Hospice and Managed Long Term Care (MLTC)

Frequently Asked Questions (FAQs)

December 31, 2015

  • FAQs is also available in Portable Document Format (PDF, 251KB)

With the transition of the nursing home population to Medicaid Managed Care, there has been some confusion with regard to the coverage of and billing for hospice services under Managed Long Term Care (MLTC) - specifically in relation to those MLTC plan enrollees residing in a nursing facility or a hospice residence. In an effort to help clarify some of the questions that have arisen as part of the nursing home transition to managed care, the Department is releasing the FAQs below, in addition to MLTC Policy 13.18(b).

In addition to MLTC Policy 13.18(b) and this FAQ document, please also refer to MLTC Policies 13.18 and 13.18(a).

General Questions

Q1.) When a nursing home resident enrolled in MLTC elects their hospice benefit, who is responsible for room and board reimbursement to the nursing home?

A1.) Nursing home room and board is part of the MLTC plan´s capitation rate, and there is a current benchmark rate for this benefit. For nursing home residents who are enrolled in MLTC and also enrolled in hospice, room and board is paid directly to the nursing home by the MLTC plan.

Q2.) Is the reimbursement paid directly to the nursing home, not "passed through" the hospice?

A2.) There is no pass through; see Q1.

Q3.) Where is it documented that the MLTC plan is responsible for room and board?

A3.) Please refer to the attached MLTC Policy 13.18(b).

Q4.) When a MLTC member who is enrolled in hospice resides in a hospice residence, is the MLTC plan responsible for the room and board reimbursement to the hospice?

A4.) The per diem room and board component of the hospice residence shall be covered by a MLTC plan and authorized as a respite service under the definition of social and environmental supports.

Q5.) Is nursing home room and board currently included in the MLTC plan benchmark rate?

A5.) Yes.

Q6.) Is hospice residence room and board currently included in the MLTC plan member capitation?

A6.) No, the per diem room and board component of the hospice residence shall be authorized as a respite service under the definition of social and environmental supports.

Q7.) Do MLTC plans have a benchmark rate for room and board?

A7.) There is no discrete room and board rate. It is the MLTC plan´s responsibility to pay the nursing facility their contractual rate, inclusive of the room and board.

Q8.) What is the "hot line" number for providers to call if they have a question or problem regarding hospice and MLTC?

A8.) For questions or issues related to MLTC that cannot be resolved directly with the plan, the Department staffs a MLTC Technical Assistance Center (TAC). The TAC can be reached via phone or email at: 1-866-712-7197 or mltctac@health.ny.gov.

Q9.) Can a MLTC plan enrollee also on hospice transfer to another MLTC plan without dis-enrolling from hospice?

A9.) Yes, please see MLTC Policy 13.18(a).

Q10.) Are nursing home residents currently enrolled in hospice exempt from the mandate that they enroll in a MLTC plan?

A10.) Yes, pursuant to MLTC Policy 13.18, individuals currently receiving hospice that are not enrolled in a MLTC plan are not eligible to enroll in a MLTC plan. However, current MLTC enrollees who require hospice care may elect hospice services without dis- enrolling from the MLTC plan (see MLTC Policy 13.18(a) also).

Q11.) How can hospices be assured that there will not be barriers to terminally ill nursing facility residents being referred to hospice? There is concern that nursing facilities will fear they will not be reimbursed for room and board for hospice patients and, therefore, will be averse to making hospice referrals.

A11.) The MLTC plan pays the nursing home directly for room and board as it is within their MLTC scope of benefits as established by the Department.

Q12.) How will changes in NAMIs and rates be processed - by payor as a retroactive adjustment or will hospices have to file adjustment claims?

A12.) Collection of the NAMI, determined by the local department of social services, is the responsibility of the MLTC plan, unless designated via contract to the nursing facility.

Q13.) Will hospices have to revise their contracts with nursing homes?

A13.) Yes.

Q14.) Previously the nursing home received 95% of the facility´s rate plus the contractual arrangement between the hospice and the nursing home, i.e., add-on (covers hospice meds, hospice DME, hospice medical supplies). Is the hospice still responsible to pay the nursing home the add-on?

A14.) No - this is part of the nursing home rate and the MLTC plan is paying the nursing home directly.

Q15.) Hospices reimburse partner nursing homes 100% of the room and board rate. Federal regulations require 95% reimbursement. What will the pass-through amount from MLTC plans to the nursing home be?

A15.) There is no pass-through. The nursing home is reimbursed directly by the MLTC plan.