Hospice
Provider Manual
Provider and Chapter
Hospice
Chapter III. Provider-Specific Policies
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Table of Contents
Chapter I. General Program Policies
Chapter II. Member Eligibility
Chapter III. Provider-Specific Policies
Chapter IV. Billing Iowa Medicaid
Appendix
III. Provider-Specific Policies
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Table of Contents
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Preamble........................................................................................................ 1
CHAPTER III. PROVIDER-SPECIFIC POLICIES ............................................... 1
A. HOSPICE PROGRAM BASICS ........................................................................ 1
1. Description ........................................................................................ 1
2. Terminal Illness .................................................................................. 1
3. Hospice Election Periods ...................................................................... 1
4. Physician Certification ......................................................................... 2
5. Hospice Plan of Care ........................................................................... 2
6. Face-to-Face Encounter ....................................................................... 2
7. Hospice Responsibility for Services ........................................................ 2
8. Palliative Care .................................................................................... 3
9. Role of Interdisciplinary Team .............................................................. 3
10. Medicare Certification .......................................................................... 3
11. Availability of Hospice Services Supports ................................................ 3
12. Discharge from Hospice ....................................................................... 4
B. COVERAGE OF SERVICES ............................................................................ 4
1. Covered Services ................................................................................ 4
2. Non-Covered Services ......................................................................... 7
C. HOSPICE FORMS RELATED TO SERVICE DELIVERY ......................................... 7
D. BASIS OF PAYMENT .................................................................................... 9
1. Nonreimbursable Diagnosis for Hospice .................................................. 9
2. Categories of Care ............................................................................. 11
a. Methodology .............................................................................. 11
b. Description of Categories of Hospice Care and Assigned
Revenue Codes .......................................................................... 11
3. Hospice in a Nursing Facility ................................................................ 15
a. Hospice/Nursing Facility Agreement............................................... 15
b. Inpatient Respite ........................................................................ 16
c. Daily Routine Care Reimbursement ............................................... 16
d. Daily Nursing Facility Reimbursement ............................................ 16
e. Client Participation ...................................................................... 17
f. Hospice and Nursing Facility Reimbursement Based on Location ........ 17
4. Hospice in an Assisted Living Program .................................................. 17
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5. Nonreimbursable Hospice Physician Payment ......................................... 17
a. Physicians Employed by or Under Contract with the Hospice ............. 17
b. Attending Physician Services ........................................................ 18
c. Voluntary Physician Care ............................................................. 18
E. BILLING POLICIES AND CLAIM FORM INSTRUCTIONS FOR MEDICAID
FEE-FOR-SERVICE..................................................................................... 19
APPENDIX A: Instructions to Complete Form 470-2618, Election of Medicaid
Hospice Benefit................................................................................................ 20
APPENDIX B: Instructions to Complete Form 470-0042, Case Activity Report .......... 24
APPENDIX C: Instructions to Complete Form 470-2619, Revocation of Medicaid
Hospice Benefit................................................................................................ 28
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Preamble
This provider manual is intended to provide general coverage guidelines for members
that are currently Medicaid Fee-for-Service (FFS) eligible. Verifying a member’s
eligibility is crucial to ensure correct coverage of services and limitations. Once an
assignment to the IA Health Link managed care organization (MCO) has been
completed, please refer to the provider manual for the IA Health Link MCO assigned.
CHAPTER III. PROVIDER-SPECIFIC POLICIES
A. HOSPICE PROGRAM BASICS
1. Description
Hospice is a comprehensive set of services, identified and coordinated by a
hospice interdisciplinary team (IDT), to provide for the physical, psychosocial,
spiritual, and emotional needs of a terminally ill member and family
members. The priority of hospice care services is to meet the needs and
goals of the hospice member and family.
The hospice must organize, manage, and administer its resources to provide
the hospice care and services to members, caregivers, and families necessary
for the palliation and management of the terminal illness and related
conditions.
2. Terminal Illness
A terminally ill member is an individual who has a life expectancy of six
months or less if the illness runs its normal course.
3. Hospice Election Periods
Hospice election periods consist of the following:
An initial 90-day period
A subsequent 90-day period
An unlimited number of subsequent 60-day periods based on continued
eligibility for the hospice program.
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4. Physician Certification
The hospice must obtain a physician’s certification that the member is
terminally ill. The certification must be signed by the medical director of the
hospice or the physician member of the hospice interdisciplinary group and
the member’s attending physician (if the member has an attending
physician). The attending physician is a physician who is a doctor of
medicine or osteopathy and is identified by the member at the time the
member elects to receive hospice care, as having the most significant role in
the determination and delivery of the member’s medical care.
5. Hospice Plan of Care
A hospice plan of care (POC) must be completed for each hospice member to
meet the member and family’s assessed needs under direction of the hospice
IDT and in collaboration with other non-duplicative Medicaid services, if
applicable.
The hospice POC must be reviewed, revised and documented, at a minimum,
every 15 days, or less if the member’s condition changes.
6. Face-to-Face Encounter
A hospice physician or hospice nurse practitioner must have a face-to-face
encounter with each hospice member whose total hospice support is
anticipated to exceed 180 calendar days or the two initial hospice benefit
periods or ninety days each. The face-to-face encounter must occur prior to,
but no more than 30 calendar days prior to, the 180
th
day or the beginning
day of the third benefit period recertification) and every benefit period
recertification thereafter.
7. Hospice Responsibility for Services
All services related to the terminal illness and related conditions are the
responsibility of the hospice provider.
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8. Palliative Care
Hospice provides palliative care, not active or curative care. Palliative care
means member and family-centered care that optimizes quality of life by
anticipating, preventing, and treating suffering. Palliative care throughout
the continuum of illness involves addressing physical, intellectual, emotional,
social, and spiritual needs and to facilitate member autonomy, access to
information, and choice.
EXCEPTION: The palliative, non-active, and non-curative requirement for
hospice care does not include terminally ill children, up to age 21. Children
may concurrently receive the hospice benefit and curative or active care.
9. Role of Interdisciplinary Team
The hospice IDT maintains the responsibility for directing, coordinating, and
supervising the care and the services provided to the member. The hospice
IDT must ensure the ongoing sharing of information between all disciplines
providing care and services in all settings, whether the care and services are
provided directly or under arrangement in order to maintain a current POC.
The hospice IDT must ensure the ongoing sharing of information with other
non-hospice providers furnishing services unrelated to the terminal illness
and related conditions in order to maintain a current POC.
10. Medicare Certification
Only hospice providers certified to participate in the Medicare hospice
program are eligible to participate as Medicaid or IA Health Link hospice
providers.
11. Availability of Hospice Services Supports
Nursing services, physician services, and drugs and biologicals are considered
the core services of the hospice benefit. These services must be made
routinely available on a 24-hour basis 7 days a week. Covered services are
included in Covered Services in this chapter.
Other services included in the hospice benefit, must be available on a
24-hour basis when medically necessary to meet the needs of the member
and family.
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12. Discharge from Hospice
A member will be discharged from a hospice agency if:
The member moves out of the hospice provider’s service area,
The member transfers or changes to another hospice provider,
The hospice physician determines that the member is no longer terminally
ill.
Based on written and approved policy developed by the hospice provider,
the member (or other persons in the member’s home) behavior is
disruptive, abusive, or uncooperative to the extent that delivery of care to
the member or the ability of the hospice to operate effectively is seriously
impaired.
If the member is discharged for cause, the hospice provider must ensure that
it meets all of the criteria stated in 42 Code of Federal Regulations (CFR)
418(a)(3)(i)-(iv) before discharging.
B. COVERAGE OF SERVICES
1. Covered Services
The hospice program includes the following bulleted services. Any of the
services can be combined, by duration or frequency, to meet the daily needs
of the member and family.
Nursing care. Skilled nursing care must be provided by or under the
supervision of a registered nurse.
A hospice must provide nursing care directly unless a waiver has been
submitted and approved by the Centers for Medicare and Medicaid
Services (CMS).
Nursing care must ensure that the nursing needs of the member are met
as identified in the member’s initial assessment, comprehensive
assessment, and updated assessments.
Medical social services. Medical social services must be provided by a
qualified social worker, under the direction of a physician.
Social work services must be based on the member’s psychosocial
assessment and the member’s and family’s needs and acceptance of these
services.
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Physician services. Physicians’ services are performed by a physician or
a nurse practitioner with the exception of the hospice medical director or
the physician member of the hospice interdisciplinary team. The hospice
medical director or the interdisciplinary team (IDT) physician must be a
doctor of medicine or osteopathy.
The hospice medical director, physician employees, and contracted
physicians of the hospice, in conjunction with the member’s attending
physician, are responsible for the palliation and management of the
terminal illness and conditions related to the terminal illness.
All physician employees and physicians under contract are under the
supervision of the hospice medical director.
All hospice physicians shall coordinate care with the attending physician, if
the member chooses an attending physician outside of the hospice
network. If the attending physician is unavailable, the hospice medical
director, hospice physician or contracted physician shall coordinate care.
Spiritual counseling. Spiritual counseling must provide the following:
An assessment of the member’s and family’s spiritual needs.
Meet needs in accordance with the member and family’s acceptance of
this service and in a manner consistent with member and family beliefs
and desires.
Make all reasonable efforts to facilitate visits by local clergy, pastoral
counselors, or other individuals who can support the member’s
spiritual needs.
Advise the member and family of this service.
Dietary counseling. Dietary counseling is provided by a qualified
professional who is able to address and assure that the identified dietary
need of a hospice member is met.
Bereavement counseling. Bereavement counseling is a required
service but is not reimbursable.
Services must be provided under the supervision of a qualified
professional with experience or education in grief or loss counseling.
Bereavement services are available to the family and other individuals in
the bereavement plan of care up to one year following the death of the
member. Bereavement counseling may also be provided to residents of:
A skilled nursing facility (SNF),
A nursing facility (NF), or
An intermediate care facility for the intellectually disabled (ICF/ID).
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Hospice aide. Hospice aides provide personal care services and
household services to maintain a safe and sanitary environment in areas
of the home used by the member, such as changing the bed or light
cleaning and laundering essential to the comfort and cleanliness of the
member. Hospice aide services must be provided under the general
supervision of a registered nurse.
Homemaker. Homemaker services may include assistance in personal
care, maintenance of a safe and healthy environment, and services to
enable the hospice aide to carry out the plan of care.
Physical therapy, occupational therapy, and speech-language
pathology. Physical therapy, occupational therapy, and speech-language
pathology services are provided for purposes of symptom control or to
enable the member to maintain activities of daily living and basic
functional skills.
Volunteer services. Volunteers must provide day-to-day administrative
or direct member care services in an amount that, at a minimum, equals
five percent of the total member care hours of all paid hospice employees
and contract staff.
The hospice must maintain records on the use of volunteers for member
care and administrative services, including the type of services and time
worked.
Short-term inpatient care. Short-term inpatient care is provided in a
participating hospital. Services provided in an inpatient setting must
conform to the written hospice plan of care. General inpatient care may
be required for procedures necessary for pain control or acute or chronic
symptom management which cannot be provided in other settings.
Inpatient care may also be furnished to provide respite for the member’s
family or other persons caring for the member at home. Respite care is
the only type of inpatient care that may be provided in a nursing facility
when the member is otherwise receiving hospice services in a home
setting.
Medical supplies and medical equipment. Medical supplies include
drugs and biologicals. Only drugs which are used primarily for the relief
of pain and symptom control related to member’s terminal illness are
covered.
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Medical equipment includes durable medical equipment and other self-
help and personal comfort items related to the palliation or management
of the member’s terminal illness. Equipment is provided by the hospice
for use in the member’s home while the member is under hospice care.
Medical supplies include those that are part of the written hospice plan of
care.
Other services. Any other service that is medically necessary for the
palliation and management of the member’s terminal illness and related
conditions and for which reimbursement may otherwise be made under
Iowa Medicaid or IA Health Link MCO shall be covered under the hospice
program.
2. Non-Covered Services
Medicaid-covered services, including direct physician care that are
unrelated to the terminal illness or related conditions. These shall be
billed separately by the respective provider.
AZT (Retrovir) and other curative antiviral drugs targeted at the human
immunodeficiency virus for the treatment of AIDS.
C. HOSPICE FORMS RELATED TO SERVICE DELIVERY
For services provided through IA Health Link MCO, refer to the MCO-specific
provider manual for any required hospice forms related to service delivery.
For services provided under Medicaid fee-for-service, the following hospice forms
must be completed by the hospice provider, according to the purpose for each,
and the originals retained in the member’s case file:
Election of Medicaid Hospice Benefit, form 470-2618. See Appendix A for form
instructions.
Case Activity Report (CAR), form 470-0042. See Appendix B for form
instructions.
Revocation of Medicaid Hospice Benefit, form 470-2619. See Appendix C for
form instructions.
NOTE: All hospice forms must be completed, dated, and signed on the day that the
action is effective.
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For hospice members who are living in a nursing facility (NF), please note the
following:
Information needed to complete these forms may require communication with
the NF.
Any required forms, must be submitted to the Department of Human Services
(DHS) Centralized Facility Eligibility Unit (CFEU) within 2 working days after
the form was completed (per preceding bullet). The mailing, fax, and email
information for the CFEU is included in Appendices A, B, and C.
Hospice provider reimbursement is directly related to the timely and accurate
completion and submission to the CFEU of all hospice forms. This includes the
hospice provider reimbursement (Revenue Code 651) as well as pass through
NF reimbursement that the hospice provider will forward to the NF.
A CAR form must be submitted with either the Election of Medicaid Hospice
Benefit form, and/or the Election of Medicare Hospice Benefit form, or the
Revocation of Medicaid Hospice Benefit form at the time of CFEU submission.
If Medicare is the funding source for the member when hospice services begin,
and if the member becomes Medicaid-eligible at a later date, the hospice
provider must submit the Election of Medicare Hospice Benefit and/or the
Election of Medicaid Hospice Benefit to the CFEU along with the CAR form.
If a Medicaid member revokes or is discharged from the hospice benefit, any
other Medicaid benefits for which the member is eligible will be initiated. The
hospice provider must insure that notification to the CFEU is made for these
changes.
The submission of forms, as described above for a hospice member living in an NF,
applies to a hospice ICF/ID member. However, submit the CAR and the Election of
Medicaid Hospice Benefit to the CFEU within the two working days requirement.
Also, please note that reimbursement for time for a member living in an ICF/ID is
also dependent on the timely submission of required forms to the DHS CFEU.
In lieu of the Election of Medicaid Hospice Benefit form or the Election of Medicare
Hospice Benefit, an alternate form can be used. An alternate election form must
provide the following information:
1. Identification of the hospice that will provide the care.
2. Acknowledgement that the member has been given a full understanding of
hospice care
3. Acknowledgement that the member waives the right to regular Medicaid benefits,
except for payment to the regular physician and treatment for medical conditions
unrelated to the terminal illness.
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4. Acknowledgement that members are not responsible for copayment or other
deductibles.
5. The member’s Medicaid number.
6. The effective date of election
7. The member’s signature.
D. BASIS OF PAYMENT
1. Nonreimbursable Diagnosis for Hospice
The hospice provider is to report diagnosis coding on the hospice claim
required by ICD-10 coding guidelines. The principal diagnosis reported on
the claim is the diagnosis most contributory to the terminal prognosis.
A list of nonreimbursable ICD-10 codes is available below:
NOT REIMBURSABLE AS HOSPICE ICD-10 PRIMARY DIAGNOSES
Coding
Guideline
ICD-10 Diagnosis
Dementia –
Code the associ-
ated neurological
or physical
condition as
primary.
Unspecified dementia without behavioral
disturbance
Unspecified dementia with behavioral disturbance
Delirium due to known physiological condition
Vascular dementia without behavioral disturbance
Vascular dementia with behavioral disturbance
Dementia in other diseases classified elsewhere
without behavioral disturbance
Dementia in other diseases classified elsewhere
with behavioral disturbance
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Coding
Guideline
ICD-10 Diagnosis
Unspecified
conditions
Unspecified dementia without behavioral
disturbance
Unspecified dementia with behavioral disturbance
Heart failure, unspecified
Unspecified systolic heart failure
Unspecified diastolic heart failure
Unspecified combined systolic and diastolic heart
failure
Chronic kidney disease, unspecified
Unspecified kidney failure
Respiratory failure, unspecified with hypoxia
Respiratory failure, unspecified with hypercapnia
Acute
respiratory
failure –
Acute is defined
as a rapid onset
and a short,
severe course.
Chronic respir-
atory required
for terminal
diagnosis.
Acute post procedural respiratory failure
Acute respiratory failure, unspecified whether
with hypoxia or hypercapnia
Acute respiratory failure with hypoxia
Acute respiratory failure with hypercapnia
Respiratory failure, unspecified, unspecified
whether with hypoxia or hypercapnia
Chronic kidney
disease –
Renal failure
required for
terminal
diagnosis.
Chronic kidney disease, Stage I
Chronic kidney disease, Stage II (mild)
Chronic kidney disease, Stage III (moderate)
Chronic kidney disease, Stage IV (severe)
Chronic kidney disease, Stage V
Symptoms,
signs and ill-
defined
conditions
All codes included in ICD-10, Chapter 16,
Symptoms, Signs, and Ill-Defined Conditions
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2. Categories of Care
a. Methodology
Medicaid uses the same methodology as CMS uses to determine
Medicare hospice rates. This method adjusts to disregard cost offsets
attributable to Medicare coinsurance amounts and applies area wage
adjustments for four categories of hospice care.
Hospice rates are prospective. There is not any retrospective
adjustment.
Hospice rates are updated annually.
b. Description of Categories of Hospice Care and Assigned Revenue
Codes
Medicaid provides a daily reimbursement for every day that a member is
hospice eligible. The daily rate is one of the four categories of care.
The categories of care are not based on the qualifications of the staff
providing services. There may be a number of hospice staff who may
support a hospice member during a day. Hospice staff supporting a
member could include, but not limited to, a:
Nurse practitioner (NP),
Registered nurse,
Hospice aide,
Medical social worker,
Clergy,
Volunteer, and
Physical therapist.
As an example, the medical expertise of the NP was required for a
member. The NP provided both direct and indirect services for a total of
six hours. The daily hospice reimbursement would not increase because
of the NP qualifications, medical expertise or the NP’s time. The daily
hospice reimbursement remains a fixed rate.
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All hospice services must be performed by appropriately qualified
personnel; but it is the comprehensive, inclusive nature of multiple
services of the hospice program that determines the daily category
reimbursement rather than the qualifications of any category of staff
that provides services.
Each of the four levels of care has a predetermined reimbursement rate.
Payment is based on the geographic location at which the service is
furnished. For hospice services provided in the member’s residence,
geographical region is based on the member’s county of residence. For
hospice services provided in an inpatient setting, geographical region is
based on the county of the enrolled billing hospice provider. The
metropolitan statistical area (MSA)/rural state code must be included on
the claim for these revenue codes. The four categories of hospice are:
Routine Home Hospice Care (Revenue Code 651)
The hospice will be paid the Routine Home Care (RHC) rate for each
day the member is at home, under the care of the hospice, and not
receiving continuous home care.
A routine rate is paid without regard to the volume or intensity of
routine home care services provided on any given day.
A nursing facility may be considered the home for a member who
has elected the hospice benefit.
RHC is paid one of two RHC rates based on the following:
1. The day is billed as a RHC level of care.
2. If the day occurs during the first 60 days, the RHC will be equal
to the RHC “High” rated.
3. If the day occurs during days 61 or later, the RHC rate will be
equal to the RHC “Low” rate.
4. For a hospice member who is discharged and readmitted to
hospice within 60 days of that discharge, their prior hospice days
will continue to follow the member in determining the “High” or
“Low” rate.
5. For a hospice member who has been discharged from hospice
care for more than 60 days, a new period of hospice will apply
and be paid at the “High” rate.
These rates are calculated on the annual hospice rates established
under Medicare.
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Service Intensity Add-on (SIA)
A hospice claim will be eligible for a SIA payment if the following
criteria are met:
1. The day is billed as a RHC level of care day: the day occurs
during the last seven (7) days of life and the member is
discharged as deceased;
40 Expired at home
41 Expired in a medical facility
42 Expired place unknown
2. Direct member is provided by a Registered Nurse (RN) or social
worker that day for at least 15 minutes and up to four hours
total.
3. The service is not provided by a social worker via telephone.
Continuous Home Hospice Care (Revenue Code 652)
Continuous home care is covered when it is provided to maintain a
member at home during a period of medical crisis. A period of crisis
is a period of time when a member requires continuous care which is
primarily nursing care to achieve palliation or management of acute
medical symptoms.
Nursing care must be provided by either a registered nurse or a
licensed practical nurse. A nurse must be providing care for more
than half of the care given in an hour period. If less skilled care is
needed on a continuous basis to enable the person to remain at
home, this is covered as routine home care.
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The amount of payment is determined based on the number of hours
of continuous care furnished to the member on that day. A
minimum of eight hours must be provided during a 24-hour period
which begins and ends at midnight before the continuous home care
rate can be billed.
This care need not be provided all at once, i.e., four hours could be
provided in the morning and another four hours provided in the
evening of that day. Homemaker and aide services may also be
provided to supplement the nursing care.
Inpatient Respite Care (Revenue Code 655)
Respite inpatient care is short-term inpatient care provided to the
member only when necessary to relieve the family members or other
persons caring for the member at home. Respite care is not paid
when the hospice member is residing in a nursing facility.
The hospice is paid at the inpatient rate for a maximum of five days
at a time when the member is in an approved inpatient facility.
Payment is made for the date of admission but not for the date of
discharge. The discharge day for inpatient respite care is billed as
routine home care or continuing home care, unless the member is
discharged as deceased. When the member is discharged as
deceased, the inpatient respite care rate is billed.
General Inpatient Care (Revenue Code 656)
General inpatient care is provided in periods of acute medical crisis
when the member is hospitalized for pain control or acute or chronic
symptom management. None of the other fixed payment rates
(e.g., routine home care) are applicable for a day on which the
member receives hospice inpatient care, except for the day of
discharge from an inpatient unit.
The discharge day for general inpatient care is billed as routine home
care or continuous home care, unless the member is discharged as
deceased. When the member is discharged as deceased, the general
inpatient rate is billed.
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Physician Services (Revenue Code 657)
Direct physician care provided to a Medicaid member by a hospice
employee or any contracted physician is billed to Medicaid by the
hospice agency. Reimbursement will be in accordance with the
Medicaid physician payment schedule for Medicaid fee-for-service
members. On the UB-04 billing form, include Revenue Code 657
and the CPT-4 code that identifies the physician service provided.
NOTE: The bulleted physician services below are not billed using
Revenue Code 657. Please refer to Nonreimbursable Hospice
Physician Payment for further clarification:
General and supervisory physician services provided by
physicians employed by or under contract with the hospice
provider
Attending physician services
Voluntary physician services
3. Hospice in a Nursing Facility
For the purpose of the hospice benefit, a nursing facility (NF) may be
considered the home of a member receiving hospice. Hospice in an NF is
identified by the acronym hospice/NF.
a. Hospice/Nursing Facility Agreement
For hospice/NF care, the NF and the hospice provider must enter into a
written agreement which states that the hospice provider takes full
responsibility for the professional management of the member’s hospice
care and the NF agrees to provide room and board along with basic NF
services. Basic NF services include:
The performance of personal care services, including assistance in
activities of daily living;
Socializing activities;
Administration of medication;
Maintaining the cleanliness of the member’s room; and
Supervising and assisting in the use of durable medical equipment
and prescribed therapies.
A copy of the written agreement shall be filed in member’s records.
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b. Inpatient Respite
Medicaid will not pay for inpatient respite care (Revenue Code 655) for a
member who resides in a nursing facility.
Respite provided in a NF is designed to provide temporary relief for
family members or other caregivers who are supporting the hospice
member in the caregivers’ residential community homes. For the
purposes of the respite benefit provided under hospice, an assisted
living facility is not considered a residential community home.
c. Daily Routine Care Reimbursement
Medicaid will reimburse the hospice provider for daily routine home care
(Revenue Code 651) for a hospice member who resides in a nursing
facility.
d. Daily Nursing Facility Reimbursement
Medicaid will also reimburse the hospice provider for 95 percent of the
NF’s daily reimbursement (Revenue Code 658). The cost of room and
board can be obtained from the facility. The hospice agency may also
use the online cumulative rate listing. Click on the following link to be
redirected to the rate listing online:
http://dhs.iowa.gov/ime/providers/csrp/nrf
Use the most recent posting of the cumulative rate listing to research
nursing facility rates. Each quarter the rate listing is updated, however,
only the most recent sheet is updated with that data.
For hospice members entering a nursing facility, the adjustment will be
effective the date of entry. For persons in a nursing care facility before
the hospice election, the adjustment rate shall be effective the date of
hospice election. Reminder: In order to ensure timely reimbursement,
the hospice provider must submit the required forms to the DHS CFEU:
CAR and the Election of the Medicaid Hospice Benefit or the Election of
Medicare .
The hospice reimbursement for the NF room and board and basic NF
activities is a pass-through payment. When the hospice receives
Medicaid reimbursement (Revenue Code 658), the hospice provider
forwards the payment amount to the NF.
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e. Client Participation
Client participation is collected when the member is in an NF and
receives hospice. The hospice provider is responsible for collection of
the client participation. The amount collected is forwarded to the NF.
The Iowa Medicaid will deduct the amount of the client participation
automatically from the hospice/NF reimbursement (Revenue Code 658).
f. Hospice and Nursing Facility Reimbursement Based on Location
The location of a hospice member’s home is used as the basis for
hospice reimbursement when the hospice member lives in the
community. However, when the hospice member lives in a nursing
facility, the location of the nursing facility is used as the basis for
hospice reimbursement.
4. Hospice in an Assisted Living Program
For payment of hospice services, an assisted living environment (hospice/AL)
is considered a community, not a facility, living environment.
Hospice/AL does not require the submission of any hospice forms to the DHS
CFEU. However, hospice/AL does require hospice form completion, with the
exception of the CAR, in the hospice member’s case file. All other
documentation requirements, in accordance with Medicare hospice
certification and Medicaid must be maintained.
5. Nonreimbursable Hospice Physician Payment
a. Physicians Employed by or Under Contract with the Hospice
The basic payment rate for hospice reimbursement reflects the costs of
covered services related to the treatment of the member’s terminal
illness. This includes the administrative and general supervisory
activities performed by the medical director, physicians, if employed by
the hospice, or consulting physician. Group activities include
participation in the establishment of plans of care, supervision of care
and services, periodic review and updating of plans of care, and
establishment of governing policies. The costs of these services are
included in the reimbursement rates for routine home care, continuous
home care, inpatient respite care, and general inpatient care.
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b. Attending Physician Services
When the designated attending physician is not a hospice employee or
volunteer, the reimbursement of an independent physician is made in
accordance with usual Medicaid reimbursement. The physician bills
Medicaid directly. The only services billed by the attending physician
shall be the physician’s personal professional services. Costs for
services such as lab or X-rays shall not be included on the attending
physician’s bill.
c. Voluntary Physician Care
Physician services furnished on a volunteer basis are excluded from
Medicaid reimbursement. A physician may volunteer to provide specific
services and seek reimbursement for some other services. The hospice
must have a liability to reimburse the physician for services provided
before reimbursement is claimed.
In determining which services are furnished on a volunteer basis and
which services are not, a physician must treat Medicaid members on the
same basis as other patients in the hospice. For instance, a physician
may not designate all physician services rendered to non-Medicaid
patients as volunteered and at the same time seek payment from the
hospice for all physician services rendered to Medicaid members.
EXAMPLE:
Dr. Jones has an agreement with a hospice to serve as its medical
director on a volunteer basis. Mrs. Smith, a Medicaid member, enters
this hospice and designates Dr. Jones as her attending physician. Dr.
Jones, who does not furnish direct member care services on a
volunteer basis, renders a direct member care service to Mrs. Smith.
Dr. Jones seeks reimbursement from the hospice for this service. The
hospice is paid by Medicaid at the usual payment rate for the specific
services Dr. Jones rendered to Mrs. Smith. The hospice then
reimburses Dr. Jones for this service. Dr. Jones, by virtue of his
volunteer activities, is deemed to be an employee of the hospice.
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E. BILLING POLICIES AND CLAIM FORM INSTRUCTIONS FOR MEDICAID
FEE-FOR-SERVICE
Claims for hospice providers are billed on federal form UB-04, Health Insurance
Claim Form.
Click here to view a sample of the UB-04.
Click here to view billing instructions for the UB-04.
Refer to Chapter IV. Billing Iowa Medicaid for claim form instructions, all billing
procedures, and a guide to reading the Iowa Medicaid Remittance Advice
statement.
The Billing Manual can be located online at:
http://dhs.iowa.gov/sites/default/files/All-IV.pdf
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APPENDIX A:
Instructions to Complete
Form 470-2618, Election of Medicaid Hospice Benefit
Click here to view the form online.
A. Purpose of Form
The purpose of the form is to accurately record the date on which a Medicaid
member chooses the Medicaid hospice benefit.
B. When the Election of Medicaid Hospice Benefit Must be Completed
This form must be completed on the date when a Medicaid-eligible member or
legal representative chooses to receive the Medicaid hospice benefit.
Special note for dual eligibility for Medicare and Medicaid: Any member
who is eligible for hospice services under the Medicare benefit, must access
funding through the Medicare benefit. Only members who are determined
ineligible for Medicare can receive hospice services funded by Medicaid. If the
Medicare member becomes eligible for Medicaid funding only; and, chooses to
continue to receive hospice, the member must sign the Election of Medicaid
Hospice Benefit to reflect the date that Medicaid hospice services began after
Medicare hospice ended.
C. Responsibility for Completion
The hospice provider may assist the member or the legal representative with
completion of this form, if needed. The member or the legal representative must
sign and date the form.
D. Instructions
1. Section 1 – Medicaid Information
Recipient Name. Enter the Medicaid member’s name as it appears on the
Medical Assistance Eligibility Card.
Medicaid Number. Enter the member’s state identification number (SID) as
it appears on the Medical Assistance Eligibility Card. This number consists of
seven numeric characters and an ending alphabetic character.
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If the member has both Medicare and Medicaid eligibility, add the member’s
Medicare number under the member’s SID.
Beginning Date of Care. Enter the date hospice service was first provided.
If the member received hospice services funded through Medicare before
becoming Medicaid eligible, the Election of Medicaid Hospice Benefit must be
completed with the date that Medicaid hospice services began.
Hospice Name. Enter the hospice provider’s name.
Medicaid Provider Number. Enter the hospice’s seven-digit Iowa Medicaid
identification number.
Attending Physician Name and Phone Number. Enter this information if
the attending physician is not an employee or contracted with the hospice
provider.
2. Section 2 – Medicare Information
Medicare Patient Name. Enter the member’s name as it appears on the
Medicare card.
Medicare Claim Number. Enter the Medicare claim number as it appears
on the Medicare card.
Begin Date. Enter the date Medicare hospice coverage began.
End Date. Enter the date Medicare hospice benefit was terminated, if
applicable.
3. Section 3 – Nursing Facility Information
Facility Name. Enter the name of the NF.
Medicaid Provider Number. Enter the facility’s seven-digit Iowa Medicaid
provider number. ICF level always begins with 080 and SNF level always
begins with 065.
Facility Address. Enter the complete mailing address of the facility.
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4. Section 4 – Hospice Change
Present Hospice. Enter the provider name for the hospice before the
change.
Medicaid Provider Number. Enter the provider number for the hospice
before the change.
Effective Date of Change. Enter the last date that the hospice provider
provided services before the change.
New Hospice. Enter the provider name for the hospice after the change.
Medicaid Provider Number. Enter the provider number for the hospice
after the change.
Effective Date of Change. Enter the first date that the hospice provider
provided services after the change.
Special Note: Completing Form for a Change of Hospice Providers.
Section 1. Medicaid Information, and Section 5. Signatures, also need to be
completed for a change in hospice providers. No other sections on the form
need to be completed.
5. Section 5 – Signatures
Recipient’s Signature or Mark. The hospice provider may assist the
member or legal representative with completion of information on the form.
The member or legal representative must sign this section
Date. The member or legal representative must write the date the form was
signed.
Witness’ Signature. The person who witnessed the member’s or legal
representative’s signature must sign this form.
A legal representative who witnessed the member’s signature can sign
this form.
A hospice staff who witnessed the member’s or the legal representative’s
signature cannot sign as a witness for this form. Enter the date this form
is signed.
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Date. The witness must date this form.
A legal representative who witnessed the member’s signature can date
this form.
A hospice staff who witnessed the member’s or the legal representative’s
signature cannot date this form.
6. Section 6 – Distribution
Retain the original in the member’s case file.
Send a copy to the member or the legal representative.
If the member resides in an NF, send a copy to the:
Nursing facility.
DHS CFEU within two days of action, by mail, fax or email per the
information below:
Mailing Address:
DHS CFEU
Imaging Center 1
Iowa Department of Human Services
417 E. Kanesville Blvd.
Council Bluffs, IA 51503-4470
Fax: 515-564-4040
Email: facilitie[email protected]tate.ia.us
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APPENDIX B:
Instructions to Complete
Form 470-0042, Case Activity Report
Click here to view the form online.
A. Purpose of Form
The Case Activity Report (CAR) provides a mechanism for hospice providers to
report individual member changes that may affect eligibility for a member who
receives the hospice benefit and also resides in an NF.
B. When the CAR Must be Completed
A Medicaid-eligible or dual-eligible member enters the NF and begins hospice
on the same day.
A member living in an NF chooses the hospice benefit.
A dual-eligible member chooses the hospice benefit.
The status of a dual-eligible hospice/NF member changes to Medicaid only.
A hospice/NF member dies.
A hospice/NF member does not qualify for or revokes the hospice benefit.
A hospice/NF member changes or transfers to another NF or to another hospice
provider.
C. Responsibility for Completion
The hospice provider may assist the member or the legal representative with
completion of this form, if needed. The member or the legal representative must
sign and date the form.
D. Instructions
1. Member Data
Name. Enter the member’s first, middle initial, and the last name as it
appears on the Medical Assistance Eligibility Card.
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Date Entered Facility. This date will be one of the following:
If the date that hospice began is the same day that the member entered
the nursing facility, enter the day that the member entered the NF.
If the date that hospice begins occurs sometime after the admission date,
enter the date that hospice service actually began.
Social Security Number. Enter the social security number.
State ID. This number consists of seven numeric characters and an ending
alphabetic character.
Case Number. Enter, if known. DHS income maintenance uses this
number.
2. Facility Data
Provider Number/NPI Number. Enter the NF’s provider numbers followed
by the hospice provider numbers.
Facility Type. Check “Hospice” for facility type.
Name. Enter the name of the hospice provider.
DHS Per Diem. Enter the NF’s daily reimbursement. The current rate can
be located at the following link: http://dhs.iowa.gov/ime/providers/csrp/nrf
Street Address. Enter the street address of the hospice provider.
Signature of Person Completing Form. Enter the signature of the hospice
staff completing form.
Date Completed. Enter the date the form was completed and sent to the
DHS Centralized Facility Eligibility Unit (CFEU). CFEU submission information
follows.
Contact Name. Enter the hospice contact’s name.
Contact Phone Number. Enter the hospice contact’s telephone and email
address, if available.
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3. Level of Care
Hospice eligibility does not require a level of care (LOC) determination unless
the following applies:
IME Medical Services has not completed a LOC for the NF member when
hospice begins.
If an LOC is needed for the above reason, submit documentation for a
LOC determination in accordance with the Centers for Medicare and
Medicaid Services (CMS) Minimum Data Set (MDS) requirements.
4. Medicare Information for Either Skilled Patients or Hospice Patients
in Nursing Facilities
Do you expect this stay to be covered by Medicare? Answer “yes” or
“no” to the question. If yes, complete the next box.
Expected dates of Medicare coverage. Enter the dates of expected
Medicare coverage.
This section will be completed for hospice/NF members who are dual
eligible and whose hospice benefit is funded by Medicare and the NF daily
reimbursement is funded by Medicaid.
Please note: If dual eligibility ends for the hospice/NF member and full
Medicaid eligibility begins, another CAR must be completed, along with
the Election of the Medicaid Hospice Benefit, form 470-2618.
5. Discharge Data
Date of Discharge. Enter the discharge date.
The information regarding various types of days is not completed, under
“Last Month in Facility,” unless the hospice/NF member dies on the last day of
the month.
Reason for Discharge. Check the applicable box for discharge reason. If
the reason for discharge is not listed, draw in another box at the bottom and
write the reason for discharge.
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6. Distribution
Retain the original in the member’s case file.
Submit a copy to the member or the legal representative.
If the member resides in an NF, submit a copy to the:
Nursing facility.
DHS CFEU within two days of action by mail, fax or email per the
information below:
Mailing Address:
DHS CFEU
Imaging Center 1
Iowa Department of Human Services
417 E. Kanesville Blvd.
Council Bluffs, IA 51503-4470
Fax: (515) 564-4040
Email: facilitie[email protected]tate.ia.us
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APPENDIX C:
Instructions to Complete
Form 470-2619, Revocation of Medicaid Hospice Benefit
Click here to view the form online.
A. Purpose of Revocation of Medicaid Hospice Benefit
If a member or legal representative wants to stop receiving hospice services, this
form is completed.
A member or legal representative may revoke services at any time. The member
may choose to begin hospice services at any time after a revocation also.
B. When the Form Must be Completed
This form must be completed when a conscious decision by the member or legal
representative is made to stop receiving hospice services.
A revocation does not include ineligibility for the hospice benefit or death (see
Discharge from Hospice).
C. Responsibility for Completion
The hospice provider may assist the member or the legal representative with
completion of this form, if needed. The member or the legal representative must
sign and date the form.
D. Instructions
Recipient’s name and Medicaid number. Enter the member’s state
identification (SID) number as it appears on the Medical Assistance Eligibility Card.
This number consists of seven numeric characters and an ending alphabetic
character.
If the member has both Medicare and Medicaid eligibility, add the member’s
Medicare number under the member’s SID.
Agency name and Agency provider number. Enter the hospice agency’s name
and the hospice agency’s Iowa Medicaid provider number in the spaces provided.
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Recipient’s signature. The signature of the member or legal representative.
Date. The member or legal representative must write the date the form was
signed.
Witness’ signature. The person who witnessed the member’s or legal
representative’s signature must sign this form.
A legal representative who witnessed the member’s signature can sign this
form.
A hospice staff who witnessed the member’s or the legal representative’s
signature cannot sign as a witness for this form.
Witness’ signature. The signature of the person who witnessed the member’s
sign this form is required.
Date. The witness must date this form.
A legal representative who witnessed the member’s signature can date this
form.
A hospice staff who witnessed the member’s or the legal representative’s
signature cannot date this form.
E. Distribution
Keep the original in the member’s case file.
Submit a copy to the member or the legal representative.
If the member resides in an NF, submit a copy to the:
Nursing facility.
DHS CFEU within two days of action by mail, fax or email per the
information below:
Mailing Address:
DHS CFEU
Imaging Center 1
Iowa Department of Human Services
417 E. Kanesville Blvd.
Council Bluffs, IA 51503-4470
Fax: (515) 564-4040
Email: facilitie[email protected]tate.ia.us