Del. Medical Assistance Program Hospice Provider Specific Policy Manual § 3.5

3.5.1 Federal Medicaid requirements mandate that payments to a hospice for inpatient

care must be limited according to the number of days of inpatient care furnished

to DMAP patients. Beginning November 1 of each year and ending October 31,

during the 12-month period the aggregate number of inpatient days (both for

general inpatient care and inpatient respite care) may not exceed 20 percent of

the aggregate total number of days of hospice care provided to all DMAP

members during that same period. The State may exclude Medicaid members

afflicted with Acquired Immunodeficiency Syndrome (AIDS) in calculating this

inpatient care limitation. This limitation is applied once each year, at the end of

the hospices’ “cap period” (11/1 – 10/31). For purposes of this computation, if it is

determined that the inpatient rate should not be paid, any days for which the

hospice receives payment at a home care rate are not counted as inpatient days.

The limitation is calculated as follows:

A. The maximum allowable number of inpatient days is calculated by multiplying

the total number of days of DMAP hospice care by 0.2.

B. If the total number of days of inpatient care furnished to DMAP hospice

patients is less than or equal to the maximum, no adjustment is necessary.

C. If the total number of days of inpatient care exceeded the maximum allowable

number, the limitation is determined by:

1. Calculating a ratio of the maximum allowable days to the number of

actual days of inpatient care, and multiplying this ratio by the total

reimbursement for inpatient care, (general inpatient and inpatient respite

reimbursement) that was made,

2. Multiplying excess inpatient care days by the routine home care rate,

3. Adding together the amounts calculated in 1 and 2, and

4. Comparing the amount in 3 with interim payments made to the hospice

for inpatient care during the “cap period.”

5. Any excess reimbursement is refunded by the hospice.