3.1 Statutory
Background
The National Defense Authorization
Act (NDAA) for Fiscal Year (FY) 1992-1993, Public Law 102-190, directed
TRICARE to provide hospice care in the manner and under the conditions
provided in section 1861(dd) of the Social Security Act (42 USC
1395x(dd)). This section of the Social Security Act sets forth coverage/benefit
guidelines, along with certification criteria for participation
in a hospice program. Since it was Congress’ specific intent to
establish a benefit identical to that of Medicare, the program has
adopted the provisions currently set out in Medicare’s hospice coverage/benefit guidelines,
reimbursement methodologies (including national hospice rates and
wage indices), and certification criteria for participation in the
hospice program (42 CFR 418, Hospice Care).
3.2 Scope of
Coverage
The hospice benefit is designed
to provide palliative care to individuals with prognoses of less than
six months to live if the terminal illness runs its normal course.
The benefit is based upon a patient and family-centered model where
the views of the patient and family or friends figure predominantly in
the care decisions. Since this type of care emphasizes supportive
services, such as pain control and home care, rather than cure-oriented
treatment, the hospice benefit is exempt from those limitations on
custodial care and personal comfort items currently in force under
the Basic Program. As a result, a beneficiary who elects to receive
care under a hospice program cannot receive other Basic Program services/benefits
(curative treatment related to the terminal illness unless the hospice
care has been formally revoked.
3.3 Reimbursement
3.3.1 National Medicare hospice
rates will be used for reimbursement of each of the following levels
of care provided by, or under arrangement with, a Medicare-approved
hospice program:
• Routine home care.
• Continuous home
care.
• Inpatient
respite care.
• General inpatient
care.
Note: Reimbursement
can be extended for routine and continuous hospice care provided
to beneficiaries residing in a nursing home facility, that is, physician,
nurse, social worker, and home health aide visits to patients requiring
palliative care for a terminal illness. The TRICARE Program will
not pay for the room and board charges of the nursing home.
3.3.2 The hospice
will be reimbursed for the amount applicable to the type and intensity
of the services furnished to the beneficiary on a particular day.
One rate will be paid for each level of care except for continuous
home care which will be reimbursed based on the number of hours
of continuous care furnished to the beneficiary on a given day.
The rates will be adjusted for regional differences by using appropriate
Medicare area wage indices.
3.3.3 The national payment rates
are designed to reimburse the hospice for the costs of all covered
services related to the treatment of the beneficiary’s terminal
illness, including the administrative and general supervisory activities
performed by physicians who are employees of, or working under arrangements
made with, the hospice. The only amounts which will be allowed outside the
locally adjusted national payment rates will be for direct patient
care services rendered by either an independent attending physician
or physician employed by, or under contract with, the hospice program.
3.3.3.1 A beneficiary
may receive a hospice consultation service from a physician who
is the director or employee of the hospice program if the beneficiary:
• Has
not yet elected the hospice benefit at the time of consultation.
• Has not been seen
by the physician on a previous occasion.
Such consult shall be paid at the appropriate
level and shall be equal or less in equivalent reimbursement for
a doctor office visit by a patient presenting a problem of “moderate
severity and requiring medical decision making of low complexity”
under the TRICARE Program physician fee schedule and will exclude
the practice expense component. The receipt and payment of such
service shall not count toward the hospice cap amount.
3.3.3.2 The hospice
will bill for its physician charges/services on a Centers for Medicare
and Medicaid Services (CMS) 1450 UB-04 using the appropriate Current
Procedural Terminology (CPT) codes. Payments for hospice-based physician
services will be paid at 100% of the CHAMPUS Maximum Allowable Charge
(CMAC) and will be subject to the hospice cap amount; i.e., it will
be figured into the total hospice payments made during the cap period.
3.3.4 Independent
attending physician services are not considered a part of the hospice
benefit and are not figured into the cap amount calculations. The
provider will bill for these services on a CMS 1500 Claim Form using
the appropriate CPT codes. These services will be subject to TRICARE reimbursement
and cost-sharing/deductible provisions.
3.4 Authorized
Providers
3.4.1 Social workers, hospice counselors, and home
health aides which are not otherwise authorized providers of care
under Basic Program may provide those services necessary for the palliation
or management of terminally ill patients electing hospice coverage.
These services are part of a package of services for which there
is single all-inclusive rate for each day of care.
3.4.2 Hospice
programs must be Medicare certified and meet all Medicare conditions
of participation (42 CFR 418) in relation to patients in order to
receive payment under the TRICARE program.
Note: The hospice program will be responsible for assuring
that the individuals rendering hospice services meet the qualification
standards specified in
Section 2. The contractor shall not be responsible for
certification of individuals employed by or contracted with a hospice
program.