Long Term Care Division

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Long Term Care Division

• Alabama Medicaid Agency
• Long Term Care Division
• Outreach and Education Unit
• Revised July 2004

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P R E S E N T S

• An Overview of
• HOSPICE CARE

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HOSPICE CARE

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

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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 physicians clinical judgment
  regarding the normal course of the individuals
  illness.

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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.

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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
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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 patients
  representative.

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HOSPICE ELECTION AND CERTIFICATION

• The signature or mark of the patient or the
  patients 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.

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HOSPICE ELECTION AND CERTIFICATION

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

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HOSPICE ELECTION AND CERTIFICATION

• If there is a verbal order the physicians
  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.

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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
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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
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TRANSFERS

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

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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.

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TRANSFERS

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

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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.

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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.

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SSI Recipients Transitioning from Home to
Institution

• SSI must be notified of the individuals change of
  residence so the individuals income may be
  adjusted accordingly.

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Retrospective Review Process
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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.

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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.

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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 care provider.

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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.

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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.

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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.

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RETROSPECTIVE REVIEW PROCESS...CONTINUED

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

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Recoupment Procedures
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RECOUPMENT PROCESS

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

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RECOUPMENT PROCESS...CONTINUED

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

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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.

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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.

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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 AMAs concerns.

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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.

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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.

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RECOUPMENT PROCESS...CONTINUED

• If the providers 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 providers
  contention that all requirements are satisfied,
  the AMA will proceed with recoupment actions.

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RECOUPMENT PROCESSCONTINUED

• 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.

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Hospice in the Nursing Home
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HOSPICE IN THE NURSING HOME

• Medicaid will not restrict hospice services based
  on a patients 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.

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HOSPICE IN NURSING HOMES

• If the 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.

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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.

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HOSPICE IN THE NURSING HOME

• The level of care determination and admissions
  process would be the same as in the community.

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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
  individuals income can be adjusted accordingly.

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CONTACT INFORMATION

• Policy Questions
• Nancy Headley, Associate Director, LTC
  Admissions Records Unit, 334.242.5684,
  nheadley_at_medicaid.state.al.us
• Billing Questions
• EDS
• 334.215.0111
• Admission Questions
• Long Term Care Admission/Records
• 334.242.5684

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The End