Tex. HHSC Medicaid Hospice Provider Manual § 4540

Revision 08-1; Effective November 12, 2008

HHSC pays the hospice provider a room and board rate that is 95% of the Texas Medicaid NF per diem rate for each Medicaid or dually eligible individual on hospice residing in the NF. This rate is required by Section 1902 (a)(13)(D) of the Social Security Act and is an additional per diem rate paid on routine home care and continuous home care days. The payment amounts are not subject to the Medicaid hospice cap on overall Medicaid hospice payments. When the rate is paid to the hospice provider, all Medicaid NF per diem payments for NF care cease. The hospice provider pays the 95% rate to the NF for room and board. For more information regarding NF per diem rates, see Item 6310, Hospice – Nursing Facility Per Diem Rate. For more information on Medicaid eligibility, see Section 3200, Three-Month Prior Eligibility.

NF and hospice providers complete and submit a signed and dated Minimum Data Set (MDS) assessment, to TMHP as justification for payment of the room and board rate. For a hospice recipient or applicant currently residing in the facility with a current MDS assessment, no action is required until the next required MDS assessment. For a hospice recipient or applicant newly admitted to the facility, the hospice and the NF must complete and submit an MDS assessment as required by 40 TAC §19.801, Resident Assessment. An MDS assessment received after the required date will have the stamp-in date as the effective date.

The room and board rate also applies to those individuals participating in the Intermediate Care Facility for Persons with Mental Retardation or Related Conditions (ICF/MR-RC) Program. The Medicaid Hospice Program pays the hospice provider per diem rate for each individual on hospice, who is a Medicaid hospice recipient residing in an ICF/MR-RC. The per diem rate is 95% of the reimbursement amount for the individual who resides in an ICF/MR-RC. This information is extrapolated from Form 3650, Level of Care. For additional information, contact Policy Development, Regulatory Services, Texas Health and Human Services Commission (HHSC).