Mich. Medicaid Provider Manual, Hospice § 7.3.H

When Medicaid reimburses the hospice for room and board in a NF, the beneficiary must

be placed in a bed certified by Medicaid (i.e., a Medicare/Medicaid certified bed or one

certified Medicaid-only). If the beneficiary is not placed in a bed certified for Medicaid,

MDHHS does not pay for any services. Except for State Veterans’ Homes, MDHHS pays

the hospice 95 percent of the individual or specific facility’s Medicaid rate for room and

board plus 100 percent of the nursing facility’s Quality Assurance Supplement (QAS) rate.

Hospice reimbursement to the NF for room and board must be outlined in the contract

established between the hospice and the NF.

• Holding a Bed (Hospital Leave and Therapeutic Leave). For NF beneficiaries on

hospice, Medicaid reimburses the hospice for holding a NF bed as indicated below.

Hospice reimbursement to the NF for bed holds must be outlined in the contract between

the NF and the hospice.

Family members/responsible parties for the hospice/NF beneficiary must be informed of

the bed hold and readmission policy of the NF. If the beneficiary refuses to have a

family member/responsible party notified, this must be documented in the beneficiary’s

medical record.

• Hospital Leave Days. For Hospital Leave Days, Medicaid will pay to hold a

beneficiary’s bed only when the facility’s total available bed occupancy is at 98 percent or

more on the day the beneficiary leaves the facility. Facilities at 97.5 percent occupancy

may round up to 98 percent. Medicaid reimburses during a beneficiary's temporary

absence (up to 10 days) from the NF for admission to the hospital for emergency medical

treatment as documented by the attending physician in the beneficiary’s medical record.

The facility must hold the bed, and the hospice may bill Medicaid, if the attending

physician documents a reasonable expectation at the point of admission to the hospital

that the beneficiary will return to the NF by the end of the 10th day.

The beneficiary must return to the NF within 10 days for the hospice to bill for hospital

leave days. If the beneficiary is in the hospital for more than 10 days, the NF is released

from its obligation to hold the bed and the hospice cannot bill Medicaid for any leave

days. Reimbursement to the hospice is at 100 percent of the class wide NF hospital

leave day rate. This rate, determined annually by MDHHS, is available on the MDHHS

website. (Refer to the Directory Appendix for website information.)

If the beneficiary is expected to be in the hospital for 10 days or fewer, and dies while in

the hospital, the hospice may bill Medicaid for the hospital leave days up to the day

before the beneficiary died.

If the beneficiary returns to the NF under Medicare coverage and still elects hospice care,

the hospice may bill Medicaid for the hospital leave days if the emergency hospitalization

was for no more than 10 consecutive days.

Patient-pay amounts and billing methods are not affected by this hospital leave day

policy. The hospice/NF should continue to collect any patient-pay amount, typically on

the first day of the month, and indicate the amount collected on the Medicaid claim.

CHAMPS automatically deducts the patient-pay amount and reimburses the provider for

the balance. If the hospice bills Medicaid for hospital leave days that occur at the

beginning of the month, then the hospice should collect the patient-pay amount as usual.

The hospice should charge the amount against the patient-pay that Medicaid pays for

that day. For example, if a beneficiary has a patient-pay of $200 and is in the hospital

for an emergency condition for the first five days of the month (the stay totals no more

than 10 consecutive days), the hospice should collect the patient-pay amount from the

beneficiary and then submit a Medicaid claim. Medicaid reimburses the hospice for the

hospital leave day per diem rate, minus the patient-pay amount.

There is no annual limit to the number of hospital leave days per beneficiary that may be

billed to Medicaid as long as there are no more than 10 consecutive leave days per

hospital stay.

• Therapeutic Leave Days. If the beneficiary has a temporary absence from the NF for

therapeutic reasons approved by the attending physician or NPP, the hospice may be

reimbursed by Medicaid to hold the bed open for up to a total of 18 days during a 365-day period. Therapeutic leave is for nonmedical reasons such as overnight stays with

friends/relatives, Make-a-Wish Foundation trips, etc. The beneficiary’s POC must provide

for such absences. There is no limit to the number of therapeutic leave days that may

be reimbursed at one time as long as the total does not exceed 18 days in a 365-day

period. If a beneficiary does not return from a therapeutic leave, the beneficiary must be

discharged on the date they left the facility. The date of admission and the date of

discharge may not be billed as therapeutic leave days.

Reimbursement is at 95 percent of the individual or specific NF’s daily per diem rate, just

as the customary room and board rate is reimbursed.

• Hospice Revocation or Decertification. If a Medicaid hospice beneficiary who

resides in a NF revokes their hospice services or is deemed no longer certifiable for the

Medicaid hospice benefit, the hospice may bill for services on the day of revocation/

decertification, as well as the hospice/NF room and board, as long as the beneficiary is in

the facility at the midnight census.

• Ventilator Dependent Care Unit (VDCU) or Complex Care Case. Refer to the

Place of Service subsection of this chapter for information regarding payment of room

and board for these hospice beneficiaries.

• State Veterans’ Homes. MDHHS pays the hospice 100 percent of the beneficiary-

specific Patient Driven Payment Model (PDPM) Medicaid rate for room and board in a

State Veterans’ Home, and payments will be made through gross adjustments. In

addition to standard billing practices, hospice providers must follow the State Veterans’

Homes billing policy found in the Billing & Reimbursement for Institutional Providers

chapter. The hospice must submit a separate claim from other services for the room and

board provided in a State Veterans’ Home. Hospice reimbursement for room and board

must be outlined in the contract established between the hospice and the State Veterans’

Home.