S.C. Medicaid Hospice Services Provider Manual § 7

SPECIAL COVERAGE ISSUES

With the exception of payment for physician services, Medicaid reimbursement for hospice care will

be made at one of four predetermined rates for each day on which an individual is under the care of

the hospice. The four rates are prospective rates established by the Centers for Medicare &

Medicaid Services (CMS) for the Medicare hospice program. There will be no retroactive

adjustments other than the limitation on payments for inpatient care. The rate paid for any particular

day will vary depending on the LOC furnished to the individual. The limitations on payment for

inpatient care are described below.

SCDHHS will not provide payment for Medicaid hospice services where retroactive eligibility has

been determined. Please refer to the Provider Administrative and Billing Manual for information on

Medicaid eligibility.

LOC

There are four levels of care into which each day of care is classified:

• Routine Home Care

• Continuous Home Care

• Inpatient Respite Care

• GIP Care

For each day that an individual is under the care of a hospice, the hospice will be reimbursed an

amount applicable to the type and intensity of the services furnished to the individual for that day.

For continuous home care, the amount of payment is determined based on the number of hours of

continuous care furnished to the beneficiary on that day. A description of each LOC follows:

Routine Home Care

The hospice will be paid the routine home care rate for each day the patient is at home under the

care of the hospice. This includes patients residing in a nursing home. This rate is paid without

regard to the volume or intensity of routine home care services on any given day; however, the

frequency and intensity of services delivered must be consistent with the patient’s POC. The

patient’s record should include any updates to the POC and changes in the patient’s condition

between the updates. Also, the patient’s record should include all disciplines’ daily/weekly/monthly

progress notes that record the types and frequencies of the services being provided to the patient.

Continuous Home Care

The hospice will be paid the continuous home care rate when continuous home care is provided.

Continuous home care is to be provided only during a period of crisis. This is defined as a period

during which a patient requires continuous care to achieve palliation or management of acute

medical symptoms. Continuous home care is primarily nursing care — a nurse must provide the

care for more than half of the period of crisis. Nursing care must be provided by either a registered

nurse or a licensed practical nurse. A minimum of eight hours of care must be provided during a

24-hour day that begins and ends at midnight. This care need not be continuous, i.e., four hours

could be provided in the morning and another four hours in the evening of the same day.

Homemaker and aide services may also be provided to supplement the nursing care.

Continuous home care is covered when it is provided to maintain an individual at home during a

medical crisis. If less skilled care is needed on a continuous basis to enable the person to remain at

home, this is covered as routine home care.

Documentation should clearly report the reason for continuous home care, list the dates of service

and illustrate hour-by-hour and day-by-day what services were provided, the patient’s condition and

the type of personnel providing the continuous home care.

Inpatient Respite Care

The hospice will be paid at the inpatient respite care rate for each day that the beneficiary is in an

approved inpatient facility and is receiving respite care.

Respite care is short-term inpatient care provided to the individual only when necessary to relieve

the family members or other persons caring for the individual at home. Respite care may be

provided only on an occasional basis and may not be reimbursed for more than five consecutive

days at a time. Respite care may not be provided when the hospice patient is residing in a nursing

home permanently.

Services provided in the facility must conform to the hospice POC. Payment for respite care may be

made for a maximum of five consecutive days at a time including the date of admission, but not

counting the date of discharge. Payment for the sixth and any subsequent days is to be made at the

routine home care rate. Documentation in the beneficiary’s record should reflect why the respite

care was necessary. If there is more than one respite care admission in a short amount of time,

documentation should indicate why multiple admissions were necessary.

GIP Care

Payment at the inpatient rate will be made when GIP care is provided for services related to the

terminal illness. No other fixed payment rate (i.e., routine home care) will be applicable for a day

that the patient receives hospice inpatient care. Services provided in the inpatient setting must

conform to the hospice’s POC. The hospice must have a contract with the inpatient facility

delineating the roles of each provider in the hospice’s POC; however, the hospice is the

professional manager of the patient’s care, despite the physical setting of that care or the LOC. GIP

care is a short-term LOC and is not intended to be a permanent solution to a negligent or absent

caregiver. Documentation in the beneficiary’s record should clearly explain the reason for the

admission and the beneficiary’s condition during the stay in the facility at this LOC. The key to GIP

LOC is the patient’s medical condition.

Date of Discharge

The appropriate routine home care rate is to be paid for the day of discharge from an inpatient unit.

If the patient dies in the inpatient unit, the appropriate rate (general or respite) is to be paid for the

discharge date.

Hospice Payment Rates

The federal hospice rates are issued each year, effective October 1, by CMS and adjusted for local

wage indices. The SCDHHS Division of Ancillary Reimbursement, in conjunction with the hospice

program manager, will notify each hospice of the approved Medicaid hospice reimbursement rates.

Limitation of Payments for Inpatient Care

Payments to a hospice for inpatient care must be limited according to the number of days of

inpatient care furnished to Medicaid patients. During the 12-month period beginning November 1 of

each year and ending October 31, the aggregate number of inpatient days (both for GIP care and

inpatient respite care) may not exceed 20% of the aggregate total number of days of hospice care

provided to all Medicaid beneficiaries during that same period. This calculation will exclude days for

beneficiaries with acquired immunodeficiency syndrome.

This limitation is applied once each year, at the end of the hospices’ “cap period”

(November 1–October 31). For purposes of this computation, if it is determined that the inpatient

rate should not be paid, any days for which the hospice receives payment at a routine home care

rate will not be counted as inpatient days. The limitation is calculated as follows:

• The maximum allowable number of inpatient days will be calculated by multiplying the total

number of days of Medicaid hospice care by 0.2.

• If the total number of days of inpatient care furnished to Medicaid hospice patients is less than

or equal to the maximum, no adjustment will be necessary.

• If the total number of days of inpatient care exceeds the maximum allowable number, the

limitation will be determined by calculating the ratio of the maximum allowable days to the

number of actual days of inpatient care and multiplying this ratio by the total reimbursement that

was made for inpatient care (GIP and inpatient respite reimbursement).

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

– Add together the amounts calculated in 1 and 2 above.

– Compare the amount in 3 above with interim payments made to the hospice for inpatient care

during the “cap period”.

Any excess reimbursement will be recouped from the hospice by SCDHHS.

Payment for Physician Services

SCDHHS will pay the physician in accordance with the usual South Carolina Medicaid

reimbursement methodology for physician services regardless of whether services are provided by

a hospice employee, a physician under agreement with the hospice or the patient’s attending

physician for related or non-related services. Services furnished voluntarily by physicians are not

reimbursable.

Physicians’ administrative services provided by the hospice medical director or physician member of

the interdisciplinary group, such as general supervisory services or participation in the

establishment of POC, supervision of care and services, periodic review and updating of care plans

and establishment of governing policies, are included in the daily hospice reimbursement rate and

not eligible for the physician’s fee-for-service reimbursement.

The hospice must notify the Medicaid hospice program manager of the name of the physician who

has been designated as the attending physician by the beneficiary. This information is included on

the Medicaid Hospice Election Statement.

Payment for Facility Residents

When a Medicaid beneficiary who is a NF or ICF/IID resident and is also Medicare eligible (referred

to as dually eligible) chooses to elect the hospice benefit, Medicare becomes the primary payer for

the hospice benefit. For either a Medicaid only or a dually eligible resident, the state Medicaid

agency must pay the hospice agency for the facility room and board payment.

When presented with a reimbursement claim, SCDHHS will directly reimburse the hospice agency

an amount no less than 95% of the daily Medicaid rate of reimbursement for the room and board of

the patient receiving hospice. The hospice must reimburse the facility according to the terms

specified in their contract arrangements.

This rate is designed to cover room and board, which includes the following:

• Performance of personal care services.

• Assistance in the activities of daily living.

• Administration of medication.

• Maintaining the cleanliness of the patient’s environment.

• Supervision and assistance in the use of DME and prescribed therapies.

Along with this reimbursement, SCDHHS will reimburse the hospice provider the daily rate for

hospice care provided and billed on the CMS-1500.

Payment/Sponsorship Guidelines for Hospice in a NF or ICF/IDD

ELIGIBILITY

STATUS

NF

SPONSORSHIP

HOSPICE

SPONSORSHIP

COMMENTS

Dual Medicare Medicare Rare — In NF for a diagnosis code

related to the terminal illness. NF can bill

Medicare for room and board using

modifier 07.

Dual Medicare Private No Medicaid payment for hospice.

Dual Medicaid Medicare Medicare becomes the primary hospice

payer.

Medicaid Only Medicaid Medicaid SCDHHS reimburses the hospice

agency for the Medicaid room and board

rate.

Note: Medicaid is always the payer of last resort.