Ga. Medicaid Part II Policies & Procedures for Hospice Services § 1011

Individuals that have elected Medicaid hospice care and reside in a nursing facility are required to

share in the cost of their services. The amount that everyone is required to pay is called the patient

liability amount. The patient liability amount is based on the individual’s income. The local county

Division of Family and Children Services (DFCS) where the individual resides will determine the

patient liability amount when the individual submits an application for Medicaid eligibility and at

any time that the individual has his/her Medicaid eligibility re-determined. The hospice agency must

submit a copy of the HCC to the local DFCS office to notify them that the patient has elected hospice

services. If the individual is assessed a patient liability amount, DFCS will notify the hospice agency

by returning to them the HCC Form that will include the amount and the effective date of the patient

liability. The individual and /or the family will also be advised of the patient liability amount and

will receive written notification from the DFCS office. The hospice agency is responsible for

collecting the patient liability from the individual and applying it to the cost of the hospice patient’s

nursing facility services. The hospice’s Medicaid reimbursement amount for everyone residing in a

nursing facility and enrolled in the Medicaid Hospice program will be reduced by the patient liability

amount.

The nursing facility is not responsible for collecting patient liability and the individual is not

responsible for paying patient liability outside of a nursing facility residence.

Providers should complete the form 501 for patient liability adjustments on untimely claims. All

patient liability adjustments/updates made by DFCS must have support from the DFCS Summary

Notification, and this information must be sent to Gainwell Technologies. There should be no

adjustments made in GAMMIS of a paid claim that is past timely as these funds are subject to denial

and recoupment. Rather, complete the form 501 and send to Gainwell

Technologies to request the adjustment. If there is a change to a patient liability amount after a

provider’s claim has already adjudicated, it will be at the provider’s discretion to adjust the claim to

capture the new patient liability amount.

1011.1. Hospice agencies have the authority to initiate legal action against any hospice member

or their responsible family member that refuses to pay the hospice agency the patient

liability amount. In addition, the provider can discharge a member that refuses payment.

However, the following procedures must be followed:

1011.1.1. The hospice agency must have written procedures that advise members

of their payment guidelines and of the penalties for nonpayment.

1011.1.2. The hospice agency must provide the member and the member’s

physician a written notice no less than thirty (30) calendar days in

advance of a planned discharge if a decision is made to discharge the

member for refusal to pay. The written notice must provide the member

with the reason for discharge, the effective date of the discharge, and

notice of the right to a hearing pursuant to the Georgia Administrative

Procedure Act and Section 15 of the Long-term Care Facilities:

Resident’s Bill of Rights and of the right to representation by legal

counsel. If the member so desires, the facility shall also send a copy of

the notice to the community ombudsman, or state ombudsman if there is

not community ombudsman.