16.4 Policy, Delivery, and Reimbursement Trends

Policy questions punish last year’s flashcards. For 2026, hold three bright lines: HOPE is live, the Medicare hospice benefit component of VBID is not, and pediatric concurrent care is not the adult Medicare rule. Then separate hospice per diem from community palliative billing. The CHPN is not a coder, but Domain 5 expects you to know which benefit the patient is on and what that means for labs, chemotherapy, and IDG planning.

Value-based hospice and HQRP (high level)

The Hospice Quality Reporting Program (HQRP) is still largely pay-for-reporting, not a full pay-for-performance bonus model. CMS uses HOPE (patient-level assessment), Medicare claims (for measures such as the Hospice Care Index and visits in the last days of life), and CAHPS Hospice. Missing HQRP requirements can reduce the Annual Payment Update by 4 percentage points—a program-level hit that still shows up in staffing and supplies. Public data live on Care Compare. “Value-based” in conversation may also mean Medicare Advantage networks, accountable-care relationships, or commercial serious-illness bundles. Those are not a replacement for the Medicare hospice election.

HOPE and quality reporting

On October 1, 2025, the Hospice Outcomes and Patient Evaluation (HOPE) tool replaced the Hospice Item Set (HIS) as the HQRP patient-assessment instrument. HOPE adds HOPE Update Visits (HUVs) during the stay—up to two in specified windows in the first 30 days, depending on length of stay—so CMS is no longer looking only at admission and discharge snapshots. Providers submit HOPE records through iQIES. Timely, complete submission (historically a 90% within 30 days threshold in HQRP compliance checklists) protects the APU. Public reporting of HOPE-based measures was planned to follow later (CMS has indicated no earlier than the FY 2028 public-reporting cycle after analyzing calendar-year 2026 data). You do not need every HOPE item number for CHPN. You do need: HOPE replaced HIS, HUV is a real visit-based timepoint, and CAHPS exemptions do not waive HOPE.

Concurrent care and the VBID trap

Under ordinary Medicare hospice, the patient elects the benefit and waives Medicare payment for curative treatment of the terminal illness and related conditions. Symptom management, related medications, and the four levels of hospice care are in the per diem. Unrelated conditions can still be billed outside hospice with careful documentation.

Concurrent care (hospice-level support plus disease-directed treatment) is not 2026 national Medicare policy for adults. If a question mentions the Value-Based Insurance Design (VBID) model: the Medicare hospice benefit component of VBID ended December 31, 2024. Do not describe it as current 2026 national policy. Some Medicare Advantage plans still offer supplemental palliative benefits, and other CMS Innovation Center models have tested concurrent-care flexibilities, but those are model- or plan-specific. Veterans Affairs and some state Medicaid adult programs may wrap palliative or concurrent services. Read the payer in the stem.

Children are different. Affordable Care Act section 2302 (Concurrent Care for Children) requires Medicaid and CHIP to pay for hospice and curative treatment together for eligible children. A 12-year-old with relapsed leukemia whose family will not stop disease-directed therapy is not forced into the adult Medicare waiver logic. Adult CHPN items that apply the adult waiver to a Medicaid child are wrong.

Medicaid expansion variation

As of 2026, 40 states and the District of Columbia have full ACA Medicaid expansion. Ten have not (including large Southern states such as Texas and Florida; Georgia and Wisconsin are partial rather than full expansion). In non-expansion states, adults in the coverage gap may reach hospice only after Medicare eligibility, a disability determination, or spend-down—later, sicker, and with less prior palliative support. Pediatric concurrent care still rides on Medicaid/CHIP enrollment; expansion politics change who is insured, not the federal pediatric concurrent statute itself.

Workforce shortages and pediatric versus adult programs

Hospice and palliative teams face RN, aide, and after-hours shortages, rural travel time, and competition from hospitals. Short staffing shows up as missed last-days visits (a claims-based quality signal), thinner GIP nursing, and pressure to skip precepting. The CHPN answer is still safe staffing and QAPI, not silent overtime as a business model.

Adult programs (the CHPN population) run on Medicare hospice rules, NHPCO standards, and HPNA RN competencies. Pediatric programs are often smaller, school- and sibling-centered, and built around CHPPN competencies and concurrent care. Do not assume a pediatric hospice must stop chemotherapy the day of election. Do not assume an adult Medicare patient may keep disease-modifying treatment of the terminal diagnosis as a national 2026 default.

Community palliative billing versus hospice per diem

Medicare does not have a dedicated community palliative-care benefit. Hospital and clinic palliative teams bill Part B like other specialists: evaluation and management (E/M) visits, advance care planning (CPT 99497 and 99498), and care-management codes (chronic care management and related codes) when requirements are met. Patients may still receive curative treatment. There is no six-month prognosis requirement for palliative care as a philosophy of care.

Medicare hospice is Part A, per diem by RHC, CHC, GIP, or IRC, wage-indexed, subject to the aggregate cap and inpatient cap, with HOPE and CAHPS obligations. The nurse’s visit is not a 99214; it is covered inside the daily rate. Mixing the two—billing ACP codes as if they were the hospice payment, or telling a palliative-clinic patient they must waive chemotherapy—is the policy error the exam is fishing for.

HPCC will still convert your raw CHPN score to a scaled 500 passing standard on a 200–800 scale. Policy items are an easy place to fall below that line if you studied a 2023 concurrent-care headline and never updated it.

Exam trap

If the option says VBID is how Medicare now pays concurrent hospice nationally in 2026, it is out of date. If the option says HOPE never started or HIS is still the only tool, it is out of date. If the option applies the adult curative waiver to a Medicaid child, it is the wrong population.