MO HealthNet Hospice Provider Manual § 2.16

Payments to a hospice for inpatient care are limited according to the number of days of inpatient care furnished to MO HealthNet participants. During the 12-month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient days (both for general inpatient care and inpatient respite care) may not exceed 20 percent (20%) of the aggregate total number of days of hospice care provided to all MO HealthNet participants during that same period. This limitation is applied once each year, at the end of the hospice’s ‘cap period’ (November 1 to October 31). For purposes of this computation, if it is determined that the inpatient rate should not be paid, any days for which the payment is recalculated at a home care rate are not counted as inpatient days. The limitation is calculated as follows:

The maximum allowable number of inpatient days is calculated by multiplying the total number of days of MO HealthNet hospice care by 0.2

If the total number of days of inpatient care furnished to MO HealthNet hospice participants is less than or equal to the maximum, no adjustment is necessary

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 one (1) and two (2) above

4. Comparing the amount in three (3) above with interim payments made to the hospice for inpatient care during the ‘cap period,’ (November 1 to October 31)

Any excess reimbursement is recouped from the hospice.