For more than forty years, the Medicare Hospice Benefit has stood as one of the most trusted promises our healthcare system offers. It gives patients and families comfort, dignity, and coordinated support during one of life’s most vulnerable moments. Today, that promise is once again facing scrutiny as Congress considers reforms to the Medicare Advantage…
For more than forty years, the Medicare Hospice Benefit has stood as one of the most trusted promises our healthcare system offers. It gives patients and families comfort, dignity, and coordinated support during one of life’s most vulnerable moments. Today, that promise is once again facing scrutiny as Congress considers reforms to the Medicare Advantage program. In response, key lawmakers are stepping forward to make their position clear: the Hospice Benefit must be protected under Original Medicare.
On November 20, 2025, Senator Roger Marshall (R – Kansas) and Senator Sheldon Whitehouse (D –Rhode Island) sent a joint letter to Senate leadership. Their message was both bipartisan and unmistakable. They urged Congress to preserve the existing structure of the Hospice Benefit, including its protections for beneficiaries who are enrolled in Medicare Advantage plans. They also asked Senate leaders to reject any proposal that would fold hospice into Medicare Advantage or remove the Special Rule for Hospice that has been in place since 1997.
Their letter arrives at a critical moment. It underscores the belief of many hospice leaders that this benefit is unlike any other Medicare service and requires exceptional safeguards.
Why the Special Rule Matters
The Special Rule for Hospice was created through the Balanced Budget Act of 1997. It ensures that when a Medicare Advantage enrollee elects hospice, the benefit shifts back to Original Medicare for the remainder of that patient’s hospice experience. The Medicare Advantage plan continues to cover unrelated or supplemental care, but the hospice benefit itself remains under Medicare Part A.
This structure protects patients in several important ways:
Patients keep full freedom to choose any Medicare-certified hospice provider.
There are no restrictive networks and no delays caused by referrals or prior authorizations.
Care begins without unnecessary barriers.
More than half of all hospice beneficiaries die within fourteen days of electing hospice. Any delay during those final days can cause real harm that cannot be undone.
Clinical judgment stays where it belongs.
Federal law affirms that decisions about prognosis and related care rest with the hospice medical director and attending physician. Keeping hospice under Original Medicare helps preserve that authority.
The letter from Senators Marshall and Whitehouse reflects deep concern that moving hospice into Medicare Advantage would disrupt these protections. Hospice already functions as a form of managed care through its interdisciplinary model of physicians, nurses, social workers, chaplains, and other team members who coordinate a comprehensive plan of care. Adding Medicare Advantage plan management on top of this would create duplication rather than improvement.
What We Learned from the VBID Demonstration
In 2021, CMS tested a new approach through the Value Based Insurance Design (VBID) demonstration that placed hospice inside the Medicare Advantage benefit structure. The results highlighted the very concerns raised by hospice providers for years.
Plans struggled to create networks. Administrative hurdles multiplied. Payments for claims were often delayed. Some hospices reported lower reimbursement rates that raised concerns about financial stability and access. These challenges appeared without any evidence of improved care coordination or earlier access to hospice. The demonstration was eventually terminated seven years ahead of schedule. Its early end serves as a clear cautionary example of what can happen when the existing hospice framework is disrupted.
A Long Tradition of Bipartisan Support
Congress has a long track record of reaffirming the Special Rule for Hospice. The Medicare Modernization Act of 2003 and the Affordable Care Act of 2010 both preserved this safeguard. The principle has always been the same. End-of-life care deserves unique protection. Families deserve to know that when a loved one chooses hospice, they will receive timely, patient-centered care without unnecessary administrative interference.
The recent letter to Senate leadership echoes that tradition. It reflects a shared belief that the Hospice Benefit is a promise worth defending and that policymakers must proceed carefully whenever reforms to Medicare Advantage are on the table.
Moving Forward
The future of hospice will depend on continued advocacy, continued clarity, and continued commitment to the values that shaped the benefit in the first place. Hospice was designed to honor choice and compassion during life’s final chapter. Preserving the Special Rule for Hospice is essential to maintaining that design.
As the policy conversation continues in Washington, hospice leaders have an important role. By staying informed, engaging in dialogue, and elevating the patient experience, leaders can help ensure that this vital benefit remains protected for generations to come.
Read the letter here: Marshall-Whitehouse MA Letter
