MO HealthNet Hospice Provider Manual § 2.13

MO HealthNet eligible individuals who reside in MO HealthNet-certified NFs or intermediate care home and who meet the hospice eligibility criteria may elect MO HealthNet hospice care services. Nursing home room and board payments cannot be made for a participant residing in an area that has not been certified for MO HealthNet participants. It is the provider’s responsibility to ensure that a participant for whom MO HealthNet payment is made is placed in a Title XIX certified bed. Any payments made for a participant who was not in a Title XIX certified bed will be recouped.

In addition to the routine home care or continuous home care per diem rates, an amount may be paid to the hospice to cover the NF or intermediate care home room and board costs. The hospice reimburses the NF or intermediate care home. Room and board include the performance of personal care services that a caregiver would provide if the individual were at home. These services include assistance in the ADL: washing and grooming, toileting, dressing, meal service, socializing (companionship, hobbies, etc.), administration of medication, maintaining the cleanliness of the resident’s bed and room, and supervising and assisting in the use of DME and prescribed therapies (such as range of motion exercises and speech exercises).

There must be a written agreement between the hospice and the NF or intermediate care home under which the hospice takes full responsibility for the professional management of the individual’s hospice care and the NF or intermediate care home agrees to provide room and board to the individual. The hospice and the NF or intermediate care home must retain a copy of the agreement and a Hospice-NF Contract Update form advising of this agreement must be on file with Missouri Medicaid Audit and Compliance (MMAC). Providers may submit this information to MMAC.ProviderEnrollment@dss.mo.gov, fax to (573) 634-3105, or to the following address prior to submitting claims for NF or intermediate care home room and board services:

Missouri Medicaid Audit and Compliance Provider Enrollment Unit

P.O. Box 6500

Jefferson City, Missouri 65102-6500

Licensed/Certified Facilities

To participate in the MO HealthNet Vendor Nursing Care Program (Title XIX), a facility must be licensed as a skilled NF or intermediate care home and must also be certified as meeting federal requirements as a provider of NF services or intermediate care facility for individuals with intellectual disabilities (ICF/IID). Provider participation in the Vendor Nursing Care Program is voluntary. Refer to the Nursing Home Provider Manual for more information.

When a participant, who has elected hospice services, enters a NF or intermediate care home, the participant must reside in a ‘vendor’ (MO HealthNet-certified) bed for FSD to do a division of assets and/or to calculate surplus.

The following outline represents the procedure for each MO HealthNet participant or applicant who enters a MO HealthNet-certified facility.

Any MO HealthNet participant (or applicant) who enters a MO HealthNet-certified facility (in a vendor bed) has the Level One Nursing Facility Pre-Admission Screening for Mental Illness, Intellectual Disability, or Related Condition and when required, the Level II Nursing Facility Level of Care Assessment, completed by NF or intermediate care home personnel

FSD must be notified that the individual has entered a vendor bed

FSD performs necessary a ‘division of assets’ for MO HealthNet applicants; this allows a spouse who remains in the community to retain a portion of the couple’s resources while the institutionalized spouse becomes eligible for the MO HealthNet Vendor NF Program

FSD calculates surpluses for all individuals in MO HealthNet vendor beds which includes all income paid to the NF minus a portion for a personal needs allowance and allowable deductions like medical insurance premiums, allotments, and child support

FSD sends a MO HealthNet Vendor Notice (FA-465) to the NF or intermediate care home for each MO HealthNet participant in a vendor bed. The FA-465 notifies the NF or intermediate care home of the surplus amount, the effective date of vendor status, and provides the NF authorization to bill MHD. The hospice should request and maintain, from the nursing home, a copy of the FA-465 and any subsequent FA-465s.

The contract/agreement established between the hospice and NF should identify whether the hospice or NF is responsible for collecting the surplus

The hospice is reimbursed for NF room and board for each MO HealthNet hospice participant residing in a MO HealthNet-certified NF or intermediate care home (vendor bed). Surplus is deducted from the hospice room and board payment (revenue code: 0658). The hospice reimburses the NF or intermediate care home.

Refer to Preadmission Screening and Resident Review (PASRR) for more information.

Distinct Part

A NF may choose not to have all its licensed areas certified for participation in the MO HealthNet Program or there may be some licensed areas that do not meet MO HealthNet certification requirements. Federal regulations allow a facility to establish a ‘distinct part’ provided the distinct part meets requirements for certification. The distinct part must be an identifiable unit such as an entire ward, floor, or wing. When a NF designates a distinct part, a Bed Listing for Licensure and Certification (DA-113) must be completed showing which rooms are in the distinct part.

Revenue Code 0658

Hospice billing instructions require that hospice providers include the NF MO HealthNet Provider ID in Field 56 (the National Provider Identifier (NPI) field) of the Hospital Claim Form (UB-04) when billing for NF room and board (0658). Refer to Section 4 in this manual for billing instructions.

The NF MO HealthNet Provider ID shown in Field 56 of the Hospital Claim Form (UB-04) must agree with a corresponding NF provider identifier included in the Hospice-Nursing Facility (NF) Contract Update form. The information in the MO HealthNet hospice provider file must show a valid contract with the NF shown in Field 56 in effect for the dates of service billed.

It is the hospice’s responsibility to determine that a hospice participant residing in a NF is in a MO HealthNet-certified vendor bed prior to submitting claims for NF room and board charges. If MO HealthNet's file does not indicate the participant is in a MO HealthNet-certified vendor bed, the claim will deny. Certification in the correct NF is dependent upon the proper forms being completed by the NF and submitted to the DHSS Division of Senior and Disability Services (DSDS). The hospice should request, for each hospice nursing home patient, a copy of the MO HealthNet Vendor Notice (FA-465) and any subsequent FA-465s from the participant, the participant’s family, or the NF. This form is the hospice’s assurance that the certification has been completed. It also identifies the participant’s surplus amount that is applied to the reimbursement amount for the NF room and board claim.