Instantly calculate Medicare hospice aggregate cap compliance and inpatient day limitations. Protect your agency's reimbursements with accurate, real-time analysis based on the 2025–2026 CMS statutory rate.
This analysis is based on 2025–2026 statutory rates ($35,361.44).
Provided as a courtesy by Right on Time Medical Billing.
The Hospice Cap and Inpatient Day Limitation Calculator is a free, web-based compliance tool designed for hospice administrators, billing managers, and revenue cycle professionals. It helps you determine whether your hospice agency is at risk of exceeding Medicare’s annual aggregate cap or the inpatient day limitation — and calculates your maximum allowable payments before any overpayment obligation is triggered.
Built on the 2025–2026 CMS statutory rate of $35,361.44 per beneficiary, this calculator delivers instant, accurate analysis so your team can make proactive decisions throughout the cap year — not just at year end.
Input your estimated beneficiary count and total Medicare payments received to date for the current cap year.
›Enter your RHC, CHC, IRC, and GIP days for the cap year. Each level of care is factored separately in the analysis.
›The tool instantly displays Total Care Days, Allowable IP Days, Actual IP Days, Excess IP Days, and Allowable Payments.
›Upload your agency logo and download a branded compliance report to share with your leadership team or for audit purposes.
The Medicare hospice aggregate cap limits the total amount a hospice agency can receive from Medicare in a given cap year. For 2025–2026, the cap is set at $35,361.44 per beneficiary. If total Medicare payments exceed this threshold multiplied by your number of Medicare beneficiaries, your agency must return the excess as an overpayment.
Medicare limits the number of inpatient care days — both General Inpatient (GIP) and Inpatient Respite Care (IRC) — to no more than 20% of total hospice care days in a cap year. Exceeding this threshold can result in required refunds and compliance consequences for your agency.
If your agency exceeds either the aggregate cap or the inpatient day limit, CMS requires reimbursement of overpayments. This can significantly impact your agency’s cash flow and compliance standing. Proactive monitoring throughout the year is essential to avoid year-end surprises.
Per-beneficiary cap rate for the 2025–2026 hospice cap year, as established by CMS under 42 CFR § 418.309.
20%Maximum percentage of total care days that may be provided as inpatient care (GIP + IRC combined) before the inpatient day limitation applies.
The hospice cap year runs from October 1 through September 30 annually. CMS notifies agencies of any overpayment obligation following full reconciliation of claims for the cap year period.
The combined sum of all hospice care days across every level of care: Routine Home Care (RHC), Continuous Home Care (CHC), Inpatient Respite Care (IRC), and General Inpatient Care (GIP).
The maximum number of inpatient days (IRC + GIP) permitted under Medicare rules before the inpatient day limitation applies. Calculated as 20% of your total care days.
The real number of inpatient care days your agency provided during the cap year — the combined total of Inpatient Respite Care days and General Inpatient Care days entered into the tool.
The number of inpatient days exceeding the allowable threshold. If this value is greater than zero, your agency may face a reimbursement obligation to Medicare for those excess days.
The maximum total Medicare payment your agency is entitled to receive, based on your beneficiary count and the 2025–2026 statutory rate, before any cap deductions are applied.
By comparing Allowable Payments against total Medicare payments received, you can determine how close you are to exceeding the aggregate cap and take corrective action early.
Identify cap exposure before year-end so you can manage admissions and census proactively — avoiding surprise Medicare recoupments that disrupt your cash flow.
Understand your maximum allowable reimbursement and ensure your billing practices align with Medicare hospice regulations throughout the entire year.
No manual spreadsheets or complex formulas needed. Enter your data and get a complete inpatient day and cap analysis in seconds, every time.
Upload your agency’s logo and generate a professional, shareable report ready for leadership reviews, board presentations, or compliance audits.
Provided as a courtesy by Right on Time Medical Billing. No account creation, no subscription fee — just open the tool and start calculating right away.
The calculator is updated each cap year to reflect the latest CMS statutory rates, ensuring your compliance analysis is always accurate and current.
Don’t wait until the end of the cap year to assess your exposure. Running this calculator monthly lets your team identify trends early and adjust operations before a cap violation becomes unavoidable and costly.
Medicare calculates beneficiary counts using a proportional allocation method across cap years. If a patient was enrolled across two cap years, their time is divided proportionally — directly affecting your per-beneficiary cap calculation.
General Inpatient Care is the highest-cost level and the most likely driver of exceeding the 20% inpatient day threshold. Ensure GIP is used only when medically necessary and always properly documented in the clinical record.
Medicare compliance in hospice billing demands specialized expertise. A dedicated partner like Right on Time Medical Billing monitors your cap position year-round, handles CMS reconciliation, and helps you avoid costly overpayment obligations before they occur.