CMS's Reliance on Illinois Licensure Requirements Could Not Ensure the Quality of Care Provided to Medicaid Hospice Beneficiaries

The Centers for Medicare & Medicaid Services' (CMS) reliance on Illinois licensure requirements could not ensure quality of care and that adequate protection was provided to Medicaid hospice beneficiaries. We determined in most cases that hospices did not meet State hospice licensure requirements related to hospice workers. Of the 120 claims that we sampled, 110 involved direct care provided by unqualified hospice workers. On the basis of these sample results, we estimated that 51,374 of the 56,044 claims covered by our review were associated with unqualified hospice workers.

Of the 110 claims that involved direct care provided by unqualified hospice workers, 93 claims were for room and board only, with Medicare covering the corresponding hospice care service claims. The remaining 17 claims included hospice care services covered by Medicaid. Unqualified hospice workers only affect Medicaid payments for hospice care services, not payments for room and board; therefore, on the basis of our sample results, we estimated that $13.4 million ($8.2 million Federal share) in Medicaid payments for hospice care services included in the claims covered by our review were provided by unqualified hospice workers.

To improve protection provided to Medicaid hospice beneficiaries, we recommended that CMS

(1) work with the Illinois Department of Healthcare and Family Services (State agency) and the Illinois Department of Public Health to ensure that hospices meet the State licensure requirements for hospice workers and (2) consider working with the State agency to modify the State agency's hospice payment conditions by implementing provisions similar to the State licensure requirements for hospice workers. CMS concurred with our recommendations.