OAR 410-142-0300: Hospice Reimbursement and Limitations

(1) The Division recalculates its hospice rates annually. When billing for hospice services, the provider must bill the usual charge or the rate based upon the geographic location in which the care is furnished, whichever is lower. See hospice rates on the Oregon Health Authority (Authority) website at: http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Hospice.aspx . (2) Rates: (a) The Division bases its rates on the methodology used in setting Medicare rates, adjusted to disregard cost offsets attributable to Medicare coinsurance amounts; (b) Under the Medicaid hospice benefit regulations, the Division cannot impose cost sharing for hospice services rendered to Medicaid recipients; (c) The Division sets rates no lower than the rates used under Part A of Title XVIII of the Social Security Act (Medicare); (d) The Division uses prospective hospice rates; (e) The Division makes no retroactive adjustments other than the optional application of the cap on overall payments and the limitation on payments for inpatient care, if applicable. (3) With the exception of payment for physician services, the Division reimburses providers of hospice services for each day of care at one of five predetermined rates. Rates are based on intensity and type of care, which the Division defines as: (a) Routine home care. The Division pays the hospice the routine home care rate for each day that the client is under the care of the hospice and that the Division does not reimburse at another rate. The Division pays this rate without regard to the volume or intensity of services provided on any given day; (b) Continuous home care. The Hospice must provide a minimum of eight hours of continuous home care per day to receive the continuous home care rate: (A) The continuous home care rate is divided by 24 hours in order to arrive at an hourly rate; (B) The Division pays the hospice for every hour or part of an hour of continuous care furnished up to a maximum of 24 hours a day. (c) Inpatient respite care. The Division pays the hospice at the Inpatient Respite Care rate for each day on which the client is in an approved inpatient facility and is receiving respite care: (A) The Division pays for inpatient respite care for a maximum of five days at a time, including the date of admission but not counting the date of discharge; (B) The Division pays for the sixth and any subsequent days at the routine home care rate. (d) General inpatient care. The Division pays providers at the general inpatient rate when general inpatient care is provided; (e) In-home respite care. An in-home respite care day is a day on which short-term in-home care is provided to the client only when necessary to relieve the family members or other persons caring for the client at home. Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time. In-home respite care will be provided at the level necessary to meet the client's need, with a minimum of eight hours of care provided in a 24-hour day, which begins and ends at midnight. Hospice aide/CNA or homemaker services or both may be utilized for providing in-home respite care. (4) On the day of discharge from an inpatient unit, the Division pays the appropriate home care rate unless the client dies as an inpatient. When the client is discharged deceased, the Division pays the appropriate inpatient rate (general or respite) for the discharge date.