evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
Proportional Method :   Under the proportional method, Ms. Smith would be counted as follows:   Hospice A:  2018 cap year (June 1st  August 15th):    76 days   =   76/119 =  0.64  Hospice B  2019 cap year (Jan 15th -  Feb 26th):     43 days   =     43/119 =  0.36 Total days:      119 days   =     1.00  The Medicare contractor uses the best data available at the time the cap is calculated to determine the proportional allocation of Ms. Smiths time.  Because the Medicare contractor calculates the cap after allowing time for claims and adjustments to flow through the claims processing system, and assuming Hospice A files its claims without delay, by the time the 2018 cap is calculated the Medicare contractor would have information about Ms. Smiths complete hospice stay.  Therefore, the Medicare contractor is able to correctly count Ms. Smiths stay for the 2018 and 2019 cap determinations, without having to make prior year adjustments to her proportional shares.   90.2. 3  Changing Aggregate Cap Calculation Methods  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)  Hospices are not allowed to switch back and forth between cap calculation methods, as doing so would greatly complicate the cap determination calculation, would be difficult to administer, and could lead to inappropriate switching by hospices seeking merely to maximize Medicare payments.  Additionally, in the year of a change in the calculation method or when a previous cap determination cannot be re -opened, there is a potential for over-counting some beneficiaries.  Allowing hospices to switch back and fort h between methods would perpetuate the risk of over -counting beneficiaries.  Therefore:
(Medicare Benefit Policy Manual)
1) Hospices that have their cap determination calculated using the proportional method for any cap year prior to the 2012 cap year will continue to have their cap calculated using the proportional method for the 2012 cap year and all subsequent cap years; and,  2) All other hospices would have their cap determinations for the 2012 cap year and all subsequent cap years calculated using the proportional method unless they make a one-time election to have their cap determinations for cap year 2012 and beyond calculated  using the streamlined method.  A/B MACs (HHH) do not reopen cap determinations for the 2011 cap year and prior cap years as a result of a hospice transition from the streamlined to the proportional method for the 2012 cap year.  NOTE : this does not apply to hospices that appealed their cap determination.   3) A hospice would be able to elect the streamlined method no later than 60 days following the receipt of its 2012 cap determination.  4) Hospices which elected to have their cap determination calculated using the streamlined method may later elect to have their cap determinations calculated using the proportional method by either:   a. electing to change to the proportional method (if the election is made prior to receipt of the cap determination associated with the cap year where the change is desired); or   b. appealing a cap determination calculated using the streamlined method to determine the number of Medicare beneficiaries.   5) If a hospice elected the streamlined method, and  changed to the proportional method for a subsequent cap year, the hospices aggregate cap determination for that cap year (i.e., the cap year of the change) and all subsequent cap years would be calculated using the proportional method.  Past cap year det erminations for the 2012 cap year and later cap years are subject to reopening; existing re -opening rules allow reopening for up to 3 years from the date of the cap determination, except in cases of fraud, where reopening is unlimited.  A revised cap deter mination letter issued as a result of reopening may itself be reopened, subject to the 3 year limitation on reopening.   90.2. 4  Other Issues  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)  The computation of  the aggregate cap is  made by the  hospice  after the cap year ends, which now is in alignment with the federal fiscal year.
(Medicare Benefit Policy Manual)
The computation of  the aggregate cap is  made by the  hospice  after the cap year ends, which now is in alignment with the federal fiscal year.     Hospices can obtain instructions regarding the cap determination method election process from their Medicare contractor.  Regardless of which method is used, the Medicare contractor  shall continue to demand any additional overpayment amounts due to CMS at the time of the hospice cap determination.  Cap determinations are subject to the existing CMS reopening regulations, which allow reopening for up to 3 years from the date of the cap determination letter, except in cases of fraud, where reopening is not li mited.   If a providers covered days of hospice care or Medicare payments are adjusted through an audit or other review, the Medicare contractor  may recalculate the aggregate cap if the amount is material.   90.2. 5  Updates to the Cap Amount  (Rev. 11056; Issued: 10- 21-21; Effective: 10 -01-21; Implementation: 12 -22-21)  The aggregate cap amount was set at $6,500 per beneficiary when first enacted in 1983.  Since 1983, the $6,500 amount has been adjusted annually by the change in the medical care expenditure category of the consumer price index for urban consumers (CPI U, United  States  city average),  published by the  Bureau  of Labor  Statistics, from March 1984 to the fifth month of the cap year, as required by section 1814(i)(2)(B) of the Act.
(Medicare Benefit Policy Manual)
Section 1814(i)(2)(B)(i) and (ii) of the Act, as added by section 3(b) of the Improving Medicare Post -Acute Care Transformation Act (IMPACT Act) of 2014 (Pub. L. 113185) requires, effective for the 2016 cap year (November 1, 2015 through October 31, 2016) , that the cap amount for the previous year to be updated by the hospice payment update percentage, rather than the original $6,500 being annually adjusted by the change in the CPI U for medical care expenditures since 1984.  This provision would have sunset for cap years ending after September 30, 2025, at which time the annual update to the cap amount would have reverted back to the original methodology.  However, division CC, section 404 of the Consolidated Appropriations Act, 2021 (CAA 2021) has extended the accounting years impacted by the adjustment made to the hospice cap calculation until 2030.  Therefore, for accounting years that end after September 30, 2016 and before October 1, 2030, the hospice cap amount is updated by the hospice payment update percentage rather than using the CPI U.  This provision will sunset for cap years ending after September 30, 2030, at which time the annual update to the cap amount will revert back to the original methodology.  In those  situations  where  a hospice  begins  participation  in Medicare at any time other  than the beginning of  a cap year,  and hence has  an initial cap  calculation  for a  period in  excess  of 12 months, a  weighted  average cap amount  is used.  The  following example illustrates  how  this is accomplished.   EXAMPLE ( Cap amounts utilized in this example are for illustrative purposes only and do not reflect actual cap amounts.)   09/01/18 -  Hospice  A is Medicare certified.   09/01/18 to  10/31/19  -  First  cap period (13  months)  for hospice  A.  Statutory  cap amount for  first Medicare cap  year  (09/01/18 -  09/30/18)  = $28,000.00   Statutory  cap amount for  second  Medicare cap year   (10/01/18 -  09/30/19)  = $28,500.00  Weighted  average cap amount calculation  for hospice  A:  One month (09/01/18  09/30/18)  at $28,000.00 =  $28,000.00
(Medicare Benefit Policy Manual)
Weighted  average cap amount calculation  for hospice  A:  One month (09/01/18  09/30/18)  at $28,000.00 =  $28,000.00  12 months  (10/01/18 -  09/30/19)  at $28,500.00 =  $342,000.00  13 month period $370,000.00 divided by 13 =  $28,461.54 (rounded)   In this example,  $28,461.54 is  the weighted  average cap  amount  used  in the initial cap  calculation  for Hospice  A for the  period September 1,  2018, through September 30, 2019.   NOTE: If  Hospice  A had been  certified  in mid-month, a  weighted  average  cap amount  based  on the  number  of days  falling  within  each  cap period is  used.   90.3  Administrative Appeals  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)  The applicable Medicare contractor shall issue a Cap Determination Letter to notify hospice providers of the results of the Medicare contractors cap calculations and to serve as the providers Notice of Program Reimbursement (NPR).  If there is a cap overpayment, there shall be an accompanying demand for repayment.  As indicated in 42 CFR 418.311, a hospice that believes that its payments have not been properly determined may request a review from the applicable Medicare contractor or the Provider Reimbursement Review Board (PRRB). Each determination of program reimbursement shall inclu de language describing the providers appeal rights.  The above described letter, serving as the provider's determination of program reimbursement, shall include the following language:   This notice is the Medicare contractors final determination for purposes of appeal rights.  If you disagree with this determination, you may file an appeal, in accordance with 42 CFR 418.311 and 42 CFR, part 405, subpart R.  The appeal should be filed wi th either the applicable Medicare contractor or the Provider Reimbursement Review Board (PRRB), depending on the amount in controversy.  Appeal requests must be in writing and be filed within 180 days from the date of this determination.                                        Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12400BP
(Medicare Benefit Policy Manual)
Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12400BP   12/06/2023 Hospice Benefit Policy Manual Updates Related to the Addition of Marriage and Family Therapists (MFTs) or Mental Health Counselors (MHCs) to the Hospice Interdisciplinary Team  01/02/2024  13437  R12385BP
(Medicare Benefit Policy Manual)
11/30/2023 Hospice Benefit Policy Manual Updates Related to the Addition of Marriage and Family Therapists (MFTs) or Mental Health Counselors (MHCs) to the Hospice Interdisciplinary Team - Rescinded and Replaced by Transmittal 12400  01/02/2024  13437  R11056BP  10/22/2021 Manual Updates for Clarification on the Election Statement Addendum and Extension of the Hospice Cap Calculation Methodology 12/22/2021  12491  R10437BP  11/06/2020 Manual Updates Related to the Hospice Election Statement and the Implementation of the Election Statement Addendum  12/09/2020  12015  R246BP  09/14/2018 Manual Updates Related to Payment Policy Changes Affecting the Hospice Aggregate Cap Calculation and the Designation of Hospice Attending Physicians  12/17/2018  10517  R209BP  05/08/2015 Updates on Hospice Election Form, Revocation, and Attending Physician 05/04/2015  9114 R205BP  04/03/2015 Updates on Hospice Election Form, Revocation, and Attending Physician  Rescinded and replaced by Transmittal 209 05/04/2015  9114 R188BP  05/01/2014 Updates and Clarifications to the Hospice Policy Chapter of the Benefit Policy Manual  08/04/2014  8727 R156BP  06/01/2012 Updates to Caps and Limitations on Hospice Payments  07/02/2012  7838 R141BP  03/02/2011 New Hospice Certification Requirements and Revised Conditions of Participation (CoPs) 03/23/2011  7337 R121BP  02/05/2010 Medicare Systems Edits Refinements Related to Hospice Services  07/06/2010  6778 R28BP  12/03/2004 Hospice Pre- Election Evaluation and Counseling Services  01/03/2005  3585 R22BP  10/24/2004 Nurse Practitioners As Attending Physicians in the Medicare Hospice Benefit  06/28/2004  3226 R15BP  06/15/2004 Nurse Practitioners As Attending Physicians in the Medicare Hospice Benefit  N/A 3226 R1BP  10/01/2003 Introduction to the Benefit Policy Manual  N/A N/A Back to top of Chapter
(Medicare Benefit Policy Manual)
Medicare Benefit Policy Manual  Chapter 10 - Ambulance Services   Table of Contents (Rev. 243, 04-13-18)  Transmittals for Chapter 10  10 - Ambulance Service 10.1 - Vehicle and Crew Requirement  10.1.1 - The Vehicle 10.1.2 - Vehicle Requirements for Basic Life Support and Advanced Life Support  10.1.3 - Verification of Compliance  10.1.4 - Ambulance Services Furnished by Providers of Services  10.1.5 - Equipment and Supplies  10.2 - Necessity and Reasonableness  10.2.1 - Necessity for the Service  10.2.2 - Reasonableness of the Ambulance Trip  10.2.3 - Medicare Policy Concerning Bed -Confinement  10.2.4 - Documentation Requirements  10.2.5-Transport of Persons Other Than the Beneficiary  10.2.6 - Effect of Beneficiary Death on Medicare Payment for Ground Ambulance Transports  10.3 - The Destination  10.3.1 - Institution to Beneficiarys Home  10.3.2 - Institution to Institution  10.3.3  Separately Payable Ambulance Transport Under Part B Versus Patient Transportation that is Covered Under a Packaged Institutional Service 10.3.4  Transports to and from Medical Services for Beneficiaries who are not Inpatients  10.3.5 - Locality  10.3.6 - Appropriate Facilities  10.3.7 - Partial Payment
(Medicare Benefit Policy Manual)
10.3.8 - Ambulance Service to Physicians Office  10.3.9 - Transportation Requested by Home Health Agency  10.3.10  Multiple Patient Ambulance Transport  10.4 - Air Ambulance Services  10.4.1 -  Coverage Requirements  10.4.2 -  Medical Reasonablenes s 10.4.3 -  Time Needed for Ground Transport  10.4.4 -  Hospital to Hospital Transport  10.4.5 -  Special Coverage Rule 10.4.6 -  Special Payment Limitations  10.4.7 -  Documentation 10.4.8 -  Air Ambulance Transports Canceled Due to Weather or Other Circumstances Beyond the Pilots Control  10.4.9 -  Effect of Beneficiary Death on Program Payment for Air Ambulance Transports  10.5 -  Joint Responses  20 - Coverage Guidelines for Ambulance Service Claims  20.1 -  Mandatory Assignment Requirements  20.1.1 -  Managed Care Providers/Suppliers  20.1.2 -  Beneficiary Signature Requirements  30 - Implementation of the Ambulance Fee Schedule  30.1 -  Definition  of Ambulance Services  30.1.1 -  Ground Ambulance Services  30.1.2 -  Air Ambulance Services  10 - Ambulance Service  (Rev. 1, 10-01-03) B3-2120, A3-3114, HO-236  Ambulance services are separately payable only under Part B.  There are certain circumstances in which the service is covered and payable as a beneficiary transportation service under Part A; however in this case the service cannot be classified and paid f or as an ambulance service under Part B. (See 10.3.3 for a description of this exception.  Also see 10.2.4  for the required documentation for ambulance services.)  Payment  may be made for expenses incurred for ambulance service provided the conditions specified in the following subsections are met.  (See the Medicare Claims Processing Manual, Chapter 15, Ambulance, for instructions for processing ambulance service claims. )  The Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.  When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance provider/supplier that actually furnishes the transport.  10.1 - Vehicle and Crew Requirement  (Rev. 1, 10-01-03) B3-2120.1, A3-3114, HO-236.1
(Medicare Benefit Policy Manual)
10.1.1 - The Vehicle  (Rev. 1, 10-01-03) B3-2120.1.A, A3-3114.A, HO-236.1.A   Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies and, in nonemergency situations, be capable of transporting beneficiaries with acute medical conditions.  The vehicle must comply with State or local laws governing the licensing and certification of an emergency medical t ransportation vehicle.  At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by State or local law.  This should include, at a minimum, one 2-way voice radio or wireless telephone.   10.1.2 - Vehicle Requirements for Basic Life Support and Advanced Life Support  (Rev. 226, Issued: 09-12-16, Effective: 01-01-16, Implementation: 12 -12-16)  Basic Life Support (BLS) ambulances must be staffed by at least two people, who meet the requirements of state and local laws where the services are being furnished and where, at least one of whom must (1) be certified at a minimum as an emergency medical technician -basic (EMT -basic) by the state or local authority where the services are being furnished and ( 2) be legally authorized to operate all lifesaving and life -sustaining equipment on board the vehicle.   Advanced Life Support (ALS) vehicles must be staffed by at least two people , who meet the requirements of state and local laws where the services are being furnished and where at least one of whom must (1) meet the vehicle staff requirements above for BLS vehicles and (2) be certified as an EMT -Intermediate or an EMT -Paramedic by the state or local authority where the services are being furnished to perform one or more ALS services.   10.1.3 - Verification of Compliance  (Rev. 1, 10- 01-03) B3-2120.1.C, B3- 2120.1.C, HO -236.1
(Medicare Benefit Policy Manual)
10.1.3 - Verification of Compliance  (Rev. 1, 10- 01-03) B3-2120.1.C, B3- 2120.1.C, HO -236.1  In determining whether the vehicles and personnel of each supplier meet all of the above requirements, A/B MACs (B) may accept the supp liers statement (absent information to the contrary) that its vehicles and personnel meet all of the requirements if:  1. The statement describes the first aid, safety, and other patient care items with which the vehicles are equipped;   2. The statement shows t he extent of first aid training acquired by the personnel assigned to those vehicles;   3. The statement contains the suppliers agreement to notify the A/B MAC (B) of any change in operation which could affect the coverage of ambulance services; and   4. The information provided indicates that the requirements are met.  The statement must be accompanied by documentary evidence that the ambulance has the equipment required by State and local authorities.  Documentary evidence could include a letter from such au thorities, a copy of a license, permit, certificate, etc., issued by the authorities.  The A/B MAC (B) will keep the statement and supporting documentation on file.  When a supplier does not submit such a statement or whenever there is a question about a suppliers compliance with any of the above requirements for vehicle and crew (including suppliers who have completed the statement), A/B MACs (B) will take appropriate action including, where necessary, on -site inspection of the vehicles and verification of the qualifications of personnel to determine whether the ambulance service qualifies for reimbursement under Medicare.  Since the requirements described above for coverage of ambulance services are applicable to the overall operation of the ambulance suppliers service, information regarding personnel and vehicles need not be obtained on an individual trip basis.  10.1.4 - Ambulance Services Furnished by Providers of Services  (Rev. 1, 10- 01-03) A3-3114, B3- 2120.1, HO -236.1
(Medicare Benefit Policy Manual)
10.1.4 - Ambulance Services Furnished by Providers of Services  (Rev. 1, 10- 01-03) A3-3114, B3- 2120.1, HO -236.1  The A/B MAC (A) is responsible for the processing of claims for ambulance service furnished under arrangements by participating hospitals, skilled nursing facilities, and home health agencies.  Since provider ambulance services furnished under arrangements with suppliers can be covered only if the supplier meets the above requirements, the A/B MAC (A) may ask the A/B MAC (B) to identify those suppliers who meet the requirements.  Where the "under arrangement" supplier also supplies ambulance services directly to Medicare beneficiaries,  i.e., services that are not pursuant to an arrangement with a provider, the A/B MAC (A) contacts the A/B MAC (B) to ascertain whether it has already determined whether the crew and ambulance requirements are met.  In such a situation, the A/B MAC (A) should accept the A/B MAC (B)s determination without pursuing its own investigation.  10.1.5 - Equipment and Supplies  (Rev. 1, 10- 01-03) A3-3114.A, B3- 2120.2.E   As mentioned above, the ambulance must have customary patient care equipment and first aid supplie s, including reusable devices and equipment such as backboards, neckboards, and inflatable leg and arm splints.  These are all considered part of the general ambulance service and payment for them is included in the payment rate for the transport.  10.2 - Necessity and Reasonableness  (Rev. 1, 10- 01-03) B3-2120.2, A3- 3114.B, HO -236.2  To be covered, ambulance services must be medically necessary and reasonable.   10.2.1 - Necessity for the Service (Rev. 1, 10- 01-03) B3-2120.2.A, A3- 3114.B, HO -236.2
(Medicare Benefit Policy Manual)
10.2.1 - Necessity for the Service (Rev. 1, 10- 01-03) B3-2120.2.A, A3- 3114.B, HO -236.2  Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated.  In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance services.  In all cases, the appropriate documentation must be kept on file and, upon request, presented to the A/B MAC (A) or (B).  It is important to note that the presence (or absence) of a physicians order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary.  The ambulance service must meet all program coverage criteria in order for payment to be made.   In addition, the reason for the ambulance transport must be medically necessary.  That is, the transport must be to obtain a Medicare covered service, or to return from such a service.   10.2.2 - Reasonableness of the Ambulance Trip  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)  Under the FS payment is made according to the level of medically necessary services actually furnished.  That is, payment is based on the level of service furnished (provided they were medically necessary), not simply on the vehicle used.  Even if a local government requires an ALS response for all calls, payment under the FS is made only for the level of service furnished, and then only when the service is medically nece ssary.   10.2.3 - Medicare Policy Concerning Bed -Confinement  (Rev. 1, 10- 01-03)  As stated above, medical necessity is established when the patients condition is such that the use of any other method of transportation is contraindicated.  A/B MACs (A) and (B) may presume this requirement is met under certain circumstances, including w hen the beneficiary was bed -confined before and after the ambulance trip (see 20  for the complete list of circumstances).   A beneficiary is bed -confined if he/she is: