Vt. Medicaid Hospice Provider Manual § 2

Hospice-eligible members have the right to select qualified hospice providers of their choice.

• Hospice services to terminally ill recipients are covered in accordance with Section 1905(o)

of the Social Security Act and must comply with the requirement in section 4305 of the

Medicaid State Plan. A physician must certify that the eligible person is within the last six

(6) months of life. These services may be provided on a 24-hour, continuous basis.

Coverage is available for an unlimited duration. All services must be performed by

appropriately qualified personnel, for the nature of service being provided.

• When hospice care is furnished to a member in a nursing facility, the hospice agency must

submit a claim for the hospice room and board charges. The hospice agency is responsible

for paying the nursing facility for the hospice room and board charges. The hospice room

and board rate equals at least 95 percent of the nursing facility per diem rate that would

have been paid to the nursing facility under the Medicaid State Plan.

• Hospice services are reimbursed at the lower of the actual charge or the Medicaid rate on

file. These rates follow the Medicare-defined urban/rural differential, with the exception of

payment for physician services. Medicaid reimbursement for hospice care will be made at

one of the following five predetermined rates for each day in which a member receives the

respective type, duration and intensity of the services furnished under the care of the

hospice agency.

1. Routine Home Care (RHC) Hospice providers are paid one of two levels of RHC.

This two-rate payment methodology will result in a higher RHC rate based on

payment for days one (1) through sixty (60) of hospice services care and a lower

RHC rate for days sixty-one (61) or later. A minimum of a sixty (60) day gap in

hospice services is required to reset the counter which determines the member’s

payment category.

2. Continuous Home Care

3. Inpatient Respite Care

4. General Inpatient Care

5. Service Intensity Add-On

The State does not apply the optional cap limitation on payments.