Hospice: Reimbursement

Except for payment of physician services, Medicaid pays for hospice care under one (1) of five (5) predetermined daily rates depending on type and intensity of services. There are no retroactive rate adjustments other than application of a “cap” on overall payments, a service intensity add-on, and limitations on inpatient care payments. Payment levels include: (7-1-26) 01. Routine Home Care. Payment includes one (1) of two (2) routine home care rates for each day of residence, under hospice care, and not receiving continuous home care. The rate paid disregarding the volume or intensity of routine services provided any given day. The two-rate payment methodology results in a higher payment for days one (1) through sixty (60) of hospice care and a reduced rate for all subsequent days. If a participant leaves hospice care and later resumes hospice care, regardless of provider, a minimum 60-day gap in hospice services is required for payment of the higher base routine home care rate. If a minimum 60-day gap in hospice services is not met, providers are paid the lower base rate. (7-1-26) 02. Continuous Home Care. Continuous home care is provided only during crisis periods when a patient requires continuous nursing care to achieve palliation and manage acute medical symptoms. Care must be provided by either an RN or LPN for at least half the total period of care. A minimum of eight (8) hours of care must be provided during a 24-hour day beginning and ending at midnight and does not need to be continuous and uninterrupted. Less skilled care needed on a continuous basis to enable a person to remain at home is covered as routine home care. For every hour or part of an hour of continuous care furnished, the hourly rate is paid to the hospice up to twenty-four (24) hours per day. (7-1-26) 03. Inpatient Respite Care. Payment is the inpatient respite care rate for each day a participant resides in an approved inpatient facility receiving respite care. Payment for a maximum of five (5) days includes the admission date but not the discharge date in any monthly election period. Payment for the sixth and any subsequent days is made at an appropriate rate: routine, continuous, or general inpatient rate. (7-1-26) 04. General Inpatient Care. Payments are made for general inpatient care provided. No other fixed payment rates are applicable for a day a participant receives hospice general inpatient care except qualifying physician services. (7-1-26) a. An appropriate home care rate is paid for discharge dates unless a patient dies in an inpatient unit. Date of a patient death is considered the discharge date and paid at the inpatient rate. (7-1-26) b. Medicaid hospice rates are the same as Medicare hospice rates, adjusted to disregard cost offsets for Medicare coinsurance amounts. No cost sharing is imposed for participants receiving hospice services. (7-1-26) c. Medicaid hospice benefits continue after a participant’s Medicare hospice benefit expires. The hospice must continue providing care until a patient dies or revokes a hospice care election. (7-1-26) 05. Service Intensity Add-On. Add-on payments are made for visits by an RN or social worker during the last seven (7) days of life in addition to the routine home care rate, calculated by multiplying the continuous home care rate per fifteen (15) minutes by the number of units for combined daily visits. Payments do not exceed sixteen (16) units per day, are adjusted for geographic wage differences, and do not include a social worker’s phone time. (7-1-26)