Mont. Admin. r. 37.40.830 - HOSPICE, REIMBURSEMENT
(1)
Medicaid payment for covered hospice care will be made in accordance with the
specific categories of covered hospice care and the payment amounts and
procedures established by Medicare under
42 CFR
418.301 through
418.312. The specific categories
of covered hospice care include:
(a) routine
home care day;
(b) continuous home
care day;
(c) inpatient respite
care day;
(d) general inpatient
care day; and
(e) service intensity
add-on.
(2) Hospice
Routine Home Care (RHC) level of care days will be paid at one of two RHC
rates. RHC per-diem payment rates for the RHC level of care will be paid
depending on the timing of the day within the patient's episode of care. Days 1
through 60 will be paid at the RHC "High" rate while all other days will be
paid at the RHC "Low" rate.
(3) The
room and board rate to be paid a hospice for a Medicaid beneficiary who resides
in a nursing facility will be the Medicaid rate established by the department
in ARM 37.40.307 for the individual
facility minus the amount the beneficiary pays toward their own cost of care.
Payment for room and board will be made to the hospice and, in turn, the
hospice will reimburse the nursing facility. General inpatient care or hospice
respite care in a nursing facility will not be reimbursed directly by the
Medicaid program when a Medicaid recipient elects the hospice benefit payment.
Under such circumstances payment will be made to the hospice in accordance with
this rule.
(a) In this context, the term
"room and board" includes performance of personal care services, including
assistance in the activities of daily living, socializing activities,
administration of medication, maintaining the cleanliness of a resident's room,
and supervision and assisting in the use of durable medical equipment and
prescribed therapies.
(4)
The following services performed by hospice physicians are included in the
rates described in (1)(a) through (1)(d):
(a)
general supervisory services of the medical director; and
(b) participation in the establishment of
plans of care, supervision of care and services, periodic review and updating
of plans of care, and establishment of governing policies by the physician
member of the interdisciplinary group.
(5) For services not described in (4),
Medicaid will pay the hospice for those physician services furnished by hospice
employees or under arrangements with the hospice in accordance with ARM
37.86.101,
37.86.104, and
37.86.105. Reimbursement for these
physician services is included in the amount subject to the hospice limit
described in (6). Services furnished voluntarily by physicians are not
reimbursable.
(6) Services of the
patient's attending physician , if he or she is not an employee of the hospice
or providing services under arrangements with the hospice, are not considered
hospice services and are not included in the amount subject to the hospice
payment limit.
(7) Medicaid
reimbursement to a hospice in a cap period is limited to a cap amount
established using Medicare principles.
(8) The department will notify the hospice of
the determination of program reimbursement at the end of the cap
year.
(9) Payments made to a
hospice during a cap period that exceed the cap amount are overpayments and
must be refunded.
(10) The
department adopts and incorporates by reference the Hospice Rates FFY 24 fee
schedule, effective October 1, 2023. Copies of the department 's current fee
schedules are posted at http://medicaidprovider.mt.gov and
may be obtained from the Department of Public Health and Human Services, Senior
and Long Term Care Division, P.O. Box 4210, Helena, MT 59604-4210.
Notes
AUTH: 53-6-113, MCA; IMP: 53-6-101, MCA
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