Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 36 - HOSPICE SERVICES
Section 471-36-005 - BILLING AND PAYMENT FOR HOSPICE SERVICES

Universal Citation: 471 NE Admin Rules and Regs ch 36 ยง 005

Current through September 17, 2024

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements in 471 NAC 3. In the event that billing requirements in 471 NAC 3 conflict with billing requirements outlined in this chapter, the billing requirements in this chapter will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS. The hospice provider must bill for services provided using Form CMS-1450 or the standard electronic health care claim. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes used by Medicaid are listed in the Nebraska Medicaid Fee Schedule.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the payment regulations in this chapter will govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS. Medicaid pays for services provided under the Medicaid hospice benefit using the Medicaid hospice payment rates established by Centers for Medicare and Medicaid services (CMS).
005.02(B)(i) ROUTINE HOME CARE (RHC). Medicaid pays the routine home care (RHC) rate to the hospice provider for every day the client is at home, under the care of hospice, and not receiving continuous home care (CHC). This rate is paid without regard to the volume or intensity of routine home care (RHC) services provided on any given day. Medicaid pays two separate rates for routine home care (RHC) depending on the length of stay. For the first 60 days of care, routine home care (RHC) will be paid at an increased rate, with a reduced routine home care (RHC) rate applicable to services provided on day 61 and greater.
005.02(B)(i)(1) SERVICE INTENSITY ADD-ON (SIA). In addition to the per diem rate for routine home care (RHC) level of care, Medicaid will include a service intensity add-on (SIA) payment for direct client care services provided by a registered nurse (RN) or social worker during the last seven days of a client's life. The service intensity add-on (SIA) payment will equal the continuous home care (CHC) hourly rate multiplied by the hours of nursing or social work service, for at least 15 minutes and up to four hours total, that occurred on a routine home care (RHC) day during the last seven days of life.

005.02(B)(ii) CONTINUOUS HOME CARE (CHC). A continuous home care (CHC) day is a day on which an individual who has elected to receive hospice care is not in an inpatient facility, hospital, short term nursing facility, or hospice inpatient unit and receives hospice care consisting predominantly of nursing care on a continuous basis at home. Continuous home care (CHC) is only furnished during brief periods of crisis and only as necessary to maintain the terminally ill client at home. Medicaid pays the continuous home care (CHC) rate to the hospice provider to maintain a client at his or her place of residence when a period of medical crisis occurs. A period of medical crisis is a time when a client requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms. A registered nurse (RN) or licensed practical nurse (LPN) must provide nursing care. A nurse must be providing more than one half of care given in a 24-hour period. A minimum of eight hours of care must be provided in a 24-hour period, which begins and ends at midnight. When the number of hours is less than 24, Medicaid pays the hourly rate. The hours may be split over the 24 hours to meet the needs of the client. Routine home care (RHC) must be billed when fewer than eight hours of nursing care are provided.

005.02(B)(iii) INPATIENT HOSPITAL OR NURSING FACILITY (NF) RESPITE CARE. Inpatient respite care may be necessary to relieve the caregiver who normally cares for the client at home.
005.02(B)(iii)(1) INPATIENT RESPITE CARE FOR ADULT CLIENTS. Medicaid pays the inpatient respite care rate to the hospice provider for each day the client is in an inpatient facility and receiving respite care. Payment may be made for a maximum of five days per month counting the day of admission but not the day of discharge. The discharge day for inpatient respite care is billed as routine home care (RHC) unless the client is discharged as deceased. When the client dies under inpatient respite care, the day of death is paid at the inpatient respite care rate.

005.02(B)(iii)(2) INPATIENT RESPITE CARE FOR CHILD CLIENTS. Medicaid payment for hospital and nursing facility (NF) services must be made directly to the hospital or nursing facility (NF) for inpatient respite care.

005.02(B)(iv) GENERAL INPATIENT CARE. General inpatient care may be necessary for pain control or acute or chronic symptom management that cannot be provided in any other setting. Care must be provided in a hospital or a contracted hospice inpatient facility that meets the hospice standards regarding staffing and client care. The hospice must have a written contract and retain professional management of hospice services and care.
005.02(B)(iv)(1) GENERAL INPATIENT CARE FOR ADULT CLIENTS. Medicaid pays the general inpatient care rate to the hospice provider during a period of acute medical crisis.

005.02(B)(iv)(2) GENERAL INPATIENT CARE FOR CHILD CLIENTS. Medicaid payment for hospital and nursing facility (NF) services must be made directly to the hospital or nursing facility (NF) for general inpatient care.

005.02(B)(iv)(3) GENERAL INPATIENT CARE HOSPICE FACILITY REQUIREMENTS. A hospice that provides general inpatient care directly in its own facility must demonstrate compliance with the following standards:
(a) The hospice is responsible for ensuring that staffing for all services reflects its volume of clients, their acuity, and the level of intensity of services needed to ensure that plan of care outcomes are achieved and negative outcomes are avoided; and

(b) The hospice facility must provide 24-hour nursing services that meet the nursing needs of all clients and are furnished in accordance with each client's plan of care. Each client must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed, and protected from accident, injury, and infection.

005.02(B)(iv)(4) GENERAL INPATIENT CARE RATE RESTRICTIONS. When a severe breakdown in caregiving occurs, the general inpatient care rate must be paid until other arrangements can be made, up to a maximum of 10 days per month. The discharge day for general inpatient care is billed as routine home care (RHC) unless the client is discharged as deceased. When the client dies under general inpatient care, the day of death is paid at the general inpatient care rate.

005.02(B)(v) HOSPITAL SERVICES UNRELATED TO TERMINAL DIAGNOSIS. In accordance with 471 NAC 10, Medicaid pays all costs for hospital services provided when a client receiving the Medicaid hospice benefit is hospitalized for an acute medical condition that is not related to the terminal illness or complications secondary to the terminal illness. Determination of the cause of hospitalization must be made by the hospice interdisciplinary group (IDG) with consultation from the Department. Payment for hospital services must be made directly to the hospital.

005.02(B)(vi) SERVICES RECEIVED IN FACILITIES.
005.02(B)(vi)(1) ADULT CLIENTS. Medicaid pays the hospice provider for both the hospice services provided, and for the residential services provided by the facility.
005.02(B)(vi)(1)(a) PAYMENT FOR THE MEDICAID HOSPICE BENEFIT WHEN PROVIDED IN AN INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD), A NURSING FACILITY (NF), OR AN INSTITUTION FOR MENTAL DISEASES (IMD). Payment for the Medicaid hospice benefit can be found in the applicable chapters in Title 471 NAC.

005.02(B)(vi)(1)(b) PAYMENT AND MEDICAID MANAGED CARE. When a client permanently residing in a nursing facility (NF) is enrolled in managed care and elects the hospice benefit all services not covered under the Medicaid hospice benefit are covered as part of the benefits of the managed care plan. The Medicaid hospice benefit, services covered under the hospice benefit, and nursing facility (NF) room and board payments will be paid outside of the managed care plan.

005.02(B)(vi)(2) CHILD CLIENTS. Medicaid payment for hospital and nursing facility (NF) services must be made directly to the hospital or nursing facility (NF).

005.02B(vii) MEDICARE COVERAGE. A client who has Medicare coverage must use Medicare coverage as primary payer until Medicare benefits are exhausted. Medicaid pays the Medicare co-insurance and deductible when the client is covered by both Medicare and Medicaid as indicated in 471 NAC 3.

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