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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 6142 (September 30, 2023).

55 Pa. Code § 1130.71. General payment policy.


§ 1130.71. General payment policy.

 (a)  Payment is made to a participating hospice in accordance with the coverage and payment rates established by Medicare regulations at 42 CFR 418.302 (relating to payment procedures for hospice care). Exceptions are as follows:

   (1)  A recipient with a confirmed diagnosis of acquired immune deficiency syndrome (AIDS) will not be counted when calculating the hospice inpatient care limit established by Medicare regulations at 42 CFR 418.302(f).

   (2)  A hospice provider will not be subject to the annual cap on overall payments as described by Medicare regulations at 42 CFR 418.309 (relating to hospice cap amount).

 (b)  Payment is made to the hospice for each day during which the recipient is eligible and under the care of the hospice, regardless of the amount of services furnished on a given day.

   (1)  If admission and discharge, revocation or death occur on the same day, the day will be considered a hospice care day and the hospice will be paid at the rate commensurate with the level of care provided.

   (2)  If the level of care changes, payment will be made for the new level of care beginning with the day it commences.

   (3)  If a change of hospice occurs, payment will not be made to the discharging hospice for the day of discharge. Payment will be made to the newly elected hospice.

   (4)  If the recipient is discharged from an inpatient unit, the routine home care rate will be paid unless the recipient dies as an inpatient. If the recipient is discharged deceased, the general inpatient or respite care rate will be paid for the discharge date.

 (c)  Payment is not made for days not covered by a valid certification of terminal illness.

 (d)  Payment for inpatient respite care is limited to no more than a total of 5 days in a 60-day certification period. Payment for inpatient respite care days in excess of the limit will be made at the routine home care rate.

 (e)  Payment is not made for general inpatient care if the Department determines that a lesser level of care was actually provided.

 (f)  No MA payments will be made directly to a nursing facility for services provided to a recipient who is under the care of a hospice.

 (g)  Ambulance transportation related to management of the recipient’s terminal illness is included in the daily rates. A separate payment will not be made to the hospice provider or to an ambulance provider for this service.

 (h)  The Department will reduce its payment for hospice care by the amount of income available from the recipient towards the hospice care rate established by the Department.

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