| (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.
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