MLTC Policy 13.18(b)

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 13.18(b): MLTC Guidance on Hospice Coverage Update

Date of Issuance: December 31, 2015


The purpose of this policy is to clarify for Managed Long Term Care (MLTC) plans coverage of, and billing for, hospice services provided to existing MLTC enrollees who are residents in either a skilled nursing facility or a hospice residence.

Any MLTC enrollee who requires hospice services and meets hospice eligibility requirements may elect the benefit without disenrolling from their MLTC plan. For MLTC enrollees (Partial Capitation MLTC and Medicaid Advantage Plus), hospice services (with the exception of daily room and board charges) are not included in the plan benefit and are billable directly to Medicare and Medicaid as appropriate.

MLTC enrollees who are residents of a skilled nursing facility (SNF) and subsequently elect hospice services while in the facility will remain enrolled in the MLTC plan. The MLTC plan is responsible for the room and board portion of the SNF stay, and will reimburse the facility in accordance with the MLTC - SNF provider contract. The SNF will receive additional reimbursement as indicated directly from the applicable hospice provider.

MLTC enrollees who may elect to receive hospice services in a hospice residence licensed under Article 40 will also remain enrolled in the MLTC plan. There are currently 11 such licensed hospice residences in New York State. 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.

MLTC plans should coordinate with hospices to provide the necessary care to enrollees and support the enrollee´s needs. Individuals already enrolled in hospice remain excluded from enrolling into MLTC plans. MLTC enrollees in receipt of hospice services are not prohibited from transferring to another MLTC plan.

Pursuant to federal PACE regulations found at 42 CFR Part 460.154(i), PACE enrollees who elect enrollment in the hospice benefit are considered to be voluntarily disenrolled from PACE.