Overview
During our audit, personnel at many hospice providers we visited told us that the regulatory guidance and other guidance issued by MassHealth and CMS are unclear as to who is responsible for paying for certain goods and services for dual-eligible members in hospice. For instance, hospice providers told us they found the following regulations unclear:
- According to 42 CFR 418.202, professional services, including home health aides and homemaker services, are covered in the monthly rate Medicare pays to a hospice if they are included in a member’s plan of care. However, some hospice providers we visited stated that this regulation could be clearer regarding how much of a service should be provided to a member. Specifically, some hospice providers told us they believed they were responsible for providing as many hours of professional services as were specified in the members’ plans of care. In contrast, other hospice providers stated that they believed the hospice benefit should only cover a specific number of hours per week as determined by the hospice and that that was what they included in plans of care. One hospice provider stated that one of its members revoked the hospice benefit with that provider and went to a different one that offered more home health aide services.
- According to 42 CFR 418.202(f), durable medical equipment (DME) is covered in the monthly rate Medicare pays to a hospice if it is included in a member’s plan of care. During our interviews of staff members at the 59 hospice providers we visited, many staff members indicated that in their opinion, both federal and state regulations were unclear as to who should pay for some DME. One example of this was whether products used to treat incontinence should be considered related to members’ terminal illnesses and therefore paid for by the hospice, not MassHealth. Some hospice personnel told us they paid for incontinence products for dual-eligible members and always included these items in the plans of care. Others indicated that they did not pay for incontinence products because they believed they were a “custodial product” and not included in the per diem rate the providers received from Medicare, so they did not include the products in plans of care. Others stated that they only included incontinence products in a member’s plan of care if the member lived at home, since nursing facilities and group homes pay for such products. Finally, some stated that they only included some incontinence products in plans of care, such as those that were reusable, not disposable.
Hospice providers can contact MassHealth and CMS with questions about what services should be included in dual-eligible members’ plans of care. In our interviews, many hospice providers stated that the regulations were unclear and they did not contact MassHealth or CMS for guidance. Therefore, OSA believes MassHealth should consider collaborating with CMS and providing additional guidance to address the issues detailed above. We believe this would better ensure consistency in the provision of the goods and services in question and minimize the possibility of improper billing for them.
Auditee’s Response
The auditors in providing this suggestion, cite to Federal Medicare regulations for Hospice at 42 CFR 418.202 that state that home health aide and homemaker services are included in the monthly rate that Medicare pays to a hospice provider and note that “some hospice providers we visited stated that this regulation could be clearer regarding how much of a service should be provided to a member.” Elsewhere in the audit report, the auditors cite CMS guidance on the scope of Medicare covered hospice services and state that CMS intends Medicare covered hospice services to cover “virtually all” Medicare services. . . . EOHHS notes that Medicare and Medicaid are separate benefit programs with a different scope of covered services (e.g. Medicare does not cover Medicaid 1915[c] HCBS waiver services nor many of the Medicaid services that provide long term supports, such as Adult Foster Care services). To the extent hospice providers of Medicare covered hospice services find that CMS regulations on the scope of Medicare hospice need clarification, it is unclear how EOHHS could appropriately provide such clarification, where EOHHS does not oversee the Medicare hospice program nor pay for Medicare covered hospice services.
Auditor’s Reply
OSA recognizes that Medicare and Medicaid are separate benefit programs, but hospice program services are related: dual-eligible members are entitled to receive benefits under both programs, and all services, including those paid for by Medicaid and Medicare (MassHealth), must be coordinated by members’ hospice providers. Therefore, OSA believes it is important that hospice providers fully understand the types and levels of benefits that need to be included in members’ plans of care so that MassHealth is not improperly billed for them. As noted above, management at a number of the hospices we visited stated that they would appreciate more clarity about certain hospice benefits. OSA recognizes that many of the benefits that appear to be unclear to hospice providers are ones that would typically be funded by Medicaid. However, OSA believes that MassHealth would benefit from collaborating with CMS and providing additional guidance, as needed, on federal and state regulations related to hospice benefits. We believe this would better ensure consistency in the provision of the benefits and minimize the possibility of improper billing for them.
| Date published: | July 20, 2021 |
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