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Series: Audits of Medicaid's Hospice Inpatient and Aggregate Cap Calculations

Announced on  | Last Modified on  | Series Number: W-00-24-31577
Status
Active
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

Under Medicare, CMS requires two annual limits to ensure that hospice care does not exceed the cost of conventional medical care at the end of life: the inpatient cap and the aggregate cap. Under Medicaid, however, CMS only requires States to calculate the hospice inpatient cap, and calculating the aggregate cap is optional for each State. If a State applies the hospice caps, any amount paid to a hospice for its claims in excess of each cap is considered an overpayment and must be repaid to Medicaid. We will audit selected States to determine whether the hospice caps were calculated correctly, whether cap overpayments were collected, and whether the Federal share of the collected cap overpayments was properly refunded.

There are 2 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (1)

Project OAS-25-06-098 • Announced on Apr 21, 2025

COMPLETED PROJECTS IN THIS SERIES (1)

Texas

Project A-06-24-09001 • Completed on September 17, 2025

TIMELINE

  • December 11, 2023
    Series Number W-00-24-31577 Assigned
  • December 11, 2023
    Project Announced

    Texas - A-06-24-09001

  • April 21, 2025
    Project Announced

    Project OAS-25-06-098

  • September 17, 2025
    Project Complete - A-06-24-09001

    Texas has been marked as complete. This audit resulted in 2 recommendations.

  • Today
    1 Audit In-Progress
  • Est FY2026
    Estimated Fiscal Year for Series Completion

1 REPORT PUBLISHED

Texas Did Not Calculate or Collect Hospice Cap Overpayments Totaling $10.5 Million (A-06-24-09001)

Texas overpaid $10.5 million ($6.9 million Federal share) to 174 hospices (36 percent of hospices that received payments) for services provided during Federal fiscal years 2020 through 2022 because it did not have any policies and procedures related to calculating and collecting the hospice cap overpayments. Texas did not calculate these cap overpayments; therefore, it did not collect them or return the related Federal share.

25-A-06-120.01 to CMS - Open Unimplemented
Update expected on 03/16/2026
We recommend that the Texas Health and Human Services Commission collect the hospice cap overpayments totaling $10,498,423 and refund the Federal share of $6,916,454 to the Federal Government.

25-A-06-120.02 to CMS - Open Unimplemented
Update expected on 03/16/2026
We recommend that the Texas Health and Human Services Commission develop and implement policies and procedures related to calculating and collecting hospice cap overpayments.

View in Recommendation Tracker
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Financial Stewardship
Target Groups
-
Financial Groups
Medicaid