Hospice Billing INTRODUCTION
Hospice is a health care program designed to meet the needs of terminally ill individuals when the individual decides that the physical and emotional toll of curative treatment is no longer in their best interest. These individuals choose palliative care, which is not a cure, but ensures comfort, dignity and quality of life. Hospice is intended to address the full range of needs of the individual with a terminal illness, while also considering family needs. Care must be consistent with the individual’s values, regardless of the location where care is provided.
The primary objective of the Medicaid Hospice Program is to ensure that essential medical/health services are available to those who would not otherwise have the financial resources to purchase them. Medicaid policies are designed to achieve this objective with fiscal responsibility. Hospice providers must verify eligibility before providing services. Hospice beneficiaries are identified in the eligibility response with the Benefit Plan ID of Hospice. (Refer to the Beneficiary Eligibility chapter for additional information.)
PROVIDER REQUIREMENTS
Hospice providers are bound to all rules, regulations, and policies specified in this chapter for program participation/enrollment of Medicaid beneficiaries. Hospice providers must also comply with the Medicare Conditions of Participation (42 CFR § 418) which generally apply to non-Medicare beneficiaries as well as to Medicare beneficiaries.
Additional information regarding federal Hospice requirements and guidelines is contained in the Centers for Medicare & Medicaid Services (CMS) State Operations Manual 2083.
Michigan Department of Health and Human Services (MDHHS) requires Hospice agencies to be licensed in Michigan by the state-licensing agency, certified by Medicare, and enrolled in Medicaid. (Refer to the General Information for Providers Chapter of this manual for additional information.)
Hospice providers cannot engage in any of the following marketing-related practices:
* Provide cash, gift incentives, or rebates to prospective covered persons;
* Claim superior medical care or provider skills; or
* Make untruthful statements regarding the merits of the hospice.
The use of marketing practices that mislead, confuse, or defraud either the beneficiary or MDHHS is considered grounds for terminating the hospice from participation in Medicaid. Such actions may also result in investigation leading to possible prosecution under applicable State and Federal statutes.
Hospice Services – Medicaid Guidelines
Service delivered to terminally ill patients (six months life expectancy) who elect palliative versus aggressive care. Hospice care is to be rendered by a Medicare-certified hospice.
1. Covered Services for Hospice
Covered Procedure Codes are: T2042, T2043, T2044, T2045, T2046.
2. Non Covered Services for Hospice
Nursing or aide services requested for convenience of family, i.e., bathing, feeding, exercising, homemaking services, transfer services, giving medication, or acting as a companion or sitter, which do not require training, medical judgment technical skills of a nurse whether or not another person is available to perform such services, are not covered. This exclusion applies regardless of whether services were recommended by a provider. Non-covered services are:
a. Private duty nursing.
b. Home health aide.
c. Custodial care.
d. Transportation, travel, escort services or food services.
BENEFICIARY ENROLLMENT
BENEFICIARY ENROLLMENT DETERMINATION
A terminally ill Medicaid beneficiary who lives in a hospice service area and whose life expectancy is six months or less (if the illness runs its normal course), as determined by a licensed physician and the Hospice Medical Director, has the option to enroll in a hospice program. A representative, such as a spouse, parent, legal guardian, or other authorized adult, may act on behalf of the beneficiary.
Medicaid does not cover Hospice services if the following conditions exist:
* The individual is not eligible for the Medicaid benefit.
* The beneficiary does not meet the hospice’s enrollment criteria.
* If the beneficiary is currently enrolled in a Medicaid Health Plan (MHP), the hospice services must be arranged and reimbursed by the MHP.
All Hospice enrollment activities must be conducted according to MDHHS policies and in such a manner as to maximize the beneficiary’s ability to make a choice between enrollment in hospice or maintaining current active treatment with Medicaid coverage. Such activities must assure that the beneficiary fully understands how to use hospice services and that all care must be received from or through the hospice (except those services not related to the terminal illness or services provided by his attending physician).
It is imperative that the Hospice provider read the Conditions of Enrollment on the Hospice Membership Notice form (DCH-1074) to the beneficiary and answer any questions raised by the beneficiary. (Refer to the Forms Appendix for an example of the DCH-1074 and instructions for its completion.)
BENEFICIARY ENROLLMENT PROCESS
Hospice providers are responsible for enrolling beneficiaries for hospice services. A DCH-1074 must be completed, including the signature of the beneficiary or his legally appointed representative. Fax the completed form to the MDHHS Enrollment Services Section. (Providers are not required to submit the form by US mail.) A copy of the form must be given to the beneficiary, and the original filed in the beneficiary’s record. Do not submit the form if the beneficiary is enrolled in the Adult Home and Community Based Waiver (MI Choice).
A copy of the following information must be retained in the beneficiary’s record:
* Hospice Membership Notice form (DCH-1074).
* Effective date of enrollment. (If the date entered on the DCH-1074 is changed, the hospice must contact the beneficiary to notify him of the new effective date.)
* Hospice enrollment identification card (if the hospice chooses to issue one to their beneficiaries).
BENEFICIARY NOTIFICATION
Hospice providers must provide Medicaid beneficiaries with the following materials and written information within ten days of the effective date of enrollment in hospice:
* Conditions of enrollment, including:
* Scope, content, and duration of coverage;
* Enrollee grievance procedure; and
* Beneficiary responsibility for reporting coverage by any other insurance.
* Procedures for obtaining health care, including:
* Address, telephone number, and service hours of the health care providers;
* Emergency medical care (other than for the treatment of the terminal illness); and
* Health care provision outside of the hospice.
PLACE OF SERVICE
BENEFICIARY’S HOME
A beneficiary eligible for hospice may receive hospice services in their home. If the beneficiary is eligible for hospice services but does not have family or friends to provide the necessary home care, the beneficiary may live in a residential setting that may include an Adult Foster Care (AFC) facility, boarding home, Home for the Aged (HFA), or assisted living facility. The setting must be appropriate for the type of care required by the beneficiary. Medicaid does not pay room and board in these settings.
Beneficiaries may receive hospice services in these settings. The hospice is responsible for developing and implementing a coordinated plan of care to avoid duplication ofservices. These care settings are available for Medicare, Medicaid, and dually eligible beneficiaries.
NURSING FACILITY
When a dually enrolled Medicare/Medicaid beneficiary enters a nursing facility (NF), the beneficiary can elect the Medicare hospice benefit if that NF has hospice services available. In this case, the beneficiary revokes the 100 days of Medicare reimbursement for skilled NF care.
Revocation of the 100-day NF skilled care is a beneficiary’s decision and should not be influenced by the NF’s funding source for the bed.
The DCH-1074 is used as the benefit election form for Medicaid eligible beneficiaries.
This does not mean that the beneficiary has revoked the Medicare benefit for services not related to their terminal illness. The beneficiary remains eligible for Medicare, but has elected to use only the hospice portion of the Medicare benefit.
If the NF contracts to make hospice services available, the hospice must provide DCH-1074 forms to Medicaid, Medicare and dually eligible beneficiaries. The facility must provide room and board for the beneficiary, and the hospice must provide its normal services.
The Pre-Admission Screening/Annual Resident Review (PASARR) form (DCH-3877) must be completed for a hospice patient entering a NF unless the hospice beneficiary is entering for a five-day respite period. The DCH-3877 is not required for the respite
period. The DCH-3877 is to identify ind ividuals who may have a mental illness or intellectual disability. If the patient is on antipsychotic, antianxiety, or antidepressant medications for purposes of pain control/symptom relief for end of life, it should be noted on the DCH-3877. This allows the Community Mental Health Services Program (CMHSP) worker to better evaluate the need for further (Level II) screening. If the patient is on any of the above mentioned psychotropic medications for a related mental illness, the CMHSP will determine the need for a Level II screening.
Medicaid will reimburse the hospice for room and board for a hospice beneficiary who resides in a NF (including a beneficiary for whom a complex care authorization has been approved) or in a Ventilator Dependent Care Unit (VDCU). The hospice then reimburses the NF. The Medicaid reimbursement to the hospice for NF room and board is equal to 95% of the total Medicaid NF rate. For Class I, III, and V facilities, reimbursement also includes 100% of the Quality Assurance Supplement (QAS) amount due the NF through the Quality Assurance Assessment Program (QAAP). QAS funds are not included in the reimbursement for Hospital Swing Beds as they are not eligible for that program.
Per Medicare guidelines, the term “room and board” in a NF includes the performance of personal care services that a family caregiver would provide if the individual were at home. This includes assistance in the activities of daily living such as bathing, grooming, toileting, dressing, meal service, socializing, companionship, hobbies, administration of medication, maintaining the cleanliness of the beneficiary’s bed and room, and supervising/assisting in the use of durable medical equipment (DME) and prescribed therapies (e.g., range of motion, speech and language exercises). The NF may not include hospice staff to meet its staffing requirements.
Hospice covered beneficiaries residing in the NF must not experience any lack of NF services or personal care due to their status as a hospice beneficiary. NFs must offer the same drugs, services, medical supplies and DME to all residents who have lected the hospice benefit in the same manner that services are provided to other residents in the facility who have not elected hospice care. If a service is normally furnished as part of the facility’s per diem, the service must also be provided to hospice beneficiaries. If services are provided for needs associated with a non-terminal illness and are normally furnished and billed by another provider, that practice would continue.
HOSPITAL INPATIENT CARE
Medicaid hospice reimbursement includes payment for any hospitalizations related to the terminal illness. The hospice must contract with, and reimburse, a hospital for medically necessary inpatient services related to the beneficiary’s terminal illness. Medicaid does not reimburse the hospital separately unless the hospitalization is not related to the terminal illness.
DURATION OF COVERAGE
Based on hospice eligibility criteria, the duration of hospice services is generally six months or less. There is no minimum period of hospice enrollment. A change in the beneficiary’s prognosis could eliminate the need for hospice care. A beneficiary may cancel his enrollment in the hospice at any time and without cause. Beneficiaries who become ineligible for Medicaid while enrolled in a hospice also become ineligible for Medicaid reimbursement for hospice services.
BENEFICIARY DISENROLLMENT
A beneficiary may disenroll or be discharged from hospice as noted below. A DCH-1074 indicating the reason for the disenrollment or discharge must be signed and dated by the beneficiary and/or authorized representative as proof of notification (unless the beneficiary has expired). The hospice must submit a copy of the disenrollment notice to the MDHHS Enrollment Services Section. (Refer to the Directory Appendix for contact information.)
BENEFICIARY DIES
When a hospice-enrolled beneficiary dies, the hospice must complete the DCH-1074 indicating the date the beneficiary expired and submit it to MDHHS.
BENEFICIARY ELECTS TO DISENROLL/REVOKE THEIR HOSPICE BENEFIT
A beneficiary may choose to disenroll from, or revoke their election of, hospice care at any time during an election period. The hospice must obtain written documentation, signed and dated by the beneficiary or their representative, stating they are revoking the hospice benefit for the remainder of that election period. The disenrollment or revocation is effective with the date of the beneficiary’s/representative’s signature. The hospice must give a copy of the disenrollment notice to the beneficiary when he signs it and retain another copy in the beneficiary’s record.
HOSPICE REVOCATION, DISENROLLMENT, OR DISCHARGE WHEN BENEFICIARY IS HOSPITALIZED
A beneficiary should not revoke, disenroll, or be discharged from hospice for the purpose of admission to the hospital for care related to the hospice diagnosis. Medicaid does not reimburse the hospital separately unless the hospitalization is not related to the terminal illness. When this is the case, the hospice may continue to provide care to the beneficiary under the routine hospice care benefit.
BENEFICIARY NO LONGER MEETS ENROLLMENT CRITERIA
An enrolled beneficiary may have a change in condition and no longer qualify for hospice services. If the beneficiary is discharged for this reason, the hospice must send a copy of the DCH-1074 (indicating the disenrollment) to the beneficiary along with a letter explaining the reason and effective date for the disenrollment.
BENEFICIARY BECOMES INELIGIBLE FOR MEDICAID
The hospice is responsible for verifying the beneficiary’s continued Medicaid eligibility once he is enrolled. Medicaid does not reimburse hospice services rendered to a Medicaid ineligible beneficiary.
BENEFICIARY MOVES OUTSIDE THE HOSPICE SERVICE AREA
At the time of enrollment, beneficiaries must be told to notify the hospice and their local MDHHS worker if their place of residence changes. If the new residence is located in the hospice’s normal service area, or if the hospice agrees to continue to provide services to the beneficiary, the move creates no changes except an address change. However, if the move is too far for the hospice to continue services for the beneficiary, the hospice must arrange a transfer of care for the beneficiary to another Medicaid enrolled hospice. The two hospices must work together to assure that no lapse occurs in services to the
beneficiary.
The effective date of disenrollment for a beneficiary who has moved is the day that the beneficiary moves. It is preferable that the DCH-1074 indicating the disenrollment from the first hospice, and the DCH-1074 indicating enrollment for the second hospice be sent to MDHHS together. If the notices are sent separately, each hospice must place an explanation in the Remarks box on the DCH-1074 indicating the reason for the transition to the new hospice.
HOSPICE ELECTS TO TERMINATE THE BENEFICIARY’S ENROLLMENT
The hospice may discharge a beneficiary if the beneficiary violates any of the conditions of membership in the hospice. The decision to discharge a beneficiary and the effective date of the discharge aredetermined on an individual basis by the hospice Medical Director.
The hospice may request disenrollment of a beneficiary for any of the following reasons:
* Fraud;
* Abuse (including repeated instances of willfully and knowingly obtaining health care services for the terminal illness from non-hospice providers); or
* Misconduct (including violence that interferes with or interrupts the provider’s proper delivery of health care to the patient or other patients)
MEDICARE CONDITIONS OF PARTICIPATION
HOSPICE ELECTION PERIODS
The duration of hospice coverage is measured in election periods, also known as benefit periods. A beneficiary may elect to receive hospice care during one or more of the following election periods:
* An initial 90-day period;
* A subsequent 90-day period; or
* An unlimited number of subsequent 60-day periods.
CERTIFICATION OF THE TERMINAL ILLNESS
A hospice must obtain written certification of the terminal illness for each election period before a claim for services is submitted. If the hospice is unable to obtain a written certification within three days of initiation of hospice care, a verbal certification must be obtained, documented, and signed by the person receiving the certification. Statements covering a beneficiary’s initial certification must be obtained from the hospice medical director or the physician member of the Interdisciplinary Group (IDG), and the beneficiary’s attending physician if the beneficiary has an attending physician. The hospice medical director or the physician member of the IDG certifies the terminal illness for all subsequent election
periods.
Each written certification must include:
* A statement that the beneficiary’s life expectancy is six months or less if the terminal illness runs its normal course;
* Specific clinical findings and other documentation as needed to support the life expectancy of six months or less;
* A brief narrative summary;
* An explanation why the clinical findings of the face-to-face encounter support a life expectancy of six months or less (beginning with the third benefit period and thereafter); and
* Physician signature(s), date signed, and specific election period dates covered by the certification or recertification.
Documentation of all written/verbal certifications must be prepared no more than 15 calendar days prior to the effective date of election and must be kept in the beneficiary’s medical record.
NARRATIVE SUMMARY
Each hospice certification and recertification must be accompanied by a brief narrative describing the clinical findings supporting the beneficiary’s life expectancy of six months or less. Each narrative must reflect the clinical circumstances and should not contain checkboxes or non-specific, standard language.
FACE-TO-FACE ENCOUNTER
A hospice physician, hospice-employed nurse practitioner (NP), or hospice-employed physician assistant (PA) must have a face-to-face encounter with every hospice beneficiary prior to the 180th day of recertification of the beneficiary’s terminal illness for the purpose of determining continued eligibility. The 180th day recertification is defined as the recertification that occurs at the start of the third benefit (election) period or the benefit period following the second 90-day benefit period. Additionally, a face-toface must be conducted at each subsequent recertification (every 60 days thereafter) for as long as the beneficiary is in hospice. Face-to-face encounters must occur no more than 30 calendar days prior to the start of the third benefit period and no more than 30 calendar days prior to each subsequent benefit period thereafter.
The hospice physician, NP, or PA must attest in writing to the face-to-face encounter with the beneficiary and include the date of the visit. A NP or PA is allowed to perform and attest to the face-to-faceencounter; however, the hospice physician must certify and recertify the terminal illness.
Failure to meet the face-to-face encounter requirements results in a failure by the hospice to meet the recertification of the terminal illness requirement. This results in the beneficiary no longer being eligible for the hospice benefit. If this should happen, the hospice must complete a Hospice Membership Notice (form DCH-1074), with the last date of the benefit period as the effective disenrollment date. A comment in the Remarks Section of the form is required to explain the reason for the disenrollment.
There may be an occasional case when a hospice admits a beneficiary who received services from another hospice provider, and the beneficiary chose to revoke or was discharged from that provider. When this occurs, the admitting hospice may begin their care with the beneficiary’s first benefit period unless the beneficiary is a direct transfer from the other hospice. When this is the case, the beneficiary’s benefit period remains the same, and the transferring hospice should provide the receiving hospice with all required documentation. A hospice resuming care for a beneficiary formerly served by their hospice must restart care in the next or subsequent benefit period.
HOSPICE SERVICES
CORE SERVICES
The hospice must provide all or substantially all of the core services applicable for the terminal illness in the beneficiary’s home. (Home may include the beneficiary’s private dwelling, apartment, boarding home, assisted living facility, AFC facility, HFA, NF or hospice-owned NF.)
These core services are:
* Physician care
* Nursing care
* Social work
* Counseling
* Bereavement
* Spiritual
* Dietary
OTHER HOSPICE COVERED SERVICES
Other services that may be necessary due to the terminal illness and must be available but are not considered core services are:
* Drugs*/Biologicals
* Home Health Aide services
* Homemaker services
* Medical Supplies/Durable Medical Equipment (DME)
* Occupational Therapy
* Physical Therapy
* Short-Term Inpatient care
* Speech Therapy
These other services may be provided by contractual agreement or provided by the hospice directly and are not reimbursed separately.
BILLING & REIMBURSEMENT
MEDICARE/MEDICAID BENEFICIARIES
If a beneficiary is dually enrolled in Medicare and Medicaid, he must receive hospice coverage under the Medicare benefit. (Medicaid is the payer of last resort.) If the beneficiary resides in a NF, Medicare may pay hospice services, with NF room and board paid for by Medicaid. When a beneficiary is receiving services through the Medicare hospice benefit, Medicaid does not pay for curative or duplicative services.
The hospice provider must complete the DCH-1074 whenever Medicaid is billed (i.e., coinsurance, deductibles, and room and board in the NF or hospice-owned NF).
If the hospice benefit is revoked under Medicare, the beneficiary cannot use the Medicaid hospice benefit as a replacement. Hospices should carefully explain this situation to the dually eligible beneficiary, especially during the fourth Medicare benefit period.* However, if the dually eligible beneficiary is no longer appropriate for hospice care and is disenrolled as a hospice beneficiary, that beneficiary is able to re-enroll with the hospice for the Medicaid benefit period if he becomes eligible for hospice again.
MEDICAID HEALTH PLAN ENROLLEES
Hospice services are included in the Medicaid Health Plan (MHP) covered services package for Medicaid enrollees. If the terminally ill enrollee requests and meets the criteria for hospice services, the MHP must cover the requested hospice services. If the terminally ill enrollee does not request hospice services, theMHP may provide its own array of services for the terminally ill. If the beneficiary is enrolled in a MHP (eligibility response indicates the Benefit Plan ID of MA-MC or MA-HMP-MC), the hospice must contact the MHP immediately to receive prior authorization (PA) from the MHP before furnishing services. The MHP may require its enrollees to receive hospice services through a contracted hospice with which they have made arrangements. MHPs are responsible for the hospice care arrangement and payment if the eligibility response indicates a Benefit Plan ID of MA-MC or MA-HMP-MC for the beneficiary.
If a fee-for-service (FFS) Medicaid beneficiary is automatically enrolled in a MHP while receiving hospice care, the beneficiary or his representative should contact the MDHHS Hospice Enrollment Coordinator if he wishes to continue receiving services from his current hospice provider. (Refer to the Directory Appendix for contact information.) The hospice enrollment coordinator initiates the process of disenrollment from the MHP. It is not the intent of MDHHS to disrupt a hospice beneficiary’s care through automatic enrollment in a MHP. If the beneficiary subsequently disenrolls or is discharged from hospice care, the beneficiary may be offered the opportunity to join a MHP. If the MHP enrollee requires hospice services in a NF or hospice-owned NF, the MHP pays a negotiated rate for room and board in addition to the payment for the hospice services. The hospice must contact the MHP prior to enrolling the beneficiary to request authorization by the MHP.
REIMBURSEMENT
MDHHS employs the following standards when reimbursing for hospice care:
MDHHS uses the Medicaid hospice payment base rates established and provided by CMS and applies the appropriate local wage adjustors provided by CMS for the four categories of hospice care in each Core Based Statistical Area (CBSA). Medicaid Fee for Service hospice providers who have not submitted required quality data to the Centers for Medicare & Medicaid Services (CMS) in compliance with the Hospice Quality Reporting Program (HQRP) will receive reduced reimbursement. Medicaid publishes and implements rate updates each fiscal year or when directed by CMS. (Refer to the MDHHS Hospice Reimbursement Rates on the MDHHS website.)
COINSURANCE
When a Medicaid beneficiary is receiving hospice services under Medicare, the hospice may bill Medicaid for the coinsurance, as well as room and board, if the beneficiary resides in a NF or hospice-owned NF. Coinsurance and/or room and board cannot be billed to a Medicaid beneficiary, his family, or his representative.
DATE OF DISCHARGE
Hospice services are reimbursable for day of discharge if services were rendered, regardless of the setting in which the services were provided. This includes the t ransfer of the beneficiary from one hospice provider to another as long as services were provided by both agencies. (This will be randomly verified by post payment audit and as indicated.) If the beneficiary has hospice as of 12:01 am, the hospice is responsible for the payment of services provided to the beneficiary until midnight. The hospice will continue, for payment purposes, as the primary provider for the full day of discharge.
Room and board for a hospice/nursing facility (NF) resident is reimbursable on the day of discharge if the discharge is due to resident death or the resident is discharged from hospice but remains in the NF. Room and board reimbursement for the day of discharge from the NF for any other reason is not covered.
PHYSICIAN SERVICES
Reimbursement for administrative duties performed by the Medical Director is included in normal hospice rates. Direct patient care provided by the Medical Director, hospiceemployed physician or consulting physician may be billed by the hospice and is separately reimbursable based on the lesser of Medicaid’s maximum allowable amount for the service or the charge. Claims must reflect the Healthcare Common Procedure Coding System (HCPCS) procedure codes for the physician’s direct patient care.
PATIENT-PAY AMOUNT
If the Medicaid beneficiary residing in a NF has a patient-pay amount (PPA), the hospice must collect that amount each month and apply it toward the beneficiary’s Medicaid covered services, and non-covered services as allowed by Medicaid. While the hospice is responsible for collecting the PPA, this duty may be delegated to the NF (via contract with the hospice) as long as the amount is applied to the room and board bill. The PPA must be exhausted each month (even if services do not span the entire month) before any Medicaid payment can be made. Whenever the hospice collects a PPA, a receipt must be given to the beneficiary (or family).
The provider must bill Medicaid for services rendered even if the PPA exceeds the Medicaid reimbursement rate resulting in a zero dollar payment. The Hospice Claim Completion Section of the Billing & Reimbursement for Institutional Providers Chapter
contains examples of the application of the PPA.
CHAMPS handles the PPA in the following manner: When a beneficiary has a monthly PPA and a level of care (LOC) for nursing facility (02) and hospice (16) on file, the PPA will be deducted from the first claim received in CHAMPS. This will occur regardless of whether the PPA is located on the eligibility segment for LOC 02 or LOC 16, and the higher PPA amount will be deducted. If the PPA is greater than the amount of the first submitted claim, the difference will be applied to subsequent claims until the total PPA for that month is met. The PPA must be exhausted each month before any Medicaid payment will be made. The nursing facility and hospice must bill in sequence according to the level of care the beneficiary was at on the first of the month. This will prevent the PPA from being deducted from the wrong claim.
PAYMENT FOR NONCOVERED SERVICES
For necessary medical or remedial care recognized under State law but not covered by Medicaid, the Medicare Catastrophic Coverage Act of 1988, Public Law 100-360, allows NF beneficiaries to access their patient-pay amount to pay for these services as allowed by Medicaid. If Medicare covers the beneficiary’s need for medical services, then Medicaid continues to cover the Medicare deductible and coinsurance in the event it does not exceed the Medicaid fee screen.
MEDICAID DEDUCTIBLE
The hospice must verify eligibility before providing hospice services to the beneficiary in a home setting. (Refer to the Beneficiary Eligibility chapter for additional information.) If the eligibility response indicates a Benefit Plan ID of Spend-down, the hospice should askthe beneficiary or their responsible person for a copy of the MDHHS letter sent the first of each month which indicates the dollar amount the beneficiary must spend before becoming Medicaid-eligible for services. Medicaid may not be billed until the Medicaid deductible obligation is met and the eligibility response indicates a Benefit Plan ID of MA or MA-HMP.
ROOM AND BOARD TO NURSING FACILITIES
When Medicaid reimburses the hospice for room and board in a NF, the beneficiary must be placed in a bed certified by Medicaid (i.e., a Medicare/Medicaid certified bed or one certified Medicaid-only). If the beneficiary is not placed in a bed certified for Medicaid, MDHHS does not pay for any services. MDHHS pays the hospice 95 percent of the individual or specific facility’s Medicaid rate for room and board plus 100 percent of the nursing facility’s Quality Assurance Supplement (QAS) rate. Hospice reimbursement to the NF for room and board must be outlined in the contract established between the hospice and the NF.
* Holding a Bed (Hospital Leave and Therapeutic Leave). For NF beneficiaries on hospice, Medicaid reimburses the hospice for holding a NF bed as indicated below. Hospice reimbursement to the NF for bed holds must be outlined in the contract between the NF and the hospice.
Family members/responsible parties for the hospice/NF beneficiary must be informed of the bed hold and readmission policy of the NF. If the beneficiary refuses to have a family member/responsible party notified, this must be documented in the beneficiary’s medical record.
* Hospital Leave Days. For Hospital Leave Days, Medicaid will pay to hold a beneficiary’s bed only when the facility’s total available bed occupancy is at 98 percent or more on the day the beneficiary leaves the facility. Facilities at 97.5 percent occupancy may round up to 98 percent. Medicaid reimburses during a beneficiary’s temporary absence (up to 10 days) from the NF for admission to the hospital for emergency medical treatment as documented by the attending physician in the beneficiary’s medical record.
The facility must hold the bed, and the hospice may bill Medicaid, if the attending physician documents a reasonable expectation at the point of admission to the hospital that the beneficiary will return to the NF by the end of the 10th day.
The beneficiary must return to the NF within 10 days for the hospice to bill for hospital leave days. If the beneficiary is in the hospital for more than 10 days, the NF is released from its obligation to hold the bed and the hospice cannot bill Medicaid for any leave days. Reimbursement to the hospice is at 100 percent of the class wide NF hospital leave day rate. This rate, determined annually by MDHHS, is available on the MDHHS website. (Refer to the Directory Appendix for website information.)
If the beneficiary is expected to be in the hospital for 10 days or fewer, and dies while in the hospital, the hospice may bill Medicaid for the hospital leave days up to the day before the beneficiary died.
If the beneficiary returns to the NF under Medicare coverage and still elects hospice care, the hospice may bill Medicaid for the hospital leave days if the emergency hospitalization was for no more than 10 consecutive days.
Patient-pay amounts and billing methods are not affected by this hospital leave day policy. The hospice/NF should continue to collect any patient-pay amount, typically on the first day of the month, and indicate the amount collected on the Medicaid claim.
CHAMPS automatically deducts the patient-pay amount and reimburses the provider for the balance. If the hospice bills Medicaid for hospital leave days that occur at the beginning of the month, then the hospice should collect the patient-pay amount as usual.
The hospice should charge the amount against the patient-pay that Medicaid pays for that day. For example, if a beneficiary has a patient-pay of $200 and is in the hospital for an emergency condition for the first five days of the month (the stay totals no more than 10 consecutive days), the hospice should collect the patient-pay amount from the beneficiary and then submit a Medicaid claim. Medicaid reimburses the hospice for the hospital leave day per diem rate, minus the patient-pay amount. The hospice reimbursement, based on 2003 rates, would be $132.80 [($66.56 x 5) – $200].
* Therapeutic Leave Days. If the beneficiary has a temporary absence from the NF for therapeutic reasons approved by the attending physician, the hospice may be reimbursed by Medicaid to hold the bed open for up to a total of 18 days during a 365-day period.
Therapeutic leave is for nonmedical reasons such as overnight stays with friends/relatives, Make-a-Wish Foundation trips, etc. The beneficiary’s POC must provide for such absences. There is no limit to the number of therapeutic leave days that may be reimbursed at one time as long as the total does not exceed 18 days in a 365-day period. If a beneficiary does not return from a therapeutic leave, the beneficiary must be discharged on the date he left the facility. The date of admission and the date of discharge may not be billed as therapeutic leave days.
Reimbursement is at 95 percent of the individual or specific NF’s daily per diem rate, just as the customary room and board rate is reimbursed.
* Hospice Revocation or Decertification. If a Medicaid hospice beneficiary who resides in a NF revokes his hospice services or is deemed no longer certifiable for the Medicaid hospice benefit, the hospice may bill for services on the day of revocation/ decertification, as well as the hospice/NF room and board, as long as the beneficiary is in the facility at the midnight census.
* Ventilator Dependent Care Unit (VDCU) or Complex Care Case. Refer to the Place of Service subsection of this chapter for information regarding payment of room and board for these hospice beneficiaries.
ADULT FOSTER CARE FACILITIES/HOME FOR THE AGED FACILITIES
Medicaid does not reimburse for room and board in these settings. Reimbursement is made directly to the facility provider in the normal manner (i.e., Supplemental Security Income, Personal Care/Supplemental Payment). This payment is made in full. The AFC or HFA cannot seek additional restitution from the beneficiary or the hospice provider.
BOARDING HOMES
Medicaid does not reimburse for room and board in these settings.
ASSISTED LIVING FACILITY
Medicaid does not reimburse for room and board in these settings.
REIMBURSEMENT LIMITS
Medicaid does not apply an aggregate dollar capitation. (The Medicare program establishes the maximum total dollar amount per year that Medicare pays for hospice services. Medicaid does not apply this policy to beneficiaries receiving hospice care.)
Medicaid applies the same number of inpatient respite days as Medicare (i.e., no more than five consecutive days are allowed). If more than five consecutive days are billed, the number is reduced to five days, and the excess days must be billed as routine care by the hospice.
Reimbursement for routine, non-emergent transportation is included in the per diem (room and board amount) negotiated between the hospice and the NF.
