Ga. Medicaid Part II Policies & Procedures for Hospice Services § 1008

The Division will limit overall aggregate payments made to a hospice during a hospice cap period.

The cap period runs from November 1 of each year through October 31 of the next year. The total

payments made for services furnished to Medicaid beneficiaries during this period will be compared

to the “cap amount” for this period. Any payments more than the cap must be refunded by the

hospice. “Total payment made for services furnished to Medicaid beneficiaries during this period”

refers to payment for services rendered during the cap year beginning November 1 and ending

October 31, regardless of when payment is made. Payments are measured in terms of all payments

made to hospices on behalf of all Medicaid hospice beneficiaries receiving services during the cap

year, regardless of which year the beneficiary is counted in determining the cap.

For example, payments made to a hospice for an individual electing hospice care on October 5, 1989,

would be counted as payments made during the first cap year (November 1, 1988 - October 31,

1989), even though that individual would not be counted in the calculation of the cap for that year.

(The individual would, however, be counted in the cap calculation for the following year since the

election occurred after September 27, see below).

The hospice cap is to be calculated in a different manner for new hospices entering the program if

the hospice has not participated in the program for an entire cap year. In this situation, the initial cap

calculations for newly certified hospices cover a period of at least 12 months but not more than 23

months. For example, the first cap period for a hospice entering the program on July 1, 1988, would

run from July 1, 1988 through October 31, 1989. Similarly, the first cap period for hospice providers

entering the program after November 1, 1988, but before November 1, 1989, would end October 31,

1990.

The “cap amount” is calculated by multiplying the number of beneficiaries electing hospice care

during the period by a statutory amount of $6,500. This amount will be adjusted in future years as

outlined in Section 1003.

The computation and application of the “cap amount” is made by the Division at the end of the cap

period. The material is presented here for the benefit of the hospice as an aid of planning. The

hospice will be responsible for reporting the number of Medicaid members electing hospice care

during the period to the Division. This must be done within 30 days after the end of the cap period.

1008.1. The following rules must be adhered to by the hospice in determining the number of

Medicaid members who have elected hospice care during the period:

1008.1.1. The member must not have been counted previously in either another

hospice’s cap or another reporting year.

1008.1.2. Those Medicaid beneficiaries who have not previously been included in

the calculation of any hospice cap and who has filed an election to

receive hospice care from the hospice. Those beneficiaries must file an

initial election during the period beginning September 28 (34 days before

the beginning of the cap period) and ending on September 27 (35 days

before the end of the cap period).

1008.1.3. Once a member has been included in the calculation of a hospice cap

amount, he or she may not be included in the cap for that hospice again,

even if the number of covered days in a subsequent reporting period

exceeds that of the period where the member was included. (This could

occur when the member has breaks between periods of election).

1008.1.4. When a member elects to receive hospice benefits from two or more

different Medicaid certified hospices, proportional application of the cap

amount will be necessary. A calculation will be made by the Division to

determine the percentage of the member’s length of stay in each hospice

relative to the total length of hospice stay.

1008.2. EXAMPLE:

1008.2.1. John Doe, a Medicaid member, initially elects hospice care from Hospice

A on May 2, 1989. Mr. Doe stays in Hospice A until June 2, 1989 (30

days) at which time he changes his election and enters Hospice B. Mr.

Doe stays in Hospice B for 70 days until his death on December 11,

1989. The State determines that the total length of hospice stay for Mr.

Doe is 100 days (30 days in Hospice A and 70 days in Hospice B). Since

Mr. Doe was in Hospice A for 30 days, Hospice A should count .3 of a

Medicaid member for Mr. Doe in its hospice cap calculation (30 day --

100 days). Hospice B should count .7 of a Medicaid member in its cap

calculation (70 days -- 100 days). Readjustment of the hospice cap may

be required if information previously unavailable to the State at the time

the hospice cap is applied subsequently becomes available.

1008.3. EXAMPLE:

1008.3.1. Using the example above, if the State had calculated and applied the

hospice cap on October 31, 1989 information would not have been

available at that time to adjust the number of members reported by

Hospice A, since Mr. Doe did not die until December 11, 1989. The

State would recalculate and reapply the hospice cap to Hospice A based

on the information it later received. The cap for Hospice A after

recalculation would then reflect the proper beneficiary count .3 for Mr.

Doe. The cap for Hospice B would reflect the proper member count of .7

for Mr. Doe. An additional step is required when more than one

Medicaid certified hospice provides care to the same individual, and the

care overlaps 2 cap years. In this case, the State must determine in which

cap year the fraction of a member should be reported. If the member

entered the hospice before September 28, the fractional member would

be included in the current cap year. If the member entered the hospice

after September 27, the fractional member would be included in the

following cap year.

1008.4. EXAMPLE:

1008.4.1. Continuing with the case cited in the examples above, Hospice A would

include .3 of a Medicaid member in its cap calculation for the cap year

beginning November 1, 1988, and ending October 31, 1989, since Mr.

Doe entered Hospice A before September 28, 1989. Hospice B would

include .7 of a Medicaid member in its cap calculation for the cap year

beginning November 1, 1989, and ending October 31, 1990, since Mr.

Doe entered Hospice B. after September 27, 1989.

When services are rendered by two different hospices to a Medicaid

member, and one of the hospices is not certified by Medicaid, no

proportional application is necessary. One member will be counted and

the total cap for the certified hospice will be used.