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Medicaid Managed Care & Hospice

Managed Care

The Best Care for Your Frailest Members

Many states contract with managed care organizations to deliver Medicaid services to beneficiaries. Knowing how hospice services meet the needs of the frailest of those constituents, and how services are billed and paid for, ensures the best possible post-acute care for your members. 

Hospice is a way of caring for patients near the end of life. 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.

Let VITAS® Healthcare be your partner. As the nation’s leading hospice provider, our specialists can provide you with a better understanding of the hospice benefit and end-of-life care. You can be confident that your members are receiving appropriate care, and that claims administration is accurate and efficient. Assuring communication between providers and health plans increases service to your members and our patients.

For information or to make a referral, call 800.93.VITAS.

Facts about Hospice and Medicaid

  • Your state Medicaid Agency publishes reimbursement rates for core hospice services and nursing facility daily room & 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 CMS
  • Typically when a patient elects hospice, the nursing facility room & 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 & 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.

FAQs about Hospice Care and Payment

What is the prerequisite for hospice care?

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.”

What does it cost to have a member evaluated?

To qualify for services, a member is evaluated by a VITAS registered nurse at no cost to the member or the plan. Similar to Medicare guidelines, patients receiving hospice care beyond the original six-month prognosis must be evaluated “face to face” by the hospice physician. Coverage is extended into 60-day benefit periods as long as the patient is determined to be medically hospice appropriate.

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:

  • Routine Home Care–provided wherever the patient calls home: private residence, nursing facility, LTC, etc.
  • Intensive Comfort Care (continuous care)–- When medically necessary, shifts of care provided in the home setting until symptoms are brought under control.
  • General Inpatient Careprovided in an inpatient hospice unit or facility for a short period when symptoms cannot be managed in the home.
  • Respite Careprovides 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 & 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 MMC organization for nursing facility room & board. When the health plan reimburses the hospice, the hospice passes the room and board payment through to the contracted facility. Health 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 & board bill for a hospice patient?

In most states, the health plan will pay 95 percent of the nursing facility room & 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 & 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 & board charges/dates when applicable. Health plans will need to adjudicate claims for both services. For dually eligible Medicare and Medicaid patients, only room & 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

658659–Nursing Facility Room & Board