[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR418.302]



[Page 928-929]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 418_HOSPICE CARE--Table of Contents

 

                   Subpart G_Payment for Hospice Care

 

Sec. 418.302  Payment procedures for hospice care.



    (a) CMS establishes payment amounts for specific categories of 

covered hospice care.

    (b) Payment amounts are determined within each of the following 

categories:

    (1) Routine home care day. A routine home care day is a day on which 

an individual who has elected to receive hospice care is at home and is 

not receiving continuous care as defined in paragraph (b)(2) of this 

section.

    (2) Continuous home care day. A continuous home care day is a day on 

which an individual who has elected to receive hospice care is not in an 

inpatient facility and receives hospice care consisting predominantly of 

nursing care on a continuous basis at home. Home health aide or 

homemaker services or both may also be provided on a continuous basis. 

Continuous home care is only furnished during brief periods of crisis as 

described in Sec. 418.204(a) and only as necessary to maintain the 

terminally ill patient at home.

    (3) Inpatient respite care day. An inpatient respite care day is a 

day on which the individual who has elected hospice care receives care 

in an approved facility on a short-term basis for respite.

    (4) General inpatient care day. A general inpatient care day is a 

day on which an individual who has elected hospice care receives general 

inpatient care in an inpatient facility for pain control or acute or 

chronic symptom management which cannot be managed in other settings.

    (c) The payment amounts for the categories of hospice care are fixed 

payment rates that are established by CMS in accordance with the 

procedures described in Sec. 418.306. Payment rates are determined for 

the following categories:

    (1) Routine home care.

    (2) Continuous home care.

    (3) Inpatient respite care.

    (4) General inpatient care.

    (d)(1) The intermediary reimburses the hospice its appropriate 

payment amount for each day for which an eligible Medicare beneficiary 

is under the hospice's care.

    (2) Effective December 8, 2003, if a hospice makes arrangements with 

another hospice to provide services under the circumstances specified in 

section 1861(dd)(5)(D) of the Act, the intermediary reimburses the 

hospice for which the beneficiary has made an



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election as described in paragraph (d)(1) of this section.

    (e) The intermediary makes payment according to the following 

procedures:

    (1) Payment is made to the hospice for each day during which the 

beneficiary is eligible and under the care of the hospice, regardless of 

the amount of services furnished on any given day.

    (2) Payment is made for only one of the categories of hospice care 

described in Sec. 418.302(b) for any particular day.

    (3) On any day on which the beneficiary is not an inpatient, the 

hospice is paid the routine home care rate, unless the patient receives 

continuous care as defined in paragraph (b)(2) of this section for a 

period of at least 8 hours. In that case, a portion of the continuous 

care day rate is paid in accordance with paragraph (e)(4) of this 

section.

    (4) The hospice payment on a continuous care day varies depending on 

the number of hours of continuous services provided. The continuous home 

care rate is divided by 24 to yield an hourly rate. The number of hours 

of continuous care provided during a continuous home care day is then 

multiplied by the hourly rate to yield the continuous home care payment 

for that day. A minimum of 8 hours of care must be furnished on a 

particular day to qualify for the continuous home care rate.

    (5) Subject to the limitations described in paragraph (f) of this 

section, on any day on which the beneficiary is an inpatient in an 

approved facility for inpatient care, the appropriate inpatient rate 

(general or respite) is paid depending on the category of care 

furnished. The inpatient rate (general or respite) is paid for the date 

of admission and all subsequent inpatient days, except the day on which 

the patient is discharged. For the day of discharge, the appropriate 

home care rate is paid unless the patient dies as an inpatient. In the 

case where the beneficiary is discharged deceased, the inpatient rate 

(general or respite) is paid for the discharge day. Payment for 

inpatient respite care is subject to the requirement that it may not be 

provided consecutively for more than 5 days at a time. Payment for the 

sixth and any subsequent day of respite care is made at the routine home 

care rate.

    (f) Payment for inpatient care is limited as follows: (1) The total 

payment to the hospice for inpatient care (general or respite) is 

subject to a limitation that total inpatient care days for Medicare 

patients not exceed 20 percent of the total days for which these 

patients had elected hospice care.

    (2) At the end of a cap period, the intermediary calculates a 

limitation on payment for inpatient care to ensure that Medicare payment 

is not made for days of inpatient care in excess of 20 percent of the 

total number of days of hospice care furnished to Medicare patients.

    (3) If the number of days of inpatient care furnished to Medicare 

patients is equal to or less than 20 percent of the total days of 

hospice care to Medicare patients, no adjustment is necessary. Overall 

payments to a hospice are subject to the cap amount specified in Sec. 

418.309.

    (4) If the number of days of inpatient care furnished to Medicare 

patients exceeds 20 percent of the total days of hospice care to 

Medicare patients, the total payment for inpatient care is determined in 

accordance with the procedures specified in paragraph (f)(5) of this 

section. That amount is compared to actual payments for inpatient care, 

and any excess reimbursement must be refunded by the hospice. Overall 

payments to the hospice are subject to the cap amount specified in Sec. 

418.309.

    (5) If a hospice exceeds the number of inpatient care days described 

in paragraph (f)(4), the total payment for inpatient care is determined 

as follows:

    (i) Calculate the ratio of the maximum number of allowable inpatient 

days to the actual number of inpatient care days furnished by the 

hospice to Medicare patients.

    (ii) Multiply this ratio by the total reimbursement for inpatient 

care made by the intermediary.

    (iii) Multiply the number of actual inpatient days in excess of the 

limitation by the routine home care rate.

    (iv) Add the amounts calculated in paragraphs (f)(5)(ii) and (iii) 

of this section.



[48 FR 56026, Dec. 16, 1983, as amended at 56 FR 26919, June 12, 1991; 

70 FR 45145, Aug. 4, 2005]



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