Section 17b-262-846 - Payment limitations(a) It is expected that the provider shall provide bereavement counseling to the client's family after the client's death; however the department shall not pay the provider for such bereavement counseling.(b) For a twelve month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient days, both general inpatient and respite, shall not exceed twenty percent of the aggregate number of days of hospice care provided to all hospice clients during that same period. At the department's discretion, the days of inpatient care provided to individuals with AIDS may be excluded from the days counted toward the twenty percent limitation.(c) Payment for inpatient care is limited as follows:(1) The total payment to the provider for inpatient care, general and respite, is subject to a limitation that total inpatient care days for Medicaid clients not exceed 20 percent of the total days for which these clients had elected hospice care.(2) At the end of a twelve-month period specified in subsection (b) of this section, the department calculates a limitation on payment for inpatient care to ensure that Medicaid 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 Medicaid clients. Payments to nursing facilities and ICF/MRs where Medicaid is the secondary payer to Medicare shall be excluded from the calculation.(3) If the number of days of inpatient care furnished to Medicaid clients is equal to or less than 20 percent of the total days of hospice care to Medicaid clients, no adjustment is necessary. Overall payments to a provider are subject to the cap amount specified in 42 CFR 418.309. Any provider that has received an exemption as specified in 42 CFR 418.108(e) shall be exempt from this provision.(4) If the number of days of inpatient care furnished to Medicaid clients exceeds 20 percent of the total days of hospice care to Medicaid clients, the total payment for inpatient care is determined in accordance with subsection (c)(5) of this section. That amount is compared to actual payments for inpatient care and any excess reimbursement shall be refunded by the provider or recouped from subsequent claims. Overall payments to the provider are subject to the cap amount specified in 42 CFR 418.309.(5) If a provider exceeds the number of inpatient care days described in subsection (c)(4) of this section, the total payment for inpatient care is determined as follows: (A) calculate the ratio of the maximum number of allowable inpatient days to the actual number of inpatient care days furnished by the provider to Medicaid clients;(B) multiply this ratio by the total reimbursement for inpatient care made by the department;(C) multiply the number of actual inpatient days in excess of the limitation by the routine home care rate;(D) add the amounts calculated in subsections (c)(5)(B) and (C) of this section.(E) compare the amount in section 5(D) of this section with the total reimbursement to the hospice provider for inpatient care during that period. The amount that total reimbursement to the hospice exceeds the amount calculated in section 5(D) of this section is the amount due from the hospice provider.(d) Applied income shall be calculated and deducted from the department's payment to the provider for a client living in a nursing facility or a hospice facility as follows: (1) Clients who receive hospice services while residing in a hospice facility or in a nursing facility pursuant to a room and board arrangement with a hospice are responsible for paying applied income to the hospice provider.(2) The department shall calculate the applied income liability and shall inform the client and the provider of the amount that the client is required to contribute towards the cost of care each month. The client's applied income liability shall be deducted from the amount that the department would otherwise pay to the hospice provider each month.(3) The provider and the nursing facility may assign responsibility for collecting the client's applied income and may assign the risk of loss for nonpayment in their agreement, depending on the result of their negotiations. In no event shall the department be liable to a hospice or to a nursing facility in the event that a client fails to pay his or her applied income obligation.(4) The provider shall notify the department's caseworker of any errors in the amount of applied income processed against the claim using the form specified by the department. Payment adjustments resulting from retroactive applied income corrections shall be processed periodically.(5) In any month that a resident returns to the community or dies, and the cost of care is less than the applied income, the department shall adjust the applied income as follows: the applied income shall equal the number of days that the resident was in the hospice multiplied by the per diem rate.(6) Applied income is not pro rated. It is used to cover the cost of care until it is expended.(e) A nursing facility that enters into an agreement with a hospice to provide room and board services for clients shall accept the amount paid by the hospice, if any, pursuant to the contractual agreement between the hospice and the nursing facility as payment in full. In no event may a nursing facility assert a claim against a client, or against the department, in the event that the hospice fails to pay the nursing facility in accordance with their agreement, except that a nursing facility may assert a claim against a client for nonpayment of the client's applied income amount only when the agreement between the hospice and the nursing facility assigns responsibility for collecting the client's applied income liability to the nursing facility.Conn. Agencies Regs. § 17b-262-846
Adopted effective July 7, 2009