Va. DMAS Hospice Provider Manual ch. IV, Responsibilities Of The Nursing Facility And The ICF/IDD

"Room and board" furnished to the individual enrolled in hospice by a nursing facility or

intermediate care facility for those with intellectual disabilities (ICF/IDD) is defined as

follows:

•

Performance of personal care services, including assistance in activities of

daily living and in socializing activities;

•

Administration of medications;

•

Maintaining the cleanliness of a resident's room; and

•

Supervising and assisting in the use of durable medical equipment and

prescribed therapies.

The nursing facility or ICF/IDD must bill the hospice provider, not DMAS, for

reimbursement that would normally be paid to the facility by DMAS. Individuals receiving

hospice services in nursing facilities or ICFs/IDD have the same responsibility to apply

their income to their cost of care as other nursing facility residents. Local Departments

of Social Services will send the facility the DMAS-225 form as with any other resident, for

FFS members. The facility bills the hospice provider instead of DMAS, but the facility

must deduct the patient-pay amount from the bill it submits to the hospice provider. The

nursing facility and ICF/IDD must account for the patient pay for these individuals and

provide the hospice with a copy of the current DMAS-225. Hospice must adjust its total

charges for revenue code 658 (percentage of nursing facility per diem). Any patient pay

amount cannot be included in the nursing facility charges. Hospice must submit a copy

of the current DMAS-225 identifying the patient-pay amount with its invoice when billing

for revenue code 658.

For individuals eligible for hospice benefits under Medicare and Medicaid, the hospice

provider must bill Medicare. Unless specifically prohibited by statute, Medicaid is the

payer of last resort. In these instances (for example, because Medicare only reimburses

for nursing facility care when it is provided in a skilled nursing bed), the routine or

continuous home care charges would be billed to Medicare and the hospice provider

would bill Medicaid for nursing facility charges for FFS members. For dates of service

July 1, 2019 and after, Hospice providers do not bill Cardinal Care MCOs for nursing

facility room and board charges. The nursing facility must bill the MCO directly for these

charges and not the hospice provider.

In addition, Medicaid does not make bed-hold payments to any nursing facility when an

individual is in an acute care setting. Any arrangement to hold a bed for an individual

enrolled in hospice would be made between the hospice provider and the nursing facility.

The individual and/or his or her family may elect to pay to reserve the bed while the

individual is hospitalized, but they cannot be required to do so. All residents and their

families must be informed the resident has the right to be admitted at the time of the next

available vacancy following discharge from the hospital.

Individuals who are dual eligible and qualify for and are admitted to a Medicare skilled

bed must dually elect their Medicare/Medicaid hospice benefit. Therefore, Medicaid

cannot become the primary payer for dually eligible individuals who elect skilled nursing

facility placement.

When an individual residing in a nursing facility elects the hospice benefit, the nursing

facility is not required to submit a patient intensity rating system (DMAS 80) form to DMAS

on admission, or any subsequent nursing facility stays, as long as the individual remains

in hospice care. The hospice provider must submit the current version of the DMAS 421A

to the DMAS Division of Aging and Disability Services to request authorization of

enrollment for individuals under Medicaid fee-for-service. Nursing facilities must continue

to complete a Minimum Data Set (MDS) on individuals receiving hospice care, as required

for all nursing facility residents.

If a resident is in a nursing facility under the DMAS specialized care program, no payment

for hospice services will be made to the hospice provider by DMAS. The nursing facility

specialized care provider is responsible for providing and billing for all services needed

by the resident.