Hospice Cap/Inpatient Day Limitation Calculator
This calculator will assist hospice providers in calculating the hospice cap on aggregate payments and the inpatient day limitation. The purpose of the calculator is to offer assistance in monitoring payments for these limitations. The hospice cap period for both limitations is October 1 through September 30 of each year (for cap years 2018 and later). The following sections explain further the components of this computation.
The Inpatient Day Limitation
During the 12-month period beginning October 1 and ending September 30, the aggregate number of inpatient days (both general and respite) may not exceed 20 percent of the total days provided. The calculator below will indicate if an Inpatient Day Limitation potentially exists.
Aggregate Cap Calculation
Overall aggregate Medicare payments made to a Medicare-certified hospice are subject to an aggregate cap. This cap is calculated by multiplying the statutory cap amount by the number of beneficiaries in the cap period and comparing this to payments received. The statutory cap amount is updated and published each year. The number of beneficiaries is determined by either the Proportional Method or the Streamlined Method. For either method, the PS&R system provides reports of the data in the Miscellaneous Reports section to identify the beneficiary counts.
Proportional Method (applies to most hospices)
For each hospice, the count of the number of Medicare beneficiaries counted is the fraction which represents the portion of a patient’s total days of care in all hospices and all years that was spent in this hospice in this cap year (October 1 to September 30)
The count includes those Medicare beneficiaries who have not previously been included in the calculation of any hospice cap and who have filed an election to receive hospice care from the hospice during the period beginning on October 1st and ending on September 30th.
Under the Streamlined Method, when a beneficiary has received care from more than one hospice, each hospice includes in its number of Medicare beneficiaries only that fraction which represents the portion of a patient's total stay in all hospices that was spent in this hospice in this cap year.
Comment: The Streamlined method is only available to hospices that previously elected this method back in 2012.
Items to obtain to evaluate these limitations:
- Number of beneficiaries electing hospice coverage
- For Patient by Patient Proportional Method (Hospice Beneficiary Count Summary) – The 'From' date is 10/01/xxxx; and 'Through' date is 09/ 30/xxxx.
- For Streamlined Method – The 'From' date is 10/01/xxxx and 'Through' date is 09/30/xxxx
- Medicare reimbursement for the service period 10/1 through 09/30
- Visit data by revenue type
Total Medicare Visits
(Excess inpatient days will create an overpayment based on the difference
in the Inpatient Rate and the Routine Home Care Rate)
(These amounts are estimates and do not include
the impact of the Sequestration adjustment)
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