IN FOCUS: Hospice/Medicaid Issues
October 9, 2015 03:34 PM
Hospice Payment Reform/Medicaid: In response to the Centers for Medicare & Medicaid Services (CMS) proposed hospice payment reforms that, by law, are applicable to fee-for-service Medicaid hospice benefits, there was widespread concern that hospices, vendors, Medicare Administrative Contractors (MACs), and state Medicaid programs would not be ready for the anticipated Oct. 1, 2015, implementation. As part of the final hospice payment rule and out of particular concern for state Medicaid programs, CMS delayed implementation of the two-tiered payment system for Routine Home Care (RHC)/Service-intensity Add-on (SIA) until Jan. 1, 2016.
In recent months the National Association for Home Care & Hospice (NAHC) examined billing requirements for some state Medicaid programs to ascertain whether Medicaid programs required sufficient information on hospice claims to allow for the payment reform changes and discovered that a number of states do not currently require hospices to report sufficient detail (including skilled visits, which are essential for implementation of the SIA) on claims to facilitate implementation of the payment changes. NAHC contacted officials at CMS to convey these concerns, and CMS conducted outreach to select states to ascertain their states of readiness. Our understanding is that as part of the calls CMS was able to ascertain that all states are not currently securing information on hospice claims that would facilitate implementation of the payment reforms. As a result, CMS is planning on sending information to state Medicaid offices to assist them in implementing the changes that are needed to be able to move forward with payment reform on the Medicaid side.
At this stage it is unclear whether state programs will be able to change billing processes in time for the scheduled January 1, 2016, implementation or whether CMS will need to allow more time; it is also unclear whether states will use a uniform process or choose their own method (including some type of work-around) for securing the information required for payment reform implementation. NAHC will provide additional details as they are available.
Medicaid Hospice/Managed Care:States are at different points in their development of Medicaid managed care contracts that include the hospice benefit. On the fee-for-service side, Medicaid programs are required, under Section 1902(a)(13)(B), to pay for hospice care based on existing Medicare rates. NAHC has had inquiries relative as to whether this same requirement applies when hospice care is provided by a managed care organization. NAHC has posed specific questions to CMS, to which we received the following response:
Under Medicaid fee-for-service (FFS), the State plan payment must meet the requirements specified in Section §1902(a)(13)(B). However, under Medicaid managed care, as specified in 42 CFR §438.6(c)(2), CMS only requires that payment rates between the State and health plans be actuarially sound. Managed Care Organizations (MCOs), Prepaid Inpatient Health Plans (PIHPs), and Prepaid Ambulatory Health Plans (PAHPs) may negotiate different payment amounts with providers, unless the State requires the MCO, PIHP, or PAHP (specified in the contract) to pay at the same rate as the Medicaid State plan.
Legal research conducted by NAHC staff concluded that, because of the way Medicaid MCO authorizing language is crafted, payments for hospice services provided through a MCO likely are not required to follow Medicare reimbursement requirements. NAHC has submitted follow up questions to CMS and will report on additional findings as they become available.