Idaho Medicaid Provider Handbook, Home Health and Hospice Services § 4.7

Providers must be enrolled to receive reimbursement from Idaho Medicaid. Providers have

the burden of proof to establish entitlement to payment. All hospice providers are paid through

the use of prospective daily rates determined by the department except where specified. All

services related to the terminal illness are included in the prospective rates paid. The hospice

provider is responsible for all services bundled in the prospective rate regardless of whether

they are supplied directly by the hospice provider or by a non-hospice provider.

Service reimbursement is based on the services provided and not the credentials of the person

performing the service. Hospice services in the bundled reimbursement rate are the

responsibility of the agency regardless of the service location, which include:

•

Nursing care provided by, or under the supervision of, a registered nurse (RN);

•

Medical social services under the direction of a physician;

•

Counseling services for the care of the participant or the acceptance of death;

•

Home health aide and homemaker services;

•

Physical therapy, occupational therapy, and speech-language pathology services; and

•

Medical equipment and supplies including:

o

Durable medical equipment and supplies related to the palliation or

management of the patient’s terminal illness; and

o

Self-help and personal comfort items related to the palliation or management

of the patient’s terminal illness; and

•

Drugs and biologicals, as defined in Subsection 1861(t) of the Social Security Act,

which are used primarily for the relief of pain and symptoms related to the patient’s

terminal illness.

Prospective rates are divided into routine home care, continuous home care, inpatient respite

care, general inpatient care and service intensity add-ons for hospice care. Hospice

reimbursement represents full payment to the provider for all costs of covered services,

including administrative and general activities performed by physicians providing services for

the hospice. Direct care by physicians working under the hospice is counted in the overall

hospice cap and is reimbursed under the Numerical Fee Schedule. Laboratory and X-ray

services are included in the hospice daily rate. Volunteer physician services are not

reimbursed unless the physician is paid for their services. Physicians may not volunteer based

on the participant’s ability to pay. Independent physicians are paid as normal and outside the

hospice benefit.

Routine home care rates are paid at a higher rate in the first 60 days of care despite the level

of intensity. Regardless of the hospice providing services, when a participant leaves care and

later returns, a new higher rate 60 day period only occurs if there has been a 60 day gap in

service. If there has not been a sufficient gap, rates are paid at the lower rate.

Continuous home care is for crisis periods requiring continuous nursing care to achieve

palliation and manage acute medical symptoms. Nursing service must be provided by an RN

or licensed practical nurse (LPN) for at least half the total period of care. A minimum of eight

hours of care must be provided during a 24-hour day beginning and ending at midnight and

does not need to be continuous and uninterrupted. For every hour, or part of an hour of

continuous care furnished, the hourly rate is paid to the hospice up to 24-hours per day.

General inpatient care is paid at a separate designated payment rate. No other rates are

available during these days except for physician services. Home care rates are paid for the

day of discharge unless the participant dies while inpatient. The date of death is paid at the

inpatient rate. Inpatient rates are paid at Medicare hospice rates without decreases for

coinsurance amounts. Medicaid continues to cover inpatient care once the Medicare benefit is

exhausted. Hospice agencies must continue to provide care until the participant revokes

services or passes away.

Inpatient respite care has a designated rate for each day a participant resides in an approved

inpatient facility receiving respite care. Payment is limited to a maximum of five days. The

first day includes the admission date but the period does not include the discharge date in

any monthly election period. Payment for the sixth and any subsequent days is made at a

routine, continuous, or general inpatient rate.

A maximum number of allowable inpatient days is calculated by multiplying the total number

of a provider’s Medicaid hospice days by 20%. If the total is exceeded, payment is limited by

calculating the ratio of maximum allowable inpatient days by the number of actual inpatient

care days and multiplying the ratio by the total payment for inpatient care made. Excess

inpatient care days are multiplied by the routine home care rate. The two amounts will be

added and the sum compared to the interim inpatient hospice care payments made during

the “cap period.” Days determined to not be eligible for the inpatient rate will not be counted

as inpatient days and paid at the home care rate.

It is a federal requirement that room and board “pass through” the hospice agency when a

hospice participant resides in a skilled nursing facility, and Medicaid’s Long-Term Care Unit

has authorized a nursing facility payment. If a hospice participant resides in a skilled nursing

facility or intermediate care facility with intellectual disabilities (ICF/IID), an authorization

number is required so that the hospice provider can be paid by Medicaid for room and board

(revenue code 658). Hospice agencies are reimbursed an additional per diem amount for

participants in nursing facilities of 95% of the per diem interim nursing home daily or special

rate for the nursing facility providing room and board to the hospice participant. These

additions are not subject to payment caps. The hospice agency is then responsible to

reimburse the facility for the room and board payment.

A payment for a service intensity add-on is made for visits by an RN or social worker during

the last seven days of life. This is in addition to routine home care rates. The rate is

determined by multiplying the continuous home care rate per 15-minutes by the number of

units for combined daily visits and adjusted for geographic wage differences. Reimbursement

is capped at 16 units per day. A social worker’s time on the phone is not eligible for this

reimbursement.

A reimbursement cap is calculated by aggregate payments to each hospice during a cap

period. It is calculated by multiplying the number of participants on hospice care during the

period by an amount adjusted for each cap year reflecting the percentage change in the

medical care expenditure category of the Consumer Price Index for all urban consumers as

published by the U.S. Bureau of Labor and Statistics. The number of participants must be

reported to Medicaid within 30-days of the end of the cap year. If a participant was transferred

to a non-certified hospice where no payment is made, the certified hospice may count the

complete participant benefit period in their cap. A weighted average cap amount based on

the number of days falling within each cap period is used to certify mid-month amounts.

Adjustments are made to the cap based on which hospice is designated during the

participant’s election period. The number of days services are rendered are multiplied by the

cap amount to adjust the overall cap. The share of the cap amount allowed by each hospice

is based on the proportion of total covered days provided by each hospice in a cap period.

The maximum number of allowable inpatient days for each hospice is multiplied by the cap

amount for the cap period in which the participant first elected hospice. The participant must

file an initial election during the period beginning September 28th of the previous year through

September 27th of the current cap year for it to count as an election during the current cap

year. The inpatient limitation is deducted from the total reimbursement amount. The total in

payments includes all services rendered in a cap year regardless of when the payment is

made. Total payments are compared to the cap amount and providers must return any excess

payments.

Claims for services rendered to participants receiving hospice services are pended for review

by the department to determine whether the hospice agency or Medicaid is responsible for

payment. Refer to the Provider Reimbursement Rates’ HCBS and LTSS folder for the Hospice

Fee Schedule rates. See the Hospice Billing Appendix for more information on allowed revenue

codes and bill types. Those participants that have special rate pricing must bill revenue code

0658 and the appropriate CPT® procedure codes.

See the General Billing Instructions, Idaho Medicaid Provider Handbook regarding Medicaid

policy on billing all other third party resources before submitting claims to Medicaid.

Participants cannot be billed for any non-reimbursed amount except as allowed by the

department such as in Participant Liability, and if the provider meets the requirements in the

Participant Financial Responsibility section of the General Information and Requirements for

Providers, Idaho Medicaid Provider Handbook.