September 20, 2021

Volume XI, Number 263

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September 17, 2021

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Skilled Nursing Facilities No Longer Permitted to Bill for Room and Board for Residents Receiving Hospice Care

Beginning July 1, 2019, the Ohio Department of Medicaid (ODM) is requiring all Ohio managed care plans to make room and board payments directly to hospice providers when hospice services are provided to individuals residing at skilled nursing facilities (SNF). Molina, UHC Community Plan, Aetna Better Health, and Buckeye Health Plan have confirmed the ODM requirement and have announced they will only accept billing for room and board services from hospice providers when hospice services are provided to residents at skilled nursing facilities.[1] The ODM mandate is based on federal regulations concerning provider payments. Room and board payments must go to the hospice provider in these cases because the hospice provider is considered the “provider of record,”[2] and provider payments cannot be reassigned.[3] SNFs should review their contracts with hospice providers regarding the assignment of payment to make sure they are compliant with regulations.

Although these federal regulations require room and board payments to be made to the hospice providers, SNFs would traditionally bill the state Medicaid program for nursing home care, including room and board services.[4] The payments would then be remitted by Medicaid to the hospice provider per federal law, which would in turn pay the SNF for room and board.[5] The new billing requirements more closely align the room and board billing process with the federal regulations.

In a notice for the new billing requirement, Aetna Better Health provided guidelines for hospice providers and skilled nursing facilities. SNFs should continue to bill for room and board for residents in hospice for dates of service through June 30, 2019, but should no longer bill for room and board for residents in hospice for dates of service on or after July 1, 2019. For more information on Aetna’s specific billing requirements, please click here.

UHC Community Plan has provided clarification regarding its implementation of the requirement, including that the Plan will require prior authorization for hospice room and board for out of network providers, as well as a single case agreement. However, UHC will not accept prior authorization requests until July 1, 2019. For more information on UHC Community Plan’s specific billing requirements for room and board, please click here

While Molina has not released its specific billing requirements for hospice room and board services, it has clarified it is accepting contracts from hospices and billing requirements will be consistent with CMS.

We recommend hospice providers perform a Medicaid eligibility check on all inpatient residents on July 1 to ensure all patients with room and board components are identified and authorizations, if required, can be requested without penalty or delay. 


[1] See https://www.ohca.org/docs/hch_bites_may_31_2019

[2] 42 U.S.C. 1396d

[3] 42 C.F.R. 447.10

[4] National Hospice & Palliative Care Organization (NHPCO), Medicaid and Hospice Care Issue Brief, October 2011. 

[5] Id.

© 2021 Dinsmore & Shohl LLP. All rights reserved.National Law Review, Volume IX, Number 179
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About this Author

Thomas Hess, health care industry attorney, Dinsmore Shohl, law firm
Partner

Annually appearing on The Best Lawyers in America list, as well as the Ohio Super Lawyers list, Tom has over 30 years of experience representing health care providers before state, federal and administrative courts across the country. He is the Practice Group Leader for the Government Relations and Health Law Practice Groups.

Leveraging extensive experience with a thorough understanding of the issues facing the health care industry, Tom takes a practical, yet aggressive approach to help clients meet their needs while also...

614-227-4260
Sydney Pahren, Dinsmore Law Firm, Columbus, Corporate Law Attorney
Associate

Sydney is a member of Dinsmore’s Corporate Department, where she focuses her practice on health care law. 

She has experience researching legal issues in health care, litigation, labor & employment and corporate law. She is a graduate of The Ohio State University Moritz College of Law where she was an articles editor on the Ohio State Law Journal and an executive board member of the Black Law Students Association. 

614-628-6971
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