Ga. Medicaid Part II Policies & Procedures for Hospice Services § 1001

The Affordable Care Act (ACA) requires physicians or other eligible providers to be enrolled in the

GA Medicaid Program to order, prescribe and refer items or services for Medicaid beneficiaries. The

National Provider Identifier (NPI) of the ordering, prescribing, or referring (OPR) provider should be

noted on the GA Medicaid rendering provider’s claim. See Appendix M.

The Medicaid reimbursement is based on the status of the member’s eligibility days and a hospice

lock-in span. Effective, January 1, 2016, the Department implemented the Centers for Medicare and

Medicaid, two (2) final Medicare hospice payment reform policies for the routine home care (RHC)

and the service intensity add-on (SIA) rates:

1001.1. The Medicare hospice final rule replaces the single RHC per diem rate with two

different RHC payment rates, a higher payment rate for the first 60 days of hospice

care, and a reduced payment rate for 61 days and over of hospice care. If a member has

a break within the hospice period that is greater than 60 days, the hospice span starts

over.

1001.2. The Service Intensity Add-on (SIA) payment is in addition to the per diem RHC rate

when all the following criteria are met: The day is an RHC level of care day. The day

occurs during the last 7 days of the patient’s life, and the patient is discharged expired.

Direct patient care is furnished by a registered nurse (RN) or social worker (SW) that

day. The SIA payment will equal the Continuous Home Care (CHC) hourly payment

rate, for a minimum of 15 minutes and up to 4 hours total per day. G-codes are used to

identify the SW and RN versus LPN visits.

Updates have been made to the Georgia Medicaid Management Information System

(GAMMIS) to accommodate the new reimbursement methodology. GAMMIS updates

included creating custom pricing methods to handle the different hospice pricing

periods for the RHC and the SIA. Providers’ claims submitted on or after September 01,

2016, and are now processing with the 2016 methodology.