(a) Except as specified in paragraph (b) of this section, the total Medicare payment to a hospice for care furnished during a cap period is limited by the hospice cap amount specified in § 418.309.
(b) Until October 1, 1986, payment to a hospice that began operation before January 1, 1975 is not limited by the amount of the hospice cap specified in § 418.309.
(c) The hospice must file its aggregate cap determination notice with its Medicare contractor no later than 5 months after the end of the cap year and remit any overpayment due at that time. Hospices shall file the aggregate cap using data no earlier than 3 months after the end of the cap period. The Medicare contractor will notify the hospice of the final determination of program reimbursement in accordance with procedures similar to those described in § 405.1803 of this chapter. If a provider fails to file its self-determined cap determination with its Medicare contractor within 5 months after the cap year, payments to the hospice will be suspended in whole or in part, until a self-determined cap determination is filed with the Medicare contractor, in accordance with§ 405.371(e) of this chapter.
(d) Payments made to a hospice during a cap period that exceed the cap amount are overpayments and must be refunded.
[48 FR 56026, Dec. 16, 1983; 48 FR 57282, Dec. 29, 1983, as amended at 79 FR 50509, Aug. 22, 2014; 80 FR 47207, Aug. 6, 2015]
Notes of Decisions
Gentiva Health Services, Inc. v. Becerra (2022)
cadc · cites it 3×
“42 C.F.R. § 418.308 (d). If a hospice concludes a contractor’s determination of its overpayment obligation (if any) is mistaken, it can administratively challenge that determination before the Provider Reimbursement Review Board.”
Los Angeles Haven Hospice, Inc. v. Sebelius (2011)
ca9
“See 42 C.F.R. § 418.308 (d). 3 If a hospice provider dis *652 agrees with the repayment demand, and the amount in controversy is at least $10,000, it may seek a hearing before the Provider Reimbursement Review Board (“PRRB”).”
Lion Health Services, Inc. v. Sebelius (2011)
ca5
“See 42 C.F.R. § 418.308 (c). If a provider’s total reimbursement payments received from the intermediary over the course of the fiscal year exceed its aggregate cap amount for that year, the intermediary demands that the provider refund the amount of the overpayments to Medicare.”
Hospice of New Mexico, LLC v. Sebelius (2011)
ca10 · cites it 2×
“See 42 C.F.R. § 418.308 (c). If the provider’s total reimbursement payments do not exceed its fiscal cap, the provider owes nothing.”
Southeast Arkansas Hospice, Inc. v. Sebelius (2014)
ared
“See 42 C.F.R. § 418.308 (d). Under 42 U.S.C. § 1395oo(a), a hospice provider may challenge an NPR and seek a hearing before the Provider Reimbursement Review Board (“PRRB”), so long as the amount in controversy is at least $10,000.”
Gentiva Health Services, Inc. v. Azar (2021)
dcd · cites it 4×
“” 42 C.F.R. §§ 418.308 , 405.1803(a). A similar process applies to the inpatient cap, and, if the MAC determines “[a]t the end of a cap period” that the hospice exceeded the cap, “any excess reimbursement must be refunded by the hospice.”
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