Or. Admin. R. 410-142-0300 - Hospice Reimbursement and Limitations
(1) The Division recalculates its hospice
rates annually. When billing for hospice services, the provider must bill the
usual charge or the rate based upon the geographic location in which the care
is furnished, whichever is lower. See hospice rates on the Oregon Health
Authority (Authority) website at:
http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Hospice.aspx.
(2) Rates:
(a) The Division bases its rates on the
methodology used in setting Medicare rates, adjusted to disregard cost offsets
attributable to Medicare coinsurance amounts;
(b) Under the Medicaid hospice benefit
regulations, the Division cannot impose cost sharing for hospice services
rendered to Medicaid recipients;
(c) The Division sets rates no lower than the
rates used under Part A of Title XVIII of the Social Security Act
(Medicare);
(d) The Division uses
prospective hospice rates;
(e) The
Division makes no retroactive adjustments other than the optional application
of the cap on overall payments and the limitation on payments for inpatient
care, if applicable.
(3)
With the exception of payment for physician services, the Division reimburses
providers of hospice services for each day of care at one of five predetermined
rates. Rates are based on intensity and type of care, which the Division
defines as:
(a) Routine home care. The
Division pays the hospice the routine home care rate for each day that the
client is under the care of the hospice and that the Division does not
reimburse at another rate. The Division pays this rate without regard to the
volume or intensity of services provided on any given day;
(b) Continuous home care. The Hospice must
provide a minimum of eight hours of continuous home care per day to receive the
continuous home care rate:
(A) The continuous
home care rate is divided by 24 hours in order to arrive at an hourly
rate;
(B) The Division pays the
hospice for every hour or part of an hour of continuous care furnished up to a
maximum of 24 hours a day.
(c) Inpatient respite care. The Division pays
the hospice at the Inpatient Respite Care rate for each day on which the client
is in an approved inpatient facility and is receiving respite care:
(A) The Division pays for inpatient respite
care for a maximum of five days at a time, including the date of admission but
not counting the date of discharge;
(B) The Division pays for the sixth and any
subsequent days at the routine home care rate.
(d) General inpatient care. The Division pays
providers at the general inpatient rate when general inpatient care is
provided;
(e) In-home respite care.
An in-home respite care day is a day on which short-term in-home care is
provided to the client only when necessary to relieve the family members or
other persons caring for the client at home. Respite care may be provided only
on an occasional basis and may not be reimbursed for more than five consecutive
days at a time. In-home respite care will be provided at the level necessary to
meet the client's need, with a minimum of eight hours of care provided in a
24-hour day, which begins and ends at midnight. Hospice aide/CNA or homemaker
services or both may be utilized for providing in-home respite care.
(4) On the day of discharge from
an inpatient unit, the Division pays the appropriate home care rate unless the
client dies as an inpatient. When the client is discharged deceased, the
Division pays the appropriate inpatient rate (general or respite) for the
discharge date.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
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