• Tom Boyd

Hospice Cap

Hospice Cap / Inpatient Day Limitation Calculator

The Hospice Limitation Calculator will assist hospice providers in calculating the hospice cap and inpatient day limitation.  The purpose of the calculator is to make the provider aware of a hospice cap and inpatient day limitation and to provide assistance in monitoring payment for those services.  The hospice cap period for both limitations is November 1st through October 31st of any given year.  The following sections explain further the components of this computation.

The Inpatient Day Limitation

During the 12-month period beginning November 1st and ending October 31st, the aggregate number of inpatient days (both general and respite) may not exceed 20% of the total days provided to all Medicare beneficiaries.  In situations where the inpatient care days exceeds 20%, the reimbursement for the excess inpatient care days is limited to the reimbursement as calculated at the routine care rate of the hospice.  The difference between the reimbursement at the inpatient care rate and the routine care rate for the excess days becomes the overpayment due from the hospice.  The calculator below will indicate only if an Inpatient Day Limitation potentially exists, the actual calculation is more detailed.

Hospice Cap Calculation

CMS annually updates the Hospice cap amount to be used in determining the maximum allowable payments per beneficiary.  The updates are published prior to September 30 of each year and reflect the present year cap amount.  The hospice cap computation compares the census count for the period September 28 of the previous year to September 27 of the current year to payments for the period November 1 to October 31.  For a beneficiary to be counted in the cap period the beneficiary’s Notice of Initial Elections (NOEs) must be made during the current cap period.  Once the beneficiary is counted as a census, they cannot be counted for that hospice again, even though they may have had breaks in periods of elections.

There can be instances where a hospice services a beneficiary in the current cap period, even though the beneficiary has received services from another hospice in the current or prior cap period.  In such cases, these fractional beneficiaries will receive a percentage of the pro-rata cap amount.  Each provider receives a fractional percentage based upon the days of service to the total hospice days.  For example, if hospice A, services beneficiary 1 for 30 days, and thereafter, hospice B, services beneficiary 1 for 70 days, hospice A will receive a fractional beneficiary count of .30 or 30 out of 100 days of total hospice care, and hospice B will receive a fractional beneficiary count of .70 based upon the same proportion as hospice A.

Determining the Hospice Cap / Inpatient Day Limitation

The provider will use the census, visit, and payment information from its records in determining the cap calculation.

In order to calculate the hospice cap/inpatient day limitation you will need the following:

  1. Number of beneficiaries electing hospice coverage for 9/28 to 9/27

  2. Medicare reimbursement for the service dates of 11/1 through 10/31

  3. Visit data by revenue type

The above article is from the PBGA web site.  The explanation and information is valid for all Medicare certified hospices.

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