N.J. Admin. Code § 10:53A-4.2

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:53A-4.2 - Basis of payment-hospice providers

(a) The Division reimburses an approved hospice provider for those hospice services related to the terminal illness and included in the beneficiary's plan of care according to the methodology and indices in section 1814(i)(1)(C)(ii), 1814(i)(2)(B), and 1814(i)(2)(D) of the Social Security Act.

1. One of the four predetermined, cost-related prospective payment rates subject to the "cap" amounts (see 10:53A-1.2 for definition of "cap") is reimbursed for each day the beneficiary is receiving hospice services (see 10:53A-4.4 for calculations). The rates vary depending on the level of care which is based on the type and intensity of services furnished on that day and are consistent with the plan of care. The levels of care are, as follows:

i. Routine home care;

ii. Continuous home care;

iii. Inpatient respite care; and

iv. General inpatient care.

(b) The rules regarding the reimbursement for each level of care related to the per diem are described below:

1. The hospice is reimbursed at the routine home care rate for routine nursing services, social work, counseling services, durable medical equipment, medical supplies and equipment, drugs, biologicals, home health aide/homemaker services, physical therapy, occupational therapy, and speech-language pathology services. The "routine home care rate" is also reimbursed to the hospice for home care provided continuously that is not predominately nursing care and includes respite care delivered in the home.

i. The "routine home care rate" is reimbursed when the beneficiary is not receiving "continuous home care rate" regardless of the volume and intensity of routine home care services.

2. The hospice is reimbursed at the continuous home care rate for services provided in periods of acute medical crisis, where the predominance of care is skilled nursing care on a continuous basis, to achieve palliation or management of the beneficiary's acute medical symptoms and only as necessary to maintain the beneficiary at home.

i. At least eight hours of nursing care in a 24-hour period has to be provided before the continuous home care rate may be paid. Continuous home care is reimbursed at the continuous home care daily rate divided by 24 to determine the hourly rate. For every hour of continuous care furnished, the hourly rate is reimbursed up to 24 hours furnished in a day, as applicable.

ii. Up to 24 hours of nursing care in a 24-hour period in the home may be provided primarily by the registered professional nurse, or a licensed practical nurse together with and under the supervision of a registered professional nurse, with the support of the homemaker/home health aide staff.

3. The hospice is reimbursed at the inpatient respite care rate for care provided on an intermittent, non-routine, and/or occasional need basis for each day a hospice eligible beneficiary is in an approved inpatient facility (nursing facility or general hospital) receiving respite care. The beneficiary is not in need of general inpatient care.

i. Payment for inpatient respite care is made for a maximum of five consecutive days at a time, including the date of admission but not counting the date of discharge. Payment of the sixth day and any subsequent day is reimbursed at the routine home care rate.

(1) The hospice may be paid the appropriate home care rate (either the routine or continuous home care rate) for the discharge day unless the beneficiary dies as an inpatient. When the beneficiary dies as an inpatient, the inpatient respite rate is reimbursed for the day of death.

ii. Payments to a hospice for inpatient respite care are also limited according to the aggregate number of days of inpatient respite care furnished to Medicaid/NJ FamilyCare FFS patients per year for that particular hospice. (See 10:53A-4.4 for further description relating to the calculation of this limitation.)

iii. The hospice "inpatient respite care rate" is not reimbursed to the nursing facility for care provided to nursing facility patients that are not Medicaid/NJ FamilyCare FFS hospice patients of a Medicaid/NJ FamilyCare participating hospice. Thus, even though the hospice patients are residing in a nursing facility, the provider shall consider the beneficiary, for reimbursement purposes, a hospice patient, not a nursing facility patient.

4. The general inpatient care rate is reimbursed for services provided in a hospital or nursing facility in periods of acute medical crisis, for hospitalized beneficiaries for palliative care for pain control or management of acute and severe clinical problems which cannot be managed in other settings. For example, reimbursement at the general inpatient care rate is made during situations when the beneficiary's condition is such that it is no longer possible to maintain the beneficiary at home, as determined and specified in the plan of care.

i. None of the other fixed payment rates, such as routine home care, are applicable for the day on which the patient receives hospice general inpatient care, except as stated below for the day of discharge.

(1) For the day of discharge from an inpatient unit, the appropriate home care rate (either the routine or continuous home care rate) is reimbursed unless the beneficiary dies as an inpatient. In this situation, when the beneficiary dies, the general inpatient care rate is reimbursed for the day of death.

ii. Payments to a hospice for general inpatient care are limited according to the aggregate number of days of inpatient care furnished to Medicaid/NJ FamilyCare FFS patients per year for that particular hospice. (See 10:53A-4.4 for information on calculating this limitation.)

(c) In addition to the per diem rates listed in (a) above, the following rates may be reimbursed according to the special circumstances listed below:

1. The room and board rate is reimbursed on a per diem basis for hospice services provided to Medicaid/NJ FamilyCare FFS hospice beneficiaries at the specific Medicaid participating NF where the hospice beneficiary is residing. This rate may be reimbursed to the hospice in addition to the rate for routine home care or continuous home care. (Note: The Medicaid/NJ FamilyCare FFS hospice beneficiary residing in a NF is not a beneficiary of the nursing facility (NF) but a hospice beneficiary.)

i. The room and board rate is calculated at 95 percent of the approved Medicaid NF per diem rate (institutionally specific) effective at the time services are provided, and excluding retroactive rate adjustments, retroactive add-ons and special program rates for private and county nursing facilities. The "approved Medicaid NF per diem rate effective at the time services are provided," means the rate that was effective for the date of service, and shall not include any subsequent retroactive rate adjustments made between the date of service and the date of claim submission. After the NF's room and board rate is calculated, the patient's total available income shall be deducted to determine the rate billed to the Medicaid program. The NF contracts with the hospice to accept the beneficiary based on actual room and board components provided to the beneficiary by the NF. The provider number and name of the nursing facility where the beneficiary resides and with whom the hospice contracts must be placed in the "REMARKS" area of the CMS 1500 claim.

(1) The calculated rate used by the hospice as the per diem room and board rate may be obtained from:

Department of Health

Division of Senior Benefits and Utilization

Office of Nursing Facility Rate Setting and Reimbursement

PO Box 715

Trenton, New Jersey 08625

ii. The Division shall continue to pay the hospice the room and board rate for the purpose of retaining the bed for therapeutic leave or during a period of hospitalization, if indicated. The hospice is responsible through its contract with the NF to reimburse the NF to retain the bed.

(1) Nursing facility bed reservation days rate (for therapeutic leave from the NF to home): The hospice is reimbursed the room and board rate for reserving an NF bed for hospice beneficiaries residing in an NF who return to a home setting temporarily for therapeutic leave. The bed reservation days rate (not to exceed 24 days per calendar year) is paid to the hospice provider in addition to the rate of routine home care or continuous home care.

(2) Nursing facility bed reservation days rate is reimbursed during a period of hospitalization (commonly known as "bed hold days"): The hospice is reimbursed the room and board rate for reserving a nursing facility bed for hospice beneficiaries residing in a nursing facility who require inpatient hospitalization. Bed reservation days (not to exceed 10 consecutive days per period of hospitalization) are paid to the hospice in addition to the rate for general inpatient care.

(3) The responsibility for the bed reservation policy, listed in (c)1ii(1) and (2) above, and the submission of claims for these days rests with the hospice.

(d) Payment of the four "level of care" rates will be made to hospice providers at the predetermined minimum prospective Medicaid payment rates revised annually by the Federal Centers for Medicare and Medicaid Services (CMS) (see N.J.A.C. 10:53A-5 for the references for the methodology). The payment rates will be adjusted by the Division for regional differences in wages, using indices and methodology determined by CMS.

1. A hospice program shall submit claims for payment for hospice routine home care and continuous home care furnished in an individual's home based on the geographic location at which the service is furnished, that is, the county in which the beneficiary's home is located, rather than the location of the service provider's business office.

2. A hospice program shall submit claims for payment for hospice routine home care and continuous home care provided to a beneficiary whose permanent residence is a nursing facility based on the geographic location at which the service is furnished; that is, the county in which the nursing facility is located, rather than the location of the service provider's business office.

3. A hospice program shall submit claims for payment for hospice inpatient respite care and general inpatient care, which is furnished in an approved inpatient facility based on the geographic location at which the service is furnished, that is, the county in which the approved inpatient facility is located, rather than the location of the service provider's business office.

4. The regional designation of a provider for wage adjustment purposes will be determined by the location at which the hospice service is provided to the beneficiary.

5. Since the four level of care rates are prospective rates, there shall be no retroactive adjustments other than the application of the "cap" on overall payments and the limitation on payments for inpatient care, if applicable. The rate paid for any particular day may vary depending on the level of care furnished to the beneficiary. The cap and limitation on payment for inpatient care are described in 10:53A-4.4.

(e) No deductible shall be imposed for services furnished by hospices to Medicaid/NJ FamilyCare FFS beneficiaries during the period of election, regardless of the setting in which the services are provided.

1. Hospices shall not charge Medicaid/NJ FamilyCare beneficiaries directly for Medicare coinsurance amounts.

(f) For beneficiaries at home who are dually eligible for both Medicare and Medicaid, and who are receiving Medicare hospice benefits, the hospice may bill the Medicaid fiscal agent for the five percent co-payment for outpatient drugs and biologicals on the CMS 1500 claim.

1. The co-payment reimbursement shall be a maximum of five percent per prescription cost of each outpatient drug and/or biologicals but shall not exceed $ 5.00 for each prescription.

2. Copies of the Explanation of Medicare Benefits (EOMB), or other health, or insurance carriers' denial, or Explanation of Benefits (EOB) statements, or other third party liability statements shall be attached to the copy of the CMS 1500 claim filed in the beneficiary's billing record, as well as an invoice for the outpatient drugs and/or biologicals to which the five percent co-payment is applied for post payment review. The pharmacy attachment or EOMB (EOB, etc.) shall not be attached to the CMS 1500 claim submitted to the Medicaid fiscal agent.

(g) For beneficiaries who are dually eligible for Medicare and Medicaid and who are receiving Medicare hospice benefits, the hospice may bill the Medicaid fiscal agent for the Medicare co-payment for each inpatient respite care day equal to five percent of the payment made for each respite care day by Medicare.

1. Copies of the EOMB, or other health or life insurance carriers' denial, or EOB statements, or other third party liability statements shall be attached to a copy of the CMS 1500 claim filed in the beneficiary's medical record, as well as an invoice for inpatient respite care to which the five percent co-payment is applied. The invoice for inpatient respite care or the EOMB (EOB, etc.) shall not be attached when submitting the CMS 1500 claim to the fiscal agent.

(h) In addition, for dually eligible Medicare and Medicaid hospice beneficiaries, the hospice shall submit claims first to Medicare. Payment by Medicaid for unrelated services or for coinsurance requires an EOMB or EOB to be attached to the claim submitted to the Medicaid Fiscal Agent.

(i) The hospice shall not overlap from one calendar month to another in the billing process or bill for more than one calendar month's hospice benefit and/or room and board charges on each claim form.

(j) The amount of the Medicare coinsurance payment to be reimbursed to the hospice by Medicaid shall be submitted on a separate CMS 1500 claim from the other per diem charges.

N.J. Admin. Code § 10:53A-4.2

Amended by 48 N.J.R. 134(a), effective 1/19/2016