Medicare Two Tier Routine Home Care Payment Rate
Prior to 1/1/2016, Medicare paid a flat RHC level of payment for beneficiaries in a routine level of care. With the implementation of CR 9201, the single Medicare RHC rate will now be paid at a two tier level of payment, for claims with a date of service on or after 1/1/2016. Medicare will pay the RHC level of care at either a “high” RHC or a “low” RHC level of care based on the beneficiaries day count in the Medicare hospice program. Beneficiaries with a day count of 1-60, Medicare will pay a RHC “high” rate, and for beneficiaries with a day count of 61 or more days a RHC “low” rate will be paid.
Episode of Hospice Care
In order to better understand a beneficiary’s day count, it is important to first understand a new term, “episode of hospice care.” Episode of hospice care is defined as a hospice election period or series of election periods separated by no more than a 60 day gap in hospice care. Meaning, the first day of the beneficiary’s day count will start with the first day of the hospice episode of care. The hospice episode of care will continue until there is a break in hospice service of 60 or more days, even if some of the days are non-covered days. The beneficiary may revoke or be discharged during a hospice episode of care, however unless there is a 60 day or more break in service the hospice episode of care and beneficiary day count will resume when the beneficiary re-enters the Medicare hospice benefit. Once the beneficiary has had a 60 day gap in service a new hospice episode of care will start and this will initiate the start of a new patient day count.
The Medicare system does not require any special coding by provider. The Medicare system will calculate the patient’s episode day count based on the total number of days the patient has been receiving hospice care, separated by no more than 60 day gap in hospice care, regardless of level of care or whether those days were billable or not. This calculation would include hospice days that occurred prior to 1/1/2016.
Beneficiary Day Count Examples
Beneficiary on service prior to 1/1/2016:
A brand new beneficiary with no previous Medicare hospice elections or has had a gap in service greater than 60 days is admitted to hospice on 12/1/2015; 12/1/2015 would be the start day of the beneficiary’s hospice episode of care, so the “day” count will start on 12/1/2015 as day one. On 1/1/2016 the beneficiary has a day count of 32 days. The RHC “high” rate will be paid from 1/1/2016 through day 60 (1/29/2016). The RHC “low” rate would start on day 61 (1/30/2016).
Beneficiary on service prior to 1/1/2016 with a break in service less than 60 days:
A brand new beneficiary with no previous Medicare hospice elections or has had a gap in service greater than 60 days is admitted to hospice on 11/1/2015; 11/1/2015 would be the start day of the beneficiary’s hospice episode of care, so the “day” count will start on 11/1/2015 as day one. Beneficiary revokes the benefit on 12/10/2015. The “day” count on 12/10/2015 is 40 days. The beneficiary re-elects the Medicare hospice benefit on 12/30/2015. Since there was not a 60 day gap in service between the revocation on December 10th and the re-election on 12/30/2015 the hospice episode of care will continue and the day count will NOT restart. The “day” count on 12/30/2015 is 41 days. On 1/1/2016 the beneficiary “day” count is 43 and Medicare would pay at the “high” RHC rate through day 60.
Beneficiary on service prior to 1/1/2016 with a break in service greater than 60 days:
A brand new beneficiary with no previous Medicare hospice elections is admitted to the Medicare hospice benefit on 9/8/2015. The beneficiary revokes the benefit on September 18th, and re-elects the benefit on January 12th. Since the beneficiary has had a gap in Medicare hospice coverage, greater than 60 days, the beneficiary would start a new “episode of hospice care” on 1/12/2016; 1/12/2016 would be the first day of the next episode of care, and the provider would be paid at the “high” RHC rate through the sixtieth day. Day 60 one the payment would be at the “low” RHC rate.
How to Check the Hospice Health Insurance Query Access for the Number of Days Used of the Medicare Hospice Benefit
Provided below are examples of how to check HIQA to determine the number of days used in a hospice episode of care.
Special note: Information in HIQA is only current to the date of latest billing. If there is missing billing or incorrect billing in the system, this may affect the beneficiary day count until the system is updated. For example if you are checking HIQA in January and notice that the date of latest billing is for September 2015 and the revocation indicator shows the patient is still on service, there may be outstanding billing. The beneficiary day count will only be as current as of the date of latest billing (DOLBA) provided there is no outstanding billing or incorrect billing prior to the date of latest billing.
Determining Episode of Care Day Count for a Single Medicare Election
In this screen shot we can tell that the beneficiary as of 12/31/2015 has used 71 days of the Medicare hospice benefit. There are several key factors that you want to look at when you are determining the number of days used.
This beneficiary is in their first election period, the start of care date is 10/22/2015. The system will automatically calculate the number of days in the benefit period depending on which benefit period the beneficiary is in. Since this is a new election the system has calculated a ninety-day benefit period, and reports the last day of the benefit period as 1/19/2016.
The DOEBA is the “date of earliest billing,” which is the first date of the start of the benefit period. The first day that was billed to the Medicare system is 10/22/2016. The DOLBA is the “date of latest billing,” meaning the last date in which a claim was submitted to Medicare for hospice. In this case we can see that the DOLBA was 12/31/2015. This means the last date that was billed to Medicare for hospice was 12/31/2015, and the number of days used through this date is 71 days. It will be important to check the DOLBA when determining the days used to make sure the billing is current. The revocation indicator is zero, meaning as of the time of the last billing this beneficiary is still on service.
Based on the information provided in this screen shot, we can see that as of 12/31/2015 this beneficiary has more than 60 one days on the Medicare hospice benefit and the RHC low payment rate will be applied to the January claim.
Determining Episode of Care Day Count for Multiple Benefit Periods
GAP in service greater than 60 days
This beneficiary is in their fourth benefit period. In order to determine the beneficiary’s day count as of 1/1/2016, we will first need to look at the prior election period.
Election period three shows the DOLBA is 7/20/2015 and the revocation indicator is a one. So, we know as of 7/20/2015, which is the date of latest billing; the beneficiary had revoked or was discharged from the Medicare hospice benefit.
Benefit period four started on 12/12/2015. Since, the date of latest billing for the third benefit period shows a gap in service of greater than 60 days, the beneficiary will start with a new episode of hospice care on 12/12/2015. As of the DOLBA, 12/31/2015 the beneficiary has used 20 days of the new episode of care. This beneficiary will have a day count on 1/1/2015 of 21.
Determining Episode of Care Day Count for Concurrent Benefit Periods
This beneficiary is in their fourth benefit period. In order to determine the beneficiary’s day count as of 1/1/2016, we will first need to look at the prior election periods. In this example the first day of the hospice episode of care will start with the third benefit period, because there was a gap in service of greater than 60 days between the second and third benefit period.
Benefit period three shows the DOLBA is 12/11/2015 and the revocation indicator is a zero. So, we know as of 12/11/2015, which is the date of latest billing; the beneficiary is still on service and has a day count of 60 days.
Benefit period four started on 12/12/2015, without a gap in service from the prior benefit period. Since there is no gap in service greater than 60 days, the day count will continue with the next benefit period. The DOLBA is 12/31/2015 and the beneficiary has used twenty days in benefit period four.
In order to determine the total number of days in this episode of hospice care, we will need to add the number of days used in benefit period three and four. As of 12/31/2015, this beneficiary has a day count of eighty days in this episode of hospice care.