Ind. IHCP Hospice Services Provider Reference Module, Section 6, Limitation of Payments for Inpatient Care

Reimbursement for inpatient days, general and respite, is subject to an overall annual limitation established

by the federal Medicare program as described in federal regulations at 42 CFR 418.302(f) and state

regulations at 405 IAC 1-16-3. Total inpatient days (general inpatient days and inpatient respite care days)

for an individual hospice provider and any contracted agents may not exceed 20% of all days provided to

all IHCP hospice members serviced by that specific provider during the 12-month period beginning Nov. 1

of each year, and ending Oct. 31 of the next year.

This payment limitation for inpatient services at the end of the inpatient capitation period, Oct. 31, is

determined by the following calculation:

1. The maximum number of allowable inpatient days is calculated by multiplying the total number of a

provider’s IHCP hospice days by 20.

2. If the total number of days of inpatient care to IHCP hospice members is less than or equal to the

maximum number of inpatient days computed in step 1, then there is no adjustment.

3. If the total number of days of inpatient care to IHCP hospice members is greater than the maximum

number of inpatient days computed in step 1, then the payment limitation is determined by the

following calculation:

a. Calculate the ratio of maximum allowable inpatient days to the number of actual days of

inpatient care, and multiply this ratio by the total reimbursement for inpatient care.

b. Multiply excess inpatient care days by the routine home care rate.

c. Add together the amounts calculated in 3a and 3b.

d. Compare the amount in 3c with total reimbursement to the hospice provider for inpatient care

during the cap period. The amount that total reimbursement to the hospice for inpatient care

exceeds the amount calculated in 3c is the amount due from the hospice provider.

If it is determined the inpatient rate should not be paid, any days the hospice receives payment at a routine

home care rate are not counted as inpatient days.