Hospice Reimbursement

The Affordable Care Act requires physicians or other eligible providers to be enrolled in the GA Medicaid Program to order, prescribe and refer items or services for Medicaid beneficiaries. The National Provider Identifier (NPI) of the ordering, prescribing or referring provider should be noted on the GA Medicaid rendering provider's claim.

The Medicaid reimbursement is based on the status of the member's eligibility days and a hospice lock-in span. Effective, January 1, 2016, the Department implemented the Centers for Medicare and Medicaid, two final Medicare hospice payment reform policies for the routine home care (RHC) and the service intensity add-on (SIA) rates:

1) The Medicare hospice final rule replaces the single RHC per diem rate with two different RHC payment rates, a higher payment rate for the first 60 days of hospice care, and a reduced payment rate for 61 days and over of hospice care. If a member has a break within the hospice period that is greater than 60 days, the hospice span starts over.

2) The SIA payment is in addition to the per diem RHC rate when all the following criteria are met:

(a) The day is an RHC level of care day. The day occurs during the last seven days of the patient's life, and the patient is discharged.

(b) 40660 The SIA Claim may cover up to the last seven days of life and include the date of death. Direct patient care is furnished by a registered nurse (RN) or social worker (SW) that day. The SIA payment will equal the Continuous Home Care (CHC) hourly payment rate, for a minimum of 15 minutes and up to 4 hours total per day. G-codes are used to identify the SW and RN versus LPN visits.

Hospice Payment Rates

Hospice payment rates are made in accordance with CMS guidelines and at rates published in the Federal Register each year. Rates will be in effect October 1 of that year through September 30 of the following year.

Download this pdf file.Hospice Rate File FFY2020 Effective 10/01/2019

Payment for Physician Services

The division will pay the hospice in accordance with the usual Medicaid reimbursement for physician services (such as direct patient care services) when these services are provided by hospice employees or physicians under agreement with the hospice. This reimbursement is in addition to the per diem rate.

Reimbursement for physician services is included in the amount subject to the hospice payment cap described in Section 1007 of the Hospice Services Manual.

Services furnished voluntarily by physicians are not reimbursable.

Consultant specialty services, when necessary for the palliative care and management of the terminal illness (e.g., radiation for pain relief), are covered separately and are reimbursed only to the elected hospice.

Services of the patient's attending physician, if he or she is not an employee of the hospice or providing services under arrangements with the hospice, are not considered covered hospice services and are not included in the amount subject to the hospice cap.

These services are paid directly to the provider physician. Reimbursement is provided for enrolled nurse practitioner services, except for certifying the terminal illness with a prognosis of six months or less, to Medicaid members who have elected the hospice benefit and have selected a nurse practitioner as the attending physician.

The hospice must notify the Division of the name of the physician/nurse practitioner who has been designated as the attending physician/nurse practitioner by the member.