Section 182-551-1510. Rates methodology and payment method for hospice agencies.

This section describes rates methodology and payment methods for hospice care provided to hospice clients.

(1) The medicaid agency uses the same rates methodology as medicare uses for the four levels of hospice care identified in WAC 182-551-1500.

(2) Each of the four levels of hospice care has the following three rate components:

(a) Wage component;

(b) Wage index; and

(c) Unweighted amount.

(3) To allow hospice payment rates to be adjusted for regional differences in wages, the medicaid agency bases payment rates on the core-based statistical area (CBSA) county location. CBSAs are identified in the medicaid agency's provider guides.

(4) The medicaid agency pays hospice agencies for services (not room and board) at a daily rate methodology as follows:

(a) Payments for services delivered in a client's residence (routine and continuous home care) are based on the county location of the client's residence.

(b) Payments for routine home care (RHC) are based on a two-tiered payment methodology.

(i) Days one through sixty are paid at the base RHC rate.

(ii) Days sixty-one and after are paid at a lower RHC rate.

(iii) If a client discharges and readmits to a hospice agency's program within sixty calendar days of that discharge, the prior hospice days will continue to follow the client and count towards the client's eligible days in determining whether the hospice agency may bill at the base or lower RHC rate.

(iv) If a client discharges from a hospice agency's program for more than sixty calendar days, a readmit to the hospice agency's program will reset the client's hospice days.

(c) Hospice services are eligible for an end-of-life service intensity add-on (SIA) payment when the following criteria are met:

(i) The day on which the services are provided is an RHC level of care;

(ii) The day on which the service is provided occurs during the last seven days of life, and the client is discharged deceased;

(iii) The service is provided by a registered nurse or social worker that day for at least fifteen minutes and up to four hours total; and

(iv) The service is not provided by the social worker via telephone.

(d) Payments for respite and general inpatient care are based on the county location of the providing hospice agency.

(5) The medicaid agency:

(a) Pays for routine hospice care, continuous home care, respite care, or general inpatient care for the day of death;

(b) Does not pay room and board for the day of death; and

(c) Does not pay hospice agencies for the client's last day of hospice care when the last day is for the client's discharge, revocation, or transfer.

(6) Hospice agencies must bill the medicaid agency for their services using hospice-specific revenue codes.

(7) For hospice clients in a nursing facility:

(a) The medicaid agency pays nursing facility room and board payments at a daily rate directly to the hospice agency at ninety-five percent of the nursing facility's current medicaid daily rate in effect on the date the services were provided; and

(b) The hospice agency pays the nursing facility at a daily rate no more than the nursing facility's current medicaid daily rate.

(8) The medicaid agency:

(a) Pays a hospice care center a daily rate for room and board based on the average room and board rate for all nursing facilities in effect on the date the services were provided.

(b) Does not pay hospice agencies or hospice care centers a nursing facility room and board payment for:

(i) A client's last day of hospice care (e.g., client's discharge, revocation, or transfer); or

(ii) The day of death.

(9) The daily rate for authorized out-of-state hospice services is the same as for in-state non-CBSA hospice services.

(10) The client's notice of action (award) letter states the amount the client is responsible to pay each month towards the total cost of hospice care. The hospice agency receives a copy of the award letter and:

(a) Is responsible to collect the correct amount that the client is required to pay, if any; and

(b) Must show the client's monthly required payment on the hospice claim. (Hospice providers may refer to the medicaid agency's provider guides for how to bill a hospice claim.) If a client has a required payment amount that is not reflected on the claim and the medicaid agency reimburses the amount to the hospice agency, the amount is subject to recoupment by the medicaid agency.

[Statutory Authority: RCW 41.05.021, 41.05.160, and 42 C.F.R. 418 Subpart G. WSR 16-14-009, § 182-551-1510, filed 6/23/16, effective 7/24/16. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-03-035, § 182-551-1510, filed 1/12/16, effective 2/12/16. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1510, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1510, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1510, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1510, filed 4/9/99, effective 5/10/99.]

RCW 41.05.021, 41.05.160, and 42 C.F.R. 418 Subpart G. WSR 16-14-009, § 182-551-1510, filed 6/23/16, effective 7/24/16. Statutory Authority: RCW 41.05.021, 41.05.160. WSR 16-03-035, § 182-551-1510, filed 1/12/16, effective 2/12/16. Statutory Authority: RCW 41.05.021, Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), and Section 1814 (a)(7) of the Social Security Act. WSR 12-09-079, § 182-551-1510, filed 4/17/12, effective 5/18/12. WSR 11-14-075, recodified as § 182-551-1510, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-18-033, § 388-551-1510, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. WSR 99-09-007, § 388-551-1510, filed 4/9/99, effective 5/10/99.

Rules

182-551-1500,