Levels of Care Transition Criteria

Levels of care transition criteria are the clinical conditions that determine which of the four Medicare hospice levels of care a patient receives on a given day: routine home care (RHC), continuous home care (CHC), inpatient respite care (IRC), and general inpatient care (GIP) (42 CFR 418.302)^[1]. Each level carries a different daily payment and a different clinical justification.

Routine home care is the default level for a patient who is not in crisis, whether at home, in a nursing facility, or in assisted living; for FY 2026 (effective October 1, 2025) it pays $230.83 per day for the first 60 days of the election and $181.94 per day from day 61 onward (CMS MM14190)^[2]. A service intensity add-on (SIA) pays separately, at the continuous home care hourly rate, for registered nurse and social worker visits during the last seven days of life, up to four hours combined per day (CMS MM14190)^[2]. Continuous home care is furnished only during a period of crisis to manage acute medical symptoms and requires a minimum of eight hours of care in a 24-hour day, provided predominantly (more than half) by a nurse; it pays $69.76 per hour, or $1,674.29 for a full 24-hour day, in FY 2026 (42 CFR 418.204, https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-F/section-418.204; CMS MM14190, https://www.cms.gov/files/document/mm14190-hospice-payments-fy-2026-update.pdf). Inpatient respite care gives a home caregiver a short break, is provided in a facility, may not be billed for more than five consecutive days at a time, and pays $532.48 per day in FY 2026 (42 CFR 418.204). General inpatient care is for pain control or acute symptom management that cannot be managed in another setting, is delivered in a Medicare-participating hospital, SNF, or hospice inpatient facility, and pays $1,199.86 per day in FY 2026 (Medicare Benefit Policy Manual, Chapter 9, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf).

The rate spread is enormous — GIP pays roughly five times RHC per day — which makes the higher levels both a revenue lever and the sharpest audit target in hospice billing. Billing CHC or GIP without daily documentation that the crisis or acute-symptom criteria were met is a classic overpayment finding; contractors will recoup the differential and often extrapolate. The mirror-image risk is under-utilization: hospices that reflexively keep crashing patients on RHC to avoid scrutiny leave legitimate revenue unbilled and, worse, create a quality-of-care and CAHPS exposure by under-serving symptomatic patients. The eight-hour CHC minimum and the five-day respite limit are hard thresholds that claims scrubbing enforces before submission, because a CHC day that logs seven hours or is not predominantly nursing is not a CHC day.