Eli's Hospice Insider

Published on Wed Oct 12, 2022 PDF

Don’t make the mistake of thinking you won’t be affected if you don’t operate in one of those counties.

Chances are going up that you’ll have to deal with the Medicare managed care’s Value-Based Insurance Design (VBID) Model hospice carve-in next year.

Why? Of the 52 Medicare Advantage Organizations participating in 2023, 15 will offer the Hospice Benefit Component, the Centers for Medicare & Medicaid Services points out in a fact sheet about the calendar year 2023 VBID Model. That’s “six more than in 2021 and two more than in 2022,” CMS notes.

Reminder: “In participating in this voluntary Model component, MAOs are incorporating the Medicare hospice benefit into MA covered benefits while offering comprehensive palliative care services outside the hospice benefit for enrollees with serious illness,” CMS recaps. “In addition, participating MAOs are able to provide individualized, clinically appropriate transitional concurrent care through in-network providers and offer hospice-specific supplemental benefits,” the fact sheet adds.

The 15 organizations will test the inclusion of the Part A hospice benefit in MA through 119 plan benefit packages (PBPs), CMS reveals. That’s up from 53 PBPs in 2021 and 115 PBPs in 2022.

Those PBPs will run in 806 counties, up from 206 counties in 2021 and 461 counties this year, CMS highlights.

Don’t assume new counties will be merely added to last year’s. “There’s a lot of shifting that is going on, with a good number of new plans and plans that are dropping, as well as plans that are expanding their footprint in the model,” the National Association for Home Care & Hospice’s Theresa Forster notes on the trade group’s listserv.

“The estimated number of hospice enrollees who will be part of the model starting in 2023 is not yet known,” NAHC points out in its member newsletter. But “during CY2022, CMS estimated that approximately 20,000 hospice enrollees would be part of the model,” it says.

Heads up: Hospices should remember that the MA VBID hospice carve-in affects providers that are not in the 806 included counties too. “The VBID Pilot Program could impact your agency today,” warns billing and consulting firm Advanced Hospice Management on its website. “If a Medicare patient elects a Medicare Advantage plan participating in the Hospice VBID Pilot Program and moves outside the VBID geographical area, the plan must still be billed for hospice services,” AHM explains.

“In the absence of direct guidance from the plan, CMS says if a patient has a VBID plan and moves outside of the geographical area, the hospice services must still be billed to both the plan and Medicare and will be paid by the plan — if all criteria are met,” New Orleans-based AHM elaborates.

What that means: In those cases, “you must file the VBID plan [Notice of Election] timely as well,” AHM warns. Hospices must file such NOEs “based on the plan’s required time frame and method,” the firm stresses in its blog. “Hospices cannot ‘opt-out’ or decline participation,” AHM adds.

To avoid non-payment, hospices should ask every new patient if they’ve recently moved to the area and if so, whether they were under an MA plan in their previous location. If that’s a yes, then hospices need to chase down the MA plan information to ascertain whether it includes a VBID hospice carve-in, AHM advises. (For 2023, you can check the plan against the list on p. 279.)

CMS Says It Will Be Keeping An Eye On MAOs

Medicare officials may be acknowledging complaints they’ve received from hospices, patients, and their advocates with new monitoring policies and procedures in 2023.

CMS “is standardizing access- and equity-focused network adequacy requirements for MAO participants that have at least one year of participation by the start of CY 2023,” the fact sheet notes.

Stay tuned: “Data files further describing the quantitative element of these network adequacy requirements will be released on the VBID Model website in the coming months,” CMS says in the fact sheet.

CMS provided some details in a CY 2023 VBID Model fact sheet earlier this year. In 2023, participants with at least one year of participation must meet two model-specific requirements:

“1) create and maintain a network of hospice providers so that enrollees in each county of an MA plan’s service area(s) have access to a minimum number of network hospice providers; and

“2) describe their comprehensive strategy for forming a network of hospice providers to ensure that enrollees receive a set of timely, comprehensive, and high-quality services aligned with enrollee preferences in a culturally-sensitive and equitable fashion.”

More details of the requirements are in a 40-page document, CY 2023 Monitoring Guidelines for the VBID Model’s Hospice Benefit Component, and a 20-page document, CY 2023 Phase 2 Network Adequacy Requirements Policy and Technical Guidance, on the VBID webpage. According to the latter, CMS will make a Minimum Number of Provider (MNP) Data Book available to all stakeholders this month.

Plus: Throughout 2023, “CMS will perform ongoing reviews of hospice provider networks to ensure compliance with all Model-specific requirements,” the agency pledges in the network adequacy guidance.

In addition to the network adequacy rules, “each participating MAO prepared health equity plans on how they will address potential inequities and disparities in access, outcomes, and/ or enrollee experience of care as it relates to their participation in the Hospice Benefit Component,” CMS also notes in the earlier fact sheet.

The VBID model is scheduled to end in December 2024.

Note: Links to the participant announcement, monitoring guidelines, network adequacy guidance, and more are at https://innovation.cms.gov/innovation-models/vbid#cy2023 in the “CY 2023 Materials” section.