010.01
STANDARDS 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).
010.02
COVERED
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.
010.03
PRIOR 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.
010.04
PAYMENT 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.
010.05
BILLING. 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.
