, it is important to evaluate the breadth of services and then determine the cost of delivering a comprehensive palliative care program. The minimum requirements (page 28) include:

  • Expert pain and symptom management
  • Meaningful 24/7 clinician availability
  • Shared decision making and education around disease progression and treatments
  • Advance care planning
  • Family and caregiver support
  • Benefits and entitlements assistance
  • Linkage to community supports, food, transport, safety and housing services
  • Linkage to financial assistance
  • Home environment safety assessment and follow-up
  • Home adaptations or modifications
  • Home-based physical and/or occupational therapy
  • Personal care services
  • Respite services for family caregivers
  • Access to a spiritual professional
  • Psychological counseling

Payment may evolve toward bundled payments that cover both comprehensive palliative and hospice care as a seamless continuum of care

Palliative and hospice care may be bundled to encourage a seamless transition. (page 28)

This may include “total cost of care structures” for specific members with cognitive disorders, cancer, end-organ failure, and other potential disease state bundles. (page 28)

MAOs are required to make it easy for hospice providers to apply for in-network status

The RFA specifies that MAOs should make it easy for hospice providers to share information about the quality and breadth of their services when applying for in-network status. (page 22)

Please contact Bob Tavares at btavares@cyft.com to learn more about how Cyft is helping hospice and palliative care organizations use their data to prepare for and succeed in value-based contracts.