N.J. Admin. Code § 10:53A-4.1

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:53A-4.1 - Post-eligibility treatment of income

(a) For a hospice beneficiary residing at home, who is eligible only for hospice services, the policy for handling the post-eligibility treatment of income is the same as that of the Division's home and community-based waivers, for example ACCAP. For these beneficiaries, there is no available income to be applied to the cost of care because the maintenance standard in the home and community based waiver programs has been determined to be equal to the income eligibility standards for Title XIX approved facilities (see N.J.A.C. 10:71-5).

(b) For a beneficiary who is residing in a nursing facility and receiving hospice under Medicaid/NJ FamilyCare FFS, payment to the hospice for room and board services shall be reduced by the beneficiary's available income. Available income is that amount, which remains after deducting certain amounts from the beneficiary's gross income, as determined in accordance with N.J.A.C. 10:71.

1. Instructions for the use of the Statement of Available Income for Medicaid Payment PR-1 Form #10 in the Appendix, incorporated herein by reference, are as follows:

i. The hospice is responsible for ensuring that the amount of the beneficiary's available income is reported and that the amount corresponds to that attributed to the beneficiary's account on the Statement of Available Income for Medicaid Payment PR-1. The hospice shall be liable to the Division for any available income not reported to the fiscal agent by the hospice. A PR-1 table, that is maintained by the fiscal agent, will be referenced during claims processing to determine the PR-1 amount to be deducted from the hospice claims during claims processing.

ii. The Statement of Available Income for Medicaid Payment PR-1 is completed by the CWA on each non-SSI Medicaid/NJ FamilyCare FFS beneficiary that receives hospice services, who is a hospice beneficiary residing in the NF.

(1) The PR-1 form reflects the beneficiary's available income that remains after deducting certain amounts for the maintenance of a community spouse, the maintenance of other dependent relatives, health insurance premiums, and the personal needs allowance (PNA). A PR-1 form must be attached to a copy of the CMS 1500 claim, and be kept in the beneficiary's billing record when requesting payment from Medicaid/NJ FamilyCare FFS for the cost of hospice care, as specified in (b)1ii(2) through (5) below.

(2) The hospice is responsible for maintaining a personal needs allowance (PNA) account and making these monies available for use by the beneficiary.

(3) The PR-1 form shall be obtained by the hospice from the NF for each beneficiary of hospice services who has been on the Long Term Care Facility billing system. The hospice shall negotiate the change in the collection of this income with the nursing facility, if applicable, or collect it from the beneficiary and/or family.

(4) For the hospice applicant who has not previously been on the Long Term Care Facility billing system as an NF patient, the CBOSS shall generate the PR-1 form for the use of the hospice.

(5) For individuals with no income, or income below $ 60.00 per month, who continue to qualify for Supplemental Security Income (SSI) payments and Medicaid, no PR-1 form is required upon admission to hospice care status.

(A) For these hospice beneficiaries, confirmation of the SSI status should be obtained from the MACC and documented in the hospice billing record.

(B) When submitting the CMS 1500 claim, the hospice shall note in the beneficiary's billing record and state in the "REMARKS" area of the claim, the wording "SSI Eligible."

(c) Regarding adjustments to the PR-1, the CWA is required to report all changes of income on an amended PR-1 to the hospice.

1. When special exceptions apply (for example, in the month of admission, for verified living expenses, and for the first two months of Medicare premium deductions), the PR-1 form will reflect those changes for the applicable month(s).

2. The beneficiary and/or the family are required to report all changes of available income to the CWA. Additionally, the hospice should report any changes in financial circumstances to the CWA. For those changes which impact on available income, a new PR-1 form must be generated by the CWA, indicating the month for which the change is effective.

3. When an amended PR-1 form affects the periods of service that have already been billed by the hospice, a "RETROACTIVE ADJUSTMENT" shall be submitted to the fiscal agent. The reason for the adjustment shall be recorded in the "REMARKS" area of the CMS 1500 claim and also in the beneficiary billing record at the hospice.

4. On post-payment quality assurance review, the hospice is liable to the Division for any of the beneficiary's available income not deducted appropriately from the claim forms.

(d) The hospice shall receive the PR-1 completed by the CWA according to the following instructions for when the available income is applied: For any full or part of a calendar month in hospice care status, all available income shown on the PR-1 form shall be applied to the cost of the care except as indicated in (d)1 through 4 below.

1. The instructions in this paragraph apply on admission from a nursing facility. For the beneficiary who is admitted to hospice care status from an NF during a given calendar month, the available income may have already been utilized by the NF to offset the cost of care in the same month of admission to hospice care status. Thus, no income is applicable to the hospice for the first calendar month. This applies only if it is a partial calendar month of hospice room and board services. No new PR-1 form is generated by the CWA but a copy of the PR-1 form must be obtained from the NF and kept in the patient's record. The hospice must certify to this fact in the beneficiary's billing record. and in the "REMARKS" area of the claim form with the following statement:

"INCOME APPLIED TO THE NF COST OF CARE FOR

(ADD THE MONTH AND YEAR TO WHICH THE COST IS APPLIED)"

The fiscal agent shall deduct the PR-1 amount from the first claim submitted for a beneficiary by either an NF or hospice provider for any calendar month. For example, when the first claim received by the fiscal agent is submitted by a hospice for services provided in an NF, the PR-1 amount will be applied to the fullest extent possible. PR-1 amounts not exhausted by hospice claims for NF room and board services for a beneficiary for any given month will be applied to NF claims for the same beneficiary for the same calendar month and vice versa.

2. The instructions in this paragraph apply on admission from the community. For a hospice beneficiary admitted from the community, an exemption for verified living expenses is permitted in computing available income. An amended PR-1 form shall be generated from the CWA indicating the adjusted amount to be deducted from the hospice per diem charge for that month. Under no circumstances must the requested exemption exceed the verified living expenses. (This deduction is not applicable for hospice beneficiaries who are returning to hospice care from the hospital.)

3. In reviewing the PR-1 form to determine what income should be applied to a billing month, the effective date in each of the numbered columns (PR-1 #1, #2, and #3) shall be carefully checked. This is particularly significant for hospice beneficiaries admitted from the community or the hospital, as income may change within the first three months due to changes in income deductions, specifically Medicare premium payments.

4. The instructions for completing the PR-1 form when the beneficiary has been discharged or has died, are as follows:

i. For the discharge month or that partial part of the month in the hospice care, the available income amount shown on the PR-1 form shall be applied to the cost of care. If the income exceeds the charge for that month, the balance of income not applied to the cost of care shall be returned to the beneficiary. Exceptions to this general policy are indicated in (d)4ii through v below.

ii. For the hospice beneficiary who is discharged to the community, the amount of available income may be reduced by an amount to cover anticipated living expenses. However, this must be reflected on the PR-1 form by the CWA. When the PR-1 form does not reflect the reduction, contact the CWA to effect the change.

iii. For the hospice beneficiary who dies on the first, second, or third day of the month, and income is not available because the check could not be endorsed and was returned, the CMS 1500 claim shall be so annotated in the "REMARKS" area stating "Beneficiary expired on (date)--income not available for use." A notation on the billing record shall be made that the hospice provider returned the check to the hospice beneficiary's estate.

iv. For the hospice beneficiary who dies after the third day of the month and the income is not available because the check was returned, the CMS 1500 claim should be so annotated and documentation (that is, SSA transmittal receipt) retained in the hospice billing files. The CMS 1500 claim shall be annotated in the "REMARKS" area--"Check returned--SSA transmittal receipts available--income not available for use."

v. For the hospice beneficiary who is admitted to nursing facility care (in the same or in a different NF) after being discharged from the hospice, the hospice shall notify the NF of the amount of the patient's available income that was applied to the hospice's room and board bill in the discharge month, so that the NF may accurately reflect the balance amount of the NF admission month billing. The following is directed to the hospice for informational purposes only: The nursing facility will also complete an LTC-2 form and attach a copy of the CMS 1500 claim (copy only to CWA) to notify the CWA, MACC, and the Department of Health Long-Term Care Field Office of the admission of the hospice patient from hospice care to NF care. The amount of the patient's available income that was applied to the hospice room and board care should be calculated on the CMS 1500 claim form so that a new PR-1 form can be issued for the month of admission to the NF.

N.J. Admin. Code § 10:53A-4.1

Amended by 48 N.J.R. 134(a), effective 1/19/2016