Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOSPICE › Section 16.03.10.456 - HOSPICE: PROVIDER REIMBURSEMENT

Current through August 31, 2023
With the exception of payment for physician services under
				  Section 458 of these
				  rules, Medicaid reimbursement for hospice care will be made at one (1) of five
				  (5) predetermined rates for each day in which a participant receives the
				  respective type and intensity of the services furnished under the care of the
				  hospice. The five (5) rates are prospective rates; there will be no retroactive
				  rate adjustments other than the application of the "cap" on overall payments,
				  the service intensity add-on, and the limitation on payments for inpatient
				  care, if applicable. A description of the payment for each level of care is
				  described in Subsections
				  456.01 through
				  456.04 of these rules.
				  (3-17-22)
01.
Routine Home
				Care
. The hospice provider will be paid one (1) of two (2) routine home
				care rates for each day the patient is in residence, under the care of the
				hospice, and not receiving continuous home care. The rate is paid without
				regard to the volume or intensity of routine home care services provided on any
				given day. The two-rate payment methodology will result in a higher based
				payment for days one (1) through sixty (60) of hospice care and a reduced rate
				for days sixty-one (61) to end-of-care. If a participant leaves hospice care
				and then later is placed back on hospice care, regardless of hospice provider,
				a minimum of a sixty (60) day gap in hospice services is required in order for
				the routine home care rate to be paid at the higher base payment rate. If there
				is not a minimum of a sixty (60) day gap in hospice services being provided,
				the hospice provider will be paid at the rate for which the participant is
				qualified. (3-17-22)
02.
Continuous Home Care
. Continuous home care is to be provided only
				during a period of crisis. A period of crisis is a period in which a patient
				requires continuous care that is primarily nursing care to achieve palliation
				and management of acute medical symptoms. Care must be provided by either a
				licensed registered nurse or a licensed practical nurse and a nurse must
				provide care for at least half the total period of care. A minimum of eight (8)
				hours of care must be provided during a twenty-four (24) hour day that begins
				and ends at midnight. This care need not be continuous and uninterrupted. If
				less skilled care is needed on a continuous basis to enable the person to
				remain at home, this is covered as routine home care. For every hour or part of
				an hour of continuous care furnished, the hourly rate will be reimbursed to the
				hospice up to twenty-four (24) hours per day. (3-17-22)
03.
Inpatient Respite Care
. The
				hospice will be paid at the inpatient respite care rate for each day that the
				participant is in an approved inpatient facility and is receiving respite care.
				Payment for respite care may be made for a maximum of five (5) days at a time
				including the date of admission but not counting the date of discharge in any
				monthly election period. Payment for the sixth and any subsequent day is to be
				made at the appropriate rate routine, continuous, or general inpatient rate.
				(3-17-22)
04.
General
				Inpatient Care
. Payment at the inpatient rate will be made when general
				inpatient care is provided. No other fixed payment rates will be applicable for
				a day on which the participant receives hospice general inpatient care except
				as described in Section
				458 of these rules. (3-17-22)
a. Date of discharge. For the day of
				discharge from an inpatient unit, the appropriate home care rate is to be paid
				unless the patient dies as an inpatient. When the patient is discharged as
				deceased, the inpatient rate, either general or respite, is to be paid for the
				discharge date. (3-17-22)
b.
				Hospice payment rates. The Medicaid hospice payment rates are the same as the
				Medicare hospice rates, adjusted to disregard cost offsets attributable to
				Medicare coinsurance amounts. Under the Medicaid hospice benefit, no cost
				sharing may be imposed with respect to hospice services rendered to Medicaid
				participants. (3-17-22)
c.
				Obligation of continuing care. After the participant's hospice benefit expires,
				the patient's Medicaid hospice benefits do not expire. The hospice must
				continue to provide that participant's care until the patient expires or until
				the participant revokes the election of hospice care.
				(3-17-22)