Tex. HHSC Medicaid Hospice Provider Manual § 3300

Revision 08-1; Effective November 12, 2008

When an individual is in a lower income situation (TP12, manual certification or TP13, automated certifications), SSA staff determine the applicant's Medicaid eligibility as an SSI recipient. The recipient is then eligible for Medicaid services, which includes hospice, in the home, community, NF, hospital, ICF/MR-RC and other type facilities. Only SSI Medicaid hospice individuals are eligible for Medicaid in an NF without being in a Medicaid-contracted bed. An SSI recipient in the NF who is not in a Medicaid bed still may be eligible for SSI; however, HHSC will not pay room and board for his care.

When an individual qualifies under higher income limits (TP14), the HHSC ME staff determine the applicant's eligibility for Medicaid. The individual is eligible for Medicaid services only when he resides in a Medicaid-contracted bed in an NF. Under these circumstances, the hospice provider follows the HHSC copay procedures, outlined under Section 3400, Copay. Form 3071, Individual Election/Cancellation/Update, substitutes for the medical necessity requirement in determining eligibility. HHSC ME staff must have verification of the applicant's Form 3071 and Minimum Data Set (MDS), if applicable, in order to approve and continue the Medicaid eligibility status of the applicant or individual. This may be a copy of a statement from the provider. ME staff may contact NFs for trust fund information or earnings information.

A private-pay NF resident can occupy a Medicaid, Medicare or a non-participating bed. A facility cannot make a private-pay resident move to accommodate a Medicare or Medicaid resident.