DEPARTMENT OF HEALTH &. HUMAN SERVICES

MAR 3 1 2008

Office of Inspector General

Washington, D.C. 20201

TO:

FROM:

Kerry Weems

Acting Administrator

Centers for Medicare & Medicaid Services

Daniel R. Levinson I.

Inspector General

SUBJECT: Memorandum Report: "Hospice Beneficiaries' Use ofRespite Care,"

oEI-02-06-00222

This memorandum report describes hospice beneficiaries' use ofinpatient respite care in

2005 and identifies billing practices for such care. It is part of ongoing work by the Office

ofInspector General (OIG) on the Medicare hospice benefit and is a followup to an earlier

OIG report, "Medicare Hospice Care: A Comparison ofBeneficiaries in Nursing Facilities

and Beneficiaries in Other Settings," OEI-02-06-00220.

In response to our previous report, staff at the Centers for Medicare & Medicaid Services

(CMS) asked us to provide additional information about hospice beneficiaries' use of

inpatient respite care. Respite care is short-term inpatient care that provides respite for the

individual's family or other persons caring for the individual at home. l Staff at CMS were

concerned particularly about beneficiaries' use of inpatient respite care when they resided

in nursing facilities.

We found that 2 percent of all hospice beneficiaries received respite care during 2005.

Most ofthese beneficiaries received respite care for a total of 5 days or less. We also

found a number ofinstances in which the use ofrespite care may have been inappropriate.

Fifty-four beneficiaries received respite care longer than the 5 consecutive days allowed by

Federal regulations and 62 beneficiaries received respite care while residing in nursing

facilities, contrary to Federal requirements. 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 hospice claims limits CMS's ability to

determine whether hospice agencies are complying with the requirement that they may not

be reimbursed for more than 5 consecutive days ofrespite care at a time.

142 CFR § 418.204(b).

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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 beneficiary’s 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). 

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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 Medicarecertified 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 

resident’s time in a facility and when a resident’s 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 President’s Council on Integrity and Efficiency and the Executive Council on 

Integrity and Efficiency. 

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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 

Region Hospice Beneficiaries 

Who Received Respite Care 

Hospice Beneficiaries 

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 Alzheimer’s 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. 

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Table 2: Common Diagnosis Categories of Hospice Beneficiaries 

Diagnosis Categories 

Beneficiaries With One 

or Two Claims That 

Included Respite Care 

Beneficiaries With Three 

or More Claims That 

Included Respite Care 

Alzheimer’s and Other 

Nervous System Diseases 11% 24% 

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 beneficiary’s 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). 

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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 beneficiary’s 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 

CMS’s 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