Mont. Medicaid Hospice Policy Manual, Policy 600

PAYMENT PROCEDURES

FOR HOSPICE CARE

Centers for Medicare and Medicaid (CMS) establishes payment

amounts for specific categories of covered hospice care. Medicaid

pays hospices a daily rate for each day a patient is enrolled in the

hospice benefit. Daily payments are made regardless of the amount

of services furnished on a given day. Payment amounts are

determined within each of the following categories:

ROUTINE HOME CARE DAY:

A routine home care day is a day on which a patient who has

elected to receive hospice care is at home and is not receiving

continuous care.

1. RHC is a level of care day which will be paid one of

two RHC rates. RHC per diem payment rates for the

RHC level of care will be paid depending on the

timing of the day within the patient’s episode of care.

Days 1 through 60 will be paid at the RHC “High” rate

while days 61+ will be paid at the RHC “Low” rate.

2. Service Intensity Add-on (SIA). Routine home care

days that occur during the last 7 days of a hospice

election ending with a patient discharged due to death

are eligible for a service intensity add-on payment.

a. The service intensity add-on payment

shall be equal to the continuous home

care hourly payment rate, multiplied by

the amount of direct patient care

actually provided by a RN and/or social

worker, up to 4 hours combined per day.

CONTINUOUS

HOME CARE DAY

A continuous home care day is a day on which a patient who has

elected to receive hospice care and is:

1. Not in an inpatient facility; and

2. Receives hospice care consisting predominantly of

nursing care on a continuous basis at home.

Home health aide (also known as a hospice aide) or homemaker

services or both, may also be provided on a continuous basis.

Continuous home care is only furnished during brief periods of

crisis as described in Hospice Policy 502 and only as necessary to

maintain the terminally ill patient at home.

INPATIENT RESPITE

CARE DAY

An inpatient respite care day is a day on which the patient, who has

elected hospice care, receives care in an approved facility on a

short-term basis for respite.

GENERAL INPATIENT

CARE DAY

A general inpatient care day is a day on which a patient who has

elected hospice care receives general inpatient care in an inpatient

facility for pain control or acute or chronic symptom management

which cannot be managed in other settings.

PAYMENT RATES

The payment amounts for the categories of hospice care are fixed

payment rates that are established by CMS. Payment rates are

determined for the following categories:

1. Routine home care;

2. Service Intensity Add-On Rate;

3. Continuous home care;

4. Inpatient respite care; and

5. General inpatient care.

Medicaid reimburses the hospice its appropriate payment amount

for each day for which an eligible Medicaid beneficiary is under the

hospice's care.

If a hospice makes arrangements with another hospice to provide

services, Medicaid reimburses the hospice for which the beneficiary

has made an election.

Medicaid makes payment according to the following procedures:

1. Payment is made to the hospice for each day during

which the beneficiary is eligible and under the care of

the hospice, regardless of the amount of services

furnished on any given day except for the service

intensity add-on;

2. Payment is made for only one of the categories of

hospice care for any particular day;

3. On any day in which the beneficiary is not an

inpatient, the hospice is paid the routine home care

rate, unless the patient receives continuous care for a

period of at least eight hours. In that case, a portion of

the continuous care day rate is paid;

4. The hospice payment on a continuous care day varies

depending on the number of hours of continuous

services provided. The continuous home care rate is

divided by 24 to yield an hourly rate. The number of

hours of continuous care provided during a

continuous home care day is then multiplied by the

hourly rate to yield the continuous home care

payment for that day. A minimum of eight hours of

care must be furnished on a particular day to qualify

for the continuous home care rate.

5. Except for inpatient care limitations, on any day in

which the beneficiary is an inpatient in an approved

facility for inpatient care, the appropriate inpatient rate

(general or respite) is paid depending on the category

of care furnished.

The inpatient rate (general or respite) is paid for the

date of admission and all subsequent inpatient days,

except the day on which the patient is discharged.

6. For the day of discharge, the appropriate home care

rate is paid unless the patient dies as an inpatient.

In the case where the beneficiary is discharged

deceased, the inpatient rate (general or respite) is

paid for the discharge day.

Payment for inpatient respite care is subject to the

requirement that it may not be provided consecutively

for more than five days at a time. Payment for the

sixth and any subsequent day of respite care is made

at the routine home care rate.

a. Payment for inpatient care is limited as

follows:

i. The total payment to the hospice

for inpatient care (general or

respite) is subject to a limitation

that total inpatient care days for

Medicaid patients not exceed 20

percent of the total days for which

these patients had elected

hospice care.

ii. At the end of a cap period,

Medicaid calculates a limitation

on payment for inpatient care to

ensure that Medicaid payment is

not made for days of inpatient

care in excess of 20 percent of

the total number of days of

hospice care furnished to

Medicaid patients.

iii. Only inpatient days that were

provided and billed as general

inpatient or respite days are

counted as inpatient days when

computing the inpatient cap.

iv. If the number of days of inpatient

care furnished to Medicaid

patients is equal to or less than

20 percent of the total days of

hospice care to Medicaid

patients, no adjustment is

necessary.

v. Overall payments to a hospice

are subject to the cap amount.

vi. If the number of days of inpatient

care furnished to Medicaid

patients exceeds 20 percent of

the total days of hospice care to

Medicaid patients, the total

payment for inpatient care is

determined in accordance with

the procedures specified. That

amount is compared to actual

payments for inpatient care, and

any excess reimbursement must

be refunded by the hospice.

Overall payments to the hospice

are subject to the cap.

If a hospice exceeds the number of inpatient care days, the total

payment for inpatient care is determined as follows:

1. Calculate the ratio of the maximum

number of allowable inpatient days to

the actual number of inpatient care days

furnished by the hospice to Medicaid

patients;

2. Multiply this ratio by the total

reimbursement for inpatient care made

by the Medicaid Administrative

Contractor;

3. Multiply the number of actual inpatient

days in excess of the limitation by the

routine home care rate; and

4. Add the amounts calculated.

Payment for routine home care, continuous home care, general

inpatient care and inpatient respite care is made on the basis of the

geographic location where the services are provided.