No. 27925 (Repeal and Reenact): R414-14A. Hospice Care

DAR File No.: 27925
Filed: 05/16/2005, 04:57
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to update policies that comply with the Medicare hospice program.

 

Summary of the rule or change:

The reenacted rule details information regarding Medicare regulations for administration and reimbursement that reflect current Medicaid practice. In addition, this rule includes detailed information regarding dual eligibility for Medicare and Medicaid clients. It restricts retroactive payment for services that were provided prior to enrollment as a Medicaid provider. It allows for the re-election of a hospice benefit by a Medicaid client and allows clients to change hospice providers at will. It provides a review process for involuntary disenrollment of hospice patients due to escalating costs, changing behavior, etc. It also allows the Division of Health Care Financing (DHCF) to use a physician knowledgeable in end-of-life care to conduct an independent review of extended hospice services that go beyond 12 months. In-home physician services not included in the previous hospice rule are now included. The previous rule required prior authorization for all hospice services while the new rule designates specific instances where prior authorization is required. The new rule also contains a prior authorization grace period that allows the hospice to begin service for a new enrollee up to five days prior to notifying DHCF of the enrollment, and allows for service requiring prior authorization up to five days in advance of contacting DHCF for authorization. In addition, the new rule provides reimbursement for hospice services while an individual is in the Medicaid eligibility determination stage if the person becomes eligible within the allowed time period. Further, the rule has a provision for DHCF to review the appropriateness of the service and to deny reimbursement if found to be inconsistent with the requirements for hospice care. Finally, this new rule includes language to allow the reimbursement rate for hospice services to be held constant when the legislature provides no money for inflationary adjustments.

 

State statutory or constitutional authorization for this rule:

Section 26-1-5, Subsection 26-18-3 (2)(a), and 42 USC 1396(d)(o)

 

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this rulemaking because it does not change the way Medicare/Medicaid certified hospices or the Department of Health conduct business.

 

local governments:

There is no budget impact to local governments because there is no funding from local governments for the hospice care program.

 

other persons:

There is no budget impact to other persons because this rulemaking does not change the way Medicare/Medicaid certified hospices or the Department of Health conduct business.

 

Compliance costs for affected persons:

There are no compliance costs for affected persons because this rulemaking does not change the way Medicare/Medicaid certified hospices or the Department of Health conduct business.

 

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule appears to have the support of regulated businesses. It should remove unnecessary hurdles to Medicaid reimbursement for hospice services. Although no measurable fiscal impact is predicted by this filing, there is a reduction in regulatory burden which will have a positive impact. David N. Sundwall, MD, Executive Director

 

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

 

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

 

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/01/2005

 

This rule may become effective on:

07/02/2005

 

Authorized by:

David N. Sundwall, Executive Director

 

 

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-14A. Hospice Care.

[R414-14A-0. Policy Statement.

A. Hospice care derives from the recognition that the impending death of an individual warrants a change in focus from curative care to palliative care.

B. Hospice care shall be rendered by a Medicare-certified hospice and shall be provided in accordance with Medicare regulations.

C. Hospice coverage shall be available for at least 210 days.

 

R414-14A-1. Authority and Purpose.

A. Authority

Section 9505 of Public Law 99-272, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), enacted on April 7, 1986, amended Title XIX of the Social Security Act to permit hospice care benefits as defined under sections 1905(a)(18) and 1905(o) of the Act to be provided to individuals eligible for Medicaid under the State Plan.

B. The purpose of hospice care is to help terminally ill individuals continue life with minimal disruption in normal activities while remaining primarily in the home environment.

 

R414-14A-2. Definitions as Used in this Chapter.

A. "Hospice" means a public agency or private organization that is primarily engaged in providing care to terminally ill individuals, meets the Medicare conditions of participation for hospices, and has a valid provider agreement.

B. "Terminally ill" means that the individual has a medical prognosis that his life expectancy is six months or less.

C. "Attending physician" means a physician who is identified by the individual, at the time he elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care.

D. "Bereavement counseling" means counseling services provided to the individual's family after the individual's death.

E. "Medical social services" means the provision of counseling and assessment activities which contribute meaningfully to the treatment of a recipient's condition.

F. "Inpatient care" means the hospice services provided by an inpatient facility to a recipient who has been admitted to a hospital, long-term care facility, or facility of a hospice that provides care 24 hours a day.

G. "Interdisciplinary group" means a group of qualified individuals with expertise in meeting the special needs of hospice recipients and their families, which includes at least:

1. one physician;

2. one registered nurse;

3. one social worker; and

4. one pastoral or other counselor.

H. "Election statement" means a written statement electing hospice care and filed by a recipient, or his representative, with a hospice.

I. "Respite care" means short-term inpatient care provided to the recipient only when necessary to relieve the family members or other persons caring for the recipient.

 

R414-14A-3. Eligibility Requirements/Coverage.

To be covered, hospice services shall meet the following requirements:

A. Services shall be reasonable and necessary for the palliation or management of the terminal illness as well as related conditions.

B. A certification that the individual is terminally ill shall be completed.

C. The individual shall elect hospice care by filing an election statement with a particular hospice.

D. A plan of care shall be established by the interdisciplinary group.

 

R414-14A-4. Program Access Requirements.

Hospice care is available to categorically and medically needy individuals under Medicaid.

 

R414-14A-5. Service Coverage.

The following services are required hospice services:

A. nursing care provided by or under the supervision of a registered nurse;

B. medical social services provided by a qualified social worker under the direction of a physician;

C. administrative and general supervisory activities performed by physicians who are employees of, or working under arrangements made with, the hospice;

D. counseling services for the individual and family members or other persons caring for the person at home;

E. short-term inpatient care in a participating hospice inpatient unit, or a hospital, skilled nursing or intermediate care facility that additionally meets the special hospice standards regarding staffing and patient areas;

F. medical appliances and supplies, including drugs and biologicals. Only drugs which are used primarily for the relief of pain and symptom control related to the individual's terminal illness are covered;

G. home health aide and homemaker services furnished by qualified aides;

H. physical therapy, occupational therapy, and speech-language pathology services provided for purposes of symptom control.

 

R414-14A-6. Standards of Care.

The State shall enforce the Medicare standards of care as outlined in 42 CFR, Part 418, which are hereby adopted and incorporated by reference.

 

R414-14A-7. Limitations.

A. Recipients of hospice care shall sign an election of hospice care which waives all other Medicaid coverage except the services of a designated family physician, ambulance service, and services unrelated to the terminal illness.

B. Medicaid shall make no payment to the hospice, selected by the Medicaid recipient, for any services or supplies other than the hospice service.

C. The hospice shall not charge any amount to or collect any amount from the recipient or recipient's family for a covered hospice service during the period of hospice coverage.

D. Payments to a hospice for inpatient care shall be limited according to the number of days of inpatient care furnished to Medicaid patients. During the 12-month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient days (both for general inpatient care and inpatient respite care) may not exceed 20 percent of the aggregate total number of days of hospice care provided to all Medicaid recipients during that same period.

E. Respite care shall be provided only on an occasional basis and shall not be reimbursed for more than five consecutive days at a time.

F. Respite care shall not be provided when the hospice recipient is a nursing home resident.

 

R414-14A-8. Prior Authorization.

Prior authorization procedures are not applicable to hospice services provided to a Medicaid recipient.

 

R414-14A-9. Reimbursement for Services.

A. Medicaid payments for hospice services shall be made at one of the four predetermined rates established under Medicare.

B. The rates shall be based on the Medicare rates for Utah.

C. For each day that an individual is under the care of a Medicare-certified hospice, the hospice shall be reimbursed in accordance with the established Medicaid fee schedule.

D. Payment rates are based on the type and intensity of the services furnished to the individual for that day according to one of the following levels of care: routine home care, continuous home care, inpatient respite care, or general inpatient care.

E. For recipients in a skilled nursing facility or intermediate care facility who elect to receive hospice service from a Medicare-certified hospice agency, Medicaid shall pay the hospice agency an additional per diem for routine home care and continuous home care days only, to cover the cost of room and board.

1. The room and board rate shall be based on the statewide average base rate for nursing homes (weighted averages without rate differential factors) less a percentage for nursing and related costs.

2. The nursing and related costs are defined as cost centers 07 and 08 on the facility's cost profile. The percentage is calculated by taking the percent of 07 and 08 to the total reported costs.

3. Medicaid reimbursement to the intermediate care or skilled nursing facility for the recipient shall cease.

4. The hospice agency shall reimburse the intermediate care or skilled nursing facility for the cost of room and board.

5. Room and board costs, in this context, shall include: performance of personal care services (including assistance in the activities of daily living), socializing activities, administration of medication, maintaining the cleanliness of a resident's room, and supervision and assisting in the use of durable medical equipment and prescribed therapies.]

R414-14A-1. Introduction and Authority.

This rule is authorized by Utah Code sections 26-1-5 and 26-18-3(2)(a). It implements Medicaid hospice care services as found in 42 USCS 1396d(o).

 

R414-14A-2. Definitions.

The definitions in R414-1 apply to this rule. In addition:

(1) "Attending physician" means a physician who:

(a) is a doctor of medicine or osteopathy; and

(b) is identified by the recipient at the time he or she elects to receive hospice care as having the most significant role in the determination and delivery of the recipient's medical care.

(2) "Cap period" means the 12 month period ending October 31 used in the application of the cap on reimbursement for inpatient hospice care as described in R414-14A-22(5).

(3) "Employee" means an employee of the hospice provider or, if the hospice provider is a subdivision of an agency or organization, an employee of the agency or organization who is appropriately trained and assigned to the hospice unit. "Employee" includes a volunteer under the direction of the hospice provider.

(4) "Hospice care" means care provided to terminally ill recipients by a hospice provider.

(5) "Hospice provider" means a provider that is licensed under the provisions of R432-750 and is primarily engaged in providing care to terminally ill individuals.

(6) "Physician" means a doctor of medicine or osteopathy who is licensed by the state of Utah.

(7) "Representative" means an individual who has been authorized under state law to make health care decisions, including initiating, continuing, refusing, or terminating medical treatments for a recipient who is mentally unable to make health care decisions.

(8) "Terminally ill" means the recipient has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.

 

R414-14A-3. Client Eligibility Requirements.

(1) A recipient who is terminally ill may obtain hospice care pursuant to this rule.

(2) A recipient's certification of a terminal condition required for hospice eligibility must be based on a face-to-face assessment by a physician conducted no more than 90 days prior to the date of enrollment.

(3) A recipient dually enrolled in Medicare and Medicaid must elect the hospice benefit for both Medicare and Medicaid. The recipient must receive hospice coverage under Medicare. Election for the Medicaid hospice benefit provides the recipient coverage for Medicare co-insurance and coverage for room and board expenses while a resident of a Medicare-certified nursing facility, Intermediate Care Facility for the Mentally Retarded (ICF/MR), or freestanding hospice facility.

 

R414-14A-4. Program Access Requirements.

(1) Hospice care may be provided only by a hospice provider licensed by the Department, that is Medicare certified in accordance with 42 CFR 418, and that is a Medicaid provider.

(2) A hospice provider must have a valid Medicaid provider agreement in place prior to initiating hospice care for Medicaid clients. The Medicaid provider agreement is effective on the date a Medicaid provider application is received in the Department and shall not be made retroactive to an earlier date, including an earlier effective date of Medicare hospice certification.

(3) At the time of a change of ownership, the previous owner's provider agreement terminates as of the effective date of the change of ownership.

(4) The Department accepts all waivers granted to hospice agencies by the Centers for Medicare and Medicaid Services as part of the Medicare certification process.

(5) Hospice agencies participating in the Medicaid program shall provide hospice care in accordance with the requirements of 42 CFR 418.3 through 418.204 as contained in this rule.

 

R414-14A-5. Service Coverage.

Hospice care categories eligible for Medicaid reimbursement are the following:

(1) "Routine home care day" is a day in which a recipient who has elected to receive hospice care is at home and is not receiving continuous home care as defined in subsection (5)(b)of this section. For purposes of routine home care day, extended stay residents of nursing facilities are considered at home.

(2) "Continuous home care day" is a day in which a recipient who has elected to receive hospice care receives a minimum of eight aggregate hours of care from the hospice provider during a 24-hour day, which begins and ends at midnight. The eight aggregate hours of care must be predominately nursing care provided by either a registered nurse or licensed practical nurse. Continuous home care is only furnished during brief periods of crisis in which a patient requires continuous care that is primarily nursing care to achieve palliation or management of acute medical symptoms. For purposes of routine home care day, extended stay residents of nursing facilities are considered at home.

(3) "Inpatient respite care day" is a day in which the recipient who has elected hospice care receives short-term inpatient care when necessary to relieve family members or other persons caring for the individual at home.

(4) "General inpatient care day" is a day in which a recipient who has elected hospice care receives general inpatient care for pain control or acute or chronic symptom management that cannot be managed in a home or other outpatient setting. General inpatient care may be provided in a hospice inpatient unit, a hospital, or a nursing facility.

(5) "Room and Board" is medication administration, performance of personal care, social activities, routine and therapeutic dietary services, meal service including direct feeding assistance, maintaining the cleanliness of the recipient's room, assistance with activities of daily living, durable equipment, prescribed therapies, and all other services unrelated to care associated with the terminal illness that would be covered under the Medicaid State plan nursing facility benefit.

 

R414-14A-6. Hospice Election.

(1) A recipient who meets the eligibility requirement for Medicaid hospice must file an election statement with a particular hospice. If the recipient is physically or mentally incapacitated, his or her legally authorized representative may file the election statement.

(2) The election statement must include the following:

(a) identification of the particular hospice that will provide care to the recipient;

(b) the recipient's or representative's acknowledgment that he or she has been given a full understanding of the palliative rather than curative nature of hospice care, as it relates to the recipient's terminal illness;

(c) acknowledgment that the recipient waives certain Medicaid services as set forth in R414-14A-11;

(d) acknowledgment that the recipient or representative may revoke the election of the hospice benefit at any time in the future and therefore become eligible for Medicaid services waived at the time of hospice election as set forth in R414-14A-8; and

(f) the signature of the recipient or representative.

(3) The effective date of the election may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement

(4) An election to receive hospice care remains effective through the initial election period and through the subsequent election periods without a break in care as long as the recipient:

(a) remains in the care of a hospice;

(b) does not revoke the election; and

(c) is not discharged from the hospice.

(5) The hospice provider must notify the Department at the time a Medicaid recipient selects the hospice benefit, including selecting the hospice provider under a change of designated hospice. The notification must include a copy of the hospice election statement and the recipient's plan of care for hospice care. Authorization for reimbursement of hospice care begins no earlier than the date notification is received by the Department for an eligible Medicaid client, except as provided in R414-14A-19.

(6) Subject to the conditions set forth in this rule, a recipient may elect to receive hospice care during one or more of the following election periods:

(a) an initial 90-day period;

(b) a subsequent 90-day period; or

(c) an unlimited number of subsequent 60-day periods.

 

R414-14A-7. Change in Hospice Provider.

(1) A recipient or representative may change, once in each election period, the designation of the particular hospice from which hospice care will be received.

(2) The change of the designated hospice is not a revocation of the election for the period in which it is made.

(3) To change the designation of hospice provider, the recipient must file, with the hospice provider from which care has been received and with the newly designated hospice provider, a statement that includes the following information:

(a) the name of the hospice provider from which the recipient has received care;

(b) the name of the hospice provider from which the recipient plans to receive care; and

(c) the date the change is to be effective.

(4) The recipient must file the change on or before the effective date.

 

R414-14A-8. Revocation and Re-election of Hospice Revocation.

(1) A recipient or representative may revoke the recipient's election of hospice care at any time during an election period.

(2) To revoke the election of hospice care, the recipient or representative must file a statement with the hospice provider that includes the following information:

(a) a signed statement that the recipient or representative revokes the recipient's election for Medicaid coverage of hospice care for the remainder of that election period; and

(b) the date that the revocation is to be effective, which may not be earlier than the date that the revocation is made.

(3) Upon revocation of the election of Medicaid coverage of hospice care for a particular election period, a recipient:

(a) is no longer covered under Medicaid for hospice care;

(b) resumes Medicaid coverage for the benefits waived under R414-14A-6; and

(c) may at any time elect to receive hospice coverage for any other hospice election periods that he or she is eligible to receive.

(4) If an election has been revoked, the recipient, or his or her representative if the recipient is mentally incapacitated, may at any time file an election, in accordance with this rule, for any other election period that is still available to the recipient.

 

R414-14A-9. Rights Waived to Some Medicaid.

(1) For the duration of an election for hospice care, a recipient waives all rights to Medicaid to the following services:

(a) hospice care provided by a hospice other than the hospice designated by the recipient, unless provided under arrangements made by the designated hospice; and

(b) any Medicaid services that are related to the treatment of the terminal condition for which hospice care was elected or a related condition or are duplicative of hospice care except for services:

(i) provided by the designated hospice;

(ii) provided by another hospice under arrangements made by the designated hospice; and

(iii) provided by the recipient's attending physician if the services provided are not otherwise covered by the payment made for hospice care.

(2) Medicaid services for illnesses or conditions not related to the recipient's terminal illness are not covered through the hospice program but are covered when provided by the appropriate provider.

 

R414-14A-10. Notice of Hospice Care in a Nursing Facility, ICF/MR, or Freestanding Inpatient Hospice Facility.

(1) The hospice provider must notify the Department at the time a Medicaid recipient residing in a Medicare certified nursing facility, a Medicaid certified ICF/MR, or a Medicare freestanding inpatient hospice facility elects the Medicaid hospice benefit or at the time a Medicaid recipient who has elected the Medicaid hospice benefit is admitted to a Medicare certified nursing facility, a Medicaid certified ICF/MR, or a Medicare freestanding inpatient hospice facility.

(2) The notification must include a prognosis of the time the individual will require skilled nursing facility services under the hospice benefit.

(3) Except as provided in R414-14A-20, reimbursement for room and board begins no earlier than the date the hospice provider notifies the Department that the recipient has elected the Medicaid hospice benefit.

 

R414-14A-11. Notice of Independent Attending Physician.

The hospice provider must notify the Department at the time a Medicaid recipient designates an attending physician who is not a hospice employee.

 

R414-14A-12. Independent Review of Extended Hospice Care.

Recipients who accumulate 12 or more months of hospice benefits are subject to an independent utilization review by a physician with expertise in end-of-life and hospice care selected by the Department.

 

R414-14A-13. Involuntary Discharge Review.

(1) A hospice provider may not involuntary discharge a Medicaid recipient from hospice care without first obtaining approval from the Department.

(2) The hospice provider must notify the Department in writing of the intent to involuntarily discharge the recipient from hospice care.

(3) The hospice provider may involuntary discharge the recipient only if it can demonstrate to the Department that the hospice, in conjunction with other Medicaid services, cannot protect the recipient's health and safety or cannot address the recipient's needs identified through the plan of care required as a condition of participation in 42 CFR 418.58

 

R414-14A-14. Hospice Room and Board Service.

If a recipient residing in a nursing facility, ICF/MR or a freestanding hospice inpatient unit elects hospice care, the hospice provider and the facility must have a written agreement under which the total care of the individual must be specified in a comprehensive service plan, the hospice provider is responsible for the professional management of the recipient's hospice care, and the facility agrees to provide room and board and services unrelated to the care of the terminal condition to the recipient. The agreement must include:

(1) identification of the services to be provided by each party and the method of care coordination to assure that all services are consistent with the hospice approach to care and are organized to achieve the outcomes defined by the hospice plan of care;

(2) a stipulation that Medicaid services may be provided only with the express authorization of the hospice;

(3) the manner in which the contracted services are coordinated, supervised and evaluated by the hospice provider;

(4) the delineation of the roles of the hospice provider and the facility in the admission process; needs assessment process, and the interdisciplinary team care conference and service planning process;

(5) requirements for documenting that services are furnished in accordance with the agreement;

(6) the qualifications of the personnel providing the services; and

(7) the billing and reimbursement process by which the nursing facility will bill the hospice provider for room and board and receive payment from the hospice provider.

 

R414-14A-15. In Home Physician Services.

In-home physician visits by the attending physician are authorized for hospice recipients if the attending physician determines that direct management of the recipient in the home setting is necessary to achieve the goals associated with a hospice approach to care.

 

R414-14A-16. Continuous Home Care.

When the hospice provider determines that a patient requires at least eight hours of primarily nursing care in order to manage an acute medical crisis, the hospice provider will maintain documentation to support the requirement that the services provided were reasonable and necessary and were in compliance with an established plan of care in order to meet a particular crisis situation. Continuous home care is a covered benefit only as necessary to maintain the terminally ill individual at home.

 

R414-14A-17. General Inpatient Care.

(1) General inpatient care is authorized without prior authorization for an initial five-day length of stay. Prior authorization is required for any additional general inpatient care days during the same stay to verify that the recipient's needs meet the requirements for general inpatient care. If a hospice provider requests additional days, the subsequent requests are subject to clinical review and approval by qualified Department staff.

(2) General inpatient care days may not be used due to the breakdown of the primary care giving living arrangements or the collapse of other sources of support for the recipient.

(3) Prior authorization for additional days beyond the initial five-day stay must be obtained before the hospice care is provided, except as allowed in R414-14A-19.

 

R414-14A-18. Inpatient Respite Care.

When the hospice provider determines that a patient requires a short-term inpatient respite stay in order to relieve the family members or other persons caring for the individual at home, the hospice provider will maintain documentation to support the requirement that the services provided were reasonable and necessary to relieve a particular caregiver situation. Inpatient respite care may not be reimbursed for more than five consecutive days at a time. Inpatient respite care may not be reimbursed for a patient residing in a nursing facility, ICF/MR, or freestanding hospice inpatient unit.

 

R414-14A-19. Notification and Prior Authorization Grace Periods.

During weekends, holidays, and after regular Department business hours, a hospice provider may begin service to a new Medicaid hospice enrollee, including covering room and board, or initiate a different hospice care requiring prior authorization for a period up to five days before notifying the Department. During the five-day period, the hospice provider must complete the required contact and notifications to the Department as outlined in R414-14A-4, 9, 15, 16, and 17. The Department pays for services during the allowed five-day grace period only if the hospice provider completes the required contact and notifications within the grace period and the Department determines that the individual met Medicaid eligibility requirements at the time the service was provided. If the hospice provider fails to complete the required contact and notifications to the Department within the allowed five day period, the Department does not reimburse the hospice provider for any hospice care delivered prior to the date the hospice provider completes the contact and notifications.

 

R414-14A-20. Post-Payment for Services Provided While in Medicaid-Pending Status.

(1) The Department will reimburse a hospice provider retroactively for up to three months prior to the individual's establishing Medicaid eligibility if:

(a) the Department determines that the individual met Medicaid eligibility requirements at the time the service was provided;

(b) the hospice care met the prior authorization criteria at the time of delivery; and

(c) the hospice provider reimburses the Department for care related to the individual's terminal illness delivered by other Medicaid providers during the retroactive period.

(2) The hospice provider must provide documentation to the Department adequate to demonstrate the service met prior authorization criteria at the time of delivery.

 

R414-14A-21. Hospice Care Reimbursement.

(1) Medicaid payment for covered hospice care is made in accordance with the methodology set forth in the Utah Medicaid State Plan.

(2) A hospice provider may not charge a Medicaid recipient for services for which the recipient is entitled to have payment made under Medicaid.

(3) Medicaid reimbursement to a hospice provider for services provided during a cap period is limited to the cap amount specified in R414-14A-22(5).

(4) Medicaid does not apply the aggregate caps used by Medicare.

(5) Payment for hospice care is made on the basis of the geographic location where the service is provided as described in the Medicaid State Plan.

(6) Routine home care, continuous home care, general inpatient care, inpatient respite care services, and hospice room and board, are reimbursable to the hospice provider only.

(7) Hospice general inpatient care and inpatient respite care are not reimbursed by Medicaid for services provided in a Veterans Administration hospital or military hospital.

 

R414-14A-22. Payment for Hospice Care Categories.

(1) The Department establishes payment amounts for the following categories:

(a) Routine home care.

(b) Continuous home care.

(c) Inpatient respite care.

(d) General inpatient care.

(e) Room and Board service.

(2) The Department reimburses the hospice provider at the appropriate payment amount for each day for which an eligible Medicaid recipient is under the hospice's care.

(3) The Medicaid reimbursement covers the same services and amounts covered by the equivalent Medicare reimbursement rate for comparable service categories.

(4) The Department makes payment according to the following procedures:

(a) Payment is made to the hospice for each day during which the recipient is eligible and under the care of the hospice, regardless of the amount of services furnished on any given day.

(b) Payment is made for only one of the categories of hospice care described in R414-14A-22(1) for any particular day.

(c) On any day in which the recipient is not an inpatient, the Department pays the hospice provider the routine home care rate, unless the recipient receives continuous home care as provided in subsection R414-14A-5(b) for a period of at least eight hours. In that case, the Department pays a portion of the continuous care day rate in accordance with subsection (5)(e).

(d) The hospice payment on a continuous care day varies depending on the number of hours of continuous services provided. The number of hours of continuous care provided during a continuous home care day is multiplied by the hourly rate to yield the continuous home care payment for that day. A minimum of eight hours of licensed nursing care must be furnished on a particular day to qualify for the continuous home care rate.

(e) Subject to the limitations described in subsection (5), on any day on which the recipient is an inpatient in an approved facility for inpatient care, the appropriate inpatient rate (general or respite) is paid depending on the category of care furnished. The inpatient rate (general or respite) is paid for the date of admission and all subsequent inpatient days, except the day on which the recipient is discharged. For the day of discharge, the appropriate home care rate is paid unless the recipient dies as an inpatient. In the case where the recipient dies as an inpatient, the inpatient rate (general or respite) is paid for the discharge day. Payment for inpatient respite care is subject to the requirement that it may not be provided consecutively for more than five days at a time.

(5) Payment for inpatient care is limited as follows:

(a) The total payment to the hospice for inpatient care (general or respite) is subject to a limitation that total inpatient care days for Medicaid recipients not exceed 20 percent of the total days for which these recipients had elected hospice care. Individuals afflicted with AIDS are excluded when calculating inpatient days.

(b) At the end of a cap period, the Department calculates a limitation on payment for inpatient care for each hospice to ensure that Medicaid payment is not made for days of inpatient care in excess of 20 percent of the total number of days of hospice care furnished to Medicaid recipients by the hospice.

(c) If the number of days of inpatient care furnished to Medicaid recipients is equal to or less than 20 percent of the total days of hospice care to Medicaid recipients, no adjustment is necessary.

(d) If the number of days of inpatient care furnished to Medicaid recipients exceeds 20 percent of the total days of hospice care to Medicaid recipients, the total payment for inpatient care is determined in accordance with the procedures specified in paragraph (5)(e) of this section. That amount is compared to actual payments for inpatient care, and any excess reimbursement must be refunded by the hospice.

(e) If a hospice exceeds the number of inpatient care days described in paragraph (5)(d), the total payment for inpatient care is determined as follows:

(i) Calculate the ratio of the maximum number of allowable inpatient days to the actual number of inpatient care days furnished by the hospice to Medicaid recipients.

(ii) Multiply this ratio by the total reimbursement for inpatient care made by the Department.

(iii) Multiply the number of actual inpatient days in excess of the limitation by the routine home care rate.

(iv) Sum the amounts calculated in subsections (5)(e)(ii) and (iii).

(6) The hospice provider may request an exception to the inpatient care payment limitation if the hospice provider demonstrates the volume of Medicaid enrollees during the cap period was insufficient to reasonably achieve the required 20% ratio.

 

R414-14A-23. Payment for Physician Services.

(1) The following services performed by hospice physicians are included in the rates described in R414-14A-21 and 22:

(a) General supervisory services of the medical director.

(b) Participation in the establishment of plans of care, supervision of care and services, periodic review and updating of plans of care, and establishment of governing policies by the physician member of the interdisciplinary group.

(2) For services not described in paragraph (1) of this section, direct care services related to the terminal illness or a related condition provided by hospice physicians are reimbursed according to the Medicaid reimbursement fee schedule for physician services. Services furnished voluntarily by physicians are not reimbursable.

(3) Services of the recipient's attending physician, including in-home services, are reimbursed according to the Medicaid fee schedule for State Plan physician services. Services furnished voluntarily by physicians are not reimbursable.

 

R414-14A-24. Hospice Payment Covers Special Modalities.

No additional Medicaid payment will be made for chemotherapy, radiation therapy, and other special modalities of care for palliative purposes regardless of the cost of the services.

 

R414-14A-25. Payment for Nursing Facility, ICF/MR, and Freestanding Inpatient Hospice Unit Room and Board.

(1) For recipients in a nursing facility, ICF/MR, or a freestanding hospice inpatient unit who elect to receive hospice care from a Medicaid enrolled hospice provider, Medicaid will pay the hospice provider an additional per diem for routine home care and continuous home care services to cover the cost of room and board in the facility. For nursing facilities and ICFs/MR, the room and board rate ise 95 percent of the amount that the Department would have paid to the nursing facility or ICF/MR provider for that recipient if the recipient had not elected to receive hospice care. For freestanding hospice inpatient facilities, the room and board rate is 95 percent of the statewide average paid by Medicaid for nursing facility services.

(2) Reimbursement for room and board is made to the hospice provider. The hospice provider is responsible to reimburse the facility the room and board payment received. The reimbursement is payment in full for the services described in R414-14A-14(2) The facility cannot bill Medicaid separately.

(3) If a hospice enrollee in a nursing facility, ICF/MR, or a freestanding hospice inpatient unit has a monetary obligation to contribute to his or her cost of care in the facility, the facility must collect and retain the contribution. The hospice must reimburse the facility the reduced amount received from Medicaid directly or from a Medicaid Health Plan.

 

R414-14A-26. Limitation on Liability for Certain Hospice Coverage Denials.

If a recipient is determined not to be terminally ill while hospice care were received under this rule, the recipient is not responsible to reimburse the Department. If the Department denies reimbursement to the hospice provider, the hospice provider may not seek reimbursement from the recipient.

 

R414-14A-27. Medicaid Health Plans and Hospice.

(1) If a Medicaid-only recipient is enrolled in a Medicaid health plan, the hospice selected by the recipient must have a contract with the healthplan. The health plan is responsible to reimburse the hospice for hospice care. The Department will not directly reimburse a hospice provider for a Medicaid-only recipient covered by a health plan.

(2) If a Medicaid-only recipient enrolled in a health plan elects hospice care before being admitted to a nursing facility, ICF/MR, or a freestanding hospice inpatient unit, the health plan is responsible to reimburse the hospice provider for both the hospice care and the room and board until the individual is disenrolled from the health plan by the Department. At the point the health plan determines that the enrollee will require care in the nursing facility for greater than 30 days, the health plan will notify the Department of the prognosis of extended nursing facility services. The Department will schedule disenrollment from the health plan to occur in accordance with the terms of the health plan contract for care provided in skilled nursing facilities.

(3) If a hospice enrollee is covered by Medicare for hospice care, the Medicaid health plan is responsible for payment of the Medicare coinsurance and deductibles. The health plan is responsible for payment whether or not the Medicare covered service is rendered by a network provider or has been authorized by the health plan. If a Medicare covered service is rendered by an out-of-network Medicare provider or a non-Medicare participating provider, the health plan is responsible to pay the coinsurance and deductibles.

(4) The health plan is responsible for room and board expenses of a hospice enrollee receiving Medicare hospice care while the recipient is a resident of a Medicare-certified nursing facility, ICF/MR, or freestanding hospice facility until the individual is disenrolled from the health plan by the Department. . On the 31st day, the recipient is disenrolled from the health plan and enrolled in the Medicaid fee-for-service hospice program. At the point the Department determines that the enrollee will require care in the nursing facility for greater than 30 days, The Department will schedule disenrollment from the health plan to occur in accordance with the terms of the health plan contract for care provided in skilled nursing facilities. The room and board expenses will be set in accordance with R414-14A-25.

(5) The hospice provider is responsible for determining if an applicant for hospice care is covered by a Medicaid health plan prior to enrolling the recipient, for coordinating services and reimbursement with the health plan during the period the recipient is receiving the hospice benefit, and for notifying the health plan when the recipient disenrolls from the hospice benefit.

 

R414-14A-28. Medicaid LTC Managed Care Projects and Hospice.

(1) A recipient receiving the Medicaid hospice benefit may enroll in a Medicaid LTC Managed Care project only if the LTC Managed Care project contractor and the recipient's hospice provider agree that the hospice care must be provided in the home. Medicaid recipients are not eligible for enrollment in a Medicaid LTC Managed Care project if the hospice care will be provided in a congregate care setting.

(2) For hospice enrollees covered by a Medicaid LTC Managed Care project, the LTC managed care contractor may provide services unrelated to the recipient's terminal illness as part of a coordinated care plan with the hospice provider.

 

R414-14A-29. Medicaid 1915c HCBS Waivers and Hospice.

For hospice enrollees covered by a Medicaid 1915c Home and Community-Based Services Waiver, the waiver program may provide services unrelated to the recipient's terminal illness as part of a coordinated care plan with the hospice provider.

 

KEY: [m]Medicaid

[1989]2005

Notice of Continuation October 6, 2004

26-1-4.1

26-1-5

26-18-3