Long Term Care Division

1. Long Term Care Division Alabama Medicaid Agency Long Term Care Division Outreach and Education Unit Revised: July 2004

2. P R E S E N T S An Overview of HOSPICE CARE

3. HOSPICE CARE • Hospice care is defined as services which are necessary for the palliation or management of the terminal illness and related conditions.

4. LEVEL OF CARE DETERMINATION • The attending physician or hospice medical director certifies the recipient has a terminal illness and requires services that are medically necessary for palliative care. • Certification of the terminal illness of an individual who elects the hospice benefit shall be based on the physician’s clinical judgment regarding the normal course of the individual’s illness.

5. LEVEL OF CARE DETERMINATION • Certification of terminal illness must include specific findings and medical documentation including, but not limited to, medical records, lab, x-rays, pathology reports, etc.

6. HOSPICE ELECTION AND CERTIFICATION • If the recipient is dually eligible for Medicare and Medicaid, the hospice benefit must be elected simultaneously. • The Medicaid Hospice Election Form 165 must be completed. FORM 165

7. HOSPICE ELECTION AND CERTIFICATION • The form should indicate if the individual is a Medicare recipient and if the recipient is in a nursing facility. • The Hospice Election Form should be signed and dated by the patient or the patient’s representative.

8. HOSPICE ELECTION AND CERTIFICATION • The signature or mark of the patient or the patient’s representative signature should be witnessed and dated by the hospice provider agent obtaining the signatures. • The physician must sign and date the form with the date the signature is obtained.

9. HOSPICE ELECTION AND CERTIFICATION • The physician’s signature must be an original (white-out or CRNP signatures are not acceptable). • The date of the physician’s signature must be within 2 calendar days of the election date unless there is a verbal order received for initiation of care.

10. HOSPICE ELECTION AND CERTIFICATION • If there is a verbal order the physician’s signature and date must be within 8 days of the election date. • All subsequent benefit periods must be certified in writing within 2 calendar days. • If the recipient has Medicare Part A, the LTC Admission Notification Form should not be transmitted to EDS. In this instance, Medicare would be the payor for hospice benefits.

11. SUBMISSION OF LONG TERM CARE NOTIFICATION FORM Financial eligibility is verified Hospice Provider transmits the LTC Admission Notification Form to EDS electronically The transmission will be accepted or rejected

12. SUBMISSION OF LONG TERM CARE NOTIFICATION FORM An accepted transmission will be the providers record of approval for Hospice services If there are rejections, the provider must make the necessary corrections and resubmit the LTC Admission Notification Form

13. TRANSFERS • An individual or representative may change, once in each election period, the designation of the particular hospice from which care will be received.

14. TRANSFERS • To change the designation of the hospice provider, the individual or representative must file a signed statement that includes the following: 1. The name of the hospice from which care has been received. 2. The name of the hospice from which the individual plans to receive care. 3. The effective date of the transfer.

15. TRANSFERS • The previous hospice provider would submit a discharge. • The new hospice provider would complete the Medicaid Hospice Election Form 165.

16. REVOCATION • Notices of revocation or death should be submitted to the LTC File within 48 hours. • If the recipient is certified by the Medicaid District Office (DO), the DO must be notified of permanent changes such as revokes with no intent to return, or the death of the individual.

17. HOSPICE IN A NURSING FACILITY • Hospice providers may send the Medicaid Hospice Election Form (Form 165) to the DO, when applying for financial eligibility. • This form indicates to the DO that the client meets the level of care criteria.

18. SSI Recipients Transitioning from Home to Institution • SSI must be notified of the individuals change of residence so the individual’s income may be adjusted accordingly.

19. Retrospective Review Process

20. RETROSPECTIVE REVIEW POLICY • To ensure that state and federal rules and guidelines are adhered to by long term care providers, the Alabama Medicaid Agency (AMA) will retrospectively review monthly a 25% sample of admissions, re-admissions and re-determinations of Medicaid recipients served by long term care providers.

21. RETROSPECTIVE REVIEW PROCESS • The AMA professional nursing and medical staff will conduct retrospective reviews of long term care providers on a monthly basis. • Each provider will be notified of records to either mail into the Medicaid Agency or to have available for onsite review. • The AMA will not be responsible for any cost associated with the copying or mailing of requested documents.

22. RETROSPECTIVE REVIEW PROCESS...CONTINUED • The AMA professional staff will review requested documents to ensure compliance with federal and state guidelines governing the Hospice program and to ensure the medical necessity of the services rendered. • The review must be completed by the AMA within 30 days from receipt of the requested information from the long term careprovider.

23. RETROSPECTIVE REVIEW PROCESS...CONTINUED • The provider must make every effort to send all requested information upon the first request. • A checklist will be provided to ensure that all documents are included before mailing. • Client records which are determined to be deficient of requested documents or if the medical need for the services cannot be ascertained, may be recommended for recoupment.

24. RETROSPECTIVE REVIEW PROCESS...CONTINUED • The AMA may initiate a second request to providers for the requested information or additional information. • If this information is not received, recoupment proceedings will be initiated.

25. RETROSPECTIVE REVIEW PROCESS...CONTINUED • Upon review of the requested documents, the provider will be notified in writing within 30 days if further action will be taken or if additional information is needed. • Providers will only be notified if further action is necessary.

26. RETROSPECTIVE REVIEW PROCESS...CONTINUED • Providers will be notified of their appeal rights including the informal reconsideration, as well as a fair hearing process.

27. Recoupment Procedures

28. RECOUPMENT PROCESS • The Alabama Medicaid Agency’s (AMA) Long Term Care Admissions/Records Unit will perform a retrospective review of long term care programs, readmissions, and re-determinations.

29. RECOUPMENT PROCESS...CONTINUED • Records requested during the retrospective review process will be reviewed by the Alabama Medicaid Agency’s professional staff to ensure compliance with state and federal guidelines governing the specific program, and to ensure the medical necessity of the services rendered.

30. RECOUPMENT PROCESS...CONTINUED • If upon review, it is determined that the documents meet all state and federal requirements and that the medical necessity of the services is documented, no further action will be taken by the Medicaid Agency. • The providers will not receive further notice from Medicaid in these instances.

31. RECOUPMENT PROCESS...CONTINUED • If upon review, it is determined that the documents fail to meet all state and federal requirements or that the documentation submitted does not support the medical necessity of the service, the Alabama Medicaid Agency will initiate recoupment of funds paid for services rendered.

32. RECOUPMENT PROCESS...CONTINUED • The Alabama Medicaid Agency professional nursing and medical staff will review any additional documentation submitted within the designated timeframes to determine if the information submitted satisfies the AMA’s concerns.

33. RECOUPMENT PROCESS...CONTINUED • If it is determined that the documents meet all state and federal requirements and that the medical necessity of the service is documented, no further recoupment action will be taken. • The AMA will notify the provider in writing within 30 days from receipt of the additional information of this decision.

34. RECOUPMENT PROCESS...CONTINUED • If it is determined that the documentation does not satisfy the AMA concerns, the provider will be notified in writing within 30 days from receipt of the additional information and their right to a fair hearing.

35. RECOUPMENT PROCESS...CONTINUED • If the provider’s request for an informal appeal or fair hearing is not received timely, the right to appeal will be forfeited. • If after all appeals have been exhausted, the AMA continues to disagree with the provider’s contention that all requirements are satisfied, the AMA will proceed with recoupment actions.

36. RECOUPMENT PROCESS…CONTINUED • The Long Term Care Admissions/Records Unit will forward information to the Long Term Care Provider/Recipient Services Unit to proceed with the recoupment process.

37. Hospice in the Nursing Home

38. HOSPICE IN THE NURSING HOME • Medicaid will not restrict hospice services based on a patient’s place of residence. • A nursing facility resident may elect to receive hospice benefits if he or she meets the requirements for hospice care under the Medicaid Program.

39. HOSPICE IN NURSING HOMES • Ifthe resident elects to receive hospice benefits, the nursing home should submit the application to discharge the resident from the nursing home and admit to hospice. • The hospice provider is responsible for completion of Form 165 (Hospice Election Form) and submission of the LTC Admission Notification Form.

40. HOSPICE TRANSFERS • If the individual transfers from hospice to a nursing home or nursing home to hospice, federal guidelines indicate that hospice should be paid for each day of service. • These applications should be processed as a transfer to allow for an overlap of dates. NOTE: Same date of discharge from nursing home = admit date to hospice.

41. HOSPICE IN THE NURSING HOME • The level of care determination and admissions process would be the same as in the community.

42. HOSPICE IN THE NURSING HOME • If the recipient received hospice in the home and transitioned to a nursing home, SSI should be notified of the admission so that the individual’s income can be adjusted accordingly.

43. CONTACT INFORMATION Policy Questions Nancy Headley, Associate Director, LTC Admissions Records Unit, 334.242.5684, nheadley@medicaid.state.al.us Billing Questions EDS 334.215.0111 Admission Questions Long Term Care Admission/Records 334.242.5684

44. The End