Current through Reg. 49, No. 38; September 20, 2024
(a) Medicaid hospice per diem and hourly
rates. For each day that an individual is under the care of a hospice, the
hospice is paid an amount applicable to the type and intensity of the services
furnished to the individual. HHSC pays a daily rate for routine home care,
in-patient respite care, and general inpatient care. For CHC and the SIA, the
amount of payment is based on the number of hours of care furnished to the
individual on that day.
(1) Routine home care.
The hospice is paid the routine home care rate for each day the individual is
at home, under the care of the hospice, and not receiving CHC. The appropriate
routine home care rate is determined as follows.
(A) For routine home care delivered during
the first 60 days an individual is receiving hospice care, the routine home
care rate is the higher base payment rate.
(B) For routine home care delivered after the
first 60 days an individual is receiving hospice care, the routine home care
rate is the reduced base payment rate.
(C) If an individual receiving hospice
services is discharged and readmitted to hospice not more than 60 days after
the discharge, HHSC will count all days the individual received hospice
services since the original hospice admission in determining the proper base
payment rate.
(D) If an individual
receiving hospice services is discharged and readmitted to hospice more than 60
days after the discharge, HHSC disregards the previous hospice admission in
determining the proper base payment rate.
(2) Service Intensity Add-on. The hospice is
paid an SIA in addition to the routine home care rate for visits provided by an
RN or social worker during the last seven days of a hospice election ending
with an individual discharged due to death. The SIA is the CHC hourly rate,
multiplied by the number of hours of care provided by the RN or social worker,
up to 4 hours during a 24-hour day that begins and ends at midnight. To claim
the SIA, a hospice must submit:
(A)
documentation of the in-person, skilled services provided by the RN, the social
worker, or both;
(B) the times the
services were provided; and
(C) the
Individual Election/Cancellation/Update Form indicating the hospice election
was canceled due to death.
(3) Continuous Home Care. The hospice is paid
the CHC rate when direct patient care is provided. The CHC rate is divided by
24 hours to arrive at an hourly rate. A minimum of 8 hours of direct patient
care must be provided per day. For every hour, or part of an hour, direct
patient care is furnished, the hourly rate is paid to the hospice up to 24
hours a day. HHSC pays for a maximum of five consecutive days of CHC unless
HHSC receives and grants a request for an extension of CHC. If the hospice
ceases to provide direct patient care, CHC has ended.
(4) Inpatient respite care. The hospice is
paid at the inpatient respite care rate for each day on which the individual is
in an approved inpatient facility and is receiving respite care. Payment for
respite care may be made for a maximum of five 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 at the routine home care rate.
(A) An individual who receives hospice
respite care in a nursing facility and returns home after the respite care does
not have to be in a Medicaid bed in the nursing facility.
(B) Respite care days are subject to the
limitation on total hospice inpatient care days, as outlined in subsection (c)
of this section.
(C) If the
individual dies while receiving inpatient respite care, HHSC pays the inpatient
respite care rate for the day of death.
(5) General Inpatient Care. Payment is made
at the general inpatient rate for each day on which the individual is in an
approved inpatient facility and is receiving general inpatient care.
(A) The general inpatient care rate is paid
for the day of admission and all subsequent inpatient days except the day of
discharge.
(B) For the day of
discharge, HHSC pays the routine home care rate.
(C) If the individual dies while in an
inpatient facility, HHSC pays the general inpatient care rate for the day of
death.
(D) General inpatient care
days are subject to the limitation on total hospice inpatient care days, as
outlined in subsection (c) of this section.
(b) Medicaid payments for physician services.
The hospice:
(1) is paid for hospice physician
services in accordance with the HHSC reimbursement rates for physician
services;
(2) is paid for physician
services on the day of discharge if the physician provides direct patient
services on that day;
(3) is not
paid for hospice physician services when the services are provided by
physicians who are not on staff with the hospice or who are independent
contractors under contract with the hospice; and
(4) must include physician services in the
hospice plan of care and clinical records.
(c) Medicaid payment limitations for
inpatient care. During the cap year, the aggregate number of inpatient hospice
care days must not exceed 20 percent of the total number of hospice care days
for the same cap year. This limitation is applied once each year, at the end of
the cap year for each Medicaid hospice provider. A day counts as an inpatient
hospice care day only if it is a day on which the individual who has elected
hospice care receives inpatient respite care or general inpatient care. The
limitation is calculated as follows.
(1) The
maximum allowable number of inpatient days is calculated by multiplying the
total number of days of Medicaid hospice care by 0.2.
(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 is necessary.
(3) If the total number of days of inpatient
care exceeds the maximum allowable number, the limitation is determined by:
(A) calculating a ratio of the maximum
allowable days to the number of actual days of inpatient care and multiplying
this ratio by the total reimbursement for inpatient care that was
made;
(B) multiplying excess
inpatient care days by the reduced base payment routine home care
rate;
(C) adding together the
amounts calculated in subparagraphs (A) and (B) of this paragraph;
and
(D) comparing the amount
calculated under subparagraph (C) of this paragraph with interim payments made
to the hospice for inpatient care during the cap year.
(d) Medicaid aggregate payment
limitations. During the cap year, the aggregate payments to a hospice are
subject to an annual aggregate cap. This limitation is applied once each year,
at the end of the cap year for each Medicaid hospice provider. A hospice's
aggregate cap is calculated by multiplying the adjusted cap amount, as
determined under paragraph (1) of this subsection, by the number of Medicaid
beneficiaries, as determined under paragraph (2) of this subsection.
(1) Cap Amount. The cap amount was set at
$6,500 in 1983 and is updated using one of two methodologies described in
subparagraphs (A) and (B) of this paragraph.
(A) For accounting years that end on or after
October 1, 2025, the cap amount is adjusted for inflation by using the
percentage change in the medical care expenditure category of the Consumer
Price Index (CPI) for urban consumers that is published by the Bureau of Labor
Statistics. This adjustment is made using the change in the CPI from March 1984
to the fifth month of the cap year.
(B) For accounting years that end before
October 1, 2025, the cap amount is the cap amount for the preceding accounting
year updated by the percentage update to payment rates for hospice care for
services furnished during the fiscal year beginning on October 1st preceding
the beginning of the accounting year as determined pursuant to the Social
Security Act §1814(i)(1)(C) (42 U.S.C.
§
1395f) , including the application of
any productivity or other adjustments to the hospice percentage
update.
(2) Number of
Medicaid Beneficiaries. For purposes of this paragraph, HHSC adopts by
reference the streamlined methodology and the patient-by-patient proportional
methodology in
42 CFR §
418.309(b) and
(c), effective October 1, 2018, to determine
the number of Medicaid beneficiaries for purposes of the aggregate cap. A
hospice determines the number of Medicaid beneficiaries using the same
methodology it uses to determine the number of Medicare beneficiaries under
42 CFR §
418.309(b) or
(c).
(e) Recoupment of Excess Payments. HHSC
recoups payments in excess of the limitations for inpatient care and the
aggregate payment limitations, pursuant to § 266.225 and § 266.227 of
this subchapter (relating to Informal Review and Review Decision and Notice),
from subsequent Medicaid hospice provider claims.
(f) Pediatric Concurrent Care.
(1) An individual under 21 years of age who
elects to receive Medicaid hospice care may receive Medicaid services related
to the treatment of the terminal illness, or a related condition, for which the
hospice care was elected concurrently with the hospice care.
(2) The hospice is responsible for hospice
services related to the terminal illness or a related condition. The hospice is
not responsible for acute care services related to the treatment of the
terminal illness or a related condition or for services unrelated to the
terminal illness or a related condition.
