Revision 11-1; Effective May 11, 2011

 

 

4100 General Information

Revision 11-1; Effective May 11, 2011

 

A provider must have a DADS Medicaid contract to receive Medicaid payment for hospice services. DADS pays the Medicaid hospice provider at periodic intervals, depending on when the provider bills for approved services. Payments are based on the hospice care setting applicable to the type and intensity of hospice services provided to the Medicaid hospice recipient for that day.

DADS Provider Claims Services authorizes hospice services, according to department, state and federal regulations, for contracted providers that furnish Medicaid services to DADS consumers. Provider Claims Services does not develop program policy, but is responsible for applying established policy when performing the authorization for reimbursement function.

Payment for hospice services is controlled by receipt of information. Payment will not occur until the following conditions are verified:

  • the Medicaid Eligibility (ME) specialist or the Social Security Administration (SSA) certifies that the recipient is Medicaid eligible for the hospice program;
  • the Texas Medicaid & Healthcare Partnership (TMHP) receives Form 3071, Individual Election/Cancellation/Update;
  • TMHP receives Form 3074, Physician Certification of Terminal Illness;
  • if applicable, Minimum Data Set (MDS) assessment is received by TMHP; and
  • if applicable, the Level of Need (LON) Assessment.

Medicaid hospice providers have the option of submitting the hospice eligibility forms, Form 3071 and Form 3074, through a web-based, online system called Long Term Care (LTC) Online Portal. This new system has a web portal interface to submit forms, corrections, status inquiries and retrieve status reports. Providers interested in the web-based portal should contact TMHP at 800-626-4117.

Providers who choose to submit paper eligibility forms must submit them to:

Texas Medicaid & Healthcare Partnership
TMHP LTC Unit
P.O. Box 200765
Austin,TX 78720-0765

Eligibility forms are validated when received at TMHP. If any deficiencies are noted, the document is returned to the provider with an explanation. The hospice provider will not receive payments until Medicaid eligibility is verified and Form 3071 and Form 3074 are received at TMHP. All eligibility forms are processed according to the date they are received. Forms returned to the provider for a deficiency and then resubmitted are processed according to the new receipt date.

TMHP processes hospice forms in 14 workdays for individuals who have Medicaid eligibility. Only individuals who have Medicaid eligibility can be seen in the electronic Claims Management System (CMS) Medicaid Eligibility Services Authorization Verification (MESAV) file. Forms received for individuals who have pending eligibility are suspended in a pending file at DADS until DADS has been notified that the individual is eligible for hospice services. Direct questions about service authorizations or forms that cannot be seen on CMS to TMHP at 800-626-4117.

All payments under the Medicaid Hospice Program are only for services related to the treatment of an individual's terminal illness. DADS continues to pay through other service programs for services not related to the treatment of a individual's terminal illness. Exception: In accordance with Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L.111-148), individuals under 21 years of age are not required to waive Medicaid payment for treatments related to the terminal illness.

 

4200 Claims Management Systems (CMS)

Revision 06-2; Effective December 12, 2006

 

CMS was established to be the reimbursement method for all Long Term Care Programs effective Sept. 1, 1999. Hospice providers use CMS to submit claims to DADS, which are submitted through TDH Connect. For more information on how to bill electronically, call 800-626-4117.

Form 1290, Long Term Care Claim, is a paper voucher used for reimbursement if the electronic software supplied by TMHP is not obtained.

Form 1290 must be completed for each client and mailed to:

Texas Medicaid & Healthcare Partnership
Attention: Long Term Care MC-B02
P.O. Box 200105
Austin,TX 78720-0105

If you need assistance filling out the paper claim form or want to obtain the electronic CMS software, call 800-626-4117. A TMHP representative will assist you.

Do not mail Form 1290 to DADS.

 

4300 Withholding Payments

Revision 08-1; Effective November 12, 2008

 

Actions that may result in withholding of hospice payments, include, but are not limited to:

  • ownership changes;
  • failure to submit Form 3071, Individual Election/Cancellation/Update, Form 3074, Physician Certification of Terminal Illness, and Minimum Data Set (MDS) or LON assessment (if applicable);
  • failure to verify that an individual is Medicaid eligible; or
  • failure to submit or obtain signatures in the required time frames for Form 3071, Form 3074 and MDS assessment (if applicable).

Reasons for non-payment that cannot be corrected:

  • Form 3074 is not received within the required time frame. Payments cannot be made before this date.
  • Hospice providers cannot receive Medicaid hospice payment for dually eligible individuals.
  • Medicaid eligibility does not exist for the time period billed.
  • The type of Medicaid eligibility approved for a recipient does not include hospice services.
  • Form 3071 is effective after the date requested for payment.
  • Form 3071 indicates that this client was discharged from the hospice program.
  • Form 3071 or financial eligibility indicates that this client died. Payment cannot be made after this date.

Missing and expired documentation are usually the reasons for non-payment of hospice claims. Be sure all hardcopy forms are legible and complete. Incomplete, incorrect and difficult-to-read forms are returned to providers for correction and could cause delay in payment. Review the form for completeness before submission to TMHP to eliminate problems.

Obtain copay data directly from the local HHSC ME staff for more precise claims processing. Hospice staff should work closely with other DADS and HHSC staff in order to alleviate rejected claims because of the simultaneous provision of other Medicaid services, Medicaid eligibility approval or incorrect hospice data in the CMS and DADS systems.

 

4400 Third-Party Reimbursement

Revision 06-2; Effective December 12, 2006

 

Hospice providers cannot retain money collected from third-party payers, such as private insurance companies, on behalf of Medicaid recipients. Under terms of the contract between the provider and DADS, the provider agrees to accept DADS' vendor rate as payment in full on behalf of Medicaid recipients.

Title XIX of the Social Security Act (42 CFR 433, Subpart D) requires DADS to use all third-party payment resources before spending Medicaid funds. DADS also is required to seek reimbursement from liable third parties if Medicaid payments were made before the identification of a third-party payment resource.

When a recipient files an application for Medicaid or receives services from DADS, the recipient automatically grants the right of financial recovery for the cost of medical care to DADS. When a recipient is determined eligible for Medicaid, the provider is no longer entitled to receive financial reimbursement for the cost of the recipient's care from any other source. DADS is to be reimbursed for any insurance payment the provider received on behalf of a Medicaid recipient. State law provides that the filing of an application for, or receipt of, Medicaid benefits constitutes an automatic assignment to DADS of the applicant's or recipient's right of recovery from personal insurance, other sources or other persons for personal injury caused by the other person's negligence or wrongdoing.

The DADS Third Party Resource Unit (TPR), Provider Claims Services is responsible for recouping Medicaid expenditures from third-party resources for long term care claims. TMHP is responsible for collecting payments from third-party resources for medical expenditures, such as hospitals, laboratories and physician services.

Notify the HHSC ME staff of information concerning a recipient's third-party resources. Refer questions about third-party resources or insurance reimbursement to the TRP Unit at:


Provider Claims Services
Third Party Resource
Mail Code W-400
P.O. 149030
Austin,TX 78714-9030

 

4500 Medicaid

Revision 06-2; Effective December 12, 2006

 

 

4510 Payments

Revision 06-2; Effective December 12, 2006

 

DADS makes payment for hospice services to providers once TMHP has processed the claim. TMHP and DADS will not pay the Medicaid hospice provider until all hospice forms and documents have been submitted, as outlined in Section 4100, General Information, and Section 4300, Withholding Payments. TMHP staff verify and approve all hardcopy hospice forms for data entry and payments to hospice providers. Forms must be mailed to the TMHP address below. Mailings to a different address, an incomplete address or any variation of this address may cause claims processing delays of four weeks or more.

Texas Medicaid & Healthcare Partnership
TMHP LTC Unit
P.O. Box 200765
Austin,TX 78720-0765

Address hospice billing questions to the TMHP Help Desk at 800-626-4117.

For dually eligible recipients, Medicare is always the primary payer. Medicaid pays only for service normally billed to Medicare if the recipient has exhausted his Medicare benefits. Documentation that shows Medicare denial must be submitted to DADS before the Medicaid program pays for these services.

 

4520 Physician Services

Revision 06-2; Effective December 12, 2006

 

In addition to the per diem rate, the Medicaid Hospice Program pays providers according to customary and reasonable Medicaid physician charges. The program pays for direct patient care services provided to Medicaid hospice recipients by physicians who are on staff with the provider. The Medicaid Hospice Program does not pay when a physician provides patient care services on a volunteer basis or when physician services are provided by physicians who are not on staff with the Medicaid hospice provider. Physician payment amounts through the Medicaid Hospice Program are included in the Medicaid hospice cap amount, which varies each federal fiscal year. All claims for higher amounts are reduced to the Texas Medicaid Reimbursement Methodology (TMRM) amounts for physician services.

A provider is responsible for managing all physician services for inclusion in the hospice plan of care and to ensure physicians are paid on a timely basis. The Medicaid hospice provider has a liability to pay hospice physicians for physician services rendered.

The Texas Medicaid Program, through TMHP, makes payments directly to non-hospice physicians for physician services furnished to Medicaid hospice recipients. TMHP pays regardless of hospice status. TMHP Medicaid payment amounts to non-hospice physicians are not counted in the Medicaid Hospice Program cap.

 

4530 Physician Services on Day of Discharge

Revision 06-2; Effective December 12, 2006

 

Under the State Medicaid Manual, Section 4307, Payment for Physicians Services Under Hospice, a provider can be paid for physician services on day of discharge, if the physician is a hospice employee under arrangement by the hospice and direct patient services are provided.

To request payment for physician services on the day of discharge, providers must submit proof that the physician is a hospice employee under arrangement by the hospice and that direct patient services were provided. The information must be submitted to:


Medicaid Hospice Program Specialist
Mail Code W-521
P.O. Box 149030
Austin,TX 78714-9030

Program staff notifies the hospice provider of the approval or denial of the request for payment for physician services on the day of discharge. The hospice provider will be able to see the authorization on their Medicaid Eligibility Services Authorization Verification (MESAV) request.

 

4540 Room and Board

Revision 08-1; Effective November 12, 2008

 

DADS pays the hospice provider a room and board rate that is 95% of the Texas Medicaid NF per diem rate for each Medicaid or dually eligible individual on hospice residing in the NF. This rate is required by Section 1902 (a)(13)(D) of the Social Security Act and is an additional per diem rate paid on routine home care and continuous home care days. The payment amounts are not subject to the Medicaid hospice cap on overall Medicaid hospice payments. When the rate is paid to the hospice provider, all Medicaid NF per diem payments for NF care cease. The hospice provider pays the 95% rate to the NF for room and board. For more information regarding NF per diem rates, see Item 6310, Hospice – Nursing Facility Per Diem Rate. For more information on Medicaid eligibility, see Section 3200, Three-Month Prior Eligibility.

NF and hospice providers complete and submit a signed and dated Minimum Data Set (MDS) assessment, to TMHP as justification for payment of the room and board rate. For a hospice recipient or applicant currently residing in the facility with a current MDS assessment, no action is required until the next required MDS assessment. For a hospice recipient or applicant newly admitted to the facility, the hospice and the NF must complete and submit an MDS assessment as required by 40 TAC §19.801, Resident Assessment. An MDS assessment received after the required date will have the stamp-in date as the effective date.

The room and board rate also applies to those individuals participating in the Intermediate Care Facility for Persons with Mental Retardation or Related Conditions (ICF/MR-RC) Program. The Medicaid Hospice Program pays the hospice provider per diem rate for each individual on hospice, who is a Medicaid hospice recipient residing in an ICF/MR-RC. The per diem rate is 95% of the reimbursement amount for the individual who resides in an ICF/MR-RC. This information is extrapolated from Form 3650, Level of Care. For additional information, contact Policy Development, Regulatory Services, Department of Aging and Disability Services.

 

4550 Coinsurance for Drugs

Revision 06-2; Effective December 12, 2006

 

The Texas Medicaid Hospice Program pays the Medicaid hospice provider (for Medicare-Medicaid recipients only) a coinsurance of 5% for prescription drugs and biologicals, not to exceed $5 per prescription.

 

4560 Coinsurance for Respite Care

Revision 05-1; Effective December 2, 2005

 

The Texas Medicaid Hospice Program pays the Medicaid hospice provider (for Medicare-Medicaid recipients only) a coinsurance of 5% for each day of respite care in a hospice coinsurance period under the Texas Medicaid Hospice Program.

 

4570 Skilled Nursing Facility (SNF) Payment and the Dually Eligible Individual on Hospice

Revision 08-1; Effective November 12, 2008

 

When a dually eligible individual on hospice requires an SNF bed for treatment unrelated to his terminal illness, Medicaid hospice room and board payments end. An SNF bed is only appropriate for those aspects unrelated to the terminal illness. The first 20 days are paid by Medicare at 100%. Days 21-100 (or upon discharge, whichever occurs first) are paid by coinsurance through DADS TDHconnect/TMHP. Part of this coinsurance is considered the room and board payment. The nursing facility (NF) submits Form 3619, Medicare/SNF Patient Transaction Notice. A Minimum Data Set (MDS) assessment is not required during this period. The hospice provider must submit Form 3071, Individual Election/Cancellation/Update, to TMHP as an update for admission into the SNF bed. The date in box No. 3 is the date the individual is admitted into the SNF bed.

Coinsurance for drugs will apply to dually eligible individual on hospice who are in an SNF bed. For more information, see Item 4550, Coinsurance for Drugs.

When the individual is readmitted into the regular NF coverage, an MDS, will be completed if necessary. The hospice provider must submit Form 3071 to TMHP as an update for discharge from the SNF bed. The date in box No. 3 is the date the individual is discharged from the SNF bed.

Please note that coinsurance for respite services does not apply to dually eligible individuals on hospice residing in an NF.