Hospice Room and Board Clarification – Working with Medicaid Managed Care Plans
Due to guidance Ohio Department of Medicaid (ODM) received from the Centers for Medicare and Medicaid Services (CMS), effective July 1, 2019 Medicaid Managed Care and MyCare Ohio plans were required to make room and board payments to hospice providers directly for individuals residing in a nursing facility. ODM communicated this expectation with the plans in April 2019, and expected all contracts (if necessary) with affected providers be amended to accommodate this change for the July 1, 2019 effective date.
Hospice providers will need to work with the plans and follow their requirements in order to bill for room and board payments. This means that if a plan requires contracts, the hospice providers will need to work with the plan to set those contracts up. Since contracts can take some time to establish, plans will create single-case agreements with hospice providers to establish the rate that will be paid until the contract is completed. Hospice providers should also note that plans may or may not require prior authorization (PA) for hospice services.
ODM has provided additional guidance to the plans regarding this policy update (September 2019). Per the attached memo that was sent to the plans, hospice providers will not need to request a new PA for hospice services if an approved PA is already on file from the nursing facility – and the hospice provider shall be paid for those previously authorized services (until the authorization’s end date, if applicable). Furthermore, to ensure that hospice providers have enough time to make any additional necessary adjustments (contracts, single case agreements, PA submissions), ODM has instructed the plans to pay hospice providers for claims submitted with dates of services between July 1, 2019 to October 15, 2019 regardless of if a PA is on file. These claims are still required to be properly submitted by the hospice provider.
Hospice providers should note that beginning October 16, 2019, for any member newly receiving hospice services, plans may begin denying payment to hospice providers if a PA for services is not requested or a contract/single-case agreement is not established if either is required by the plan.
Please note, this information has been shared with the hospice providers directly. Any additional questions or comments regarding the information above should be sent to ManagedCarePolicy@medicaid.ohio.gov.