Or. Admin. R. 410-142-0290 - Hospice Services in a Nursing Facility
(1) Pursuant to Title XIX, Section 1902 and
1905, federal statute prohibits the state from paying nursing facility (NF)
providers directly for NF services when their Medicaid residents elect hospice
care. In these instances, the Centers for Medicare and Medicaid Services (CMS)
require the state to pay the hospice provider the additional amount equal to at
least 95% of the per diem rate the state would have paid to the NF for NF
services for that client in that facility.
(2) When a client resides in a NF and elects
hospice care, the hospice provider and the NF must have a written contract
which addresses the provision of hospice care and the method upon which the
hospice will pay the NF. The hospice and the NF must maintain a copy of the
completed and signed contract on file and it must be available upon request.
(3) Reimbursement when a client
resides in a NF and elects hospice care:
(a)
In accordance with CMS 4308.2, "when hospice care is furnished to an individual
residing in a NF, the state will pay hospice an additional amount on routine
home care or continuous home care days to take into account the room and board
furnished by the NF. In this context, the term 'room and board' includes
performance of personal care services, including assistance in the activities
of daily living, in socializing activities, administration of medication,
maintaining the cleanliness of a residents' room, and supervision and assisting
in the use of durable medical equipment and prescribed therapies," as well as
any other services considered under the bundled rate for which the NF is paid
pursuant to OAR 411-070.
(b) The
hospice shall bill the Division of Medical Assistance Programs (Division)
directly for the hospice care provided (under routine home care, Revenue code
651, or continuous home care, Revenue code 652) and for the cost of NF services
at their usual and customary rate for NF services delivered in that NF for that
client;
(c) The Division shall pay
the hospice provider for the hospice care provided and not to exceed 100% of
the current NF basic, complex medical, pediatric, or special contract rate
according to the rate schedule for NF services delivered in that NF for that
client;
(d) The hospice provider
must reimburse the nursing facility according to their contract and after the
hospice receives payment from the Division for that NF for that client; and
(e) Reimbursement for services
provided under this rule is available only if the recipient of the services is
Medicaid-eligible, hospice-eligible, and been found to need NF care through the
Pre-Admission Screening process under OAR 411-070-0040.
(4) NF Services Overpayment: Any payment
received from the Division by a NF for services delivered after a client has
elected hospice care shall adjust their claims from the day the client first
elected hospice care. Failure to submit an adjustment subjects the NF to
potential sanctions and all means of overpayment recovery authorized under OAR
chapter 410, division 120.
(5)
Coordination of Care (COC) must be provided according to CMS Conditions of
Participation (CoPs),
42CFR418.112
for hospice and nursing facilities.
(6) Coordinated Care Organization (CCO) and
Prepaid Health Plan (PHP) clients who reside in a NF and elect hospice care
shall remain in the CCO and PHP for all care other than hospice services in the
NF. Hospice services for a resident in a NF shall be excluded from CCO and PHP
capitation and the hospice must bill the Division directly for payment of
hospice and NF services.
Notes
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.