Medicaid Managed Care and Hospice
Advanced Illness Care for Your Medicaid and Dual-Eligible Residents
Many states contract with managed care organizations to deliver Medicaid services to beneficiaries. As your preferred partner, VITAS Healthcare and its specialists can provide you with a better understanding of the hospice benefit and end-of-life care. You can be confident that your residents with advanced illness are receiving appropriate care, and that claims administration is accurate and efficient.
VITAS has the expertise, experience and infrastructure to care for your residents. An interdisciplinary team addresses the physical, emotional and spiritual needs of patients and their families. A physician, nurse, hospice aide, chaplain, social worker and volunteers care for patients wherever they call home.
Facts About Hospice and Medicaid
- Your state Medicaid agency publishes reimbursement rates for core hospice services and nursing facility daily room and board. Check regularly for updates, as many times these are revised annually—sometimes even more frequently.
- Hospice coordinates members’ care to prevent duplication of services, as mandated by the Centers for Medicare and Medicaid Services (CMS)
- Typically when a patient elects hospice, the nursing facility room and board is paid by the Medicaid Managed Care entity directly to the hospice. The hospice organization then “passes” the payment to the nursing facility. Typically, only 95 percent of the nursing facility room and board charge should be paid by the Managed Care Organization when the member is a hospice patient in a nursing facility. This payment model and pass-through system may vary based on individual state Medicaid Agencies.
Frequently Asked Questions
What is the prerequisite for hospice care?
Patients can qualify for hospice when they have a prognosis of six months or less.
As provided by Medicare Part A, the most common prerequisite is “a medical prognosis that the resident’s life expectancy is six months or less if the illness runs its normal course.”
Is there a cost to have a resident evaluated for hospice care?
To qualify for services, a resident is evaluated by a VITAS admission team member at no cost to the resident or the facility
The initial hospice benefit period is 90 days. A patient can be recertified for an additional 90-day period. After the initial 180-day period, two subsequent 60-day recertifications are possible, and both require a face-to-face encounter between the certifying physician and the hospice patient.
What are the hospice levels of care? What services do they represent?
Care is provided and reimbursement is defined based on four levels of care following Medicare guidelines.
The four levels are:
- Routine Home Care—provided wherever the patient calls home: private residence, nursing facility, LTC, etc.
- Intensive Comfort Care® (continuous home care)—When medically necessary, shifts of care provided in the home setting until symptoms are brought under control.
- General Inpatient Care—provided in an inpatient hospice unit or facility for a short period when symptoms cannot be managed in the home.
- Respite Care—provides an inpatient bed to a home-based hospice patient in order to relieve the family caregiver for up to five days.
What is the “hospice-nursing facility room and board pass through”?
When a resident of a long-term care facility is dually eligible for Medicare and long-term Medicaid and elects hospice care, the hospice will bill Medicare Part A for core hospice services and bill the Medicaid managed care organization for nursing facility room and board.
When the Medicaid managed care organization reimburses VITAS, we then pass the room and board payment through to the contracted nursing facility. Medicaid managed care plan payments should be directed to the hospice provider.
Is it true that a health plan may not pay 100 percent of the nursing home room and board bill for a hospice patient?
In most states, the health plan will pay 95 percent of the nursing facility room and board Medicaid rate to the hospice.
The hospice forwards the full 100 percent to the patient’s nursing facility.
What does the hospice-nursing facility room and board claim look like? What billing codes may apply?
The format of the UB04, CMS 1500 or 837 electronic formats may differ state to state or even health plan to health plan.
Each should contain core hospice services/dates and nursing facility room and board charges/dates when applicable. Health plans will need to adjudicate claims for both services. For dually eligible Medicare and Medicaid patients, only room and board will appear on the claim to the health plan. The hospice will bill Medicare Part A for core hospice services.
Billing codes often follow Medicare guidelines. Other codes may apply.
- 651–Routine Home Care
- 652–Continuous Care
- 655–Inpatient Respite Care
- 656–Inpatient Care
- 657–Physician Charges
- 658–659–Nursing Facility Room and Board