Section 405IAC1-16-3. Limitation on payments for inpatient care

   (a) Payments to a hospice for inpatient care must be limited according to the number of days of inpatient care furnished to Medicaid members. During the twelve (12) month period beginning November 1 of each year and ending October 31 of the next year, the aggregate number of inpatient days (both general inpatient days and inpatient respite care days) for any given hospice provider may not exceed twenty percent (20%) of the total number of days of hospice care provided to all Medicaid members during the same period by the designated hospice provider or its contracted agent or agents. For purposes of this computation, if it is determined that the inpatient rate should not be paid, any days for which the hospice provider receives payment at a home care rate will not be counted as inpatient days.

  (b) The limitations on payment for inpatient days are as follows:

(1) The maximum number of allowable inpatient days will be calculated by multiplying the total number of a provider's Medicaid hospice days by twenty percent (20%).

(2) If the total number of days of inpatient care to Medicaid hospice members is less than or equal to the maximum number of inpatient days computed in subdivision (1), then no adjustment is made.

(3) If the total number of days of inpatient care to Medicaid hospice members is greater than the maximum number of inpatient days computed in subdivision (1), then the payment limitation will be determined by the following method:

(A) Calculating the ratio of the maximum allowable inpatient days to the number of actual days of inpatient care, and multiplying this ratio by the total reimbursement for inpatient care that was made.

(B) Multiplying excess inpatient care days by the routine home care rate.

(C) Adding together the amounts calculated in clauses (A) and (B).

(D) Comparing the amount in clause (C) with total reimbursement made to the hospice provider for inpatient care during the cap period. The amount by which total reimbursement made to the hospice provider for inpatient care for Medicaid members exceeds the amount calculated in clause (C) is due from the hospice provider.

(Office of the Secretary of Family and Social Services; 405 IAC 1-16-3; filed Mar 9, 1998, 9:30 a.m.: 21 IR 2378; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA)