Hospice Cap

Table of Contents

• The Inpatient Day Limitation
• Aggregate Cap Calculation
• Beneficiary Count
  • Proportional Method (applies to most hospices)
  • Streamlined Method 

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The Inpatient Day Limitation

During the 12-month period beginning October 1 and ending September 30, the aggregate number of inpatient days (both general and respite) may not exceed 20 percent of the total days provided.

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Aggregate Cap Calculation

Overall aggregate Medicare payments made to a Medicare-certified hospice are subject to an aggregate cap. This cap is calculated by multiplying the statutory cap amount by the number of beneficiaries in the cap period and comparing this to payments received. The statutory cap amount is updated and published each year. The number of beneficiaries is determined by either the proportional method or the streamlined method. For either method, the PS&R system provides reports of the data in the Miscellaneous Reports section to identify the beneficiary counts.

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Beneficiary Count

Proportional Method (applies to most hospices)

For each hospice, the count of the number of Medicare beneficiaries counted is the fraction which represents the portion of a patient’s total days of care in all hospices and all years that was spent in this hospice in this cap year (October 1 to September 30)

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Streamlined Method

The count includes those Medicare beneficiaries who have not previously been included in the calculation of any hospice cap and who have filed an election to receive hospice care from the hospice during the period beginning on October 1 and ending on September 30.

Under the streamlined method, when a beneficiary has received care from more than one hospice, each hospice includes in its number of Medicare beneficiaries only that fraction which represents the portion of a patient's total stay in all hospices that was spent in this hospice in this cap year.

Comment: The streamlined method is only available to hospices that previously elected this method before 2012.

Items to obtain from the PS&R for the limitations:

• Number of beneficiaries electing hospice coverage
  • For patient by patient proportional method (Hospice Beneficiary Count Summary) – The 'From' date is 10/01/xxxx; and 'Through' date is 09/30/xxxx.
  • For streamlined method – The 'From' date is 10/01/xxxx and 'Through' date is 9/30/xxxx
• Medicare reimbursement for the service period 10/01 through 09/30
• Visit data by revenue type

Please note physician services are not excluded from the net reimbursement.