Ala. Admin. Code r. 560-X-51-.10

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-51-.10 - Reimbursement For Levels Of Care

(1) With the exception of payment for direct patient care services by physicians, payment is made to the hospice for all covered services related to the treatment of the recipient's terminal illness for each day during which the recipient is Medicaid eligible and under the care of the hospice regardless of the amount of services furnished on any given day.

(2) Payment for hospice care must conform to the methodology and amounts calculated by the Centers for Medicare and Medicaid Services (CMS). Medicaid hospice payment rates are based on the same methodology used in setting Medicare rates and adjusted to disregard offsets attributable to Medicare coinsurance amounts. Each rate is a prospectively determined amount which CMS estimates generally equals the costs incurred by a hospice in efficiently providing hospice care services to Medicaid beneficiaries. The rates will be adjusted by Medicaid to reflect local differences in wages.

(3) With the exception of payment for physician services as outlined in Rule 560-X-51-.11, Medicaid reimbursement for hospice care will be made at one of four rates for each day in which a Medicaid recipient is under the care of hospice. The payment amounts are determined within each of the following categories:

(a) Routine home care. The hospice shall receive reimbursement for routine home care for each day the recipient is at home, under the care of the 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.

(b) Continuous home care. The hospice shall receive reimbursement for continuous home care when, in order to maintain the terminally ill recipient at home, nursing care is necessary on a continuous basis during periods of crises. Continuous home care is intended only for periods of crises where predominantly skilled nursing care is needed on a continuous basis to achieve palliation or management of the recipient's acute medical symptoms; and only as necessary to maintain the recipient at home. A minimum of eight (8) hours per day must be provided. For every hour or part of an hour of continuous care furnished, the hourly rate will be reimbursed to the hospice up to 24 hours a day.

(c) Inpatient respite care. The hospice shall receive reimbursement for inpatient respite care for each day that the recipient is receiving respite care. Patients admitted for this type of care are not in need of general inpatient care. Inpatient respite care may be provided only on an intermittent, non-routine, and occasional basis and may not be reimbursed for more than five consecutive days, including date of admission, but not date of discharge.

(d) General inpatient care. The hospice shall be reimbursed for general inpatient care for each day that the recipient is in an approved inpatient facility for pain control or acute or chronic symptom management. Payment for total inpatient care days (general or respite) for Medicaid patients cannot exceed twenty percent of the aggregate total number of days of hospice care provided to all Medicaid recipients during each 12-month period of November 1 through October 31.

(4) Reimbursement for drugs not related to the recipient's terminal illness may be made to the dispensing pharmacy through the Medicaid Pharmacy Program.

(5) Reimbursement for disease specific drugs related to the recipient's terminal illness and drugs related to the terminal illness found on the Hospice Palliative Drug List (HPDL) are included in the per diem rates for hospice covered services and will not be reimbursed through the Medicaid Pharmacy Program. The HPDL is on the agency website at www.medicaid.alabama.gov.

(6) Medicaid will not restrict hospice services based on a patient's place of residence. If a beneficiary residing in a nursing home elects the Medicaid Hospice benefit, the Medicaid Program will pay the hospice directly an established rate in lieu of payments directly to the nursing home. The payment rate will be 95% of the rate Medicaid would have paid the nursing home directly for the same patient.

Ala. Admin. Code r. 560-X-51-.10

Emergency Rule effective October 1, 1990. Permanent Rule effective February 13, 1991. Amended: Filed August 6, 1993; effective September 10, 1993. Amended: Filed May 16, 2001; effective June 20, 2001. Amended: Filed June 11, 2003; effective July 16, 2003. Amended: Filed June 27, 2007; effective August 1, 2007. Amended: Filed August 11, 2008; effective September 15, 2008.

Author: Hattie M. Nettles, Associate Director, LTC Policy Advisory Unit

Statutory Authority: Title XIX, Social Security Act; 42 C.F.R. § 418.302; State Medicaid Manual; State Plan.