471 Neb. Admin. Code, ch. 36, § 012 - PAYMENT

Medicaid pays for services provided under the Medicaid Hospice Benefit using the Medicaid hospice payment rates established by CMS.

012.01 For adult clients

Medicaid pays the inpatient respite care rate to the Hospice provider for each day the client is in an inpatient facility (hospital or nursing facility) and receiving respite care (See 471 NAC 36012.03).

Medicaid pays the general inpatient care rate to the Hospice provider during a period of acute medical crisis (See 471 NAC 36-012.04). Payment will be made only when the care is provided in a hospital or a contracted hospice inpatient facility.

Medicaid pays all costs for hospital services provided when a client receiving the Medicaid Hospice Benefit is hospitalized for an acute medical condition that is not related to the terminal diagnosis and/or complications secondary to the terminal diagnosis.

Determination of the cause of hospitalization will be made by the Hospice disciplinary team with consultation with the Medicaid Hospice Program Specialist. Payment for hospital services will be made directly to the hospital.

012.02 For child clients

Medicaid payment for hospital and nursing facility services shall be made directly to the hospital or nursing facility, including Inpatient Respite Care (see 471 NAC 36-012.05) and General Inpatient Care (see 471 NAC 36-012.06).

012.03 Routine Home Care

Medicaid pays the routine home care rate to the hospice provider for every day the client is at home, under the care of hospice, and not receiving continuous home care. This rate is paid without regard to the volume or intensity of routine home care services provided on any given day.

012.04 Continuous Home Care

Medicaid pays the continuous home care rate to the hospice provider to maintain a client at his/her place of residence when a period of medical crisis occurs. A period of medical crisis is a time when a client requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms. A registered nurse or a licensed practical nurse must provide nursing care. A nurse must be providing more than one half (51% or greater) of care given in a 24-hour period. A minimum of eight hours of care must be provided in a 24-hour period, which begins and ends at midnight. When the number of hours is less than 24, Medicaid pays the hourly rate. The hours may be split over the 24 hours to meet the needs of the client. Routine home care must be billed when fewer than eight hours of nursing care are provided.

012.05 Inpatient Hospital or Nursing Facility Respite Care

For adult clients, Medicaid pays the inpatient respite care rate to the hospice provider for each day the client is in an inpatient facility and receiving respite care. Hospice inpatient respite care is short-term inpatient care provided to the client when necessary to relieve the caregiver. Payment may be made for a maximum of five days per month counting the day of admission but not the day of discharge. The discharge day for inpatient respite care is billed at routine home care unless the client is discharged as deceased. When the client dies under inpatient respite care, the day of death is paid at the inpatient respite care rate. Inpatient respite care is not paid when the client is residing in a facility listed in 471 NAC 36-008.

012.06 General Inpatient Care

For adult clients, Medicaid pays the general inpatient care rate to the hospice provider during a period of acute medical crisis. General inpatient care may be necessary for pain control or acute/chronic symptom management that cannot be provided in any other setting. Care shall be provided in a hospital or a contracted hospice inpatient facility that meets the hospice standards regarding staffing and client care. When a severe breakdown in caregiving occurs, the general inpatient care rate shall be paid until other arrangements can be made, up to a maximum of ten days per month. The discharge day for general inpatient care is billed as routine home care unless the client is discharged as deceased. When the client dies under general inpatient care, the day of death is paid at the general inpatient care rate.

36-012.06A Limitation On Payments To A Hospice: Payments to a hospice for inpatient care must be limited according to the number of days of inpatient care furnished to Medicaid patients. During the 12-month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient days (both for general inpatient care and inpatient respite care) may not exceed 20 percent of the aggregate total number of days of hospice care provided to all Medicaid clients during that same period. Medicaid clients who have been diagnosed with acquired immunodeficiency syndrome (AIDS) are excluded in calculating this inpatient care limitation. This limitation is applied once each year, at the end of the hospices' "cap period" (11/1 -10/31). For purposes of this computation, if it is determined that the inpatient rate should not be paid, any days for which the hospice receives payment at a home care rate are not counted as inpatient days. The Department calculates the limitation as follows:

1. The maximum allowable number of inpatient days is calculated by multiplying the total number of days of Medicaid hospice care by 0.2.

2. If the total number of days of inpatient care furnished to Medicaid hospice patients is less than or equal to the maximum, no adjustment is necessary.

3. If the total number of days of inpatient care exceeded the maximum allowable number, the limitation is determined by:

a. Calculating a ratio of the maximum allowable days to the number of actual days of inpatient care, and multiplying this ratio by the total reimbursement for inpatient care (general inpatient and inpatient respite reimbursement) that was made;

b. Multiplying excess inpatient care days by the routine home care rate;

c. Adding together the amounts calculated in a and b; and comparing the amount in c with interim payments made to the hospice for inpatient care during the "cap period." Any excess reimbursement is refunded by the hospice.

Notes

471 Neb. Admin. Code, ch. 36, § 012