Utah Medicaid Provider Manual, Hospice Care Services § 13-4

If a Medicaid-only member is enrolled in a Medicaid Managed Care Entity (MCE),

the hospice selected by the member must have a contract with the MCE. The

MCE is responsible to reimburse the hospice for hospice care. Medicaid will not

directly reimburse a hospice agency for a Medicaid-only member covered by an

MCE.

If a Medicaid-only member enrolled in an MCE elects hospice care before being

admitted to a nursing care facility, ICF/ID, or a freestanding hospice inpatient

unit, the MCE is responsible to reimburse the hospice agency for both the

hospice care and the room and board until the member is disenrolled from the

MCE by Medicaid. At the point a determination is made as to whether the

enrollee will require care in the nursing facility for greater than 30 days, the MCE

will notify Medicaid of the prognosis of extended nursing facility services.

Medicaid will schedule disenrollment from the health plan to occur in

accordance with the terms of the health plan contract for care provided in

skilled nursing facilities.

If a hospice enrollee is covered by Medicare for hospice care, the Medicaid MCE is

responsible for the health plan’s payment rate less any amount paid by

Medicare. The MCE is responsible for payment even if the Medicare covered

service is rendered by an out-of-plan provider or was not authorized by the MCE.

The health plan is responsible for room and board expenses of a hospice

enrollee receiving Medicare hospice care while the member is a resident of a

Medicare-certified nursing facility, ICF/ID, or freestanding hospice facility until

the member is disenrolled from the MCE by Medicaid. At the point Medicaid

determines that the enrollee will require care in the nursing facility for greater

than 30 days, Medicaid will schedule disenrollment from the MCE to occur in

accordance with the terms of the health plan contract for care provided in

skilled nursing facilities.

The hospice agency is responsible for determining if an applicant for hospice

care is covered by a Medicaid MCE prior to enrolling the member, for

coordinating services and reimbursement with the MCE during the period the

member is receiving the hospice benefit, and for providing notification when the

member will be admitted to a nursing facility for a period anticipated to be

greater than 30 days.