Hospice: Reimbursement Cap

Aggregate payments to each hospice are limited during a hospice cap period. Total payments made for services during this period are compared to the “cap amount” for each period. Providers must return any payments more than the cap. (7-1-26) 01. Overall Cap. The cap is compared to reimbursement after computing the inpatient limitation and subtracting from the total reimbursement amount. (7-1-26) 02. Total Payment. All payments for services rendered during a cap year, regardless of when payment is made. (7-1-26) 03. Calculation of Cap. “Cap amount” is calculated by multiplying the number of participants of hospice care during the period by an amount adjusted for each cap year reflecting the percentage change in the medical care expenditure category of the Consumer Price Index for all urban consumers as published by the U.S. Bureau of Labor and Statistics. (7-1-26) 04. Number of Participants. Providers must report the number of Medicaid participants receiving hospice care during each period to the Department within thirty (30) days after the end of a cap period. For participants transferred to a non-certified hospice where no payment is made to the non-certified hospice, the certified provider may count a complete participant benefit period in their cap amount. (7-1-26) 05. Certified Mid-Month. A weighted average cap amount based on the number of days falling within each cap period is used. (7-1-26) 06. Adjustment to Overall Cap. Amounts in each hospice’s cap period are adjusted to reflect changes IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 660 Page 161 in the cap periods and designated hospices during a participant’s election period. The proportion of each hospice’s service days to the total number of hospice days rendered to a participant during an election period is multiplied by the cap amount to determine an adjusted cap amount. (7-1-26) a. Each hospice’s adjusted cap amount is computed as follows: (7-1-26) i. The share of the “cap amount” allowed by each hospice is based on the proportion of total covered days provided by each hospice in a “cap period.” (7-1-26) ii. The maximum number of allowable inpatient days for each certified hospice is multiplied by the “cap amount” specified for the “cap period” in which the participant first elected hospice. (7-1-26) b. The participant must file an initial election during the period beginning September 28 of the previous year through September 27 of the current cap year for it to count as an election during the current cap year. (7-1-26) 07. Additional Amount for NF Residents. Additional per diem amounts are paid for “room and board” of hospice residents in a NF who receive routine or continuous care services. Room and board include all assistance with ADLs, socializing activities, medication administration, maintaining cleanliness of resident rooms, and supervising and assisting use of DME and prescribed therapies. Additional payments are not subject to payment caps. Room and board rates are ninety-five percent (95%) of per diem interim rates assigned to a facility for the dates a participant resides in a NF. (7-1-26)