Payment for Hospice Services

(A) Type of Care. MassHealth payment for hospice services is based on the type of care provided rather than the qualifications of the person who provided the service. Payment rates correspond to the following four categories of care. (1) Routine Home Care. The routine home care rate is paid for each day the member is at home or residing in a nursing facility or ICF/IID, under the care of the hospice provider, and not receiving continuous home care. This rate is paid without regard to the volume or intensity of routine home care services provided on any given day. (2) Service-intensity Add-on (SIA). Routine home care days that occur during the last seven days of a hospice election ending with a member discharge due to death are eligible for an SIA payment. The SIA rate may be billed with the routine home care rate, for a minimum of 15 minutes and up to four hours per day for RN or social worker visits to the member during the last seven days of their hospice election ending in discharge due to death. (3) Continuous Home Care. The continuous home care rate is paid when a member receives hospice services consisting predominantly of nursing care on a continuous basis at home or in a nursing facility or ICF/IID. Hospice aide or homemaker services or both may also be provided on a continuous basis. Continuous home care is only furnished during brief periods of crisis as described in 42 CFR 418.204(a) and only as necessary to maintain the member at home. A minimum of eight hours must be provided in a 24-hour period to qualify for the continuous home care rate. (4) Inpatient Respite Care. The inpatient respite care rate is paid to the hospice provider for each day the member is in an approved inpatient facility and is receiving respite care from the hospice provider. Payment for inpatient respite care will be made for a maximum of five consecutive days' stay including the date of admission but not counting the date of discharge except in circumstances described in 42 CFR 418.302(e)(5). Payment for any subsequent days will be made at the routine home care rate. (5) General Inpatient Care. The general inpatient care rate is paid for each day the member receives general inpatient care in an inpatient facility for pain control or acute or chronic symptom management that cannot be managed in other settings. None of the other fixed payment rates will be applicable for a day on which the member receives inpatient care except for the day of discharge. (B) Room and Board in a Nursing Facility or ICF/IID. The MassHealth agency pays the hospice provider a room and board per diem amount for a member residing in a nursing facility or an ICF/IID in accordance with all applicable MassHealth regulations and in addition to either the routine home care rate (130 CMR 437.424(A)(1)) or the continuous home care rate (130 CMR 437.424(A) (2)). (1) The MassHealth agency does not pay a hospice provider the room and board per diem amount, and does not pay for medical-leave-of-absence days, for any day that a member receives inpatient respite care (130 CMR 437.424(A)(3)) or general inpatient care (130 CMR 437.424(A)(4)) from the hospice provider. (2) If a member receiving hospice services in a nursing facility or ICF/IID is hospitalized, the MassHealth agency will pay the hospice provider for the medical leave of absence in accordance with 130 CMR 456.000: Long Term Care Services, provided that the conditions for medical leave of absence are met in accordance with 130 CMR 456.000: Long Term Care Services. (C) Payment of Hospice Provider on Date of Discharge from Hospice Services. MassHealth does not pay a hospice provider the per diem hospice rate or the room and board rate on a member’s date of discharge from hospice services, except for when (1) the member is discharged due to death (2) the member was receiving hospice services in a nursing facility or ICF/IID and continue to reside in the nursing facility or ICF/IID after hospice discharge (D) Payment of Hospice Provider on Date of Death. MassHealth pays the hospice provider the hospice per diem rate and the room and board rate on the member’s date of death. (E) Change of Hospice Providers. When a member changes hospice providers, MassHealth will not pay both hospice providers for the same date of service. The new hospice provider may begin receiving payment for dates of service subsequent to the date of discharge from the previous hospice provider. (F) The Hospice Election Form. A hospice provider must complete a hospice election form and notify the MassHealth agency of the member’s hospice election in accordance with 130 CMR 437.412. The MassHealth agency will not pay for hospice services provided before the effective date entered on the hospice election form. (G) Dual-eligible members. The MassHealth agency will not pay for hospice services and/or applicable room and board in an NF or ID/DD during any period in which a dual-eligible member has not simultaneously elected both their MassHealth and Medicare hospice benefit. (H) MassHealth Members Enrolled in Capitated Programs. A hospice provider may not directly bill MassHealth for hospice services provided to a MassHealth member receiving hospice services through a capitated program. (I) Non-hospice Providers. Non-hospice providers may bill for the treatment of conditions not related to the member’s terminal illness according to the applicable MassHealth regulations for that provider type.