New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 53A - HOSPICE SERVICES MANUAL › Subchapter 4 - BASIS OF PAYMENT › Section 10:53A-4.1 - Post-eligibility treatment of income

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For a hospice beneficiary residing at home, who is eligible only for hospice services, the policy for handling the post-eligibility treatment of income is the same as that of the Division's home and community-based waivers, for example ACCAP. For these beneficiaries, there is no available income to be applied to the cost of care because the maintenance standard in the home and community based waiver programs has been determined to be equal to the income eligibility standards for Title XIX approved facilities (see N.J.A.C. 10:71-5 ).
(b) For a beneficiary who is residing in a nursing facility and receiving hospice under Medicaid/NJ FamilyCare FFS, payment to the hospice for room and board services shall be reduced by the beneficiary's available income. Available income is that amount, which remains after deducting certain amounts from the beneficiary's gross income, as determined in accordance with N.J.A.C. 10:71.
1. Instructions for the use of the Statement of Available Income for Medicaid Payment PR-1 Form #10 in the Appendix, incorporated herein by reference, are as follows:
i. The hospice is responsible for ensuring that the amount of the beneficiary's available income is reported and that the amount corresponds to that attributed to the beneficiary's account on the Statement of Available Income for Medicaid Payment PR-1. The hospice shall be liable to the Division for any available income not reported to the fiscal agent by the hospice. A PR-1 table, that is maintained by the fiscal agent, will be referenced during claims processing to determine the PR-1 amount to be deducted from the hospice claims during claims processing.
ii. The Statement of Available Income for Medicaid Payment PR-1 is completed by the CWA on each non-SSI Medicaid/NJ FamilyCare FFS beneficiary that receives hospice services, who is a hospice beneficiary residing in the NF.
(1) The PR-1 form reflects the beneficiary's available income that remains after deducting certain amounts for the maintenance of a community spouse, the maintenance of other dependent relatives, health insurance premiums, and the personal needs allowance (PNA). A PR-1 form must be attached to a copy of the CMS 1500 claim, and be kept in the beneficiary's billing record when requesting payment from Medicaid/NJ FamilyCare FFS for the cost of hospice care, as specified in (b)1ii(2) through (5) below.
(2) The hospice is responsible for maintaining a personal needs allowance (PNA) account and making these monies available for use by the beneficiary.
(3) The PR-1 form shall be obtained by the hospice from the NF for each beneficiary of hospice services who has been on the Long Term Care Facility billing system. The hospice shall negotiate the change in the collection of this income with the nursing facility, if applicable, or collect it from the beneficiary and/or family.
(4) For the hospice applicant who has not previously been on the Long Term Care Facility billing system as an NF patient, the CBOSS shall generate the PR-1 form for the use of the hospice.
(5) For individuals with no income, or income below $ 60.00 per month, who continue to qualify for Supplemental Security Income (SSI) payments and Medicaid, no PR-1 form is required upon admission to hospice care status.
(A) For these hospice beneficiaries, confirmation of the SSI status should be obtained from the MACC and documented in the hospice billing record.
(B) When submitting the CMS 1500 claim, the hospice shall note in the beneficiary's billing record and state in the "REMARKS" area of the claim, the wording "SSI Eligible."