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Supplemental Medicare payment for end-of-life RN and MSW visits
A supplemental Medicare payment at the Continuous Home Care hourly rate for qualifying RN and medical social worker visits in a patient's last seven days of life, layered on top of the Routine Home Care per diem.
The Service Intensity Add-on (SIA) is a supplemental Medicare payment made on top of the Routine Home Care (RHC) per diem for registered nurse and medical social worker visits delivered in a patient's last seven days of life. It pays for that end-of-life visit time at the hourly Continuous Home Care rate, up to four hours per patient per day.
CMS created the SIA in the FY2016 hospice final rule (CMS-1629-F) alongside the two-tier RHC structure, effective January 1, 2016 (CMS FY2016 final rule)[1]. It applies only on RHC days, only in the final seven days of life, and only for direct visits by an RN (not an LPN/LVN) or a medical social worker. The add-on equals the visit time (minimum 15 minutes, maximum four hours combined per day) multiplied by the current Continuous Home Care hourly rate, which is $69.76 for FY2026 (CMS FY2026 Hospice Wage Index final rule fact sheet)[2]. At four hours, that yields a maximum SIA of roughly $279.04 per patient per day for FY2026 (derived from the $69.76 FY2026 CHC hourly rate)[2]. SIA is budget-neutral: CMS applies an annual SIA budget-neutrality factor to the RHC rates so the add-on does not increase aggregate spending. Payment is triggered retrospectively once the patient's death and the qualifying visits are captured on the claim.
SIA payment depends on claim records that verify visit discipline, start and stop times, and RHC level-of-care coding for the date of service. Hospices whose visit documentation is incomplete or whose visit-length detail is absent from claims cannot substantiate SIA units even when qualifying visits occurred, so the revenue shortfall traces to documentation practice rather than eligibility. Because SIA is budget-neutral, the aggregate payment pool is fixed: hospices with consistent capture receive a proportionally larger share than those that under-document. The payment effect is largest for programs with a high share of deaths on Routine Home Care rather than General Inpatient Care, where SIA does not apply.
SIA is paid at the Continuous Home Care hourly rate, which is $69.76 for FY2026, applied to qualifying visit time up to four hours per patient per day (CMS FY2026 final rule fact sheet)[2].
Only direct visits by a registered nurse or a medical social worker qualify; visits by LPNs/LVNs, aides, and chaplains do not, and social worker telephone calls are excluded (Medicare Claims Processing Manual, Ch. 11, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf).
No, it applies only to patients on Routine Home Care during their final seven days of life, so it is paid retrospectively once death and the qualifying visits are recorded (CMS FY2016 final rule)[1].
Yes — the FY2027 final rule (CMS-1851-F, July 30, 2026) raises all hospice rates by 2.3%, which lifts the CHC hourly rate the SIA is based on (CMS FY2027 final rule fact sheet)[3].
Vitalis Care is the end-of-life care app that helps hospices deliver compassionate care — while staying on top of schedules, field operations, documentation, compliance, and reimbursement.
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