Reimbursement – Medicare
Proposed FY 2021 Rates
Final FY 2020 Rates
- Regulatory Alert: FY2020 Hospice Wage Index Final Rule
- FY2020 FINAL MEDICARE Hospice Wage Index State County Charts with FINAL Rates
- Changes to Hospice Regulations at 42 CFR 418
- Hospice Cap: For FY2020, the hospice cap will be $29,964.78
- Webinar recording on FY2020 Final Rule
- Webinar handout on FY2020 Final Rule
- FY2019 FINAL MEDICARE State/County Rate Charts
- Hospice aggregated caps for FY 2019: $29,205.44
CMS published a Paperwork Reduction Act notice about the Hospice Cost Report in the Federal Register on November 22, 2013. This is the last formal opportunity for commenters to review and comment on changes to the hospice cost report. At this time, CMS is projecting that the new hospice cost report will be used for cost reporting periods beginning October 1, 2014.
- Availability for J6 Home Health and Hospice providers to file electronic cost reporting files via EMAIL
- Provider Reimbursement Manual – Part 2, Provider Cost Reporting Forms and Instructions (Chapter 43, Form CMS-1984-14)
- Hospice Cost Report Draft forms and instructions
- CMS Summary of Hospice Report Comments and CMS Responses
Medicare regulations provide for two caps on Medicare expenditures for hospice care: Inpatient Cap and Aggregate Cap
Self-Determined Hospice Cap (SDHC) Report
Hospices are required to file a self-determined cap no earlier than 3 months after, and no later than 5 months after the end of the hospice cap year, October 31. The earliest a hospice may file its self-determined cap is January 31, and the latest is February 28/29 of each year.
Each Medicare Administrative Contractor (MAC) has specific instructions on the completion of the cap report. Ensure that your hospice is completing the cap report and filing it with the appropriate MAC by the February 28/29 deadline.
- Provider Statistical and Reimbursement (PS&R): Hospices should obtain their Provider Statistical and Reimbursement summary and Hospice Cap reports from the CMS Website. Each MAC has specific instructions on how to gather the necessary data to fill out the cap report, and where to file it. See the links below.
MAC Choices: Choose your MAC for Self-Determined Hospice Cap Instructions and Submission Requirements
Change in Cap Year: Beginning in FY2017, the cap year for both the inpatient cap and the aggregate cap will be aligned with the federal fiscal year of October 1, 2016 to September 30, 2017. 2017 is considered the transition year so the table below outlines the timeframes for this year.
Aggregate Cap Amount: The IMPACT Act of 2014 changed the cap calculation formula for each year that ends after September 30, 2016 and before October 1, 2025. The cap will be annually adjusted using the same hospice payment update percentage that is applied to the rates.
Change in Cap Year: In the FY2017 Hospice Wage Index Final Rule, CMS announced a change in the cap year, to align it with the federal fiscal year.
The total payment for inpatient care is subject to a limitation that total inpatient days of care (general or respite) should not exceed 20 percent of the total days for which these patients elected hospice care. At the end of a cap period, the Medicare Administrative Contractor calculates the percentage of inpatient days of care as a part of total days of care. The regulations for payment for inpatient care are found at §418.302(f) Payment procedures for hospice care.
Hospice Aggregate Cap
The hospice aggregate cap is an amount set by the Centers for Medicare and Medicaid Services each year that is used to figure, in the aggregate, the maximum amount that a hospice will be reimbursed for Medicare hospice services. The aggregate cap limits the total aggregate payment any individual hospice can receive in a year. A hospice’s ‘‘aggregate cap’’ is calculated by multiplying the number of beneficiaries who have elected hospice care during an accounting year by a per beneficiary “cap amount.” The Act established the per-beneficiary cap amount and provides an annual increase to the cap amount based on the rate of increase in the medical care expenditures category of the Consumer Price Index. A hospice’s aggregate cap is compared with the total Medicare payments made to the hospice during the same accounting year. Any Medicare payments in excess of the aggregate cap are considered overpayments and must be returned to Medicare by the hospice. The regulations for the hospice aggregate cap are found at § 418.309 Hospice cap amount.
Resources for Medicare Hospice Caps
- CGS cap report filing information
- NGS cap report filing information
- Palmetto cap report filing information
- History of the Hospice Aggregate Cap
- Medicare Benefit Policy Manual (Chapter 9 – Coverage of Hospice Services Under Hospital Insurance. See Section 90 – Caps and Limitations on Hospice Payments (Rev. 156, 6-01-12)
- Medicare Hospice Cap Statute (Social Security Act §1814(i)(2)(A))
- Medicare Hospice Conditions of Participation
- Final guidance for the Aggregate Cap Calculation Methodology (CR7838)