This bill directs the Center for Medicare and Medicaid Innovation (CMI) to design and run a payment model that allows blood transfusions furnished to Medicare hospice patients to be billed and paid separately from the hospice all‑inclusive per diem. The separate payment must equal the amount that would have applied under Medicare Part A/B (title XVIII) if the transfusion had not been furnished as part of hospice care, and CMI must implement the model within one year of enactment.
The measure matters because the hospice per‑diem can discourage transfusions for dying patients who might experience symptom relief from red‑cell or platelet transfusions. By testing separate payment and requiring a focused evaluation on utilization, hospitalizations, timing of hospice enrollment, and transfusion frequency, the bill aims to measure whether decoupling transfusion payments improves access without increasing unwanted aggressive care or costs.
At a Glance
What It Does
The bill amends Social Security Act section 1115A to require CMI to establish a model that pays for blood transfusions to hospice patients separately from the hospice per‑diem; the transfusion payment equals the non‑hospice Medicare amount. CMI must stand up the model within 1 year and include it among models selected under subsection (b)(2)(A).
Who It Affects
Medicare fee‑for‑service beneficiaries enrolled in hospice who may require transfusions, hospice providers and their billing systems, hospitals and outpatient facilities that furnish transfusions, and CMS/CMI as the implementing agency. Payers outside Medicare and private hospices are not directly required to change payment rules.
Why It Matters
This is a targeted payment‑policy experiment that could remove a financial barrier to symptom‑relieving transfusions in hospice, potentially altering hospice uptake, site‑of‑care decisions, and short‑term utilization patterns; the required evaluation metrics will inform whether broader policy changes are warranted.
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What This Bill Actually Does
The bill inserts a new testing mandate into the statute governing CMI. It does two closely linked things: first it orders CMI to create a test model that unbundles blood transfusions from the hospice all‑inclusive per diem so that transfusions furnished to hospice patients can be billed and paid the same way they would be if the patient were not in hospice.
Second, it prescribes the core evaluation framework CMI must use to compare patients in the model to similar non‑participant patients.
Practically, CMI must have the model operational within one year of enactment. The separate payment amount is not a new rate set by CMI but is defined as the payment that would apply under Medicare Part A/B if the transfusion had not been part of hospice care.
That approach keeps reimbursement tied to existing Medicare fee schedules and avoids creating an ad‑hoc hospice transfusion rate within the model.For evaluation, the bill requires CMI to compare model participants with comparable patients outside the model across a set of utilization and timing outcomes: chemotherapy in the last 14 days of life, hospital and ED use in the last 30 days (including ICU days and lengths of stay), days receiving hospice before death, and detailed transfusion counts and frequency for hospice versus non‑hospice patients. CMI also retains authority to examine additional outcomes it deems appropriate.
The evaluation design will therefore need to create a matched comparison group and capture claims‑level data on transfusions, hospice enrollment, and terminal care utilization.While the statute sets the payment rule and the evaluation metrics, operational details—how providers bill, what modifiers or place‑of‑service codes to use, how CMI selects participating hospices or regions, and how it handles potential fraud or medical necessity reviews—are left to CMI rulemaking and model design. The bill is deliberately narrow: it does not mandate national policy change, nor does it dictate broader quality measures or patient‑reported outcomes within the statutory list of required comparisons.
The Five Things You Need to Know
CMI must implement the transfusion payment model within one year of the law’s enactment.
The model allows blood transfusions for hospice patients to be billed and paid separately from the hospice per‑diem, with the payment equal to what Medicare would pay if the transfusion occurred outside hospice (i.e.
the applicable title XVIII amount).
The bill amends section 1115A(b)(2)(A) to require that models selected include the specific transfusion‑payment test described in the new subsection (h).
CMI’s evaluation must compare participants to similar non‑participants on predefined metrics including chemotherapy in the last 14 days of life, hospital/ED/ICU utilization in the last 30 days, days in hospice before death, and transfusion counts and frequency.
The statute allows CMI to analyze additional outcomes but leaves model design details—billing mechanics, provider selection, and oversight—to CMI’s implementation process.
Section-by-Section Breakdown
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Short title
Declares the Act’s short title as the Improving Access to Transfusion Care for Hospice Patients Act of 2025. This is a standard caption; it carries no operational effect but identifies the legislation in reports and agency rulemaking references.
Require CMI to include the transfusion model among selected tests
Edits the model‑selection provision of section 1115A to add a sentence requiring that models selected under the subsection include testing of the new transfusion model described in the added subsection (h). The practical effect is to make the transfusion test a mandated pick for CMI’s portfolio of demonstrations rather than an optional pilot that CMI could ignore.
Establish model and payment rule for transfusions in hospice
Directs CMI to establish and implement, within one year, a model under which blood transfusions furnished to hospice patients are paid separately from the hospice all‑inclusive per diem. It specifies the separate payment amount: the same amount that would apply under Medicare title XVIII if the transfusion had not been furnished as part of hospice care. This ties reimbursement to existing Medicare payment rules and avoids creating a bespoke hospice transfusion rate within the statute.
Required evaluation metrics and comparison approach
Prescribes that in evaluating the model, CMI must compare participants with similar patients outside the model across enumerated metrics: chemotherapy in the last 14 days of life; hospital utilization in the last 30 days including ED visits, inpatient/observation stays and ICU days; days receiving hospice care before death; counts and frequency of transfusions among hospice versus non‑hospice patients; and any other areas CMI considers appropriate. That list frames the core analytic questions CMI must address when deciding whether separate payment affects access, utilization, or end‑of‑life intensity of care.
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Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Hospice patients with symptomatic anemia or thrombocytopenia — they may gain access to transfusions that relieve symptoms without forcing disenrollment from hospice because the transfusion would no longer be carved into a fixed per‑diem. This targets patients whose goals are comfort but who need episodic transfusions to achieve it.
- Hospice providers open to treating patients who need transfusions — providers that previously declined or limited admissions of patients likely to require transfusions could accept more patients if they can bill separately, potentially increasing hospice enrollment and revenue for those services.
- Hospitals and outpatient infusion centers that administer transfusions — they will have clearer reimbursement for transfusions given to hospice patients if billed under the separate payment rule, reducing billing uncertainty and claim denials related to hospice bundling.
Who Bears the Cost
- CMS/CMI (and by extension Medicare administrative contractors) — CMI must design, implement, and evaluate the model within statutory timeframes, which requires staffing, data linkage, analytic capacity, and oversight resources that CMS must supply.
- Hospice providers with limited billing infrastructure — smaller, rural, or charity‑based hospices may face new administrative and compliance costs to bill transfusions separately, update contracts with blood suppliers, and document medical necessity.
- Medicare program/payers — if the model increases transfusion use among hospice patients, Medicare could see higher Part A/B outlays for those services; balancing those costs against potential reductions in hospital utilization will be a central budgetary question.
Key Issues
The Core Tension
The bill pits two legitimate policy goals against each other: increasing access to symptom‑relieving transfusions for dying patients enrolled in hospice versus avoiding payment incentives that could increase aggressive or low‑value interventions at the end of life. The statute removes a financial barrier by creating a separate payment, but that same step could shift clinical practice and costs—so the core dilemma is whether decoupling payment improves patient‑centered hospice care without unintentionally promoting more intensive end‑of‑life treatment or higher Medicare spending.
The bill sets a narrow, technically specific experiment but leaves many operational choices to CMI. That delegation is efficient but raises implementation questions: how will providers bill (new modifiers, place‑of‑service rules, or claim types), how will CMI prevent double billing or upcoding, and what documentation standards will establish medical necessity for transfusions in hospice?
Those operational design choices will drive whether the model reduces barriers or simply shifts billing complexity onto hospices.
The evaluation prescription focuses on utilization and hospice timing metrics but omits explicit patient‑reported outcomes, symptom relief measures, or caregiver perspectives. CMI can add measures, but statutory comparators emphasize service counts (chemotherapy, transfusions, hospital days).
That creates a tension between measuring hard utilization outcomes and capturing whether separate payment actually improves patients' comfort and quality of death. Separately, creating a valid comparison group for a short‑term model is challenging: selection bias (which patients/hospices opt into the model), confounding by indication, and small sample sizes for specific diagnoses could limit the evaluation’s ability to draw definitive causal conclusions about access versus intensity of care.
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