Current through Register Vol. 24-18, September 15, 2024
This section describes rates methodology and payment
methods for hospice care provided to hospice clients.
(1) The medicaid agency uses the same rates
methodology as medicare uses for the four levels of hospice care identified in
WAC 182-551-1500.
(2) Each of the four levels of hospice care
has the following three rate components:
(a)
Wage component;
(b) Wage index;
and
(c) Unweighted
amount.
(3) To allow
hospice payment rates to be adjusted for regional differences in wages, the
medicaid agency bases payment rates on the core-based statistical area (CBSA)
county location. CBSAs are identified in the medicaid agency's provider
guides.
(4) The medicaid agency
pays hospice agencies for services (not room and board) at a daily rate
methodology as follows:
(a) Payments for
services delivered in a client's residence (routine and continuous home care)
are based on the county location of the client's residence.
(b) Payments for routine home care are based
on a two-tiered payment methodology.
(i) Days
one through sixty are paid at the base routine home care rate.
(ii) Days sixty-one and after are paid at a
lower routine home care rate.
(iii)
If a client discharges and readmits to a hospice agency's program within sixty
calendar days of that discharge, the prior hospice days will continue to follow
the client and count towards the client's eligible days in determining whether
the hospice agency may bill at the base or lower routine home care
rate.
(iv) If a client discharges
from a hospice agency's program for more than sixty calendar days, a readmit to
the hospice agency's program will reset the client's hospice days.
(c) Hospice services are eligible
for an end-of-life service intensity add-on payment when the following criteria
are met:
(i) The day on which the services are
provided is a routine home care level of care;
(ii) The day on which the service is provided
occurs during the last seven days of life, and the client is discharged
deceased;
(iii) The service is
provided by a registered nurse or social worker that day for at least fifteen
minutes and up to four hours total; and
(iv) The service is not provided by the
social worker via telephone.
(d) Payments for respite and general
inpatient care are based on the county location of the providing hospice
agency.
(5) The medicaid
agency:
(a) Pays for routine home care,
continuous home care, respite care, or general inpatient care for the day of
death;
(b) Does not pay room and
board for the day of death; and
(c)
Does not pay hospice agencies for the client's last day of hospice care when
the last day is for the client's discharge, revocation, or transfer.
(6) Hospice agencies must bill the
medicaid agency for their services using hospice-specific revenue
codes.
(7) For hospice clients in a
nursing facility:
(a) The medicaid agency
pays nursing facility room and board payments at a daily rate directly to the
hospice agency at ninety-five percent of the nursing facility's current
medic-aid daily rate in effect on the date the services were provided;
and
(b) The hospice agency pays the
nursing facility at a daily rate no more than the nursing facility's current
medicaid daily rate.
(8)
The medicaid agency:
(a) Pays a hospice care
center a daily rate for room and board based on the average room and board rate
for all nursing facilities in effect on the date the services were
provided.
(b) Does not pay hospice
agencies or hospice care centers a nursing facility room and board payment for:
(i) A client's last day of hospice care
(e.g., client's discharge, revocation, or transfer); or
(ii) The day of death.
(9) The daily rate for authorized
out-of-state hospice services is the same as for in-state non-CBSA hospice
services.
(10) The medicaid agency
reduces hospice payments by two percent for providers who did not comply with
the annual medicare quality data reporting program as required under 42 U.S.C.
Sec. 1395f (i)(5)(A)(i). The payment reduction is effective for the fiscal
reporting year in which the provider failed to submit data required for the
annual medicare quality reporting program.
(a) The two percent payment reduction applies
to routine home care, including the service intensity add-on, continuous home
care, inpatient respite care, and general inpatient care.
(b) The two percent payment reduction does
not apply to pediatric palliative care, the hospice care center daily rate, and
the nursing facility room and board rate.
(c) Any provider affected by the two percent
payment reduction will receive written notification.
(d) Any provider affected by the two percent
payment reduction may appeal the rate reduction per WAC
182-502-0220.
(11) The client's notice of action
(award) letter states the amount the client is responsible to pay each month
towards the total cost of hospice care. The hospice agency receives a copy of
the award letter and:
(a) Is responsible to
collect the correct amount that the client is required to pay, if any;
and
(b) Must show the client's
monthly required payment on the hospice claim. (Hospice providers may refer to
the medicaid agency's provider guides for how to bill a hospice claim.) If a
client has a required payment amount that is not reflected on the claim and the
medicaid agency reimburses the amount to the hospice agency, the amount is
subject to recoupment by the medicaid agency.
Statutory Authority:
RCW
41.05.021, Section 2302 of the Patient
Protection and Affordable Care Act of 2010 (
P.L.
111-148), and Section 1814(a)(7) of the Social
Security Act. 12-09-079, §182-551-1510, filed 4/17/12, effective 5/18/12.
11-14-075, recodified as §182-551-1510, filed 6/30/11, effective 7/1/11.
Statutory Authority:
RCW
74.08.090,
74.09.520. 05-18-033, §
388-551-1510, filed 8/30/05, effective 10/1/05. Statutory Authority:
RCW
74.09.520,
74.08.090,
42 C.F.R.
418.22 and
418.24. 99-09-007, §
388-551-1510, filed 4/9/99, effective
5/10/99.
