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 FFY23 fee schedule, effective October 1, 2022.  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 & Long Term Care Division, 1100 N. Last Chance Gulch, P.O. Box 4210, Helena, MT 59604-4210.

 

History: 53-6-113, MCA; IMP, 53-6-101, MCA; NEW, 1989 MAR p. 842, Eff. 7/1/89; TRANS, from SRS, 2000 MAR p. 489; AMD, 2014 MAR p. 328, Eff. 2/14/14; AMD, 2015 MAR p. 144, Eff. 2/13/15; AMD, 2016 MAR p. 20, Eff. 1/9/16; AMD, 2016 MAR p. 1167, Eff. 7/9/16; AMD, 2017 MAR p. 305, Eff. 3/11/17; AMD, 2017 MAR p. 2287, Eff. 1/1/18; AMD, 2018 MAR p. 1288, Eff. 7/7/18; AMD, 2018 MAR p. 2057, Eff. 10/20/18; AMD, 2019 MAR p. 61, Eff. 1/12/19; AMD, 2020 MAR p. 93, Eff. 1/18/20; AMD, 2021 MAR p. 764, Eff. 6/26/21; AMD, 2022 MAR p. 1672, Eff. 8/6/22; AMD, 2023 MAR p. 672, Eff. 7/8/23.