Revision 08-1; Effective November 12, 2008    

 

 

A Medicaid recipient may elect to receive hospice care in any long term care facility such as a nursing facility (NF), intermediate care facility for persons with mental retardation or related conditions (ICF/MR-RC), or hospital. Long term care facilities must comply with all requirements for participation in the Medicaid and Medicare programs that apply to the facility. Long term care facilities do not have to participate in the hospice program; however, if a resident expresses a desire to participate in hospice and the facility does not contract with hospice providers, the facility should assist the resident in locating a facility that is willing to participate in the hospice program. The hospice rules and policies are similar for all long term care facilities, with some variances because of licensing requirements and payment rates.

 

6100 Agreements with Long Term Care Facilities

Revision 06-2; Effective December 12, 2006

 

A hospice provider must enter into an agreement with a long term care facility that is interested in participating in the hospice program. The agreement must contain at least the following:

  • description of the hospice and contractor roles in the admission process, individual/family assessment, and the interdisciplinary group care conferences.
  • services to be provided.
  • a stipulation that services related to the terminal illness may be provided only with the express authorization of the hospice.
  • the manner in which the contracted services are coordinated, supervised and evaluated by the hospice.
  • requirements for documenting services that are furnished in accordance with the agreement.
  • qualifications of the personnel providing the services.
  • the Medicaid hospice provider's responsibilities, which are the professional management of an individual's hospice care, the provision of all hospice services on a timely basis as indicated on the Medicaid hospice plan of care, and collection and management of the copay.
  • the hospice provider maintains records on the hospice plan of care, including the services provided by hospice staff, in the current NF clinical or ICF/MR-RC resident record. The hospice provider maintains a summary of an individual's long term care facility care plan and records in the hospice provider's plan of care case record.
  • the long term care facility agrees to provide certain services to the individual on Medicaid hospice on a timely basis that complement and support the hospice services under the Medicaid hospice plan of care.
  • the Medicaid hospice provider agrees to pay the NF or ICF/MR-RC provider the DADS Medicaid room and board rate that is paid to the hospice. If the hospice provider agrees to pay the facility more than this rate, the rate cannot go above the 100% rate and the agreement must specify the additional service the facility will provide. Anything above the 100% rate is considered Medicaid fraud and is reported to the federal government.

 

6200 Hospice Responsibilities in Long Term Care Facilities

Revision 05-1; Effective December 2, 2005

 

When a Medicaid recipient elects hospice in a long term care facility, the hospice provider is responsible for:

  • the Medicaid hospice election and cancellation process;
  • complying with the hospice rules and policies;
  • working with the long term care staff to arrange an individual's admission into the facility, if applicable;
  • working with the staff in the long term care facility to assure all forms are completed in order to start, continue or cancel the hospice program;
  • notifying the Social Security Administration (SSA) when a Supplemental Security Income (SSI) recipient is admitted onto hospice;
  • retaining the professional management responsibility for the provision of hospice care according to the hospice plan of care by qualified individuals;
  • maintaining a separate hospice section in the current NF clinical or ICF/MR-RC resident record that contains documentation of all the hospice services provided by hospice staff, hospice admission assessments, physician certifications and cancellations, documentation on Medicaid eligibility, advance directives and other legal documents;
  • assuring continuity of individual/family care; and
  • payment to the long term care provider for room and board.

 

6300 Hospice and Nursing Facility (NF) Care

Revision 08-1; Effective November 12, 2008

 

A Medicaid recipient may elect the Medicaid Hospice Program:

  • in a home setting and be admitted to an NF as an individual on hospice at a later time;
  • and be admitted to an NF as an individual on hospice at the same time; or
  • while residing in an NF when the hospice election is made.

The NF and hospice staff should maintain ongoing communication regarding an individual's care and changes in condition. Both entities must maintain hospice records in the individual's current clinical record. Coordinate any changes in the hospice plan of care with the NF staff.

The Medicaid hospice provider is responsible for all items outlined under Section 6200, Hospice Responsibilities in Long Term Care Facilities, as well as the following:

  • collecting and managing copay;
  • completing Minimum Data Set (MDS) assessment with the NF nursing staff, and maintaining copies of the assessment in the individual's hospice record and current clinical record at the NF;
  • ensuring that the MDS is electronically submitted to TMHP within the required time frames as outlined in 40 TAC §30.60 and 40 TAC §19.801.

The NF is responsible for the following areas:

  • managing the trust fund.
  • completing the MDS with the hospice nursing staff.
  • ensuring that the MDS is electronically submitted to TMHP within the required time frames.
  • completing Form 3618, Resident Transaction Notice, and submitting it to TMHP, indicating a discharge to hospice. A copy is kept on file with the NF.
  • all NF requirements for participation in the Medicaid and Medicare program.

 

6310 Hospice - Nursing Facility Per Diem Rate

Revision 08-1; Effective November 12, 2008

 

When a Medicaid recipient elects the Medicaid Hospice Program in an NF, the hospice program pays a per diem rate that is 95% of the NF rate as outlined under Item 4540, Room and Board.

The Medicaid Hospice Program pays the rate to Medicaid hospice providers under the following conditions:

  • Medicaid and dually eligible recipients elect the Medicaid Hospice Program and reside in an NF. Information on Medicaid eligibility is outlined in Section 3200, Three-Month Prior Eligibility.
  • Form 3618, Resident Transaction Notice was submitted to DADS, indicating a discharge to hospice. A copy is kept on file in the NF. If Form 3618 is not completed and submitted by the NF, and if DADS pays both the NF and the hospice provider, DADS will recoup the payment that was made to the NF. If the NF is not a provider in the Medicaid Nursing Facility Program, or if the individual on Medicaid hospice is not in aMedicaid contracted bed, Form 3618 is not required.
  • Hospice providers have a written agreement with the NF to provide hospice care in the facility, as outlined under Section 6100, Agreements with Long Term Care Facilities.
  • Minimum Data Set (MDS) assessment was completed by the hospice and NF providers and submitted, as necessary, to TMHP. Retain a copy in the hospice record and the current clinical record at the NF.

When an NF resident elects into the hospice program, he is electing out of the NF program. NFs must stop billing DADS for these residents as of the date of the individual's hospice election and instead, look to the hospice for the room and board payment. Regardless whether the individual is Medicaid or dually eligible, DADS pays the hospice 95% of the Resource Utilization Group (RUG) rate for that resident's room and board, as outlined under Item 4540, Room and Board. The hospice then passes that amount on to the NF.

In order to receive payment from DADS for room and board for dually eligible recipients, a hospice provider must have a valid Medicaid provider agreement.

Information on hospice program requirements for dually eligible recipients for both the Medicaid and Medicare programs may be found in several Centers for Medicare and Medicaid Services publications:

  • State Operations Manual, Section 2082, Election of Hospice Benefit by Resident of SNF, NF, ICF/MR-RC or Non-Certified Facility;
  • The Hospice Manual, Section 204.2, Skilled Nursing Facility and Nursing Facilities Residents and Dually Eligible Beneficiaries; and
  • State Medicaid Manual, Section 4305, Hospice Services.

 

6320 Vendor Drug

Revision 06-2; Effective December 12, 2006

 

Individuals on hospice who reside in NFs have access to unlimited prescriptions unrelated to the terminal illness.

 

6400 Hospice and Intermediate Care Facilities for Persons with Mental Retardation and Related Conditions (ICF/MR-RC)

Revision 06-2; Effective December 12, 2006

 

Persons who receive services from the ICF/MR-RC Program may receive hospice services.

A Medicaid recipient residing in an ICF/MR-RC may elect the Medicaid Hospice Program. When an ICF/MR-RC resident elects into the hospice program, he is electing out of the ICF/MR-RC Program. ICF/MR-RC providers must stop billing DADS for these residents as of the date of election and instead, look to the hospice for the room and board payment. The hospice passes the room and board payment to the ICF/MR-RC. For more information on the per diem rate, see Item 4540, Room and Board.

The hospice and ICF/MR-RC staff should:

  • maintain ongoing communication regarding an individual's care and condition;
  • maintain hospice records in the individual's resident record; and
  • coordinate any changes in the hospice plan of care with the ICF/MR-RC staff.