C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-43, subsec. 144-101-II-43.07

Current through 2024-51, December 18, 2024

Subsection 144-101-II-43.07 - REIMBURSEMENT

43.07-1Levels of Care

Each day of care is classified into one of four levels of care:

1. Routine Home Care

2. Continuous Home Care

3. Inpatient Respite Care

4. General Inpatient Care

For each day a member receives hospice care, the hospice will be reimbursed an amount applicable to the type and intensity of the services provided to the member for that day. For continuous home care, payment is determined based on the number of hours of continuous care furnished that day. A description of each level of care follows.

A.Routine Home Care rate is billed for each day the member is under the care of the hospice and not receiving one of the other categories of hospice care.

In-home respite care may also be billed as Routine Home Care, as long as the respite providers are qualified to perform Routine Home Care services under this Section.

B.Continuous Home Care is to be provided only during a period of crisis. A period of crisis is a period in which a member requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms. Nursing care must be provided by either a registered nurse or licensed practical nurse, and a nurse must be providing care for more than half of the period of care. A minimum of eight (8) hours of care must be provided during a twenty-four (24) hour day beginning at midnight. This care need not be continuous. For example, four (4) hours could be provided in the morning and another four (4) hours that evening. Homemaker and home health aide services may also be provided to supplement the nursing care. Continuous care is covered when it is provided to maintain a member at home during a medical crisis. If less skilled care is needed on a continuous basis to enable the person to remain at home, this is covered as routine home care.

C.Inpatient Respite Care is a day of care in which the member receives care in an approved facility for short-term respite only when necessary to relieve the family members or others caring for the member at home. Respite care may be provided only occasionally and may not be reimbursed at the inpatient respite care rate for more than five (5) consecutive days at a time. Payment for the sixth (6^th) and any subsequent day is at the routine home care rate.

Respite care may not be provided when the member is in a nursing home or any other residential facility. For in-home respite care, refer to Section 43.07-1(A), Routine Home Care.

D.General Inpatient Care is a day of care when a member receives general inpatient care in an inpatient facility for pain control or acute or chronic symptom management which cannot be managed in other settings.

43.07-2Reimbursement Policy

Reimbursement for covered services shall be made on the basis of a per diem, quarter hour, or hourly rate and shall be the lowest of:

A. The amount established by the Department and listed in the MaineCare Provider Fee Schedule; or

B. The lowest amount allowed under the Medicare Hospice benefit for covered services with the following exception:

For Routine Home Care only, as is described in Section 43.07-1(A) of this rule, that is rendered on or after April 1, 2002, the lowest rate of MaineCare reimbursement shall be equal to 123% of the Medicare rate.

43.07-3Payment for Routine Home Care

A.Routine Home Care Payment

There are two routine home care payment rates. There is a higher payment for the first sixty (60) days of hospice care and a reduced payment for days thereafter. Hospice providers are required to set their charge rate to appropriately reflect the transition to the lower Routine Home Care rate after sixty (60) days.

If a member revokes his or her election of hospice benefits, or otherwise exits from routine home care hospice status during the first sixty (60) days of routine home care, and later returns to routine home care hospice status, the revocation or exit of routine home care hospice status must last more than sixty (60) days in order for the higher payment to begin again. If the exit status is less than sixty (60) days, then the sixty (60) day count will continue as if the exit status has not occurred.

B.Service Intensity Add-On (SIA) Payment

A service intensity add-on payment will be made for a visit (not telephone or electronic) by a registered nurse (RN) or a clinical social worker when provided during routine home care in the last seven (7) days of a member's life.

The SIA payment is in addition to the routine home care rate. Payment is made only for services of at least fifteen (15) minutes and up to a total of four (4) hours of services provided (for a total of both RN and clinical social worker services) that occurred on the day of service.

In accordance with Chapter I of the MaineCare Benefits Manual, the provider must seek payment from any other available sources before billing MaineCare. MaineCare shall not provide differential payments to hospices that have entered into reimbursement agreements with other payers.

43.07-4Payment for Physician Services

The basic payment rates for hospice care are designed to reimburse the hospice for the costs of all covered services related to the treatment of the member's terminal illness, including the administrative and general supervisory activities performed by physicians who are employees of, or working under arrangements with the hospice. These activities would generally be performed by the Medical Director and the physician on the Interdisciplinary Team. Team activities would include participation in developing plans of care, supervision of care and services, periodic review and update of plans of care and establishing governing policies. The costs for these services are included in the reimbursement rates for routine home care, continuous home care and inpatient respite care.

Payment will be made to the hospice, when it also meets the provider enrollment requirements for services described in the MaineCare Benefits Manual under Section 90, "Physician Services," for other physician services not included in the reimbursement rates for routine home care, continuous home care and inpatient respite care. These include direct member care services, furnished to individual members by hospice employees and under arrangements made by the hospice, unless the member care services were furnished on a volunteer basis. The hospice will be reimbursed in accordance with the usual MaineCare reimbursement policy for Physician Services in Chapter II, Section 90 of the MaineCare Benefits Manual. This reimbursement is in addition to the daily rates.

43.07-5Payment for Inpatient Care

Payment for inpatient care is limited. During the twelve (12) month period beginning November 1 of each year and ending October 31 of the following year, the aggregate number of reimbursable inpatient days (both for inpatient general care and respite care) shall be capped. The aggregate number of reimbursable inpatient days may not exceed twenty (20) percent of the aggregate days of hospice care provided to all MaineCare members during that twelve (12) month period by the hospice provider. Days of inpatient care provided to members with AIDS (acquired immunodeficiency syndrome) may be excluded from the days counted toward the twenty (20) percent limit.

If the total number of days of inpatient hospice care furnished to MaineCare members is less than or equal to the maximum, no adjustment shall be made. If the total number of days of inpatient care exceeds the maximum allowable number, excess payments must be refunded by the hospice to the Department.

If requested, the hospice shall report to the Department the aggregate number of inpatient days (both for inpatient general care and inpatient respite care) and the aggregate number of days of hospice care provided to all MaineCare members during the "cap" period. The report shall be sent by October 1st following the end of the period (September 30 of the previous year) to:

Hospice Benefits

Division of Financial Services-Long Term Care Reimbursement

Office of MaineCare Services

11 State House Station

Augusta, ME 04333-0011

43.07-6Payment Based on Location Where Care is Provided

Hospice providers must submit claims for payment for hospice care furnished in a member's home or a nursing facility based on the place of service, rather than the location of the hospice.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-43, subsec. 144-101-II-43.07