Ind. IHCP Hospice Services Provider Reference Module, Section 6, Room and Board

In the context of the hospice benefit only, the term room and board includes personal care services not

otherwise provided by the hospice and all assistance in the activities of daily living and socializing

activities, administration of medication, maintaining the cleanliness of a resident’s room, and supervision

and assistance in the use of durable medical equipment (DME) and prescribed therapies, as stated in

Indiana Administrative Code 405 IAC 1-16-4. The room-and-board rate is 95% of the nursing facility case-mix rate paid to the nursing facility for the dates of service the member was a resident of that facility. When

a nursing facility resident elects hospice, whether it is Medicare or Medicaid, direct IHCP payment to the

nursing facility for the resident must be discontinued as the hospice provider is responsible for coordinating

all the hospice care. The nursing facility may no longer bill the IHCP directly for room-and-board services

after the resident elects the Medicare or Medicaid hospice benefit.

To ensure compliance with 405 IAC 1-16-4, IHCP-enrolled hospice providers and IHCP-enrolled nursing

facilities must comply with the following guidelines. Failure to comply with these procedures results in

recoupment of funds.

• The nursing facility and the hospice provider must first have a written agreement (contract) stating

the hospice provider takes full responsibility for the professional management of the individual’s

hospice care. This contract must also specify the nursing facility agrees to provide room-and-board

services as described in 42 USC 1396d(o)(3). Hospice services cannot be provided until both

parties have finalized a contract.

• For Medicaid-only members (those that are eligible for Medicaid but not for Medicare), the nursing

facility resident must elect hospice by signing the Medicaid Hospice Election form (State Form

48737 [R2/1-12]).

➢ The resident can designate an effective date for the election that is later than the date the election

form is signed. The effective date of the election form is the date hospice services begin and

payment by IHCP to the nursing facility must stop.

➢ Hospice providers must properly complete and submit the election form, the physician

certification form and the plan of care as required by 405 IAC 5-34-5, 405 IAC 5-34-6 and 405

IAC 5-24-7 for the Medicaid-only hospice member. All three forms must be submitted to the

Hospice Authorization Unit within 10 days of the effective date of the election.

• For dually eligible (Medicare and Medicaid) members, hospice providers must properly complete

the Hospice Authorization Notice for Dually Eligible Medicare/Medicaid Nursing Facility Residents

form (State Form 51098 [3-03]/OMPP 0014) and attach a copy of the hospice agency’s Medicare

hospice election form, which reflects the date of hospice election and includes the signature of the

member or the member’s representative. Both forms must be submitted to the IHCP Hospice

Authorization Unit within 10 days of the effective date of the election.

• Failure to comply with these paperwork submission procedures is a violation of state and federal

regulations because hospice providers are required to notify state Medicaid agencies when a dually

eligible hospice member elects, revokes or changes hospice providers under both programs. Hospice

providers are also reminded that the terms of the IHCP Provider Agreement that the hospice agency

signed include but are not limited to the following:

➢ To abide by and comply with all federal and state statutes and regulations pertaining to the IHCP

because they are amended from time to time

➢ To abide by the IHCP Provider Reference Modules when amended as well as all provider

bulletins and notices. Any amendments to the IHCP Provider Reference Modules and all

provider bulletins and notices are communicated to the provider and are binding upon receipt.

Amendments, provider bulletins and notices are posted to in.gov/medicaid/providers.

Case-mix rates are adjusted four times each calendar year in January, April, July and October. The Office

of Inspector General (OIG) has advised the IHCP that the hospice provider and the nursing facility can

negotiate payment of anywhere between 95% and 100% of the nursing facility’s IHCP daily rate for room-and-board services in their contract. This capability allows the rates to be negotiated without concern about

fraud or kickbacks.