Hospice CARE Act of 2026
- Sponsor
- Rep. Sánchez, Linda T. [D-CA-38]
- Committees
- Energy and Commerce Committee (primary)
- Last action
- Mar 17, 2026
Bottom line
The bill aims to bolster the integrity and accountability of Medicare hospice care through a combination of enrollment restrictions, enhanced oversight, and payment reforms, while also expanding access to certain palliative and respite services.
What it actually does
This bill, the Hospice CARE Act of 2026, significantly reforms the Medicare hospice program by imposing a temporary nationwide moratorium on new hospice enrollments, increasing oversight and survey frequency for existing programs, and restructuring payment methodologies. It also enhances requirements for physician certifications, ownership transparency, and discharge planning, while introducing new services like short-term home respite care and specialized palliative care payments.
Proponents argue
Proponents argue that the bill is essential to combat fraud, waste, and abuse within the rapidly growing hospice industry, particularly by addressing aberrant billing patterns and ensuring that only legitimate providers deliver high-quality care. They contend that the moratorium and increased oversight will stabilize the program, while payment reforms and expanded services will better meet patient needs and align payments with actual costs.
Opponents contend
Opponents might argue that the nationwide moratorium on new hospice enrollments, even with exemptions, could inadvertently limit access to care in areas with growing demand or stifle innovation. They may also raise concerns that increased administrative burdens and stricter payment rules could disproportionately impact smaller, rural, or non-profit hospices, potentially leading to consolidation or reduced service offerings.
The bill is moderately long and contains numerous technical amendments to the Social Security Act, requiring careful reading to understand its full implications. The estimated reading time of 40 minutes is reasonable for an informed reader to grasp the details.
Sec. 2(a)
Mandatory Temporary Moratorium on New Hospice Enrollments
This provision imposes a nationwide 5-year temporary moratorium on the enrollment of new hospice programs under Medicare. It allows for exemptions in areas with insufficient access to care, based on factors like geographic need and current availability. It also mandates prepayment medical review for existing hospice programs with aberrant billing patterns and requires revalidation of all existing hospice enrollment information, with public disclosure of ownership details.
Supporters argue
Supporters argue this moratorium is crucial to curb the proliferation of fraudulent or low-quality hospice providers, allowing CMS time to implement stronger oversight mechanisms. The exemption process ensures that legitimate needs in underserved areas can still be met.
Critics contend
Critics might argue that a broad moratorium could inadvertently harm patient access, especially in rapidly growing or changing demographics, and that the exemption process may be slow or insufficient to address real-time needs.
Tradeoffs
This provision balances the need for program integrity and fraud prevention against potential impacts on patient access and market competition for hospice services.
Sec. 2(b)
Extended Oversight for Newly-Enrolled Hospice Programs
This section extends the period of enhanced oversight for newly-enrolled hospice programs from 1 year to 2 years. It also mandates that any hospice program that would have been subject to the nationwide moratorium but received an exemption must undergo enhanced oversight for at least 30 days.
Sec. 2(c)
Increased Survey Frequency for Certain Hospice Programs
This provision increases the frequency of surveys for certain hospice programs from once every 36 months to once every 18 months. This applies to programs that first submitted a claim within the last 5 years or after the enactment date, or those identified by the Secretary as outliers (e.g., aberrant claims data, high live discharges). It also increases funding for surveys from $10 million to $15 million annually starting fiscal year 2027.
Sec. 2(d)
Prohibition on Payment for Failure to Meet Quality Data Reporting Requirements
Beginning in fiscal year 2028, hospice programs that fail to submit required quality data to the Secretary will receive no Medicare payment for that fiscal year. This changes the current penalty, which is a reduction in the market basket percentage increase, to a complete payment prohibition.
Sec. 2(e)
Ensuring Independence of Physician Certifications of Terminal Illness
Effective October 1, 2027, this provision requires that if an individual's attending physician is employed by or has a significant ownership or financial relationship with the hospice program, the certification of terminal illness must instead be made by an independent physician, physician assistant, or nurse practitioner who lacks such a relationship.
Sec. 2(f)
Allowing Additional Providers to Certify Terminal Illness
Effective October 1, 2027, this provision amends the Social Security Act to allow nurse practitioners and physician assistants to certify terminal illnesses for Medicare hospice eligibility. Previously, this authority was restricted to physicians.
Sec. 2(g)
Allowable Use of Supporting Material in Medical Review of Hospice Care
This provision clarifies that for medical review of hospice care, the Secretary may use documentation from the hospice program's medical record as supporting material, in addition to the medical record of the attending physician or other certifying practitioner.
Sec. 2(h)
Prohibition on Certain Changes in Majority Ownership
This provision extends the period during which a change in majority ownership of a hospice program requires a new Medicare enrollment application from 36 months to 60 months (5 years). This applies to changes occurring during the 5-year period beginning on the date of enactment.
Sec. 2(i)
Advanced Notice of Changes in Ownership or Control
Beginning January 1, 2028, hospice programs must provide advanced notice of changes in ownership or control interests (at least 90 days prior to the effective date) and immediate notice of changes in officers, directors, managing employees, administrators, or medical directors. Violations can result in civil monetary penalties up to $1,000,000 per violation and potential termination of Medicare enrollment.
Sec. 2(j)
Required Provision of Addendum of Noncovered Services
Effective October 1, 2027, when a Medicare beneficiary elects hospice care, the hospice program must provide an addendum specifying any items and services being furnished that are not related to the individual's terminal illness. This addendum must be updated if any alterations are made while the election is in effect.
Sec. 2(k)
Medical Review of Hospice Outliers and Care Unrelated to Terminal Condition
This provision mandates prepayment medical review for hospice care provided for more than 90 days by programs with aberrant billing patterns (starting 5 years after enactment). It also establishes a technical expert panel to define 'aberrant billing patterns'. Additionally, starting October 1, 2027, any non-hospice related services indicated by a provider for a hospice patient will be subject to prepayment medical review. $20 million is allocated for carrying out these amendments.
Sec. 2(l)
Provision of Explanation of Benefits Upon Hospice Election
This provision requires the Secretary to furnish a notice (Explanation of Benefits) to each individual electing hospice care within 15 days of their election, starting one year after enactment. The notice must include election details, hospice program information, certifying practitioner, Medicare contractor contact, information on waiver of rights, and fraud reporting hotlines. $10 million is allocated for this purpose.
Sec. 2(m)
Medical Review of Hospice Care Contractor Requirements and Report
This provision requires entities performing medical review of hospice care under contract with the Secretary to utilize only individuals who have received specialized instruction on hospice philosophy and medical prognostication, starting January 1, 2028. It also mandates a report to Congress by October 1, 2028, detailing medical review accuracy rates by different contractors, claims reviewed, appeal outcomes, and actions to reduce audit burden.
Sec. 2(n)
Requiring Face-to-Face Encounters Before Recertifications of Terminal Illness
Effective October 1, 2027, this provision mandates a face-to-face encounter between a hospice physician, nurse practitioner, or physician assistant and the patient within 30 days before each recertification of terminal illness. For 60-day recertification periods, telehealth encounters are permitted if a registered nurse, licensed practical nurse, or home health aide is physically present with the individual.
Sec. 2(o)
Ensuring Medical Director and Physician Availability
Effective January 1, 2029, this provision limits a hospice medical director to serving no more than one other hospice program, with potential waivers from the Secretary based on factors like average daily census and geographic areas. It also requires that the medical director or a physician member of the hospice's interdisciplinary group be available for immediate consultation (including via telehealth) when hospice care is provided in an individual's home.
Sec. 2(p)
Report on Hospice Accrediting Organizations
This provision requires the Comptroller General of the United States (GAO) to submit a report to Congress within 2 years of enactment on the Secretary's oversight of hospice program accrediting organizations. The report must analyze deficiencies found in accredited vs. state-certified programs, list non-compliant or problematic programs and their accreditors, and analyze conflicts of interest and performance data for accrediting organizations.
Sec. 3(a)(1)
Payment Rate Adjustments and Routine Home Care Restructuring
This provision directs the Secretary to adjust payment rates for hospice care (initially non-routine home care, later routine home care) in specified fiscal years (2030, 2035, 2040) to align with costs, potentially varying by setting. Starting FY2030, routine home care payments will be split into a per diem amount for non-direct patient care and a per visit amount for direct patient care (nursing, therapy, social services, aide, physician services), with frequency limits. It also establishes special, higher payments (400% of routine home care) for specified palliative chemotherapy, radiation, blood transfusions, and dialysis from Oct 1, 2027, to Sep 30, 2032.
Sec. 3(a)(1) (Clause (xii))
Hospice Cost Report Audits and Technical Expert Panels
This provision mandates that the Secretary conduct audits of a representative sample of hospice cost reports during specified fiscal years (2026, 2031, and 2036). For each of these years, a technical expert panel will be convened to review the audit methodology and results. $10 million is allocated for each audit cycle (FY2027, 2032, 2037).
Sec. 3(a)(2)
Hospice Outlier Payments for Routine Home Care
Starting October 1, 2032, the Secretary may provide additional payments for certain types of routine home care (e.g., specified hospice care) to account for unusual variations in cost or amount. These outlier payments are capped at 5% of total routine home care payments nationwide and 10% for any single hospice program. The per diem rate for routine home care will be reduced by a corresponding 5% in the first year these payments are made.
Sec. 3(a)(3)
Plan of Care Requirements for Specified Hospice Care
Effective October 1, 2027, if a hospice plan of care includes specified palliative care (chemotherapy, radiation, blood transfusions, or dialysis), its establishment must involve an independent nephrologist (for dialysis) or oncologist (for other specified care) who does not have a significant ownership or financial relationship with the hospice program. This independent specialist must also be involved in the periodic review of such a plan.
Sec. 3(a)(4)
Excluding Home Health Aide and Homemaker Services from Hospice Care in Certain Circumstances
Effective October 1, 2029, this provision excludes home health aide services and homemaker services from the definition of hospice care if the individual is residing in a skilled nursing facility (SNF) or nursing facility (NF). Homemaker services may still be provided in such facilities only if furnished on a volunteer basis.
Sec. 3(a)(5)
Conforming Adjustment to Hospice Payment Cap
This provision modifies the calculation of the hospice aggregate payment cap. For specified fiscal years (2030, 2035, 2040), the cap amount will be adjusted by the estimated percentage change in total Medicare hospice payments attributable to the payment reforms in this Act, and then increased by the market basket percentage. It also applies any sequester reduction to the cap amount, which will not be carried forward to succeeding fiscal years.
Sec. 3(b)
Wage Adjusting Hospice Payment Caps
Effective October 1, 2027, this provision introduces a wage-adjusted cap for hospice programs. The cap will be calculated by multiplying a wage index ratio (reflecting the proportion of payments subject to wage adjustment) by the overall cap amount. It also requires annual reports to Congress and public disclosure on CMS's website regarding hospice cap calculations, percentage of cap paid, recouped amounts, and live discharge rates for each program.
Sec. 3(c)
Modification of Requirements for Short-Term Inpatient and Respite Care
Effective October 1, 2027, this provision limits short-term inpatient respite care to 5 days per election period, but exempts the first 15 continuous days of respite care if immediately preceded by a hospital stay and the patient lacks caregiver support. It reduces the aggregate inpatient care cap from 20% to 10% of total hospice days (with Secretary discretion to raise to 20% for access) and requires real-time application. It also directs the Secretary to allow respite care in residential care facilities that exclusively serve hospice patients and meet specified health and safety standards.
Sec. 3(d)
Hospital Discharge Planning Requirements
Effective October 1, 2027, this provision amends hospital discharge planning requirements to explicitly include the availability of home health services and, for individuals likely eligible for hospice care, the availability of hospice care (including respite care) through participating programs in the patient's residential area.
Sec. 3(e)
Payment for Short-Term Home Respite Care
Effective October 1, 2029, this provision establishes 'short-term home respite care' as a new covered hospice service. It is furnished intermittently in the patient's home (excluding SNFs, NFs, assisted living facilities, or other specified facilities) for not more than 120 hours during a 90-day election period (or 80 hours for a 60-day period). Payment rates will be the sum of the routine home care per diem rate and an hourly rate, not to exceed the general inpatient care rate for a 24-hour period.
Mandatory prepayment medical review for routine home care furnished by 'applicable hospice programs' to 'covered individuals' during the 5-year moratorium period. An 'applicable hospice program' is one with aberrant claim submissions (e.g., outlier with live discharges). A 'covered individual' is one receiving hospice care during the second 90-day period or any subsequent period.
Sec. 2(a)(1), subparagraph (D)
Why it matters:The specific targeting of prepayment review to certain programs and patient periods is a technical detail that refines the broader policy, rather than being evasive.
Case for: Proponents argue this targeted review focuses resources on high-risk providers and patients, effectively addressing potential fraud and abuse without burdening all hospices.
Case against: Critics might argue that the definitions of 'aberrant' or 'outlier' could be subjective and lead to unfair targeting, potentially disrupting care for legitimate providers.
Estimated impact: Will subject a subset of hospice programs and long-stay patients to enhanced scrutiny, potentially reducing improper payments.
Establishes a temporary (Oct 1, 2027 - Sep 30, 2032) special payment rate for 'specified hospice care' (palliative chemotherapy, radiation, blood transfusions for blood cancer, and dialysis under specific conditions). The payment is 400% of the routine home care rate, or another appropriate amount, for each day such care is furnished.
Sec. 3(a)(1), clause (ix)
Why it matters:The temporary nature and specific conditions for these payments are technical details of a targeted policy, not an attempt to hide its existence.
Case for: Proponents argue this addresses a critical gap in hospice coverage, allowing patients to receive life-extending or symptom-alleviating treatments without having to dis-enroll from hospice, thereby improving quality of life.
Case against: Critics might question the specific 400% rate as potentially arbitrary or the temporary nature as creating uncertainty, and whether the conditions for dialysis (e.g., prior authorization after 10 sessions) are overly restrictive.
Estimated impact: Will significantly increase payments for a specific subset of palliative services for a limited time, potentially increasing access to these services within hospice.
Exempts the first continuous 15 days of short-term inpatient respite care from the 5-day limit per election period, but only if the care is immediately preceded by a hospital stay (including observation) where the individual made their first-ever hospice election, and the individual lacks sufficient caregiver support to be discharged home.
Sec. 3(c)(1), flush matter following subparagraph (I)
Why it matters:The specific conditions for this exemption are technical details designed to target a very particular scenario, making it complex but not necessarily evasive.
Case for: Proponents argue this exemption provides crucial support for vulnerable patients newly electing hospice after a hospital stay, who often lack immediate caregiver support, preventing premature discharge or gaps in care.
Case against: Critics might argue that the complexity of the conditions could make it difficult for hospices to apply consistently, or that it could be exploited if 'insufficient caregiver support' is broadly interpreted.
Estimated impact: Provides a safety net for a specific subset of newly-enrolled hospice patients, potentially reducing stress on families and improving initial transitions to hospice care.