Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.35 - Hospice Care
Section 10.09.35.08 - Payment Procedures
Universal Citation: MD Code Reg 10.09.35.08
Current through Register Vol. 51, No. 19, September 20, 2024
A. Reimbursement Principles.
(1) The Program
shall pay the provider at one of four rates for each day that the participant
is under the provider's care, subject to the conditions, limitations, and
exceptions set forth in this chapter.
(2) The payment rates for providers shall be
those established by the Health Care Financing Administration (HCFA) of the
U.S. Department of Health and Human Services for hospice care under a Medical
Assistance Program.
(3) The daily
rates are prospective rates, and there shall be no retroactive adjustment of
payment other than the limitation on payment for inpatient care set forth in
§C of this regulation.
B. Categories of Hospice Care for Reimbursement.
(1) Routine Home Care.
(a) The provider shall be paid the routine
home care rate for each day the participant is under the care of the provider
and another rate is not payable under §B(2)-(4) of this
regulation.
(b) The routine home
care rate is paid without regard to the volume or intensity of covered services
provided on a given day.
(2) Continuous Home Care.
(a) The provider shall be paid the continuous
home care rate for each day the participant is at home, under the care of the
provider, and all of the following requirements are met:
(i) There is a brief period of crisis during
which the participant requires continuous care, which is primarily nursing care
to achieve palliation or management of acute medical symptoms.
(ii) Nursing care shall be provided by either
a registered nurse or a licensed practical nurse, and a nurse must be providing
care for more than half the period. Homemaker or home health aide services may
be provided to supplement the nursing care.
(iii) A minimum of 8 hours of care must be
provided during a 24-hour day which begins and ends at midnight, but the hours
of care need not be continuous.
(b) The continuous home care rate is divided
by 24 hours to arrive at an hourly rate.
(c) For every hour or part of an hour of
continuous home care furnished, the hourly rate shall be paid to the provider,
up to 24 hours a day.
(d) If less
skilled care is needed on a continuous basis to maintain the patient at home
during a period of crisis, or if less than 8 hours of continuous home care is
provided during a day, payment shall be made at the routine home care
rate.
(3) Inpatient
Respite Care.
(a) The provider shall be paid
the inpatient respite care rate for each day the participant is in a qualified
inpatient facility for the purpose of respite care, subject to the following
requirements:
(i) Payment shall be made at the
inpatient respite care rate for a maximum of 5 consecutive days at a time,
including the day of admission but not counting the day of discharge;
(ii) Payment for the sixth and any subsequent
day of inpatient respite care shall be made at the routine home care
rate;
(iii) For the day of
discharge, payment shall be made at the routine or continuous home care rate,
as appropriate, unless the participant dies as an inpatient; and
(iv) Payment shall be made at the inpatient
respite care rate for the day of discharge if the participant is discharged
deceased.
(b) Inpatient
respite care may not be provided when the participant is a resident of a
nursing facility.
(4)
General Inpatient Care. The provider shall be paid the general inpatient care
rate for each day the participant is in a qualified inpatient facility for
care, subject to the following requirements:
(a) The inpatient care is required for
procedures necessary for pain control or for acute or chronic symptom
management which cannot be provided in other settings;
(b) Payment shall be made at the general
inpatient rate for the day of admission and for all subsequent inpatient days,
except for the day of discharge;
(c) For the day of discharge, payment shall
be made at the routine or continuous home care rate, as appropriate, unless the
participant dies as an inpatient; and
(d) Payment shall be made at the general
inpatient rate for the day of discharge if the participant is discharged
deceased.
C. Limitation on Payment for Inpatient Care.
(1)
Payment to a provider for inpatient care shall be limited according to the
total number of days of inpatient care the provider furnished to participants
during a specific cap period, excluding the days of inpatient care furnished to
participants diagnosed with Acquired Immune Deficiency Syndrome
(AIDS).
(2) For the cap period, the
aggregate number of inpatient days reimbursed for general inpatient and
inpatient respite care (excluding inpatient days reimbursed for participants
with AIDS) may not exceed 20 percent of the aggregate total number of days of
hospice care the provider furnished to all participants (excluding days of
hospice care furnished to participants with AIDS) during the same
period.
(3) The limitation on
payment for inpatient care days is calculated as follows:
(a) Subtract the days of care furnished to
participants with AIDS from the total days of care furnished by the provider to
all participants during the cap period;
(b) Subtract the days of inpatient care
furnished to participants with AIDS from the total days of inpatient care
furnished by the provider to all participants during the cap period;
(c) The maximum allowable number of
reimbursable inpatient days is determined by multiplying by 0.2 the adjusted
total number of days of hospice care the provider furnished to participants
during the cap period, as determined in §C(3)(a) of this
regulation;
(d) If the adjusted
total number of inpatient care days the provider furnished to participants
during the cap period, as determined in §C(3)(b) of this regulation, is
less than or equal to the maximum allowable number of reimbursable inpatient
days, no payment adjustment is necessary; and
(e) If the adjusted total number of inpatient
care days the provider furnished to participants during the cap period exceeds
the maximum allowable number of reimbursable inpatient days, the payment
limitation and the refund to the Program shall be determined by:
(i) Calculating a ratio of the maximum
allowable number of reimbursable inpatient days to the adjusted total number of
inpatient care days, and multiplying this ratio by the total reimbursement to
the provider during the cap period for general inpatient and inpatient respite
care days (minus the reimbursement for inpatient care days furnished to
participants with AIDS);
(ii)
Multiplying excess inpatient care days by the routine home care rate;
(iii) Adding together the amounts calculated
in §C(3)(e)(i) and (ii) of this regulation; and
(iv) Refunding to the Program the difference
between the interim reimbursement made for non-AIDS inpatient care during the
cap period and the amount determined in §C(3)(e)(iii) of this
regulation.
(4) This limitation shall be applied once a
year, at the end of the cap period.
D. Payment for Physician Services.
(1) The per diem rates are designed to
reimburse for those administrative and general supervisory activities performed
by physicians who are employees of or are working under arrangements with the
provider. These activities are generally performed by the physician serving as
the medical director or the physician member of the provider's
interdisciplinary group. The included activities consist of participation in
establishment of care plans, supervision of service delivery, periodic review
and updating of care plans, and establishment of governing policies.
(2) In addition to the daily rates, the
Program shall make separate payment to the provider for physician services,
subject to the following requirements:
(a)
The services shall be direct patient care services furnished to a participant
under the care of the provider;
(b)
The services shall be furnished by an employee of the provider or furnished
under arrangements made by the provider;
(c) The provider shall have a liability to
reimburse the physician for the services rendered;
(d) The provider shall bill for the physician
services in accordance with procedures established by the Program;
(e) A payment may not be made for physician
services furnished on a volunteer basis; and
(f) Payment to the provider for physicians'
services shall be made in accordance with the fee schedule contained in COMAR
10.09.02.
(3) A
physician who is designated as the attending physician by a participant and who
also volunteers services to the provider is considered an employee of the
provider, whose direct patient care services furnished to the participant on a
nonvolunteer basis shall be reimbursed to the provider in accordance with
§D(2) of this regulation.
(4)
A physician who is designated as the attending physician by a participant and
who is not an employee of the provider or receiving compensation from the
provider shall be paid by the Program in accordance with COMAR 10.09.02. The
attending physician may bill the Program only for personal professional
services.
E. When a participant resides in a nursing facility, the Program shall pay an additional per diem amount for room and board to the provider, subject to the following requirements:
(1) The additional amount shall
be paid only for those days that the provider is reimbursed at the routine or
continuous home care rate for hospice care furnished to the
participant;
(2) The amount shall
be the per diem reimbursement established by the Program to pay for room and
board in the facility;
(3) The
amount shall be paid to the provider only when the provider and the facility
have a written agreement under which the provider is responsible for the
professional management of the participant's hospice care and the facility
agrees to provide room and board to the participant;
(4) While the provider is being reimbursed
for hospice care furnished to a participant residing in a nursing facility,
Program payment to the facility shall be discontinued; and
(5) The Department of Human Resources shall
determine the application of a recipient's resource to the cost of hospice care
pursuant to COMAR 10.09.24 and COMAR 10.09.25. The provider:
(a) Shall collect a recipient's resource
available for hospice care as certified by the Department of Human
Resources,
(b) May not collect a
total payment, including the recipient's resource and the Department's payment,
which exceeds the amount the provider would be paid in accordance with this
regulation for a day of hospice care, and
(c) Shall show sums collected from a
recipient's available resource as patient collection.
F. Requests for Payment. Requests for payment for hospice care services rendered shall be submitted as set forth in COMAR 10.09.36.04A.
G. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.
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