DEPARTMENTOF HEALTH &. HUMANSERVICES Officeof Inspector General
Washington, D.C. 20201
MAR 3 1 2008
TO: Kerry Weems
Acting Administrator
Centers for Medicare & Medicaid Services
~ I. ~
FROM: Daniel R. Levinson
InspectorGeneral
SUBJECT: Memorandum Report: "Hospice Beneficiaries' Use ofRespite Care,"
oEI-02-06-00222
This memorandum report describeshospice beneficiaries' useofinpatientrespitecare in
2005 and identifies billing practices for such care. Itis part ofongoing work bythe Office
ofInspector General (OIG) onthe Medicare hospice benefit and is a followup to anearlier
OIG report, "Medicare Hospice Care: A ComparisonofBeneficiaries inNursing Facilities
and Beneficiaries in Other Settings," OEI-02-06-00220.
In response to our previous report, staffatthe Centers for Medicare& Medicaid Services
(CMS) asked us to provide additional informationabouthospice beneficiaries' useof
inpatientrespite care. Respite care is short-term inpatientcare thatprovides respite for the
individual's family orother persons caring for the individual at home.l StaffatCMS were
concernedparticularly about beneficiaries' use ofinpatientrespite carewhenthey resided
in nursing facilities.
We found that 2 percentofall hospice beneficiaries received respitecare during 2005.
Most ofthese beneficiaries received respite care for a total of5 days or less. We also
found a numberofinstances in which the use ofrespitecare may have beeninappropriate.
Fifty-four beneficiaries received respite care longerthan the 5consecutive days allowed by
Federal regulations and 62 beneficiaries received respite care while residing in nursing
facilities, contrary to Federal requirements. We will provide additional informationabout
these potentially inappropriate cases to CMS ina separate memorandum. Inaddition, we
note that the informationthat is available on hospice claims limits CMS's ability to
determine whether hospice agencies are complyingwith the requirement that they may not
bereimbursed for more than 5consecutive days ofrespite care ata time.
142CFR418.204(b).
OEI-02-06-00222 HospiceBeneficiaries'UseofRespiteCare Page 2  Kerry Weems 
 
BACKGROUND 
 
The Medicare Hospice Benefit 
The Medicare hospice benefit allows a beneficiary with a terminal illness to forgo curative 
treatment for the illness and instead receive palliative care, which is the relief of pain and 
other uncomfortable symptoms.  To be eligible for Medicare hospice care, a beneficiary 
must be entitled to Part A of Medicare and be certified as having a terminal prognosis with 
a life expectancy of 6 months or less, should the disease run its normal course.  The 
number of Medicare beneficiaries receiving hospice care has increased significantly in 
recent years, growing from approximately 594,000 in 2001 to 871,000 in 2005.2    
 
Inpatient Respite Care 
Inpatient respite care (hereafter referred to as respite care) is one of four levels of 
hospice care available to Medicare beneficiaries.  The other levels are routine home care, 
which is the most commonly provided level of care; continuous home care; and general 
inpatient care.3  Respite care is short-term inpatient care provided to the beneficiary when 
necessary to relieve the beneficiarys caregiver.  The Medicare unadjusted daily rate4 for 
respite care in 2005 was $126.18. In addition, hospice agencies may bill beneficiaries for  
5 percent of the daily rate for respite care.5  The amount collected from the beneficiary is 
not reported on Medicare hospice claims. 
 
Respite care may be provided directly by the hospice agency or indirectly under 
arrangements made by the hospice.  Respite care must be provided by a hospice, hospital, 
skilled nursing facility, or intermediate care facility that meets the standards for respite 
care set forth in regulation.6    
 
Respite care is subject to several limitations.  Respite care may be provided only on an 
occasional basis and may not be reimbursed for more than 5 consecutive days at a time.7   
Also, the total number of inpatient care days (general inpatient care or respite) for 
Medicare beneficiaries in a particular hospice agency may not exceed 20 percent of the 
total days for which these beneficiaries had elected hospice care.8  
                                                 
2 Centers for Medicare & Medicaid Services, Medicare Hospice Data  1998-2005 (December 26, 2007). 
 
Available online at http://www.cms.hhs.gov/ProspMedicareFeeSvcPmtGen/downloads/HospiceData1998-
2005.pdf.  Accessed  January 15, 2008. 

3 General inpatient care is for pain control or symptom  management that cannot  be managed in other settings. 

42  CFR  418.302(b)(4).
 
4 Payment rates are adjusted to reflect local  differences in  wages. 42 CFR  306(c). 

5 42 CFR   418.400(b). 

6 42 CFR   418.98 and  418.100. 

7 42 CFR   418.204(b)(2). 

8 42 CFR   418.98(c). 

OEI-02-06-00222      Hospice Beneficiaries Use of Respite Care   Page 3  Kerry Weems 
 
METHODOLOGY 
 
The information provided in this memorandum  report is based on an analysis of Medicare 
claims for hospice care.  It is based on the same data that we used in our previous report, 
Medicare Hospice Care: A Comparison of Beneficiaries in Nursing Facilities and 
Beneficiaries in Other Settings, OEI-02-06-00220. 
 
As we did in our previous report, we identified all beneficiaries who received hospice care 
in 2005 using the Medicare Part A hospice claims from the National Claims History file 
for 2005. We also included claims from the 2006 file that covered days of service that 
occurred in 2005. Hospice agencies typically submit claims  that cover a 1-month period.  
Therefore, some claims from the 2006 file included days from 2005.  We identified the 
beneficiaries who received respite care by using the revenue codes on their hospice claims.  
 
We identified the beneficiaries who received respite care and resided in nursing facilities 
using the Minimum Data Set (MDS).  We compared beneficiaries respite claim dates to 
beneficiaries MDS dates to identify the beneficiaries who received respite care while they 
were in nursing facilities. The MDS includes assessments on all residents in Medicare-
certified or Medicaid-certified long term care facilities, including skilled nursing facilities.  
For the purpose of this report, we refer to all such facilities as nursing facilities.  We  
considered a beneficiary to be a resident of a nursing facility if the beneficiary had an MDS 
assessment.  Nursing facilities complete these assessments at scheduled intervals during a 
residents time in a facility and when a residents health status changes.   
 
We analyzed the claims data to determine the proportion of hospice beneficiaries who 
received respite care during 2005, the number of days that they received respite care, and 
the number of claims that they had that included respite care.  Finally, we identified the 
hospice beneficiaries who received respite care for more than 5 consecutive days and those 
who received respite care while they were residents of nursing facilities.   
 
We had to limit our analysis in several ways because of the information that was available 
on hospice claims.  Hospice claims include the number of days for each level of care but 
they do not include the specific dates that the beneficiaries received each level of care.  
Therefore, we had to base the number of beneficiaries who received respite care for more 
than 5 consecutive days on the claims that included only respite care.  We also identified 
beneficiaries who had claims that included respite care and other levels of hospice care.  In 
these cases, we could not determine whether the dates that the beneficiaries received 
respite care were consecutive. Therefore, the number of beneficiaries who received respite 
care for more than 5 consecutive days could be higher than stated in the findings. 
 
This review was  conducted in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency and the Executive Council on 
Integrity and Efficiency. 
OEI-02-06-00222      Hospice Beneficiaries Use of Respite Care   Page 4  Kerry Weems 
 
RESULTS 
 
Two Percent of Hospice Beneficiaries Received Respite Care During 2005 
In 2005, 2 percent of all hospice beneficiaries, or 17,669 beneficiaries, received respite 
care. Medicare payments for respite care for these beneficiaries were approximately  
$12.8 million, an average of $722 per beneficiary who received respite care.   
 
The most common diagnosis categories for beneficiaries who received respite care were 
cancer, circulatory disease, and ill-defined conditions.  These were also the most common 
diagnosis categories for hospice beneficiaries who did not receive respite care.  The two 
groups differed slightly in terms of geographic location.  As Table 1 shows, beneficiaries 
who received respite care were more likely to reside in the Midwest and West, compared to 
hospice beneficiaries who did not receive respite care.  
 
Table 1: Location of Hospice Beneficiaries During 2005 
Hospice Beneficiaries  Hospice Beneficiaries 
Region 
Who Received Respite Care  Who Did Not Receive Respite Care 
Northeast  11%  17% 
Midwest  30%   24%  
South  34%   38%  
West  24%   20%  
Source:  Office of Inspector General analysis of  2005 Medicare claims, 2007. 
Note:   Percentages do  not add up to  100 percent because of rounding. 
 
Most Hospice Beneficiaries Who Received Respite Care Received It for 5 Days or 
Less 
Eighty-one percent of beneficiaries who received respite care received it for a total of  
5 days or less in 2005. On average, beneficiaries received respite care for 5.6 days in 
2005. The number of days in respite care ranged from 1 to 122.  In addition, 92 percent of 
beneficiaries who received respite care in 2005 had one or two claims that included respite 
care. The remaining 8 percent of beneficiaries had three or more claims that included 
respite care. These beneficiaries often received respite care every month during which 
they were in hospice care. 
 
Beneficiaries who had three or more respite claims had diagnoses different from those of 
beneficiaries who had fewer claims.  Table 2, on the next page, shows the distribution of 
the most common diagnosis categories for these two groups of beneficiaries.  Beneficiaries 
with three or more respite claims were more than twice as likely to have Alzheimers or  
another nervous system disease, compared to beneficiaries with fewer claims.  Also, 
beneficiaries with three or more respite claims  were less than half as likely to have cancer, 
compared to those with fewer claims. 
 
OEI-02-06-00222      Hospice Beneficiaries Use of Respite Care   Page 5  Kerry Weems 
 
Table 2: Common Diagnosis Categories of Hospice Beneficiaries 
Beneficiaries With One  Beneficiaries With Three  
Diagnosis Categories  or Two Claims That   or More Claims That 
Included Respite Care  Included Respite Care 
Alzheimers and Other 
11%  24%  
Nervous System Diseases 
Cancer  38%   17%  
Circulatory Diseases  20%  23% 
Ill-Defined Conditions  11%   15%  
Mental Disorders  4%  7% 
Respiratory Diseases  9%  8% 
Other  7%   6%  
Source:  Office of Inspector General analysis of  2005 Medicare claims, 2008. 
 
A Small Number of Beneficiaries Received Respite Care for More Than 
5 Consecutive Days 
According to Federal regulation, respite care may not be reimbursed for more than 
5 consecutive days.9  We identified 54 beneficiaries who received respite care for more 
than 5 consecutive days in 2005.  One of these beneficiaries received respite care for 
122 consecutive days at a cost of $16,726. The 54 beneficiaries did not exhibit any 
significant patterns in terms of diagnoses, hospice providers, or location by State.    
 
Another 685 beneficiaries had claims for respite care for more than 5 days.  However, 
these claims included at least one other level of care in addition to respite care.  Because of 
the information that was available on the hospice claims, we could not determine whether 
the days on which these beneficiaries received respite care were consecutive.   
 
A Small Number of Beneficiaries Received Respite Care While They Were Residents 
of a Nursing Facility 
Respite care is intended to provide respite for the beneficiarys family or other persons 
caring for the beneficiary at home.  It is to be provided only when necessary to relieve the 
family members or other persons caring for the [beneficiary].10  Beneficiaries who were 
cared for at home sometimes entered nursing facilities to receive respite care and then 
remained in the facilities instead of returning home.  These beneficiaries typically entered 
facilities and received 5 days of respite care.  After 5 days, the beneficiaries did not return 
home but instead stayed in the facilities and received routine or other levels of hospice 
care. 
 
However, we identified 62 beneficiaries who received respite care in 2005 when they had 
already been residing in nursing facilities.  Beneficiaries who reside in facilities are cared 
for by facility staff, unlike beneficiaries who reside at home and are often cared for by 
                                                 
9 42 CFR   418.204. 
10 42 CFR   418.204(b). 
OEI-02-06-00222      Hospice Beneficiaries Use of Respite Care   Page 6  Kerry Weems 
 
family members.  The beneficiaries who received respite care while already residing in 
nursing facilities did not exhibit any significant patterns in terms of diagnoses or hospice 
providers. Nineteen of the sixty-two beneficiaries were from Texas or California. 
 
CONCLUSION 
 
We found that respite care was infrequently used in 2005.  Two percent of all hospice 
beneficiaries received respite care and most of these beneficiaries received the care for a 
total of 5 days or less. We also found a number of instances in which the use of respite 
care may have been inappropriate.  Fifty-four beneficiaries received respite care for more 
than 5 consecutive days and 62 beneficiaries received respite care while residing in nursing 
facilities, even though respite care is designed to relieve a beneficiarys caregiver.  One 
beneficiary was included in both of these groups.  We will provide additional information 
about these potentially inappropriate cases to CMS in a separate memorandum.   
 
In addition, we note that the information that is available on the hospice claim limits 
CMSs ability to determine whether hospice agencies are complying with the requirement 
that they may not be reimbursed for more than 5 consecutive days of respite care at a time.   
 
This report is being issued directly in final form because it contains no recommendations.  
If you have comments or questions about this report, please provide them within 60 days.  
Please refer to report number OEI-02-06-00222 in all correspondence.  
 
 
OEI-02-06-00222      Hospice Beneficiaries Use of Respite Care