Counting Beneficiaries for Calculation

90.2.2 – Counting Beneficiaries for Calculation (Rev. 246, Issued: 09-14-18, Effective: 12-17- 18, Implementation: 12-17-18) Each hospice's cap amount is calculated by multiplying the adjusted cap amount by the number of Medicare beneficiaries who elected to receive hospice care from that hospice during the cap period. The two methods for counting beneficiaries are the streamlined method and the proportional method, and are explained below. Proportional Method: Under the proportional method, each hospice shall include in its number of Medicare beneficiaries only that fraction which represents the portion of a patient’s total days of care in all hospices and all years that was spent in that hospice in that cap year, using the best data available at the time of the calculation (subject to revision at a later time based on updated data). The whole and fractional shares of Medicare beneficiaries’ time in a given cap year are then summed to compute the total number of Medicare beneficiaries served by that hospice in that cap year. The fractional share for any given beneficiary counted using the proportional method shall be calculated as follows: Proportion = Beneficiary’s Hospice Days in Cap Year in a Distinct Hospice / Beneficiary’s Total Hospice Days for all Years When a hospice’s cap is calculated using the proportional method, and a beneficiary included in that calculation survives into another cap year, the Medicare contractor may need to make adjustments to prior cap determinations. Reopening is allowed for up to 3 years from the date of the cap determination notice, except in the case of fraud, where reopening is unlimited. A revised cap determination letter issued as a result of a reopening may itself be reopened, subject to the 3 year limitation on reopening. Streamlined Method: This method is used by eligible hospices that had their cap determinations calculated using the streamlined method for all cap years prior to cap year 2012 and elected to have their cap determination for cap years 2012 and beyond calculated using the streamlined method. The method that these hospices must use is described below. • When a beneficiary receives care from only one hospice: Each beneficiary is counted as 1 in the first year of services with that hospice facility and will not be counted in any following years. The hospice includes in its number of Medicare beneficiaries those Medicare beneficiaries who have not previously been included in the calculation of any hospice cap, and who have filed an election to receive hospice care during the timeframe for counting beneficiaries associated with the cap year, using the best data available at the time of the calculation. Once a beneficiary has been included in the calculation of a hospice cap, he or she may not be included in the cap for that hospice again, even if the number of covered days in a subsequent cap year exceeds that of the period where the beneficiary was included (this could occur when the beneficiary has breaks between periods of election). • When a beneficiary receives care from more than one Medicare-certified hospice during a cap year or years: Each Medicare-certified hospice includes in its number of Medicare beneficiaries only that fraction which represents the portion of a patient’s total days of care in all Medicare-certified hospices and all years that was spent in that hospice in that cap year, using the best data available at the time of the calculation. Cap determinations are subject to reopening/adjustment to account for updated data. The streamlined method cap calculation for a Medicare beneficiary who has been in more than one Medicare- certified hospice is identical to the proportional method. Beneficiary Counting Examples The following examples are for illustrative purposes only. As the examples illustrate, if the proportional method is applied for a given year, then every beneficiary who receives services in that year is counted based on the number of days of care furnished to the beneficiary in that year, relative to the total days of care for the beneficiary for all years. Example 1. (One Hospice). Jane Smith, a Medicare beneficiary, initially elected hospice care from Hospice A beginning on June 1, 2018. Her condition improved, and she was discharged from Hospice A on August 15, 2018, as she was no longer terminally ill. However, in November 2018 Ms. Smith’s condition worsened; she re-elected hospice at Hospice A on November 15, 2018, and subsequently died on December 27, 2018. Streamlined Method: Hospice A would count Ms. Smith as 1 in its 2018 cap year, but would not count Ms. Smith again in its 2019 cap year. Medicare payments for hospice care provided would be counted in the cap year in which those services were provided, regardless of when payments were actually made, using the best data available at the time of the calculation. Once a beneficiary has been included in the calculation of a hospice cap, he or she may not be included in the cap for that hospice again. Proportional Method: Ms. Smith would be counted as follows: 2018 cap year (June 1st – August 15th): 76 days = 76/119 = 0.64 2019 cap year (Nov 15th – Dec 27th): 43 days = 43/119 = 0.36 Total days: 119 days = 1.00 Hospices and Medicare contractors use the best data available at the time the cap is calculated to determine the proportional allocation of Ms. Smith’s time. Because the Medicare contractor calculates the cap after allowing time for claims and adjustments to flow through the claims processing system, and assuming Hospice A files its claims without delay, by the time the 2018 cap is calculated the Medicare contractor would have information about Ms. Smith’s complete hospice stay. Therefore, the Medicare contractor is able to correctly count Ms. Smith’s stay for the 2018 and 2019 cap determinations, without having to make prior year adjustments to her proportional shares. Example 2. (Reopening/Adjustment). Continuing with the proportional method scenario from Example 1 above, had Ms. Smith lived until August 25, 2019, the hospice and the Medicare contractor would consider the information available at the time of the cap calculation when determining proportional shares. For example, if the hospice calculated the 2018 cap on February 15, 2019, using claims for dates of service through December 31, 2018, Ms. Smith’s total stay would have been 123 days, and the 2018 proportional share would be 76 / 123 = 0.62. Cap Accounting with Claims through December 31, 2018: 2018 cap year (June 1st – August 15th): 76 days = 76/123 = 0.62 2019 cap year (Nov 15th – Dec 31st): 47 days = 47/123 = 0.38 Total days: 123 days = 1.00 When calculating the 2019 cap determination using claims for dates of service through December 31, 2019, the Medicare contractor would be able to re-open the 2018 cap determination and correct the proportional allocation made in the previous cap year, to reflect a final allocation of 76/360 = 0.21 for the 2018 cap determination and 284/360 = 0.79 in the 2019 cap determination, reflecting the final date of August 25, 2019. Cap Accounting with Claims through December 31, 2019: 2018 cap year (June 1st – Aug 15th): 76 days = 76/360 = 0.21 2019 cap year (Nov 15th – Aug 25th): 284 days = 284/360 = 0.79 Total days: 360 days = 1.00 Example 3. (Two Different Hospices). Jane Smith, a Medicare beneficiary, initially elected hospice care from Hospice A beginning on June 1, 2018. Her condition improved, and she was discharged from Hospice A on August 15, 2018, as she was no longer terminally ill. However, in January 2019, Ms. Smith’s condition worsened; she re-elected hospice at Hospice B on January 15, 2019, and subsequently died on February 26, 2019. Streamlined Method: The streamlined method cap calculation for a Medicare beneficiary who has been in more than one Medicare-certified hospice is identical to the proportional method (as described below). Therefore, Hospice A would count Ms. Smith as a fraction (0.64) in its 2018 cap year and would not count Ms. Smith again in its 2019 cap year. Hospice B would count Ms. Smith as a fraction (0.36) in its 2019 cap year and would not count Ms. Smith in its 2018 cap year. Medicare payments for hospice care provided would be counted in the cap year in which those services were provided, regardless of when payments were actually made, using the best data available at the time of the calculation. Proportional Method: Under the proportional method, Ms. Smith would be counted as follows: Hospice A: 2018 cap year (June 1st – August 15th): 76 days = 76/119 = 0.64 Hospice B 2019 cap year (Jan 15th - Feb 26th): 43 days = 43/119 = 0.36 Total days: 119 days = 1.00 The Medicare contractor uses the best data available at the time the cap is calculated to determine the proportional allocation of Ms. Smith’s time. Because the Medicare contractor calculates the cap after allowing time for claims and adjustments to flow through the claims processing system, and assuming Hospice A files its claims without delay, by the time the 2018 cap is calculated the Medicare contractor would have information about Ms. Smith’s complete hospice stay. Therefore, the Medicare contractor is able to correctly count Ms. Smith’s stay for the 2018 and 2019 cap determinations, without having to make prior year adjustments to her proportional shares.