Tex. HHSC Medicaid Hospice Provider Manual § 6310

Revision 08-1; Effective November 12, 2008

When a Medicaid recipient elects the Medicaid Hospice Program in an NF, the hospice program pays a per diem rate that is 95% of the NF rate as outlined under Item 4540, Room and Board.

The Medicaid Hospice Program pays the rate to Medicaid hospice providers under the following conditions:

Medicaid and dually eligible recipients elect the Medicaid Hospice Program and reside in an NF. Information on Medicaid eligibility is outlined in Section 3200, Three-Month Prior Eligibility.

Form 3618, Resident Transaction Notice was submitted to HHSC, indicating a discharge to hospice. A copy is kept on file in the NF. If Form 3618 is not completed and submitted by the NF, and if HHSC pays both the NF and the hospice provider, HHSC will recoup the payment that was made to the NF. If the NF is not a provider in the Medicaid Nursing Facility Program, or if the individual on Medicaid hospice is not in a Medicaid contracted bed, Form 3618 is not required.

Hospice providers have a written agreement with the NF to provide hospice care in the facility, as outlined under Section 6100, Agreements with Long Term Care Facilities.

Minimum Data Set (MDS) assessment was completed by the hospice and NF providers and submitted, as necessary, to TMHP. Retain a copy in the hospice record and the current clinical record at the NF.

When an NF resident elects into the hospice program, he is electing out of the NF program. NFs must stop billing HHSC for these residents as of the date of the individual's hospice election and instead, look to the hospice for the room and board payment. Regardless whether the individual is Medicaid or dually eligible, HHSC pays the hospice 95% of the Resource Utilization Group (RUG) rate for that resident's room and board, as outlined under Item 4540, Room and Board. The hospice then passes that amount on to the NF.

In order to receive payment from HHSC for room and board for dually eligible recipients, a hospice provider must have a valid Medicaid provider agreement.

Information on hospice program requirements for dually eligible recipients for both the Medicaid and Medicare programs may be found in several Centers for Medicare and Medicaid Services publications:

State Operations Manual, Section 2082, Election of Hospice Benefit by Resident of SNF, NF, ICF/MR-RC or Non-Certified Facility;

The Hospice Manual, Section 204.2, Skilled Nursing Facility and Nursing Facilities Residents and Dually Eligible Beneficiaries; and

State Medicaid Manual, Section 4305, Hospice Services.