Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
42 C.F.R.
418.302,
418.306,
42 U.S.C.
1396a,
1396b,
1396c,
1396d
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services has responsibility to administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the requirements for
reimbursements for hospice services.
Section
1. Definitions.
(1) "Department"
means the Department for Medicaid Services or its designee.
(2) "Home" means:
(a) A primary residence that is based on a
recipient's county of Medicaid eligibility; or
(b) A nursing facility licensed in accordance
with
902 KAR
20:300.
(3) "Hospice provider" means an agency that
is:
(a) Licensed in accordance with
902 KAR
20:140; and
(b) Medicare- and
Medicaid-certified.
(4)
"Hospice recipient" means an individual who:
(a) Is eligible for Medicaid;
(b) Is certified by a physician as terminally
ill with a medical prognosis that life expectancy is six (6) months or less in
accordance with
907 KAR 1:330;
and
(c) Elects to receive hospice
services.
Section
2. Coverage. The department shall reimburse a participating
hospice provider for a service rendered to a hospice recipient in accordance
with
907 KAR
1:330.
Section
3. Reimbursement Rates for a Covered Hospice Service.
(1) The reimbursement rate for a hospice
service shall:
(a) Be annually established in
accordance with
42
C.F.R. 418.306; and
(b)
1. For
routine home care or continuous home care, be based on the geographic location
of the hospice recipient's home; or
2. For general inpatient care or inpatient
respite care, be based on the geographic location of where the service is
provided.
(2)
If a hospice recipient resides in a nursing facility participating in the
Medicaid program and occupies a bed that is Medicaid-certified, the department
shall reimburse an amount equal to at least ninety-five (95) percent of the
nursing facility's per diem to the hospice provider to cover expenses for room
and board provided by the nursing facility.
(3) Reimbursement for bed reservation days
shall:
(a) Be made by the department if the
hospice recipient is residing in a nursing facility and has been in Medicaid
reimbursement status for at least one (1) midnight census;
(b) Be limited per hospice recipient as
follows:
1. To fourteen (14) consecutive days
and a total of forty-five (45) days per lifetime for the purpose of inpatient
hospitalization; and
2. To fifteen
(15) days per lifetime for the purpose of therapeutic home visits;
(c) Not be made after the date of
death of a hospice recipient if the hospice recipient dies while in the
hospital or on a home visit; and
(d) Be at the rate established in subsection
(2) of this section.
(4)
Reimbursement for general inpatient and inpatient respite care shall be:
(a) Limited to twenty (20) percent of the
aggregate total number of days hospice care is provided to all Medicaid
recipients during a twelve (12) month period, beginning November 1 of each year
and ending October 31 of the following year in accordance with
42 C.F.R.
418.302(f); and
(b) Subject to recoupment by the department
if in excess of paragraph (a) of this subsection.
Section 4. Limitations on Reimbursement of
Covered Hospice Services.
(1) A routine home
care service unit shall be a day during which a hospice recipient receives
routine home care.
(2) Continuous
home care shall be:
(a) Reimbursed at an
hourly rate, which shall be calculated by dividing the rate established
pursuant to Section 3(1) of this administrative regulation by twenty-four
(24);
(b) Provided a minimum of
eight (8) hours per day;
(c)
Reimbursed per unit, which shall equal one (1) hour; and
(d) Predominately nursing care provided by a
registered nurse or a licensed practical nurse.
(3) General inpatient care shall be equal to
twenty four (24) hours per (1) unit.
(4) Inpatient respite care shall:
(a) Be limited to five (5) consecutive days;
and
(b) Not be provided to a
hospice recipient who is residing in a nursing facility.
(5) Except for the day on which a hospice
recipient is discharged, the inpatient rate, either general or respite, shall
be paid for the date of admission and for all subsequent inpatient
days.
(6) On the day a hospice
recipient is discharged from inpatient care, either general or respite, a
hospice provider shall be reimbursed:
(a)
Depending on the care needs of the hospice recipient, either the routine home
care rate or the continuous home care rate; or
(b) The inpatient rate, either general or
respite, if the hospice recipient is discharged deceased.
Section 5. Copayments.
(1) The department shall pay a hospice
recipient's Medicare copayment if the individual qualifies for and has elected
to receive Medicaid hospice benefits as established in
907 KAR
1:330.
(2)
A copayment shall not be applied to a Medicaid reimbursement rate for a hospice
service.
Section 6.
Coverage of Drugs.
(1) A reimbursement rate
established in Section 3(1) of this administrative regulation shall include
reimbursement for any drug related to the terminal illness of a hospice
recipient.
(2) If a drug is not
related to the terminal illness of a hospice recipient:
(a) A hospice provider shall complete and
submit one (1) copy of the MAP-384 form to the department; and
(b) The department shall:
1. Update the MAP-384 to indicate the maximum
amount allowable for reimbursement, as determined in accordance with
907
KAR 23:020;
2. Return the updated MAP-384 to the hospice
provider; and
3. Reimburse the
hospice provider the lesser of 100 percent of the cost of the drug or the
maximum amount allowable, as determined in accordance with
907
KAR 23:020.
Section 7. Appeal Rights. A hospice provider
may appeal a department decision as to the application of this administrative
regulation in accordance with
907
KAR 1:671.
Section
8. Incorporation by Reference.
(1) "MAP-384, Hospice Drug Form", 1/18, is
incorporated by reference.
(2) This
material may be inspected, copied, or obtained, subject to applicable copyright
law, at the Department for Medicaid Services, 275 East Main Street, Frankfort,
Kentucky 40601, Monday through Friday, 8 a.m. to 4:30 p.m.
13 Ky.R. 1017;
eff. 12-2-1986; Am. 16 Ky.R. 2607; eff. 6-27-1990; 18 Ky.R. 547; eff.
10-6-1991; 28 Ky.R. 2457; 29 Ky.R. 135; eff. 7-15-2002; 30 Ky.R. 122; 658; 886;
eff. 10-31-2003; TAm eff. 10-6-2017; 45 Ky.R. 2793; eff
8-2-2019.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3)