5000, Reimbursement Rates

Revision 06-2; Effective December 12, 2006    

5100 General Information

Revision 05-1; Effective December 2, 2005

The Medicaid Hospice Program establishes and pays prospective hospice per diem rates that are no lower than the Medicare Hospice Program rates (Part A of Title XVIII of the Social Security Act). Medicaid rates are calculated on a yearly basis, based on information provided by the Centers for Medicare & Medicaid Services. The Medicaid hospice per diem rates are calculated by using the Medicare hospice methodology, but adjusted to disregard cost offsets allowed for Medicare deductibles and coinsurance amounts. HHSC does not apply or follow Medicare hospice rate freezes. Retroactive adjustments are not allowed other than for the

• application of the cap on overall Medicaid hospice payments,
• limitation on payments for inpatient care days, and
• recoupment of inaccurate payments made to providers.

The rates are effective from October 1 through September 30 of each federal fiscal year.

5200 Hospice Per Diem Rates

Revision 06-2; Effective December 12, 2006

The Medicaid program pays one of four per diem rates. Rates are paid for any particular hospice day based on the hospice care setting (of a Medicaid only recipient) applicable to the type and intensity of the hospice services provided for that day. The four Medicaid per diem rates are:

• routine home care,
• continuous home care,
• inpatient respite care, and
• general inpatient care.

DADS pays one of the per diem rates for each day an individual on Medicaid hospice qualifies for the Medicaid Hospice Program, regardless of the volume of services provided on any given day.

The following table identifies the services that can be billed for individuals on DADS Medicaid hospice based on their eligibility type and residence.

5210 Routine Home Care

Revision 05-1; Effective December 2, 2005

The routine home care rate is paid for each day an individual on Medicaid hospice has elected the Medicaid Hospice Program through a Medicaid hospice provider. DADS does not pay the routine home care rate for day of discharge; however, DADS will pay the routine home care rate for day of death.

5220 Continuous Home Care

Revision 05-1; Effective December 2, 2005

The continuous home care rate is paid by the hour. Payment can be up to 24 hours a day for each day an individual on Medicaid hospice has elected the Medicaid Hospice Program through a Medicaid hospice provider. This rate is for individuals who are not in an inpatient facility, and who receive continuous home care services.

The Medicaid hospice continuous care per diem payment rate varies depending on the number of hours of continuous services provided.

5230 Inpatient Respite Care

Revision 05-1; Effective December 2, 2005

Providers may provide respite care only on an occasional basis. If an individual resides in the home, goes into the NF for respite care and returns home after the respite care, the individual need not be in an NF Medicaid bed. Respite care days are subject to the limitation on total hospice inpatient care days. DADS pays respite care for a maximum of five consecutive days, including the date of admission but not the date of discharge. DADS will pay the inpatient respite care rate for the day of death.

5240 General Inpatient Care

Revision 05-1; Effective December 2, 2005

General inpatient care is paid for each day an individual on Medicaid hospice elects to receive care through a Medicaid hospice provider. Rates are paid for general inpatient care in approved inpatient facilities. An approved inpatient facility is a Medicaid hospice provider that meets the conditions of participation for providing direct inpatient care, a hospital or an NF that meets the standards regarding 24-hour nursing services and patient areas. Individuals may receive pain control, or acute or chronic symptom management that cannot be managed in other settings. Services must conform to a written plan of care.

DADS pays the Medicaid hospice inpatient care rate for the date of admission and all subsequent inpatient days. DADS does not pay the general inpatient care rate for day of discharge; however, DADS will pay the general inpatient care rate for day of death. General inpatient care days are subject to the limitation on total hospice inpatient care days.