Summary of Bill: S.4118 – Hospice Care Accountability, Reform, and Enforcement Act of 2026 (Hospice CARE Act of 2026)

Short title
- Known as the Hospice Care Accountability, Reform, and Enforcement Act of 2026 (Hospice CARE Act of 2026).

Purpose and intent
- To amend the Social Security Act (title XVIII, Medicare) to strengthen the integrity, oversight, payment governance, and accountability of hospice care furnished under Medicare.
- Addresses enrollment integrity, ownership transparency, data reporting, payment reforms, and quality oversight to curb aberrant billing practices, ensure appropriate access, and improve program integrity.

Key provisions and changes

1) Mandatory temporary moratorium on enrollment for new hospice programs
- Establishes a nationwide 5-year moratorium on enrollment of new hospice programs under Medicare, starting on enactment.
- Exceptions allow exemptions for certain programs, based on demonstrated need (e.g., areas with insufficient access to hospice care).
- Secretary can lift moratorium in specified states/regions.
- During moratorium, prepayment medical review would apply to routine home care for new enrollees, with exit/termination triggers based on denial rates.
- Requires ongoing revalidation of enrollment information and public disclosure of ownership and control information within a year, plus a congressionally-mandated report (by 1/1/2028) on ownership trends and private equity involvement.

2) Enhanced oversight and monitoring of newly enrolled hospice programs
- Extends oversight period for newly enrolled hospice programs to not more than 2 years.
- Introduces mandatory enhanced oversight for certain programs (e.g., those that would have been prohibited from enrolling).
- Adds increased survey frequency and a list of programs subject to enhanced oversight; removal rules for programs meeting certain compliance criteria.

3) Payment reforms and rate setting
- Adjusts how hospice payments are calculated and adjusted across settings (e.g., routine home care vs. other hospice services).
- Requires annual setting of adjustment percentages prior to each fiscal year, with variations by setting and potential for different adjustments by service type.
- Establishes new formulas for routine home care payments, including per diem and per-visit components, and potential special payment rules for specified years (e.g., 2030–2032 era adjustments).
- Introduces a cap amount, wage-adjusted cap, and related reporting requirements; provides for wind-down of cap adjustments with market basket index considerations and statutory reductions tied to broader budget controls.
- Creates a framework for periodic cost reporting audits and a technical expert panel to review methodology.

4) Ownership transparency and anti-abuse measures
- Expands requirements for ownership and control information collection and makes ownership data publicly accessible.
- Adds advanced notice of changes in ownership or control, with penalties for noncompliance (civil penalties up to $1,000,000 per violation; potential termination of enrollment).
- Requires real-time considerations for applying certain safeguards to ensure timely responses to ownership changes.
- Tightens standards around major ownership changes during the moratorium period.

5) Physician certification independence and credibility
- Strengthens independence of terminal illness certifications by ensuring that attending physicians’ certifications can be provided by non-affiliated clinicians (effective Oct 1, 2027 for certain changes).
- Expands physician assistant and nurse practitioner involvement in certifying terminal illness (effective Oct 1, 2027 for the expanded scope).

6) Face-to-face recertification requirements
- Requires face-to-face encounters for recertifications of terminal illness (on or after Oct 1, 2027, within specified windows and with allowances for telehealth in certain cases with in-person support).

7) Documentation, disclosures, and beneficiary notices
- Requires explanation of benefits (EOB) upon hospice election within 15 days, including program contact information, attending provider details, and helpline numbers (including 1-800-MEDICARE and an Inspector General contact).
- Requires addenda if items/services furnished are not related to terminal illness and requires ongoing updates to such addenda.

8) Home-based respite care and inpatient care rules
- Expands and clarifies rules for respite care, including temporary home respite care eligibility, locations, hours, and payment rates.
- Provides a pathway for respite care in residential facilities serving hospice patients (with standards aligned to hospice care).

9) Accreditation and oversight of accrediting organizations
- Requires a forthcoming GAO/Comptroller General review on hospice accrediting organizations’ oversight, including deficiencies, compliance status, deactivations, conflicts of interest, and performance data.

10) Miscellaneous provisions
- Revisions to short-term inpatient care definitions and exceptions.
- Explicit federal funding adjustments, including transfers from trust funds to CMS program management accounts for implementing various provisions.
- Effective dates vary by provision, with many key changes taking effect from 2027–2029 or later.

Who is affected
- Medicare beneficiaries enrolled in or seeking hospice care.
- New hospice programs seeking enrollment (moratorium impact; exemptions possible).
- Existing hospice providers, including their ownership structures, business arrangements, and medical directors.
- Hospice program accrediting organizations and the entities performing CMS medical reviews.
- Providers involved in terminal illness certifications (physicians, PAs, and NPs) and hospice medical leadership.
- CMS and related program management accounts, and state/local survey agencies.

Procedural and timeline highlights
- Enactment date establishes the 5-year enrollment moratorium (with possible exemptions).
- Several provisions become effective beginning Oct 1, 2027 (e.g., expanded certification scope, face-to-face recertification, and certain payment adjustments).
- 2028: Congress-directed report on ownership trends and private equity.
- 2029 onward: Medical director availability and related standards become effective.
- 2030–2040: Specified payment reform milestones and “specified fiscal year” adjustments (with annual reporting requirements on cap calculations).

Notes
- The bill includes multiple interlocking changes: enrollment integrity, enhanced oversight, payment reform with differential rates, and strengthened governance around ownership and accreditation.
- As introduced, the bill reflects a comprehensive approach to risk mitigation around hospice program integrity and beneficiary protections within Medicare.