Tex. HHSC Medicaid Hospice Provider Manual § 3400

Revision 09-1; Effective February 27, 2009

An individual on hospice may have a copay if he resides in an NF or ICF/MR-RC. Copay is the amount Medicaid recipients pay for part of their NF care. The copay is based on the amount of income they receive in excess of $60 a month and certain other allowable deductions. Certain Veterans Administration (VA) beneficiaries are allowed to keep an additional $90 a month. HHSC ME staff calculates the copay.

Hospice providers are responsible for collecting copay from individuals. The amount is the same each month, regardless of the number of days in the month. If an individual does not live in an NF every day during a month, except for therapeutic home visits, the copay amount is prorated. The copay amount is divided by the number of days in the month, and the result is multiplied by the number of days the individual is in an NF. Example: If an individual with a $93 monthly copay enters an NF on Sept. 21, and is discharged on Oct. 11, the copay collected from the individual will be $31 for September ($93 divided by 30 = $3.10 x 10 days = $31) and $30 for October ($93 divided by 31 = $3.00 x 10 days = $30).

Copay amounts may change occasionally, because of changes in an individual's financial status or corrections of income information. If an individual is overcharged copay, the hospice provider receives a corrected billing statement and must refund the amount of the overcharge to the individual. Report all apparent discrepancies regarding copay to ME staff.

The following forms relate to copay:

Form 1259, Correction of Applied Income, notifies the hospice provider of prospective changes in an SSI recipient's copay and of past over or under collections and of copay amounts to be reconciled.

Form H4808, Notification of Change in Applied Income/Denial of Medical Assistance, notifies the MAO recipient of HHSC's decisions to prospectively increase or reduce the amounts of copay payable to the hospice provider or to deny medical assistance.

Occasionally, there are problems with the receipt of amount of SSI checks received by recipients. When problems occur and there is no immediate solution, contact SSA. Notify the ME staff if an institutionalized individual, who receives SSI, also received income from other sources.

Promptly notify the ME staff of any changes in an individual's income (including non-recurring payments), resources of any individual or transfers of assets, so that appropriate and timely corrections to copay can be made. The hospice provider is responsible for ensuring that copay problems are handled according to the requirements and in the protective interest of the individual.