The SSVI: Connecting Hospice Relatedness, Spending, and Compliance Risk | Hospice Relatedness, Part 2
By Jennifer Kennedy, EdD, MA, BSN, RN, CHC
In Part 1 of this series, we looked at hospice relatedness and its importance in clinical and compliance decisions. Determining whether a condition, medication, item, or service is related to the terminal illness or related condition drives coverage responsibility under the Medicare Hospice Benefit, shapes the plan of care, and determines whether the hospice or another part of Medicare pays. Federal rules and CMS guidance make clear that, when a beneficiary elects hospice, the hospice assumes responsibility for related care. Services classified as unrelated should be exceptional and unusual; non-hospice spending should not be routine. (42 CFR §418.24; Medicare Benefit Policy Manual, Ch. 9).
In the proposed FY 2027 Hospice Payment Update Rule, CMS broke down non-hospice spending in Medicare Parts A, B, and D, raised concerns about growing dollars being spent outside the hospice benefit, and proposed the Service and Spending Variation Index (SSVI) to identify agencies whose care patterns and outside costs differ greatly from national norms. CMS finalized the SSVI in the final rule posted in the Federal Register on August 3, 2026, giving the agency a claims-based tool to flag providers whose patterns may warrant closer review.
Why CMS Created the SSVI and What It Is Designed to Do
CMS developed the SSVI in response to substantial growth in Medicare spending outside the hospice benefit. CMS reported that non-hospice Medicare Part A and B spending increased from nearly $790 million in FY 2020 to over $2 billion in FY 2024, while non-hospice Medicare Part D spending increased from approximately $553 million to over $813 million during the same period.
CMS believes high levels of non-hospice spending may indicate cost shifting, inadequate care coordination, or misuse of Medicare resources. Through the SSVI, CMS can flag unusual utilization patterns, highlight excessive non-hospice Medicare spending during hospice elections, support program integrity activities such as medical review and education, and provide consumers with additional information when selecting a hospice provider.
The SSVI represents a significant shift in how CMS may use claims data to evaluate hospice utilization, spending, and program integrity risk. For hospice providers, this is not just another data point. It is an indication that CMS is looking more closely at whether beneficiaries are receiving the care they need through the Medicare Hospice Benefit or whether services are being billed outside the benefit in ways that raise program integrity concerns.
Non-Hospice Spending and Relatedness Risk
When a beneficiary elects hospice, the hospice assumes broad responsibility for care related to the terminal illness and related conditions. If a condition, medication, item, or service is classified as unrelated, payment may shift outside the Medicare Hospice Benefit. That is why relatedness is central to the SSVI discussion: the issue is not only whether a service was billed outside hospice, but whether that billing pattern reflects defensible clinical decision-making, appropriate care coordination, and clear documentation. “Unrelated” should not become the hospice equivalent of a junk drawer where difficult decisions go to hide.
In addition to implementing the SSVI, beginning October 1, 2026, hospices must provide the hospice election statement addendum to all Medicare beneficiaries at the time of hospice election. This addendum identifies items, services, and drugs the hospice has determined are not related to the terminal illness and related conditions and therefore are not covered under the Medicare Hospice Benefit. That makes the addendum more than a paperwork requirement. It is a patient-facing record of the hospice’s relatedness decisions and a key connection point to the SSVI, because those same unrelated determinations may contribute to Medicare non-hospice spending patterns CMS is now using to identify hospices that may warrant closer review.
Review the regulatory requirements for the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” and the “Model Example of Hospice Election Statement” to ensure compliance on October 1, 2026, and forward.
What is the SSVI?
At its core, the SSVI combines hospice service patterns with non-hospice Medicare spending to produce a score for each Medicare-certified provider. CMS may use that score to identify outliers and determine where education, medical review, or additional oversight is needed for a specific hospice provider or across the field.
The SSVI score has two components. CMS first evaluates eight hospice utilization measures and assigns points when a hospice falls into higher-risk scoring categories. CMS then assigns a non-hospice spending score based on the provider’s spending octile. Together, the two components produce a total score from 0 to 16, with higher scores reflecting greater variation across the measures.
CMS calculates the SSVI using Medicare administrative claims data from the federal fiscal year, October 1 to September 30, including hospice claims and non-hospice Part A, Part B, and Part D claims during a hospice election. These data are aggregated at the provider level to measure utilization patterns, spending outside the hospice benefit, and potential outlier risk.
The SSVI Score
CMS is monitoring eight hospice utilization indicators plus non-hospice Medicare spending. The utilization indicators include:
- Absence of continuous home care and general inpatient care,
- Routine home care days in nursing homes or skilled nursing facilities,
- Visits in the last two routine home care days of life,
- Live discharge rate,
- Stays longer than 180 days,
- Skilled nursing minutes per routine home care day,
- Weekend skilled visit patterns, and;
- Live discharges followed by return to the same hospice within seven days.
Viewed together, these indicators give CMS a broader picture of how a hospice’s care delivery and billing patterns compare with peers.
CMS then calculates the hospice’s total non-hospice Medicare spending and places it into one of eight spending octiles. Unlike the utilization measures, this component can contribute 1 to 8 points. Hospices with the highest levels of non-hospice spending receive more points.
What If My Hospice is an Outlier?
A high SSVI score does not automatically mean a hospice is delivering poor-quality care, violating requirements, or engaging in fraud. The index identifies patterns that may warrant closer review; it does not make a final compliance determination. The practical takeaway is straightforward: hospices should understand what their data may suggest and be prepared to defend the clinical and operational reasons behind those patterns with documentation.
CMS may use score distribution to identify significant outliers. In one analysis, CMS described hospices scoring 13 or higher as falling at approximately the 99th percentile. Providers in that range may be more likely to receive education, medical review, or other program integrity attention. Hospice leaders should look beyond the total score and identify the specific measures driving it, then determine whether those patterns are supported by clinical documentation and operational context.
Practical Strategies for Hospice Providers
Strengthen relatedness decision-making: Hospices should have a clear, consistent process for determining whether conditions, medications, items, and services are related to the terminal illness and related conditions. When they are related, the hospice must take responsibility for providing and covering them under the Medicare Hospice Benefit rather than shifting costs to other parts of Medicare. These decisions should be clinically supported, documented, and revisited as the patient’s needs change. Don’t forget to educate physicians and staff on the relatedness process, rationale, and expectations.
Ensure accurate and complete documentation: Documentation is the bridge between clinical judgment and defensible compliance. When a hospice determines that a condition, medication, item, or service is unrelated to the terminal illness and related conditions, the record should clearly explain why. The rationale should be patient-specific, physician-driven, aligned with the plan of care, and revisited as the patient’s condition changes. As CMS focuses more attention on non-hospice spending, vague or inconsistent documentation creates avoidable risk, even when the underlying clinical decision is reasonable. In compliance, “because we said so” is not a documentation strategy.
Self-assessment and performance improvement: Hospice providers should closely monitor the indicators that align with the SSVI methodology and self-assess their performance related to each one. These data should not sit in a silo. Quality, compliance, clinical, billing, and finance leaders should review them together to identify patterns, ask better questions, and determine whether corrective action or deeper internal review is needed. Align data review with clinical and operational process improvement
Strengthen policies, procedures, and processes: Policies should clearly define how relatedness determinations are made, approved, communicated, and reassessed. Processes should address high-risk areas such as live discharges, coordination with non-hospice providers, pharmacy and DME decisions, billing safeguards, and escalation when services may be shifted outside the hospice benefit. The goal is to ensure the organization can consistently explain, document, and support its care delivery and billing patterns if SSVI data or non-hospice spending raise questions.
Final Takeaway
The SSVI may evolve as CMS refines its claims-based oversight, but the direction is clear: data-driven scrutiny is expanding. Hospices that understand their own data, strengthen relatedness processes, and document the rationale for care and billing decisions will be better prepared for transparency initiatives, medical review, and program integrity questions. The best time to understand your data is before someone else uses it to tell your story.
References
42 CFR §418.24, Election of hospice care.
Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 9:
Coverage of Hospice Services Under Hospital Insurance, Rev. 13664, issued Mar. 5, 2026.
Centers for Medicare & Medicaid Services. (2026, August 3). Medicare program; FY 2027 hospice wage index and payment rate update and Hospice Quality Reporting Program requirements. Federal Register, 91, 49118–49176.