MLTC Hospice Guidance Sets Forth New Procedures to Prevent Duplicate Billing

New Department of Health (DOH) guidance for managed long term care (MLTC) plans establishes procedures aimed at preventing duplication of services and billing between hospice programs and MLTC plans. The new guidance, distributed on June 23, 2023, notifies MLTC plans and providers of a new Recipient Restriction/Exception (RR/E) code – C2-Hospice-MM – to identify Medicaid beneficiaries who have elected to receive hospice services. It also requires MLTC plans to incorporate the DOH Form 5778 into care plans in order to coordinate services and financial obligations with the hospice provider.

For dually eligible beneficiaries who elect hospice, the new RR/E code will be automatically reflected in Electronic Provider Assisted Claim Entry System (ePACES) eligibility responses and in the 834 file. For non-dual Medicaid beneficiaries who elect hospice, the guidance includes a process and form for requesting insertion of the code.

The guidance also specifies that MLTC plans are responsible for coordinating services and financial obligations with the hospice provider when an MLTC member elects hospice, particularly for personal care/consumer directed personal assistance services (CDPAS) and durable medical equipment and supplies. Under DOH guidance for hospice programs (DHCBS 22-15), hospice providers must complete the DOH-5778 – Entity/Facility Notification of Hospice Non-Covered Items, Services, and Drugs – and share it with other health care providers, local departments of social services, and managed care organizations. MLTC plans must obtain the DOH-5778 from the hospice provider and document its receipt, incorporate the DOH-5778 into their records for appropriate care planning to ensure that there are no overlaps in services, and document in progress/case notes the reason a service is provided outside of the hospice benefit (e.g., diagnoses, medical conditions not related to the recipient's terminal illness).

The guidance reiterates that Medicaid fee-for-service beneficiaries who are in receipt of hospice services are excluded from subsequently enrolling in Medicaid managed care, as are Program of All-Inclusive Care for the Elderly (PACE) members. Medicaid beneficiaries enrolled in managed care products other than PACE may elect hospice and remain in their managed care plans.

Questions related to this guidance document may be submitted to DOH here.

Contact: Karen Lipson, klipson@leadingageny.org