This regulation establishes Medicare coinsurance liability rules for hospice beneficiaries, specifying that individuals who have elected hospice care may be charged up to 5% (capped at $5) of drug/biological costs for outpatient prescriptions, and 5% of the CMS payment rate for each respite care day, with the respite coinsurance capped at the applicable inpatient hospital deductible for the year. Hospices are permitted to charge these coinsurance amounts and must have their drug copayment schedules reviewed and approved by the intermediary before use.
View official source§ 418.400 Individual liability for coinsurance for hospice care. An individual who has filed an election for hospice care in accordance with § 418.24 is liable for the following coinsurance payments. Hospices may charge individuals the applicable coinsurance amounts. (a) Drugs and biologicals. An individual is liable for a coinsurance payment for each palliative drug and biological prescription furnished by the hospice while the individual is not an inpatient. The amount of coinsurance for each prescription approximates 5 percent of the cost of the drug or biological to the hospice determined in accordance with the drug copayment schedule established by the hospice, except that the amount of coinsurance for each prescription may not exceed $5. The cost of the drug or biological may not exceed what a prudent buyer would pay in similar circumstances. The drug copayment schedule must be reviewed for reasonableness and approved by the intermediary before it is used. (b) Respite care. (1) The amount of coinsurance for each respite care day is equal to 5 percent of the payment made by CMS for a respite care day. (2) The amount of the individual's coinsurance liability for respite care during a hospice coinsurance period may not exceed the inpatient hospital deductible applicable for the year in which the hospice coinsurance period began. (3) The individual hospice coinsurance period— (i) Begins on the first day an election filed in accordance with § 418.24 is in effect for the beneficiary; and (ii) Ends with the close of the first period of 14 consecutive days on each of which an election is not in effect for the beneficiary.