SubPart 86-6 - Hospices

Effective Date: 
Tuesday, January 1, 1991
Doc Status: 
Complete
Statutory Authority: 
Public Health Law, section 4010

Section 86-6.1 - Definitions

86-6.1 Definitions. As used in this Subpart, the following terms shall have the following meanings.

(a) Hospice shall mean a hospice as defined in article 40 of the Public Health Law possessing a valid certificate of approval issued by the State Commissioner of Health.

(b) A routine home care day is a day on which an individual who has elected to receive hospice care is at home and is not receiving continuous care as defined in subdivision (f) of this section.

(c) A routine home care day for AIDS patients is a day on which an individual who has been diagnosed with Acquired Immune Deficiency Syndrome (AIDS) has elected to receive hospice care, is at home and is not receiving continuous home care as defined in subdivision (f) of this section.

(d) A routine home care day with an escort is a day as defined in subdivision (b) of this section, when the nurse providing care requires the use of an escort for security when visiting the patient's home.

(e) A routine home care day for AIDS patients with an escort is a routine home care day as defined in subdivision (b) of this section when the individual who has elected to receive hospice care has been diagnosed with Acquired Immune Deficiency Syndrome (AIDS) and the nurse providing care requires the use of an escort for security when visiting the patient's home.

(f) A continuous home care day is a day on which an individual who has elected to receive hospice care is not in an inpatient facility and receives hospice care consisting predominantly of nursing care on a continuous basis at home. Home health aide or homemaker services or both may also be provided on a continuous basis. Continuous home care is only furnished during brief periods of crisis, and only as necessary to maintain the terminally ill patient at home. A period of crisis is a period in which the individual requires continuous care to achieve palliation or management of acute medical symptoms.

(g) A continuous home care day for AIDS patients is a day as defined in subdivision (f) of this section when the patient receiving care has been diagnosed as having Acquired Immune Deficiency Syndrome (AIDS).

(h) An inpatient respite care day is a day on which the individual who has elected hospice care receives care in an approved facility on a short-term basis for respite.

(i) A general inpatient care day is a day on which an individual who has elected hospice care receives general inpatient care in an inpatient facility for pain control or acute or chronic symptom management which cannot be managed in other settings.

(j) A general inpatient care day for AIDS patients is a day as defined in subdivision (i) of this section, when the patient receiving care has been diagnosed as having Acquired Immune Deficiency Syndrome (AIDS).

(k) Supplemental financial assistance program means the program as established pursuant to section 4012-a of the Public Health Law to provide additional payments to hospices which provide care to patients with special needs, which shall include patients diagnosed with Acquired Immune Deficiency Syndrome or patients in environment situations which require the use of escort services for the delivery of routine home care in accordance with approved plans required by subdivision (b) of section 86-6.6 of this Subpart, or persons receiving care in a hospice residence.

(l) Room and board services shall mean the provision of personal care services, including assistance in activities of daily living, socializing activities, administration of medications, maintaining the cleanliness of a resident's room and supervising and assisting in the use of durable medical equipment and prescribed therapies by a nursing facility to an individual who has elected to receive hospice care. Room and board services shall also include the services, activities and allowable costs as set forth in subdivisions (d) and (g) of section 86-2.10 of this Part.

Effective Date: 
Friday, May 10, 2002
Doc Status: 
Complete

Section 86-6.2 - Hospice rates of reimbursement

86-6.2 Hospice rates of reimbursement. (a) Pursuant to 42 USC 1396a (a)(13)(D), rates of reimbursement for hospice shall be in amounts no lower than the amounts used under part A of title XVIII of the Social Security Act. Hospices may be eligible for supplemental rates of payment under the supplemental financial assistance program in accordance with the provisions set forth in section 86-6.6 of this Subpart.

(1) The hospice payment rates are established to reimburse each of the following four specific categories of hospice care:

(i) routine home care;

(ii) continuous home care;

(iii) inpatient respite care; and

(iv) general inpatient care.

(2) Payment rates under the supplemental financial assistance program are established to reimburse each of the following special need categories of hospice care:

(i) routine home care for AIDS patients;

(ii) routine home care with escort services;

(iii) routine home care for AIDS patients with escort services;

(iv) continuous home care for AIDS patients;

(v) general inpatient care for AIDS patients;

(vi) room and board services for persons receiving care in a hospice residence.

(b) Except as otherwise stated, each hospice payment rate established pursuant to this Subpart is a prospectively determined per diem amount which has been adjusted consistent wit the requirements of 42 USC 1396a (a)(13)(D) to reflect regional variations in wage levels.

(c) Per-diem payments shall be for only one of the categories of hospice care listed in either paragraph (1) or paragraph (2) of subdivision (a) of this section for any particular day, provided that payments for continuous home care days will vary depending upon the number of hours of continuous home care provided.

(d) For continuous home care, the rates established pursuant to subdivisions (f) and (g) of this section shall be divided by 24 to yield an hourly rate. The number of hours of continuous home care provided in a given day is then multiplied by the resulting hourly rate to yield a continuous home care payment amount for that day. A minimum of 8 hours of predominantly nursing care must be furnished on a particular day to qualify for the continuous home care reimbursement rate pursuant to this section.

(e) Beginning October 1, 1990 annual adjustments to the hospice payment rates for each category of hospice care established in this section shall be made using trend factors developed by the Commissioner of Health pursuant to section 86-6.5 of this Subpart.

(f) The hospice reimbursement rates for the four standard categories of care for hospices located within the various New York State Standard Metropolitan Statistical Areas (SMSA) and rural areas are as follows:

*Routine *Continuous *InpatientHome Care Home *Respite CareSMSA Area Rate Care Rate Care Rate Rate(Counties Within Area)
(1) Albany-Schenectady-Troy,(Albany, Greene,Montgomery,Rensselaer,Saratoga andSchenectady) $70.20 $409.31 $77.64 $313.61
(2) Binghamton(Broome, Tioga 73.43 428.14 80.40 326.97
(3) Buffalo(Erie) 74.79 436.07 81.57 332.60
(4) Elmira(Chemung) 77.24 450.36 83.67 342.74
(5) Glens Falls(Warren, Washington) 69.71 406.46 77.22 311.58
(6) Nassau-Suffolk(Nassau, Suffolk) 86.81 506.19 91.87 382.38
(7) New York(Bronx, Kings, New York,Putnam, Queens, RichmondRockland, Westchester) 94.97 553.75 98.85 416.14
(8) Niagara Falls(Niagara) 69.33 404.27 76.90 310.02
(9) Orange County(Orange) 76.22 444.40 82.79 338.52
(10) Poughkeepsie(Dutchess) 80.69 470.45 86.62 357.04
(11) Rochester(Livingston, Monroe,Ontario, Orleans, Wayne) 77.88 454.07 84.21 345.38
(12) Syracuse(Madison, Onondaga,Oswego) 99.66 581.12 102.87 435.57
(13) Utica-Rome(Herkimer, Oneida) 72.52 422.82 79.62 323.19
(14) NON-SMSA Area (Rural)Includes Counties NotCovered Above 69.20 403.51 76.79 309.48
*Rates that appear on this schedule shall be effective January 1, 1990 through September 30, 1990. Beginning October 1, 1990 annual adjustments will be made to these rates pursuant to section 86-6.5 of this Subpart.
(g) The reimbursement rates under the Supplemental Financial Assistance Program for the special need categories of care for hospices located within the various New York State Standard Metropolitan Statistical Areas (SMSA) and rural areas are as follows:
*Routine*Routine *Routine Home Care *Continuous *GeneralHome Care Home Care for AIDS Home Care Inpatientfor AIDS Escort Patients for AIDS for AIDSPatients Services & Escort Patients PatientsServicesSMSA AREA(Counties Within Area)(1) Albany-Schenectady-Troy(Albany, Greene, Montgomery,Rensselaer, Saratoga, andSchenectady) 120.53 86.02 136.35 439.64 348.55
(2) Binghamton(Broome, Tioga) 126.27 89.25 142.09 467.55 363.39
(3) Buffalo(Erie) 128.69 90.61 144.51 479.32 369.65
(4) Elmira(Chemung) 133.04 93.06 148.86 500.52 380.92
(5) Glens Falls(Warren, Washington) 119.66 85.53 135.48 435.40 346.29
(6) Nassau-Suffolk(Nassau, Suffolk) 150.06 102.63 165.88 583.32 424.98
(7) New York(Bronx, Kings, New York,Putnam, Queens, Richmond,Rockland, Westchester) 164.56 110.79 180.38 653.85 462.50
(8) Niagara Falls(Niagara) 118.99 85.15 134.81 432.15 344.56
(9) Orange County(Orange) 131.23 92.04 147.05 491.68 376.23
(10) Poughkeepsie(Dutchess) 139.18 96.51 155.00 530.37 396.81
(11) Rochester(Livingston, Monroe,Ontario, Orleans, Wayne) 134.17 93.70 149.99 506.02 383.86
(12) Syracuse(Madison, Onondaga,Oswego) 172.90 115.48 188.72 694.44 484.09
(13) Utica-Rome(Herkimer, Oneida) 124.64 88.34 140.46 459.66 359.19
(14) NON-SMSA Area (Rural)Includes Counties NotCovered Above 118.76 85.02 134.58 431.03 343.96

*Rates that appear on this schedule shall be effective July 1, 1990 through September 30, 1990. Beginning October 1, 1990 annual adjustments will be made to these rates pursuant to section 86-6.5 of this Subpart.

(h) Daily payment will be made to a hospice residence for Medicaid–eligible patients who have elected hospice care and reside in a hospice residence. Payment shall be made for a hospice residence patient to take into account the room and board furnished by the hospice residence and will be in an amount equal to 94% of the weighted average Medicaid rate of the nursing facilities located in the region that the hospice residence is located in, as specified in Appendix 13-A, infra, of this Title.

(i) The hospice rates of reimbursement set forth in this section are subject to the approval of the State Director of the Budget.

Effective Date: 
Friday, May 10, 2002
Doc Status: 
Complete

Section 86-6.3 - Reimbursement for attending and consulting physician services

86-6.3 Reimbursement for attending and consulting physician services.

Reimbursement for attending and consulting physician services rendered to hospice patients shall be in accordance with the Medicaid fee schedule set forth in this title, as amended pursuant to chapter 904 of the Laws of 1984. The current fee schedule is set forth in section 7.0 of the Medicaid Management Information System Provider Manual, Physicians (Revised January 1985). Copies of this schedule may be obtained from the Bureau of Program, Policy and Operations of the Division of Medical Assistance of the New York State Department of Social Services, 40 North Pearl Street, Albany, NY 12243. The current physicians fee schedule is available for inspection and copying at the Department of Health Records Access Office, 10th Floor, Corning Tower Building, Nelson A. Rockefeller Empire State Plaza, Albany, NY 12237.
 

Doc Status: 
Complete

Section 86-6.4 - Reporting requirements

86-6.4 Reporting requirements.

(a) Each hospice provider shall complete and file with the New York State Department of Health and/or its agent, financial and statistical reports as deemed necessary by the Commissioner of Health on forms supplied by the department. In instances where the hospice is a component part of a larger organization, the cost and statistics related to the operation of the hospice shall be separately maintained from the operator's other activities.

(b) Completion of such financial and statistical reporting forms shall be in accordance with generally accepted accounting principles as applied to the hospice, unless the reporting instructions authorize specific variation in such principles.
 

Doc Status: 
Complete

Section 86-6.5 - Trend factor

86-6.5 Trend factor.

(a) The commissioner shall establish trend factors to project annual increases in the costs of hospice services. Each payment rate for the categories of hospice care, as established pursuant to the provisions of section 86-6.2 of this Subpart, shall be trended each year by the trend factors developed in accordance with the provisions of this section.

(b) The elements of certified home health agencies' costs shall be weighted based upon data for the categories listed below in developing the trend factor that will be applied to the routine and continuous home care rates. The elements of general hospitals' costs shall be weighted based upon data for the categories listed below in developing the trend factor that will be applied to the inpatient and respite care rates:

(1) salaries;

(2) employee health and welfare expense;

(3) nonpayroll administrative and general expense;

(4) nonpayroll household and maintenance expense;

(5) nonpayroll professional care expense.

(c) Each weight shall be adjusted by one or more price indices. Included among these indices are elements of the United States Department of Labor consumer and produce price indices and special indices developed by the commissioner for this purpose.

(d) The projected trend factors shall be updated on an annual basis, based upon current and available data. The commissioner shall adjust subsequent trend factors based upon such update.
 

Effective Date: 
Thursday, June 7, 1990
Doc Status: 
Complete

Section 86-6.6 - Supplemental financial assistance program

86-6.6 Supplemental financial assistance program.

(a) The supplemental financial assistance program provides enhanced payments to patients with special needs as defined in subdivision (k) of section 86-6.1 of this Subpart using payment rates established pursuant to subdivision (g) of section 86-6.2 of this Subpart.

(b) To receive the enhanced Medicaid payment rates as set forth in section 86-6.2(g) of this Subpart, a hospice must:

(1) meet all certification requirements pursuant to Article 40 of the Public Health Law;

(2) continue efforts to obtain financial support from public and community funding sources;

(3) make a reasonable effort to collect payments for services from third party insurance payers, governmental payers and self paying patients;

(4) establish a reasonable relationship between costs and charges, or establish charges at approximate costs; and

(5) with respect to the enhanced payment rates for escort services, provide the commissioner with an acceptable written plan explaining how escort services will be used by each agency which may be billing the routine home care rates with escort.

(c) The provisions set forth in this section, and sections 86-6.1(k) and 86-6.2(g) of this Subpart shall expire and be deemed to have no further force or effect on and after the date on which section 4012-a of the Public Health Law, which authorizes establishment of the supplemental financial assistance program, expires.
 

Effective Date: 
Wednesday, July 21, 1999
Doc Status: 
Complete

Section 86-6.7 - Hospice reimbursement for room and board provided to patients residing in a nursing facility

86-6.7 Hospice reimbursement for room and board provided to patients residing in a nursing facility.

(a) Daily payment will be made to a hospice for Medicaid-eligible patients who have elected the hospice benefit and reside in a nursing facility (see 42 USC 1396a (a)(13)(D)). Payment shall be made for a hospice patient to take into account the room and board furnished by the nursing facility and will be in an amount equal to 95% of the facility rate that would have been paid by the State to the facility in accordance with the applicable provisions of Subpart 86-2 of this Part, if the patient had not elected to receive hospice care. A hospice cannot bill for this additional amount on a day in which the patient who has elected hospice care is receiving either general inpatient or inpatient respite care. Patients covered under provisions set forth in this section must be patients who would be eligible under Medicaid for nursing facility services if he/she had not elected to receive hospice care.

(b) To be eligible to receive Medicaid payment as set forth in subdivision (a) of this section, a hospice must have a written agreement with a nursing facility under which the hospice takes full responsibility for the professional management of the patient's hospice care, and the nursing facility agrees to provide room and board to the patient, collect any patient payment contributions, and maintain an accounting of the patient's financial contribution.
 

Effective Date: 
Tuesday, January 1, 1991
Doc Status: 
Complete