Routine
Home Care Rate $97.1107-99 REIMBURSEMENT FOR HOSPICE CARE 402.3
401. GENERAL
With the exception of payment for physician services (see §406), Medicare reimbursement for hospice care is made at one of four predetermined rates for each day in which a Medicare beneficiary is under the care of the hospice. The four rates are prospective rates; there are no retroactive adjustments other than the application of the statutory "cap" on overall payments and the limitation on payments for inpatient care. The rate paid for any particular day varies depending on the level of care furnished to the beneficiary. The statutory "cap" (calculated by the Medicare intermediary) and the limitations on payment for inpatient care are described in sections that follow.
402. LEVELS OF CARE
There are four levels of care into which each day of care is classified:
A. Routine Home Care
B. Continuous Home Care
C. Inpatient Respite Care
D. General Inpatient Care
For each day that a Medicare beneficiary is under the care of a hospice, the hospice is reimbursed an amount applicable to the type and intensity of the services furnished to the beneficiary for that day. For levels A, C, and D only one rate is applicable for each day. For level B, the amount of payment is determined based on the number of hours of continuous care furnished to the beneficiary on that day. A description of each level of care follows.
402.1 Routine Home Care.--The hospice is paid the routine home care rate for each day the patient is under the care of the hospice and not receiving one of the other categories of hospice care. This rate is paid without regard to the volume or intensity of routine home care services provided on any given day, and is also paid when the patient is receiving hospital care for a condition unrelated to the terminal condition.
402.2 Continuous Home Care.--The hospice is paid the continuous home care rate when continuous home care is provided. (See §230.2A.) The continuous home care rate is divided by 24 hours in order to arrive at an hourly rate. A minimum of 8 hours must be provided. For every hour or part of an hour of continuous care furnished, the hourly rate is paid for up to 24 hours a day.
402.3 Inpatient Respite Care.--The hospice is paid at the inpatient respite care rate for each day on which the beneficiary is in an approved inpatient facility and is receiving respite care. (See §230.2B.) Payment for respite care may be made for a maximum of 5 days at a time including the date of admission but not counting the date of discharge. Payment for the sixth and any subsequent days is to be made at the routine home care rate.
402.4 REIMBURSEMENT FOR HOSPICE CARE 07-99
402.4 General Inpatient Care.--Payment at the inpatient rate is made when general inpatient care is provided. (See §230.1E.) None of the other fixed payment rates (i.e., routine home care) are applicable for a day on which the patient receives hospice inpatient care except as described in §402.5.
402.5 Date of Discharge.--For the day of discharge from an inpatient unit, the appropriate home care rate is to be paid unless the patient dies as an inpatient. When the patient is discharged deceased, the inpatient rate (general or respite) is to be paid for the discharge date.
403. HOSPICE PAYMENT RATES
The hospice rates, before area wage adjustments, for each of the categories of care described above, are as follows:
Routine
Home Care Rate $97.11
Continuous
Home Care Rates $566.82 Full Rate-24 hours of care
$23.62 Hourly Rate
Inpatient
Respite Care Rate $100.46
General
Inpatient Care Rate $432.01
These
rates are in effect for services provided on or after October 1, 1998 through
September 30, 1999.
404. LOCAL ADJUSTMENT OF PAYMENT RATES
The
payment rates above are adjusted for regional differences in wages. The hospice
wage index is published in the Federal Register each year, and is
effective October 1 of that year through September 30 of the following year.
Current wage index values can be obtained from the Federal Register
Notice announcing the update or from your intermediary. To select the proper
index for your area, first determine if your hospice is located in one of the
Urban Areas listed in Table A of the Federal Register notice. If
so, use the index for your area. If you are not listed as one of the Urban
Areas, use the index number of the rural area for your State, listed in Table B
of the Federal Register notice.
Once
you determine the index for your area, the computation of the rates for your
hospice can be made using the following tables in this section. Table I
indicates the portion of each of the rates subject to the wage index. Table II
is an example of the computation of wage adjusted rates for a
hospice located in Baltimore, Maryland, using the index
number of 1.0549. Table III is used to compute the rates applicable to
your hospice. The wage adjusted continuous care rate can then be divided by 24
to determine the hourly billing rate.
07-99 REIMBURSEMENT FOR HOSPICE CARE 404 (Cont.)
TABLE I
Wage
compo- Un-
National nent weighted
rate subject amount
to index
Routine Home Care $97.11 $66.72 $30.39
Continuous Home Care 566.82 389.46 177.36
Inpatient Respite 100.46 54.38 46.08
General Inpatient Care 432.01 276.53 155.48
TABLE II
Wage
Compo- Index
National nent for Adjusted Non-wage Adjusted
Rate subject Balto., Wage Component Rate
to index MD Component
Routine Home Care $97.11 $66.72 1.0549 $ 70.38 $ 30.39 $100.77
Continuous Home Care 566.82 389.46 1.0549 410.84 177.36 588.20
Inpatient Respite 100.07 54.38 1.0549 57.37 46.08 103.45
General Inpatient Care 432.01 276.53 1.0549 291.71 155.48 447.18
TABLE III
Wage Adjusted Non-wage Wage
compo- Index wage Compo- Adjusted
National nent for component nent Rates
Rate subject your (col. 2 x for
to index area*
col.3) your
area
(col. 4 +
col. 5)
col. 1 col. 2 col. 3 col.4 col. 5 col.6
Routine Home Care $ 97.11 $ 66.72 $ 30.39
Continuous Home Care 566.82 389.46 177.36
Inpatient Respite 100.07 54.38 46.08
General Inpatient Care 432.01 276.53 155.48
Continuous Home Care Rate, adjusted for wages = $ ¸24 hours = $ Hourly Rate
405. LIMITATION ON PAYMENTS FOR INPATIENT CARE
Payments to a hospice for inpatient care are subject to a limitation on the number of days of inpatient care furnished to Medicare patients. During the 12-month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient days (both for general inpatient care and inpatient respite care) may not exceed 20 percent of the aggregate total number of days of hospice care provided to all Medicare beneficiaries during that same period. This limitation is applied once each year, at the end of the hospices' "cap period" (11/1 - 10/31). For purposes of this computation, if the intermediary determines that the inpatient rate should not be paid, any days for which you receive payment at a home care rate are not counted as inpatient days. The limitation is calculated by your intermediary as follows:
o The maximum allowable number of inpatient days is calculated by multiplying the total number of days of Medicare hospice care by 0.2.
o If the total number of days of inpatient care furnished to Medicare hospice patients is less than or equal to the maximum, no adjustment is necessary.
o If the total number of days of inpatient care exceeded the maximum allowable number, the limitation is determined by:
1. calculating a ratio of the maximum allowable days to the number of actual days of inpatient care, and multiplying this ratio by the total reimbursement for inpatient care (general inpatient and inpatient respite reimbursement) that was made.
2. multiplying excess inpatient care days by the routine home care rate.
3. adding together the amounts calculated in 1. and 2. above.
4. comparing the amount in 3. above with interim payments made to the hospice for inpatient care during the "cap period."
Any excess reimbursement is refunded by the hospice.
406. PAYMENT FOR PHYSICIAN SERVICES
Payment for physician services provided in conjunction with the hospice benefit is made in different ways:
A. Administrative Activities.--Payment for physicians' administrative and general supervisory activities is included in the payment rates listed in §403. These activities include participating in the establishment, review and updating of plans of care, supervising care and services and establishing governing policies.
These activities are generally performed by the physician serving as the medical director and the physician member of the interdisciplinary group.
B. Patient Care Services.--Payment for physicians' direct patient care services furnished by hospice employees or under arrangement with the hospice is made in the following manner:
o Formulate a charge and bill the intermediary for these services.
o The intermediary pays you at the lesser of the actual charge or 100 percent of the Medicare reasonable charge for these services. This payment is in addition to the daily rates.
o Payment for physicians' services is counted with the payments made at the daily payment rates to determine whether the hospice cap amount has been exceeded.
o No payment is made for physician services furnished voluntarily. However, some physicians may seek payment for certain services while furnishing other services on a volunteer basis. Payment may be made for services not furnished voluntarily if you are obligated to reimburse the physician for the services. A physician must treat Medicare patients on the same basis as other patients in the hospice; a physician may not designate all services rendered to non-Medicare patients as volunteer and at the same time bill the hospice for services rendered to Medicare patients.
EXAMPLE: Dr. Jones has an agreement with a hospice to serve as its medical director on a volunteer basis. Dr. Jones does not furnish any direct patient care services on a volunteer basis. A Medicare beneficiary enters the hospice and designates Dr. Jones as her attending physician. When he furnishes a direct service to the beneficiary, he bills the hospice for this service and the hospice in turn bills the intermediary and is paid for the service. Dr. Jones may not bill Medicare Part B as an independent attending physician because as a volunteer he is deemed to be a hospice employee.
C. Attending Physician Services.--Payment for patient care services rendered by a physician designated by the hospice patient as the attending physician is made in the following manner:
o Patient care services rendered by an attending physician who volunteers services to the hospice is made in accordance with subsection B. (This is because physicians who volunteer services to the hospice are, as a result of this volunteer status, considered employees of the hospice in accordance with 42 CFR 418.3).
o Patient care services rendered by an independent attending physician (a physician who is not considered employed or under contract with the hospice) are not part of the hospice benefit. These physicians bill the Medicare carrier directly. Payment for services to hospice patients is made directly by the carrier to the independent attending physician at 80 percent of the reasonable charge.
Only the independent attending physician's personal professional services to the patient may be billed; the costs for services such as lab or x-rays are not to be included in the bill.
The hospice must notify the Medicare carrier of the hospice election and the name of the physician who has been designated as the attending physician whenever the attending physician is not a hospice employee.
This reimbursement is not counted in determining whether the hospice cap amount has been exceeded because services provided by an independent attending physician are not part of the hospice's care.
Services provided by an independent attending physician must be coordinated with any direct care services provided by hospice physicians.
407. CAP ON OVERALL REIMBURSEMENT
Overall aggregate payments made to a hospice are subject to a "cap amount," calculated by the intermediary at the end of the hospice cap period. The cap period runs from November 1st of each year through October 31 of the next year. The total payment made for services furnished to Medicare beneficiaries during this period are compared to the "cap amount" for this period. Any payments in excess of the cap must be refunded by the hospice. "Total payment made for services furnished to Medicare beneficiaries during this period" refers to payment for services rendered during the cap year beginning November 1st and ending October 31, regardless of when payment is actually made. Payments are measured in terms of all payments made to hospices on behalf of all Medicare hospice beneficiaries receiving services during the cap year, regardless of which year the beneficiary is counted in determining the cap. For example, payments made to a hospice for an individual electing hospice care on October 5, 1997, pertaining to services rendered in the cap year beginning November 1, 1996, and ending October 31, 1997, are counted as payments made during the first cap year (November 1, 1996 - October 31, 1997), even though that individual is not counted in the calculation of the cap for that year. (The individual is, however, to be counted in the cap calculation for the following year since the election occurred after September 27 - see below).
The hospice cap is to be calculated in a different manner for new hospices entering the program if the hospice has not participated in the program for an entire cap year. In this situation, we require that the initial cap calculations for newly certified hospices cover a period of at least 12 months but not more than 23 months. For example, the first cap period for a hospice entering the program on October 1, 1997, runs from October 1, 1997 through October 31, 1998. Similarly, the first cap period for hospice providers entering the program after November 1, 1996 but before November 1, 1997 ends October 31, 1998.
The "cap amount" is calculated by multiplying the number of beneficiaries electing hospice care during the period by a statutory amount of $6,500. This amount will be adjusted in future years to reflect the percentage increase or decrease in the medical care expenditure category of the Consumer Price Index (CPI) for all urban consumers (U.S. city average), published by the Bureau of Labor Statistics (BLS), from March 1984 to the fifth month of the accounting year. Section 407.1 explains how the statutory cap amount of $6,500 is to be adjusted in future years. Hospices that began operations before January 1, 1975, are eligible for an exception to the application of this cap. You must apply and be approved to receive this waiver. Send applications to:
Health Care Financing Administration
Chronic Care and Purchasing Policy Group, CHPP
C5-02-23
7500 Security Boulevard
Baltimore, MD. 21244-1850
The computation and application of the "cap amount" is made by the intermediary at the end of the cap period. The material is presented here for your benefit as an aid to planning. You are responsible for reporting the number of Medicare beneficiaries electing hospice care during the period to the intermediary. This must be done within 30 days after the end of the cap period.
Follow these rules in determining the number of Medicare beneficiaries who have elected hospice care during the period:
o The beneficiary must not have been counted previously in either another hospice's cap or another reporting year.
o The beneficiary must file an initial election during the period beginning September 28 of the previous cap year through September 27 of the current cap year in order to be counted as an electing Medicare beneficiary during the current cap year. This slight adjustment is necessary to produce a reasonable estimate of the proportionate number of beneficiaries to be counted in each cap period.
Once a beneficiary has been included in the calculation of a hospice cap amount, he or she may not be included in the cap for that hospice again, even if the number of covered days in a subsequent reporting period exceeds that of the period where the beneficiary was included. (This could occur when the beneficiary has breaks between periods of election.)
When a beneficiary elects to receive hospice benefits from two or more different Medicare certified hospices, proportional application of the cap amount is necessary. It is inequitable to count the patient's stay in the hospices as equivalent if there were marked differences in the lengths of stay. Consequently, a calculation must be made to determine the percentage of the patient's length of stay in each hospice relative to the total length of hospice stay. The intermediary servicing the hospice program in which the beneficiary dies or exhausts the hospice benefit is responsible for determining the proportionate lengths of stay for all preceding hospices. This intermediary is also responsible for disseminating this information to any other intermediaries servicing hospices in which the beneficiary was previously enrolled. Each intermediary then adjusts the number of beneficiaries reported by these hospices based on the latest information available at the time the cap is applied.
EXAMPLE: John Doe, a Medicare beneficiary, initially elects hospice care from hospice A on September 2, 1997. Mr. Doe stays in hospice A until October 2, 1997 (30 days) at which time he changes his election and enters hospice B. Mr. Doe stays in hospice B for 70 days until his death on December 11, 1997. The intermediary servicing hospice B is responsible for determining the proportionate number of Medicare beneficiaries to be reported by each hospice that delivered hospice services to Mr. Doe. This intermediary determines that the total length of hospice stay for Mr. Doe is 100 days (30 days in hospice A and 70 days in hospice B). Since Mr. Doe was in hospice A for 30 days, Hospice A counts .3 of a Medicare beneficiary for Mr. Doe in its hospice cap calculation (30 days/100 days). Hospice B counts .7 of a Medicare beneficiary in its cap calculation (70 days/100 days). The intermediary servicing hospice B makes these determinations and notifies the intermediary servicing hospice A of its determination. These intermediaries are then responsible for making appropriate adjustments to the number of beneficiaries reported by each hospice in the determination of the hospice cap.
Readjustment of the hospice cap may be required if information previously unavailable to the intermediary at the time the hospice cap is applied subsequently becomes available.
EXAMPLE: Using the example above, if the intermediary servicing hospice A had calculated and applied the hospice cap on November 30, 1997, information would not have been available at that time to adjust the number of beneficiaries reported by hospice A, since Mr. Doe did not die until December 11, 1997. The intermediary servicing hospice A would have to recalculate and reapply the hospice cap to hospice A based on the information it later received from the intermediary servicing hospice B. The cap for hospice A after recalculation would then reflect the proper beneficiary count of .3 for Mr. Doe.
An additional step is required when more than one Medicare certified hospice provides care to the same individual, and the care overlaps 2 cap years. In this case, each intermediary must determine in which cap year the fraction of a beneficiary is reported. If the beneficiary entered the hospice before September 28, the fractional beneficiary is included in the current cap year. If the beneficiary entered the hospice after September 27, the fractional beneficiary is included in the following cap year.
EXAMPLE: Continuing with the case cited in the examples above, hospice A includes .3 of a Medicare beneficiary in its cap calculation for the cap year beginning November 1, 1996, and ending October 31, 1997, since Mr. Doe entered hospice A before September 28, 1997. Hospice B includes .7 of a Medicare beneficiary in its cap calculation for the cap year beginning November 1, 1997, and ending October 31, 1998, since Mr. Doe entered hospice B after September 27, 1997.
Where services are rendered by two different hospices to one Medicare patient, and one of the hospices is not certified by Medicare, no proportional application is necessary. The intermediary counts one patient and uses the total cap for the certified hospice.
We do not expect that the situation of beneficiaries changing to other hospices occurs frequently, thus we do not anticipate that the effect on hospice payments is significant.
407.1 Adjustments to Cap Amount.--The original cap amount of $6,500 per year is to increase or decrease for accounting years that end after October 1, 1984 by the same percentage as the percentage of increase or decrease in the medical care expenditure category of the consumer price index for all urban consumers (United States city average), published by the Bureau of Labor Statistics, from March 1984 to the fifth month of the accounting year. As indicated in 42 CFR 418.309, the hospice cap is applied on the basis of a cap year beginning November 1 and ending the following October 31.
For example, for the cap amount for the period ending October 31, 1998, we calculate using the March 1998 price level in the medical care expenditures category of 239.8 and divide by the March 1984 price level of 105.4 to yield an index of 2.275 (rounded). The new hospice cap amount is the product of $6500 (base year cap) multiplied by 2.214. Therefore, the cap amount for the period ending October 31, 1997, is $14,788.
In those situations where a hospice begins participation in Medicare at any time other than the beginning of a cap year (November 1st), and hence has an initial cap calculation for a period in excess of 12 months, a weighted average cap amount is used. The following example illustrates how this is accomplished.
EXAMPLE:
10/01/97 - Hospice A is Medicare certified.
10/01/97 to 10/31/98 - First cap period (13 months) for hospice A.
Statutory cap for first Medicare cap year (11/01/96 - 10/31/97) = $14,394
Statutory cap for second Medicare cap year (11/01/97 - 10/31/98) = $14,788
Weighted average cap calculation for hospice A:
One month (10/01/97 - 10/31/97) at $14,394 = $ 14,394
12 months (11/01/97 - 10/31/98) at $14,788 = $177,456
13 month period $191,850 divided by 13 = $14,758 (rounded)
In this example, $14,758 is the weighted average cap amount used in the initial cap calculation for hospice A for the period October 1, 1997 through October 31, 1998.
NOTE: If hospice A had been certified in mid-month, a weighted average cap amount based on the number of days falling within each cap period is used.
408. APPEALS
A. Individual Determinations.--
1. Beneficiary Appeals.--A hospice beneficiary is entitled to the full range of appeal rights for cases involving a denial of benefits in accordance with the procedures in Part 405, Subpart G of the regulations (i.e., 42 C.F.R. §§405.701 et seq.). In these cases, a beneficiary may request a reconsideration regardless of the amount in controversy. If the beneficiary is dissatisfied with the reconsideration determination, he may request a hearing before an Administrative Law Judge (ALJ) if the amount in controversy is at least $100. If dissatisfied with the ALJ's decision, he may request an Appeals Council review. If $1,000 or more remains in controversy following the Appeals Council review or Appeals Council denial of a request for review, the beneficiary may file suit in a United States District Court.
2. Hospice Appeals.--A hospice, as is the case with any Medicare Part A provider, is entitled to appeal a claim filed on behalf of an individual only if the individual does not exercise his appeal rights and if the initial determination involves: (1) An intermediary finding that the items or services are not reasonable and necessary (§1862(a)(1) determination), and (2) An intermediary finding that either they or the beneficiary provider, or both, knew or could reasonably have been expected to know that such items or services were excluded from coverage. The authority for such provider appeal is found in §1879(d) of the Act.
In the following circumstances, a hospice has the full range of appeal rights specified in Subpart G (i.e., reconsideration, ALJ hearing, Appeals Council review and judicial review), if amounts in controversy are met and the beneficiary does not exercise his appeal rights.
a. When an intermediary finds that items or services furnished to a beneficiary are not covered because they are not reasonable and necessary for the palliation or management of terminal illness and further finds that the beneficiary or the hospice, or both, should have known this. (The hospice may not combine claims from more than one beneficiary to reach the $100 minimum for an ALJ hearing.)
b. When a hospice submits a claim requesting payment at the continuous home care rate, the intermediary is obliged to determine the medical necessity for continuous home care (i.e., an 1862(a)(1) determination).* If the intermediary decides that continuous home care is not medically necessary and pays the claim at the routine care rate, the hospice may appeal the benefit reduction if the intermediary finds that either the beneficiary or the hospice, or both, knew or should have known that the services were not covered at the continuous home care level. (The hospice may not combine claims from more than one beneficiary to reach the $100 minimum for an ALJ hearing.)
*To constitute continuous home care, care must be provided for at least 8 hours. (See §230.2.) If such care is not provided for a minimum of 8 hours, a technical denial occurs (not an 1862(a)(1) determination) and the hospice has no appeal rights.
3. Beneficiary Representation by Hospice.--To be represented by a hospice, the beneficiary must execute a form SSA-1696-U4, Appointment of Representative, in addition to the appropriate reconsideration or hearing request. The SSA-1694-U4 form must contain the signed acceptance of an authorized official of the hospice being appointed.
When the appeal involves either services that constitute custodial care or are not reasonable and necessary and thus the application of the limitation of liability provisions under §1879 of the Act, the hospice representative (attorney or non-attorney) must waive in writing any right to payment from the beneficiary for these services. The intermediary must obtain the written waiver even when the claim is initially paid under the limitation of liability provision, i.e., when it finds that neither the hospice nor the beneficiary is liable. This waiver requirement is intended to insure against conflict of interest.
A hospice representative (including an attorney) cannot charge the beneficiary a fee in connection with such representation.
The costs incurred by a hospice in representing a beneficiary in an unsuccessful appeal are not allowed as reasonable costs in determining its Medicare reimbursement.
B. Provider Payment Determinations.--A hospice dissatisfied with an intermediary determination, as set out in a notice issued to the hospice at the end of the cap year may request and obtain an intermediary hearing if the amount of program reimbursement in controversy with respect to matters for which the hospice has a right to review is at least $1,000, but less than $10,000. Where the dispute involves $10,000 or more, jurisdiction lies with the Provider Reimbursement Review Board (PRRB). A request for a hearing must be filed no later than the 180th calendar day following the date the hospice received notice of the intermediary's determination. The hearing is conducted consistent with the procedures in Part 405, Subpart R of the regulations (i.e., 42 C.F.R. §§405.1800 et seq.), and a decision by the PRRB is subject to review only by the Administrator of HCFA. There is no judicial review of the final administrative decision.
Examples of types of reimbursement issues for which a hospice may request a hearing are as follows:
1. Calculation and application of the hospice cap.
2. Calculation of reimbursement where the hospice is found to have exceeded the 80/20 ratio of home care to inpatient care days.
The methods and standards for the calculation of the hospice payment rates established by HCFA, as well as questions as to the validity of the applicable law, regulations, or HCFA rulings, are not subject to administrative review.
NOTE: Generally, matters involving payment to a hospice of an incorrect payment rate with respect to one or more of the categories of hospice care (this may, for example, result from the use of a money amount other than the applicable payment rate calculated by HCFA or from an incorrect adjustment of such rate to reflect local differences in wages) are expected to be resolved by the intermediary. However, if these matters are unresolved at the end of the cap year, the hospice has a right to a hearing.
409. COST REPORTING AND RECORDKEEPING REQUIREMENTS
A. Cost Reports.--HCFA is developing cost reporting forms and instructions and will distribute them to hospices upon completion so that any needed changes can be made in their recordkeeping systems. The information collected through these cost reports will be used to update reimbursement rates in the future. In no case will cost reports be required more often than annually.
B. Final Settlement.--There are no retroactive adjustments made to the reimbursement rates discussed above, other than application of the limits discussed in §§405 and 407 above. The cost reports are used strictly for data collection.
C. Accounting Requirements.--The cost data submitted must be on the accrual basis of accounting and in accordance with generally accepted accounting principles. All books and records shall be retained for 5 years. HCFA reserves the right to audit any cost or utilization data collected. Sufficient documentation must be maintained for audit purposes, and to support the allocation of costs.
410. HOSPICE COINSURANCE
The payment rates in §403 have been reduced by a coinsurance amount on outpatient drugs and biologicals and inpatient respite care as required by law. No other coinsurance or deductibles may be imposed for services furnished to beneficiaries during the period of an election, regardless of the setting of the services. You may charge beneficiaries for the applicable coinsurance amounts.
410.1 Coinsurance on Outpatient Drugs and Biologicals.--The statute specifies that you may charge the beneficiary a coinsurance amount equal to 5 percent of the reasonable cost of the drug or biological to the hospice, but not more than $5, for each prescription furnished on an outpatient basis. The payment rates have been reduced by average coinsurance expected to be collected. If you intend to charge coinsurance, establish a "drug copayment schedule" that specifies each drug and the copayment to be charged. The charges included on the schedule must approximate 5 percent of the cost of the drugs of biologicals to you, up to the $5 maximum. Additionally, the cost of the drug or biological may not exceed what a prudent buyer would pay in similar circumstances. Submit this schedule to the intermediary, who will review it in advance to assure that it is reasonable.
410.2 Coinsurance on Inpatient Respite Care.--You may charge the beneficiary a coinsurance amount equal to 5 percent of the amount HCFA has estimated to be the cost of respite care, after adjusting the national rate for local wage differences. The following table may be used to calculate the amount that a hospice may charge for respite coinsurance.
Wage Adjusted Inpatient Respite Care
Rate for your area (from Table III, p. 4-5) $
¸95%
Rate for Inpatient Respite Care Including Coinsurance
x
5%
Coinsurance amount your hospice may charge $
No retroactive adjustments will be made to coinsurance amounts already collected from beneficiaries for inpatient respite care days as a result of any reimbursement adjustments made, such as application of the limitation on payments for inpatient care (see §405).
The total amount of coinsurance for inpatient respite care for any beneficiary during a hospice coinsurance period may not exceed the amount of the inpatient hospital deductible applicable for the year in which the hospice coinsurance period began. A hospice coinsurance period begins with the first day for which an election for hospice services is in effect for the beneficiary and ends with the close of the first period of 14 consecutive days on which no such election is in effect for the beneficiary.
Example: Mr. Brown elected an initial 90-day period of hospice care. Five days after the initial period of hospice care ended, Mr. Brown began another period of hospice care under a subsequent election. Immediately after that period ended, he began a third period of hospice care under a final election period. Since these election periods were not separated by 14 consecutive days, they constitute a single hospice coinsurance period. Therefore, the maximum coinsurance for respite care during all three periods of hospice care may not exceed the amount of the inpatient hospital deductible for the year in which the first period began.
The hospice is responsible for billing and collecting the coinsurance amounts from the beneficiary.
411. PROHIBITION AGAINST BILLING OTHERS FOR COVERED SERVICES
Section 1866 of the Social Security Act requires providers (including hospice providers) to file an agreement with the Secretary of Health and Human Services in order to be qualified to participate and to be eligible for payment under the Medicare program. In this agreement the hospice agrees not to charge (and accordingly may not charge) any individual or any other person for items or services for which the individual is entitled to have payment made under the hospice provision. Where items and services are not subject to the Medicare secondary payer provision, Medicare is the primary payer for all covered benefits and another insurer should not be billed for these items or services. (The secondary payer provision may be in effect if the patient or spouse is employed and has coverage under the employer's health insurance program.) For example, a hospice may not bill a third party such as an insurance company or the American Cancer Society for covered palliative drugs and biologicals for which payment is made through the Medicare rates.
If a hospice furnishes, at the request of a beneficiary, items or services in addition to those that are covered under the hospice provision, the hospice may charge the beneficiary for these items or services.
Rev. 13 4-10.1