Eligible Members

To be eligible for hospice services, a member must meet the following criteria:

1. Be eligible for Medical Assistance (Medicaid) or MinnesotaCare
2. Be certified as terminally ill by the medical director of the hospice or a physician member of the interdisciplinary group and the member’s attending physician, if he/she has one

Medical Assistance (Medicaid) members who may be eligible for Medicare must be directed to the Social Security Administration for Medicare application. MinnesotaCare members must be directed to their local county human services agency for Medical Assistance (Medicaid) eligibility determination.

Dually eligible members who elect Medicare hospice must also elect Medical Assistance (Medicaid) hospice. The Medicare hospice election form must be sent to the Minnesota Department of Human Services (DHS) on the day of election.

A member may receive hospice care until one of the following occurs:

1. He/she is no longer certified as terminally ill
2. The member or his/her representative revokes the election of hospice care

Service Authorization

PrimeWest Health members require a Service Authorization before starting hospice services. Provide a statement from the physician about the member’s terminal illness and life expectancy. Service Authorization is not required for dual-eligible members when Medicare will be covering the hospice needs.

Hospice Care Provided in Conjunction with Other Medical Assistance (Medicaid)-Covered Services

PrimeWest Health understands that members facing death may have a complex set of health care needs. These needs often stem from their terminal condition. These needs may also stem from other medical conditions that either pre-existed their terminal condition or arise during the course of their terminal condition but are unrelated to their terminal condition. A member should never be asked to make an “either/or” choice between an otherwise Medical Assistance (Medicaid)-covered, medically necessary service that is not related to the terminal condition and a covered, medically necessary hospice benefit service that is related to the terminal condition.

Pre-Existing Health Care Needs

Due to the member’s pre-existing medical conditions or disability, some Medical Assistance (Medicaid)-covered services may already be needed and/or in place before the member seeks hospice. The hospice benefit is not intended to duplicate health services or supports that relate to a pre-existing condition. Examples include continuing care services such as home care related to a previous stroke, waiver services related to a disability, or adult foster care related to a disability such as elderly dementia. Examples of pre-existing medical care include services for conditions such as diabetes, amyotrophic lateral sclerosis (ALS), arthritis, cardiac conditions, Acquired Immune Deficiency Syndrome (AIDS), or high blood pressure.

Pre-existing continuing care services may need to be adjusted during the period that the member is receiving the hospice benefit. Members with pre-existing needs, such as quadriplegia or stroke, may have more intensive physical needs due to the terminal illness compared to members without such pre-existing conditions. The resulting higher needs are an interaction of the two conditions together; some needs may need to be addressed through increased continuing care services.

Medical Needs that Arise during the Period of the Hospice Benefit but that are Unrelated to the Terminal Illness

Sometimes members need new health care services in addition to the services that are offered as part of the hospice benefit. Medical Assistance (Medicaid)-covered services may be provided in response to conditions not related to the terminal condition. Examples of this include treatment for a hip fracture unrelated to the terminal diagnosis or the development of a new condition or symptom unrelated to the terminal diagnosis.

How to Determine When a Medical Assistance (Medicaid)-Covered Service Duplicates a Hospice Benefit Service

Generally, the determination about whether a service duplicates a hospice benefit service will be made as part of the hospice provider’s general responsibility to provide care coordination. The hospice care coordinator must assume the lead responsibility for collaborating with the county case manager, home care agency, physician, or other provider providing the services that are outside of the hospice benefit.

Because some hospice benefit services and Medical Assistance (Medicaid)-covered services may be similar, this determination process should focus on the purpose, rather than the type of service—that is, what member need is the service addressing?

The following considerations may be helpful in approaching the determination:

1. Is the purpose of a service to address a pre-existing condition or a pre-existing need?
2. Is the purpose of a service to address a health care problem that would have existed even without the terminal illness?
3. Is the purpose of a service to facilitate the member’s ability to live in the community setting rather than an institution, and would that need have been present with or without the terminal illness?

Documentation Requirements When a Case Manager Is Involved

When the Medical Assistance (Medicaid)-covered service is the type that includes county-based Home and Community Based Services (HCBS) case management, the hospice must notify the case manager in writing of the member’s election of hospice and the anticipated start date. Written notification via fax, mail, or hand delivery must be given to the case manager within two business days using the Hospice Transaction Form (DHS-2868).

The hospice agency staff must assume lead responsibility for collaboration and documentation of that collaboration with the case manager. The hospice staff must forward the documentation within eight calendar days of the effective date of hospice services. Collaboration may be completed via telephone, fax, email, or a face-to-face visit. Documentation such as this should be included in the member’s hospice record.

The case manager will be invited to participate in the hospice interdisciplinary care team meetings for a member receiving HCBS.

The case manager will keep a copy of the cooperative agreement in the member’s record. (This is not a mandated form but to be used as a tool for preventing duplication of services.)

When the member is receiving “traditional Medical Assistance (Medicaid)” home care and no case manager is involved, the hospice must coordinate care and communicate with the home care agency involved with the member, rather than through a county case manager.

Seeking Home and Community Based Services (HCBS) after Hospice Election

When a member is receiving concurrent HCBS and hospice services, the HCBS are usually in place before the hospice services began.

There may be situations where a member seeks case-managed HCBS or an increase in HCBS after electing the hospice benefit. Example: An adult with a disability is living with an aging mother, who is the primary caregiver. The aging mother experiences a decline in health status and has to cut back on the amount of primary care she is able to provide the member. The member therefore applies for HCBS to access available services and supports that the primary caregiver can no longer provide. In situations where the initial HCBS is added or increased after the hospice benefit is elected, county case management documentation must justify the addition/increase of the HCBS services.

County Case Manager Approval of Services that are Concurrent with the Hospice Benefit

Following coordination with the hospice provider agency, county case managers must add comments on the PrimeWest Health electronic care plan documenting the coordination of services. The notes must indicate why continuing care services are necessary (either they are pre-existing or they are new but treated as a condition not related to the terminal condition). The service agreement line items within the PrimeWest Health electronic care plan must be adjusted as needed to reflect the type and amount of services required. Changes to services continue to require a 10-day notice to members to allow for continuity of care, patient rights, and transitional needs.

When continuing care waiver provider claims are received by PrimeWest Health, a claim edit suspends the claim when the date of service overlaps with the hospice benefit period. Because the hospice provider becomes the primary payer of services, PrimeWest Health will manually review HCBS provider claims to determine if payment is appropriate. Case management notes in the Medicaid Management Information System (MMIS) will be reviewed at that time to ensure hospice provider coordination with the county case manager has occurred. If it appears that the coordination by the hospice provider has not occurred, the claim will remain in suspense until the coordination process is completed. If it appears that the coordination process has occurred, then the claim will be paid. When payment appears appropriate, the claim will be paid as requested. The informational edit and manual review of claims will remain in place temporarily to encourage consistent coordination between the provider areas.

Physician Services

An attending physician’s services are separately billable as long as the attending physician is not an employee of or under contract with the hospice. Bill Medicare Part B for dual eligible members and Medical Assistance (Medicaid) if the member has Medical Assistance (Medicaid) only.

• When submitting claims for adult hospice services, use the appropriate diagnosis code that identifies the reason for the treatment, service, or item, not the diagnosis code for the terminal illness.
• Do not submit denied Medicare physician claims to PrimeWest Health that are related to the terminal illness.
• Denied Medicare claims for physician services that are not related to the terminal illness must have an attachment stating the services billed are not related to the terminal illness, and on the claim report the reasons Medicare denied the services.

Billing for Consulting Physician Services

When billing for the services of a consulting physician for a Medical Assistance (Medicaid)-only member (no Medicare or other third party payer involved), break out the technical portion and bill PrimeWest Health for the physician portion only. Services provided to dually eligible members are first billed to Part B Medicare and cross-over for Medical Assistance (Medicaid) payment of copays and deductibles.

Establishing the Plan of Care

The attending physician, the hospice medical director or physician designee, and the interdisciplinary group must establish a written plan of care for providing hospice services. The care provided by the hospice must follow the established plan of care.

Content of Plan of Care

The written plan of care must do the following:

1. Include an assessment of the member’s needs
2. Identify services, including the management of discomfort and symptom relief
3. Detail the scope and frequency of services needed to meet the member’s and family’s needs

The hospice must designate a RN to coordinate the implementation of the plan of care for each member.

Review of Plan of Care

The plan of care must be reviewed and updated at intervals specified in the plan by the attending physician, the hospice medical director or physician designee, and the interdisciplinary group. The reviews must be documented.

Hospice Services for Residents of Long-Term Care Facilities (LTCFs)

Medical Assistance (Medicaid)-eligible residents of intermediate care facilities for the developmentally disabled (ICF/DDs) and nursing facilities (NFs) who also meet hospice service eligibility may elect to receive hospice services where they live. The hospice provider becomes the primary provider of the service and authorizes and funds the hospice benefits. Medicare and Medical Assistance (Medicaid) payments are made to the hospice provider both for the hospice services it provides and for the residential services provided by the facility. Current law requires a payment to the hospice provider of at least 95 percent of the rate that would have been paid for facility services for the individual. Effective July 1, 2001, payments to be made by DHS are indicated in column (E):

Facility Type (A)	DHS Payment Rate (B)	Percentage of Rate (C)	Private Room (D)	Hospice Payment For Room & Board (E)
ICF/DD	ICF/DD	100%		95% * [(B)*(C)]
NF	NF Case-Mix	100%		95% * [(B)*(C)]
NF	NF Case-Mix	100%	111.5%	95% * {[(B)*(D)]*(C)}
NF First 30 Days1	NF Case-Mix	120%		95% * [(B)*(C)]
NF First 30 Days1	NF Case-Mix	120%	111.5%	95% * {[(B)*(D)]*(C)}
Out-of-State NF	NF Rate	100%		95% * [(B)*(C)]

¹Begins with date of NF admission, not Medical Assistance (Medicaid) eligibility date

 

The hospice must contract with and negotiate a rate with the LTCF for members who reside in the facility and elect hospice care. The LTCF must coordinate all of the member’s services and care with the hospice. The hospice may negotiate with the LTCF for the LTCF to continue to collect the member’s spenddown.

The hospice must notify the local county human services agency of the member’s hospice election by sending (or faxing) a copy of the front page of the Hospice Transaction Form (DHS-2868) to the county. The hospice will become the designated provider for the medical spenddown, and the payment to the hospice for the room and board will exclude the amount of the member’s medical spenddown.

Residents of ICF/DDs and NFs may receive end-of-life care from their residential provider without making the hospice election. Facilities may be able to arrange for the specific care needs of people with terminal illness by making internal staffing adjustments, by also purchasing the specialized services, or by making staff additions. ICF/DDs may apply through their host counties for a variable rate adjustment in order to accommodate the increased needs of a person with terminal illness.

Bed-Hold Billing

When a hospice patient resides in a nursing home and is absent from the nursing home for hospitalization, home visits, etc., the hospice agency must verify that the NF is eligible for bed-hold days. Bed-hold days are available up to 18 consecutive days per hospital admission and 36 days annually for therapeutic leave days when the facility occupancy rate is 96 percent or greater. Bed-hold rates are 30 percent of the case-mix rate, of which the agency is entitled to 95 percent of the adjusted case-mix rate for that LTCF.

Example: If stay is May 1 – 10 with May 1 – 7 in a nursing home, submit 0658 revenue code with the case-mix for May 1 – 7; for May 8 – 10 (hospital), submit 0185 revenue code separate for bed-hold with just the rate of charges billed.

For hospice billing only: Revenue code 0185 will pay only what is submitted and can be used for hospital and/or therapeutic leave days.

Hospice Transaction Form (HTF)

The Hospice Transaction Form (DHS-2868) is a multipurpose form that is a tool for hospice providers to report hospice election, certification, revocation of hospice services, change of hospice provider, and member death.

For DHS notifications, use the Hospice Transaction Form (DHS-2868).

Submitting the HTF

PrimeWest Health must be notified within two days of members who are enrolled in hospice (regardless of whether Medical Assistance [Medicaid] is the primary payer).

The Medicare- and Medical Assistance (Medicaid)-approved criteria on the hospice agency’s election form are to be submitted to PrimeWest Health immediately upon enrolling with Medicare hospice. This election form must be completed with all the required/appropriate information (e.g., Personal Member Identifier [PMI], date of birth [DOB], National Provider Identifier [NPI], International Classification of Diseases, 10th Revision, Clinical Modification [ICD-10-CM] code, and patient’s signature). PrimeWest Health must receive the information within two days of election.

Dual-eligible Medicare and Medical Assistance (Medicaid) members may submit the Medicare-approved hospice election criteria plus the PrimeWest Health required elements to PrimeWest Health in place of the PrimeWest Health HTF.

Page one of the election form must also be sent to the county financial worker when a spenddown is involved. State staff will make the institutional to medical change in the system if the change has not been made by the county.

For members enrolled in PrimeWest Health who are residing in an LTCF, submit their hospice election forms to PrimeWest Health and DHS.

DHS must also be notified when the member is no longer receiving hospice care. Fax or mail the HTF to:
Attn: Hospice Notification
Minnesota Department of Human Services
PO Box 64993
Saint Paul, MN 55164-0993

Fax: 1-651-431-7433

Hospice overpayments for spenddowns may be sent back to the following address. A copy of the original remittance advice (RA) must be included for correct claim credit. Mail to:
Attn: Benefit Recovery/Hospice
Minnesota Department of Human Services
PO Box 64994
Saint Paul, MN 55164-0994