Ind. IHCP Hospice Services Provider Reference Module, Section 6, Patient Liability for a Hospice Member Residing in a Nursing Facility

An IHCP member (whether Medicaid-only or dually eligible for Medicare and Medicaid) residing in a

nursing facility is responsible for the member’s portion of the payment prior to the IHCP reimbursing the

remaining balance of nursing facility care (this includes room-and-board services when the individual

elects the Medicare and Medicaid hospice benefits). Patient liability includes, but is not limited to, an

individual’s personal savings account, Medicare pension funds and Social Security checks. A member’s

patient liability is deducted starting the first date of service the individual is residing in a nursing facility

and is eligible for the IHCP nursing facility level of care (LOC).

When a hospice provider submits hospice claims for nursing facility room-and-board services for a dually

eligible (Medicare and Medicaid) or Medicaid-only hospice member, the patient liability portion gets

deducted from the claim and the remaining balance reflects the room-and-board payment. The total patient

liability is not reflected on the remittance advice (RA) because the hospice claim is paid as a UB-04 claim

with home health edits.

For Traditional Medicaid (FFS) members, hospice providers can obtain the member’s patient liability

amount for a particular month by contacting Customer Assistance toll-free at 800-457-4584, or using one

of the Eligibility Verification System (EVS) options.

When a provider obtains the patient liability amount, the RA is used to determine how the paid amount is

calculated. The following formula is used if the RA does not match the rates the provider originally

submitted on the claims:

• Step 1: Nursing facility case-mix rate on file  95% (0.95) = allowed amount on the RA for room

and board

• Step 2: [Number of dates of service  allowed amount on RA] – patient liability = room-and-board

amount