Overview of the Office of Medicaid (MassHealth)—Payments for Hospice-Related Services for Dual-Eligible Members

This section describes the makeup and responsibilities of the Office of Medicaid (MassHealth)—Payments for Hospice-Related Services for Dual-Eligible Members.

Overview

Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth provides access to healthcare services for approximately 1.8 million eligible low- and moderate-income children, families, seniors, and people with disabilities annually. In fiscal year 2019, MassHealth paid healthcare providers more than $16 billion, of which approximately 50% was funded by the Commonwealth. Medicaid expenditures represent approximately 39% of the Commonwealth’s total annual budget. According to the Centers for Medicare & Medicaid Services (CMS), the fiscal year2020 national Medicaid improper payment rate estimate is 21%, representing over $86 billion in improper payments.

MassHealth is responsible for paying for all medically necessary services that are provided to dual-eligible members in hospice and are not paid for by Medicare. Medicare is the primary payer for hospice services, paying for all goods and services related to a member’s terminal illness; MassHealth pays for any goods and services provided to a member that are not related to the member’s terminal illness as determined by the member’s hospice provider. For example, MassHealth would pay for a visit to a dentist or eye doctor for a member with a terminal illness related to congestive heart failure, as neither visit is related to the terminal illness. During the audit period, January 1, 2015 through July 31, 2019, MassHealth paid claims totaling more than $620 million² for hospice-related services provided to 38,568 dual-eligible members, as detailed below.

Total Payments Made to Non-Hospice Providers

Calendar Year	Total Payments	Members Served
2015	$119,637,456	15,357
2016	138,667,368	16,383
2017	159,053,107	17,691
2018	174,539,941	17,822
2019*	28,686,299	6,370
Total	$620,584,171	38,568†

*     This row includes claims submitted from January 1, 2019 through July 31, 2019 that have been paid. Because of the timing of payments, it does not include claims submitted during that period that have not been paid.

†     This number represents the unduplicated member count over the entire audit period.

Hospice Program Enrollment, Services, and Payments

A hospice program is a coordinated program of both home and inpatient palliative care designed to help manage pain and provide comfort to individuals who have terminal illnesses. According to Section 437.402 of Title 130 of the Code of Massachusetts Regulations (CMR), an individual is considered to have a terminal illness if s/he has “a medical prognosis of a life expectancy of six months or less if the illness runs its normal course.” The goods and services offered through hospice programs include healthcare by physicians and nurses, counseling, durable medical equipment (DME), home health aide services, and physical and occupational therapy. Hospice programs do not offer curative care (treatment intended to improve patient health to its condition before the terminal illness) or treatment for any injury or complication unrelated to a member’s terminal illness. Hospice services can be provided through outpatient palliative care clinics, at home, in nursing homes, in assisted-living facilities, or in group homes.

To enroll a MassHealth member in a hospice program, a hospice provider is required to complete a Certification of Terminal Illness (CTI) form for the member. The CTI must be signed by the member’s attending physician and the hospice provider’s medical director or another hospice physician. The signers certify that the member has a terminal illness and a life expectancy of six months or less. The CTI also includes a narrative that describes the member’s terminal illness and an attestation statement from both the member’s attending physician and hospice medical personnel that they composed the narrative based on a review of the member’s medical record or, if applicable, a physical examination of the member. After a member chooses to receive hospice services, hospice medical staff members must periodically recertify that a member receiving hospice still has a terminal illness and therefore is eligible to remain in the program. These recertification periods occur after 90 days, after 180 days, and every 60 days thereafter.

For dual-eligible members, in addition to the CTI, the hospice provider must also complete both a Medicare Hospice Election Form and a MassHealth Hospice Election Form for the member. The Medicare Hospice Election Form must be submitted to CMS, and the MassHealth Hospice Election Form must be submitted to MassHealth. These forms notify CMS and MassHealth that the member is choosing to receive hospice services. By making this choice, the member waives his/her rights to MassHealth paying for any services related to his/her terminal illness, because such services are now covered by the member’s hospice provider, according to 130 CMR 437.412(B).

Once MassHealth receives a member’s MassHealth Hospice Election Form, it updates the member’s record in its Medicaid Management Information System³ with the code HSPC, which indicates that the member has now elected the hospice benefit. This code subjects all claims submitted on the member’s behalf to system edits intended to ensure that MassHealth is the payer of last resort and does not pay for any goods or services that should be paid for by Medicare directly or by the hospice provider. MassHealth may still pay for services that are provided to a member and are not related to his/her terminal illness as determined by the hospice provider. For example, if a member lives in a nursing facility, MassHealth pays 95% of the monthly rate to the hospice provider for room and board. The hospice provider then pays the full 100% of the monthly rate to the nursing facility. Hospice providers must also complete hospice election forms if the member wishes to modify or revoke his/her hospice benefit.

According to Federal Register 48, No. 243 (1983),⁴ hospice care is a covered service through Medicare Part A medical insurance coverage (one of the four parts of the federal Medicare Program), also referred to as “hospital insurance.” Authorized through Title XVIII of the Social Security Act, Medicare Part A covers hospice and additional services such as inpatient hospital care, skilled nursing facility care, and home healthcare. Additionally, in Federal Register 83, No. 89 (2018), CMS states,

Hospice services are comprehensive and we have reiterated since 1983 that ‘‘virtually all’’ care needed by the terminally ill individual would be provided by hospice. We believe that it would be unusual and exceptional to see services provided outside of hospice for those individuals who are approaching the end of life.

Medicare pays hospice providers a per diem rate for days when a dual-eligible member is enrolled in hospice. As noted above, this rate is intended to cover all the costs the hospice provider has determined that the member needs in relation to his/her terminal illness as documented in the member’s plan of care.⁵ The per diem rates that Medicare pays to hospice providers are based on four different levels of care: routine home care, continuous home care, inpatient respite care, and general inpatient care. A member’s level of care is determined by the location and frequency of the services provided under the hospice benefit. Routine home care is the most common level.

For routine home care, there are two per diem rates based on the amount of time the member receives hospice services; the rate for the first 60 days is higher. As of federal fiscal year 2021, the daily rates are $199.25 for the first 60 days and $157.49 beginning on day 61. In addition, for registered nurse and social worker visits in the last seven days of a member’s life, Medicare makes supplemental payments in addition to paying the daily rate. For continuous home care,⁶ the payment is an hourly rate ($59.68 as of federal fiscal year 2021).

When a member spends less than five days at an inpatient facility, Medicare pays the facility the per diem rate for general inpatient care, which is $1,045.66 as of federal fiscal year 2021. Medicare pays inpatient hospice facilities the per diem rate for inpatient respite care, which is $461.09 as of federal fiscal year 2021, when a member has spent at least five days at the facility.

Per diem rates are geographically adjusted based on member location and are annually updated by CMS in accordance with Sections 1814(i)(1)(C)(ii)(VII) and 1814(i)(2)(D) of the Social Security Act.

A hospice provider may discharge a patient for the following reasons:

• The patient decides to seek curative care.
• The patient moves out of the service area.
• The patient no longer meets hospice criteria because his/her health has improved.
• The patient passes away.

After the discharge, the hospice provider must file a Notice of Termination with Medicare within five calendar days, according to Section 20.2.1.3 of CMS’s Medicare Benefit Policy Manual.

MassHealth’s Office of Clinical Affairs (OCA) reviews complaints it receives about hospice providers. When OCA receives a complaint, it reviews the provider’s claims and may audit the provider.

Hospice Plans of Care and Service Coordination

Hospice providers serving dual-eligible members are required by Section 418.200 of Title IV(B)(F) of the Code of Federal Regulations (CFR) to develop a comprehensive plan of care for each member in hospice. According to this regulation, hospice providers cannot bill Medicare for hospice services until a plan of care has been developed. The services included in a member’s plan of care are targeted to enhance the quality of the member’s life while minimizing his/her pain or suffering as much as possible. Plans of care are created by a hospice’s interdisciplinary group (IDG), which typically includes the hospice’s medical director or another hospice physician, a registered nurse, a social worker, and a pastor or counselor. According to 130 CMR 437.422(C), the IDG must review each plan of care and modify it as needed, based on the member’s current needs, or at least every 15 days.

According to 42 CFR 418.56, the IDG also has other responsibilities. For example, hospice providers serving dual-eligible members must ensure that their IDGs direct, coordinate, and supervise all the goods and services (e.g., DME or ambulance rides) provided to these members:

d.   Standard: Review of the plan of care. The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) must review, revise and document the individualized plan [of care] as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. A revised plan of care must include information from the patient’s updated comprehensive assessment and must note the patient’s progress toward outcomes and goals specified in the plan of care.

e.   Standard: Coordination of services. The hospice must develop and maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures, to—

1.   Ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided.

2.   Ensure that the care and services are provided in accordance with the plan of care.

3.   Ensure that the care and services provided are based on all assessments of the patient and family needs.

4.   Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement.

5.   Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.

2.     This amount includes payments made by MassHealth directly to non-hospice providers, as well as payments made by MassHealth’s contracted managed care organizations. However, for our audit, we only tested payments made by MassHealth directly to non-hospice providers.

 

3.     This is the information technology system MassHealth uses to process claims and other member information.

4.     The Federal Register is a daily journal by the federal government that contains current and proposed rules for federal agencies and organizations, as well as presidential proclamations and executive orders.

5.     A plan of care is a written plan that details the specific medical, psychological, spiritual, and emotional needs of a member who is receiving hospice care. (See the “Hospice Plans of Care and Service Coordination” section of this report.)

6.     Continuous care is nursing care that is provided to a hospice member. Unlike routine care, which does not have a required number of hours, it must be provided for at least 8 hours in any given 24-hour period.

 

Date published:	July 20, 2021