Provider Notice issued 08/01/06

Use of Patient Credit for Hospice Residents

This notice is to clarify the use of patient credit when hospice for a resident of a long term care (LTC) facility begins after the first of the month.

When hospice for an LTC resident is effective for a date after the first of the month, the LTC facility must apply the patient credit up to the amount paid by the department. Any remaining income is applied to the claim submitted by the hospice provider, and is used to offset the LTC portion of the hospice claim (95% of the LTC facility’s Medicaid rate). The LTC facility retains the entire patient credit. Payment made to the hospice for the LTC facility will be reduced by the amount of the patient credit applied by the department. Two examples are provided below. The first example is when the patient credit exceeds the Medicaid payment due the nursing facility, and the second example is when the patient credit does not exceed the Medicaid payment due the nursing facility.

First Example

Resident is LTC for the period January 1 through January 10, and becomes hospice on January 11. The facility Medicaid rate is $100/per day and the patient credit amount is $1200.

The LTC facility will apply $1000 of the $1200 patient credit to the ten days that the resident was LTC. The remaining $200 will be applied to 95% of the Medicaid rate ($95) paid to the hospice provider for LTC room and board. The payment made to the hospice for the period of January 11 through January 31 will be reduced by $200.

LTC: 10 days x $100 = $1000 minus the patient credit of $1200 = no payment from the department, and $200 excess credit.

Hospice: 11 days x $95 (95% of $100 Medicaid rate) = $1045 minus remaining patient credit of $200 = $845 payment to the hospice from the department for the LTC room and board.

Second Example

Resident is LTC for the period January 1 through January 10, and becomes hospice on January 11. The facility Medicaid rate is $135/per day and the patient credit amount is $1200.

The LTC facility will apply the $1200 patient credit to the ten days that the resident was LTC. Because the facility charges exceed the amount of the patient credit, there is no patient credit applied to 95% of the Medicaid rate ($128) paid to the hospice provider for LTC room and board. The payment made to the hospice for the period of January 11 through January 31 will not be reduced by any patient credit amount.

LTC: 10 days x $135 = $1350 minus the patient credit of $1200 = $150 payment from the department, and no excess patient credit amount.

Hospice: 11 days x $128 (95% of $135 Medicaid rate) = $1408 payment to the hospice from the department for the LTC room and board.

Payment from the hospice to the LTC facility is made based on the terms of the contract executed by both parties, and does not involve the department.

Questions from hospice providers should be directed to the Bureau of Comprehensive Health Services at 877-782-5565. Questions from LTC facility providers should be directed to the Bureau of Long Term Care at 217-782-0545.

Anne Marie Murphy, Ph.D.

Administrator

Division of Medical Programs