Current through Register 1531, September 27, 2024
(A)
Type of Care. MassHealth payment for hospice services
is based on the type of care provided rather than the qualifications of the
person who provided the service. Payment rates correspond to the following four
categories of care.
(1)
Routine
Home Care. The routine home care rate is paid for each day the
member is at home or residing in a nursing facility or ICF/IID, under the care
of the hospice provider, and not receiving continuous home care. This rate is
paid without regard to the volume or intensity of routine home care services
provided on any given day.
(2)
Service-intensity Add-on (SIA). Routine home care days
that occur during the last seven days of a hospice election ending with a
member discharge due to death are eligible for an SIA payment. The SIA rate may
be billed with the routine home care rate, for a minimum of 15 minutes and up
to four hours per day for RN or social worker visits to the member during the
last seven days of their hospice election ending in discharge due to
death.
(3)
Continuous
Home Care. The continuous home care rate is paid when a member
receives hospice services consisting predominantly of nursing care on a
continuous basis at home or in a nursing facility or ICF/IID. 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 42 CFR
418.204(a) and only as
necessary to maintain the member at home. A minimum of eight hours must be
provided in a 24-hour period to qualify for the continuous home care
rate.
(4)
Inpatient
Respite Care. The inpatient respite care rate is paid to the
hospice provider for each day the member is in an approved inpatient facility
and is receiving respite care from the hospice provider. Payment for inpatient
respite care will be made for a maximum of five consecutive days' stay
including the date of admission but not counting the date of discharge except
in circumstances described in
42 CFR
418.302(e)(5). Payment for
any subsequent days will be made at the routine home care rate.
(5)
General Inpatient
Care. The general inpatient care rate is paid for each day the
member receives general inpatient care in an inpatient facility for pain
control or acute or chronic symptom management that cannot be managed in other
settings. None of the other fixed payment rates will be applicable for a day on
which the member receives inpatient care except for the day of
discharge.
(B)
Room and Board in a Nursing Facility or ICF/IID. The
MassHealth agency pays the hospice provider a room and board per diem amount
for a member residing in a nursing facility or an ICF/IID in accordance with
all applicable MassHealth regulations and in addition to either the routine
home care rate (130 CMR
437.424(A)(1)) or the
continuous home care rate (130 CMR 437.424(A)
(2)).
(1)
The MassHealth agency does not pay a hospice provider the room and board per
diem amount, and does not pay for medical-leave-of-absence days, for any day
that a member receives inpatient respite care (130 CMR
437.424(A)(3)) or general
inpatient care (130 CMR
437.424(A)(4)) from the
hospice provider.
(2) If a member
receiving hospice services in a nursing facility or ICF/IID is hospitalized,
the MassHealth agency will pay the hospice provider for the medical leave of
absence in accordance with 130 CMR 456.000: Long Term Care
Services, provided that the conditions for medical leave of absence
are met in accordance with 130 CMR 456.000: Long Term Care
Services.
(C)
Payment of Hospice Provider on Date of Discharge from Hospice
Services. MassHealth does not pay a hospice provider the
per diem hospice rate or the room and board rate on a member's
date of discharge from hospice services, except for when
(1) the member is discharged due to death;
or
(2) the member was receiving
hospice services in a nursing facility or ICF/IID and continue to reside in the
nursing facility or ICF/IID after hospice discharge.
(D)
Payment of Hospice Provider
on Date of Death. MassHealth pays the hospice provider the hospice
per diem rate and the room and board rate on the member's date of
death.
(E)
Change of
Hospice Providers. When a member changes hospice providers,
MassHealth will not pay both hospice providers for the same date of service.
The new hospice provider may begin receiving payment for dates of service
subsequent to the date of discharge from the previous hospice
provider.
(F)
The
Hospice Election Form. A hospice provider must complete a hospice
election form and notify the MassHealth agency of the member's hospice election
in accordance with
130
CMR 437.412. The MassHealth agency will not
pay for hospice services provided before the effective date entered on the
hospice election form.
(G)
Dual-eligible Members. The MassHealth agency will not
pay for hospice services and/or applicable room and board in an NF or ID/DD
during any period in which a dual-eligible member has not simultaneously
elected both their MassHealth and Medicare hospice benefit.
(H)
MassHealth Members Enrolled
in Capitated Programs. A hospice provider may not directly bill
MassHealth for hospice services provided to a MassHealth member receiving
hospice services through a capitated program.
(I)
Non-hospice
Providers. Non-hospice providers may bill for the treatment of
conditions not related to the member's terminal illness according to the
applicable MassHealth regulations for that provider type.
