Caps and Limitations on Hospice Payments

90 – Caps and Limitations on Hospice Payments (Rev. 246, Issued: 09-14-18, Effective: 12-17- 18, Implementation: 12-17-18) To ensure that hospice care does not exceed the cost of conventional care, there are two annual limits to hospice payments. The statute requires that hospice payments be limited by an inpatient cap and by an aggregate cap in any given cap year. The cap determinations are calculated on an annual basis. Any amounts in excess of either cap are considered to be overpayments, and must be repaid to Medicare. The hospice inpatient cap limits the total number of Medicare inpatient days to no more than 20 percent of a hospice’s total Medicare hospice days. The hospice aggregate cap limits the total aggregate payments any individual hospice can receive in a cap year to an allowable amount, based on an annual per beneficiary cap amount & the number of beneficiaries served. Medicare contractors complete the hospice cap determinations for the inpatient cap after the end of the cap year. Hospices must file their self-determined aggregate cap determination notice with their Medicare contractor no later than 5 months after the end of the cap year and remit any overpayment due at that time. The Medicare contractor then reconciles all payments at the final cap determination. If a provider fails to file its aggregate cap determination 5 months after the end of the cap year, payments to the provider are suspended in whole or in part until the self-determined cap is filed with the Medicare contractor. For the 2016 cap year and earlier, the cap year for the inpatient and aggregate cap runs from November 1st to October 31st. For the 2018 cap year and later, the cap year for both the inpatient and aggregate cap, as well as the timeframes in which beneficiaries and payments are counted for the purposes of determining each individual hospice’s aggregate cap aligns with the federal fiscal year (i.e., October 1st to September 30th). In the year of transition (2017 cap year), for the inpatient cap, the Medicare contractors will calculate the percentage of all hospice days of care that were provided as inpatient days (GIP care and respite care) from November 1, 2016 through September 30, 2017 (11 months). For the 2017 cap year, hospices using the patient-by-patient proportional method for their aggregate cap determinations should count beneficiaries from November 1, 2016 to September 30, 2017. For those hospices using the streamlined method for their aggregate cap determinations, hospices should count beneficiaries from September 28, 2016 to September 30, 2017, which is 12 months plus 3 days, in that cap year’s calculation. For the counting of hospice payments, hospices using either the streamlined method or the patient-by-patient proportional method, hospices should count 11 months of payments from November 1, 2016 to September 30, 2017 for the 2017 cap year. For the 2018 cap year and later, hospices should count both beneficiaries and payments, regardless of whether the streamlined or the patient-by-patient proportional methods are used, from October 1 to September 30. Hospice Aggregate Cap Timeframes for Counting Beneficiaries and Payments for the Alignment of the Cap Year with the Federal Fiscal Year Cap year Beneficiaries Payments Streamlined method Patient-by-patient proportional method Streamlined method Patient-by-patient proportional method 2016 9/28/15-9/27/16 11/1/15-10/31/16 11/1/15-10/31/16 11/1/15-10/31/16 2017 (Transition Year) 9/28/16-9/30/17 (12 months & 3 days) 11/1/16-9/30/17 (11 months) 11/1/16-9/30/17 (11 months) 11/1/16-9/30/17 (11 months) 2018 and later 10/1-9/30 10/1-9/30 10/1-9/30 10/1-9/30