MLN Matters Number: MM6400
Related Change Request (CR) #: 6400
Related CR Release Date: April 3, 2009
Effective Date: July 1, 2009
Related CR Transmittal #: R1708CP
Implementation Date: July 6, 2009
Provider Types Affected
Hospice providers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), Part A/B Medicare Administrative Contractors (A/B MACs), and/or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 6400 which requires Medicare contractors to send each of their providers a letter which serves as a determination of program reimbursement, regardless of whether or not they have exceeded a cap. The letter you receive will include the inpatient and aggregate cap calculation results. Additionally, it will include appeals language in every determination of program reimbursement letter. If you have exceeded the cap, the letter will include a demand for repayment.
Background
The law governing payment for hospice care subjects hospice payments to two statutory caps:
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A cap on payments for inpatient days, described in Section 1861(dd)(2)(A)(iii) of the Social Security Act and
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An aggregate cap on total payments, described in Section 1814(i)(2)(A)-(C).
These statutory caps limit total hospice payments during a cap year. Payments in excess of either cap must be refunded. Currently, after the end of the cap year, the applicable contractor (RHHI, FI, or A/B MAC) computes both cap amounts, and determines the amount of program reimbursement for each hospice provider they serve.
Important Information
The latest hospice cap amount for the cap year ending October 31, 2008 is $22,386.15. The hospice cap is discussed further in the Medicare Claims Processing Manual (Chapter 11 - Processing Hospice Claims, Section 80.2) which is available at www.cms.hhs.gov/manuals/downloads/clm104c11.pdf on the Centers for Medicare & Medicaid Services Web site. Your contractor (RHHI, FI, or AB MAC) will issue a letter to notify you of the results of the contractor’s cap calculations and to serve as your determination of program reimbursement. If there is a cap overpayment, there will be an accompanying demand for repayment.
Administrative Appeal
As indicated in section 418.311 of 42 CFR, if you believe that your payments have not been properly determined, you may request a review from the applicable contractor if the amount in controversy is $1,000 or more, but less than $10,000, or from the Provider Reimbursement Review Board (PRRB) if the amount in controversy is $10,000 or more. Appeal requests must be in writing and be filed within 180 days from the date of the determination. Your appeal rights are discussed further in the Medicare Claims Processing Manual (Chapter 11 - Processing Hospice Claims, Section 80.3), which is attached to CR 6400.
Additional Information
The official instruction, CR 6400, issued to your RHHI, FI or A/B MAC regarding this change may be viewed at www.cms.hhs.gov/Transmittals/downloads/R1708CP.pdf on the CMS Web site.
If you have any questions, please contact our provider service center at our toll-free number, (877) 567-9249 (for
North Carolina and South Carolina Part A providers) or (866)-801-5301 (for home health and hospice providers).
Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
Note: In the content of this article, the following links open a PDF document:
www.cms.hhs.gov/Transmittals/downloads/R1708CP.pdf (PDF, 126 KB)
www.cms.hhs.gov/manuals/downloads/clm104c11.pdf (PDF, 504 KB)