Section 471-12-010 - MEDICAID HOSPICE BENEFIT010.01STANDARDS FOR PARTICIPATION. To participate in Medicaid, a hospice must be a public agency or private organization or a subdivision of either that is primarily engaged in providing care to terminally ill individuals and is certified for participation in Medicare as a hospice. 010.01(A)PROVIDER ENROLLMENT. To complete the provider enrollment process, the hospice must meet the following conditions: (i) The hospice must have a signed, written and non-resident-specific contract with each certified nursing facility (NF) or intermediate care facility for individuals with developmental disabilities (ICF/DD); and(ii) The hospice must complete and submit a Medicaid provider agreement in entirety to Medicaid for each contracted nursing facility (NF) or intermediate care facility for individuals with developmental disabilities (ICF/DD).010.02COVERED SERVICES. Nebraska Medicaid must pay the hospice for the client's room and board in the facility when the following conditions are met: (1) The hospice and the facility must have a written agreement under which the hospice is responsible for the professional management of the client's hospice care;(2) The client must be eligible for Medicaid benefits;(3) The client must have elected to receive the Medicare or Medicaid hospice benefit;(4) The client must reside in a Medicaid-certified bed in the facility;(5) Prior authorization requirements must be met;(6) The client is an adult; and(7) The preadmission screening and resident review (PASRR) must be completed before the client is admitted to the facility. 010.02(A)COVERED SERVICES FOR CHILDREN. Nebraska Medicaid must pay the facility for the client's room and board expense in a nursing facility (NF) or intermediate care facility for individuals with developmental disabilities (ICF/DD) if the client is a child 18 years old or younger.010.03PRIOR AUTHORIZATION REQUIREMENTS. The following steps must be completed before Medicaid authorizes room and board payment to the hospice: (1) The hospice must obtain prior authorization for the actual hospice service when Medicaid is the primary payer;(2) The hospice must obtain prior authorization for special needs and out-of-state nursing facility payment by paper or electronically. An MC-9NF or Nursing Facility Level of Care Determination Form must be submitted with attachments according to the requirements listed in this chapter;(3) The hospice contracted nursing facility (NF) must comply with all assessment requirements as stated in this chapter. For intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care (LOC) see 471 NAC 31;(4) For a new admission to a nursing facility (NF), the hospice must submit the following to Medicaid: (a) Nebraska Level I Preadmission Screening and Resident Review (PASRR) form;(b) Form MC-9NF, or Nursing Facility Level of Care (NF LOC) Determination Form;(c) A copy of the DM-5 or history and physical;(d) The hospice plan of care and certification;(e) A list of hospice covered medications and pharmacy notification; and(f) A list of hospice covered medical appliances, supplies, and therapies and provider notification;(5) If the client is Medicaid eligible and already residing in the nursing facility (NF), the hospice must complete and submit to Medicaid:(a) Form MC-9NF, or Nursing Facility Level of Care Determination Form;(b) Hospice plan of care and certification;(c) List of hospice covered medications and pharmacy notification; and(d) List of hospice covered medical appliances, supplies, and therapies and provider notification. 010.03(A)PRIOR AUTHORIZATION EXCEPTION. When a client is eligible for the Medicare hospice benefit, prior authorization for the nursing facility (NF) room and board, not a Medicare hospice benefit, is not required for payment by Medicaid with the exception of out-of-state and special needs residents as identified in this chapter.010.03(B)REQUIRED ASSESSMENTS. The hospice contracted nursing facility must comply with all assessment requirements as stated in this chapter.010.04PAYMENT TO THE HOSPICE. Medicaid's payment to the hospice must be based on the rate established by the Department for the nursing facility (NF) in which the client resides, based on the assessment for each individual. The hospice must make payment to the nursing facility (NF) for the client's room and board according to the contract between the facility and the hospice.010.05BILLING. The hospice must bill the Department on the appropriate claim form or electronic format. 010.05(A)NURSING FACILITY BILLING. The nursing facility (NF) must not bill Medicaid for room and board for any adult client that has elected to receive the hospice benefit. 010.05(A)(i)EXCEPTION. The nursing facility (NF) must continue to bill Medicaid for room and board for clients under the age of 18.471 Neb. Admin. Code, ch. 12, § 010
Reserved effective 12/19/2018Amended effective 6/28/2020Amended effective 12/23/2020Amended effective 6/26/2021Amended effective 6/6/2022