3.0 POLICY
3.1 Beneficiaries
who are terminally ill (that is, life expectancy of six months or
less if the terminal illness runs its normal course) will be eligible
for the following services and supplies in addition to regular TRICARE
Program benefits:
3.1.1 Hospice consultation service. A beneficiary
may receive a hospice consultation service from a physician who
is also the medical director or employee of a hospice program if
the beneficiary:
• Has not yet elected
hospice coverage.
• Has not been seen
by the physician on a previous occasion.
3.1.2 The provision
of the consult service shall not count towards the hospice cap amount.
3.2 Beneficiaries
who are terminally ill (that is, life expectancy of six months or
less if the terminal illness runs its normal course) will be eligible
for the following services and supplies in lieu of other TRICARE
benefits:
3.2.1 Physician services furnished by hospice employees
or under arrangements with the hospice.
Note: Patient care services rendered by an attending
physician who is not considered employed by, or under contract with,
the hospice are not considered hospice services and are not included
in the amount subject to the hospice payment limits as described
in
Section 4, paragraphs 3.1.6 and
3.1.7. The attending physician will bill in
his/her own right and be subject to the appropriate allowable charge methodology
(refer to
Section 4, paragraph 3.1.4).
3.2.2 Nursing
care provided by or under the supervision of a Registered Nurse
(RN).
• The
RN must maintain overall nursing management of the patient (e.g.,
review and evaluation of nursing notes).
• The actual hands-on
care may be provided by a Licensed Practical Nurse (LPN) without the
RN being physically present.
3.2.3 Medical
social services provided by a social worker who has at least a bachelor’s
degree from a school accredited or approved by the Council on Social
Work Education, and who is working under the direction of a physician.
3.2.4 Counseling
services provided to the terminally ill individual and the family
members or other persons caring for the individual at home.
3.2.4.1 Counseling
services, including dietary counseling, are provided for the purpose
of training the terminally ill patient’s family or other caregiver
to provide care and to help the patient and those caring for him
or her to adjust to the individual’s approaching death.
3.2.4.2 Bereavement
counseling/therapy, which consists of counseling services provided
to the individual’s family after the individual’s death, is required
as part of the overall hospice benefit.
• There must be an organized
program for the provision of bereavement services under the supervision
of a qualified professional.
• The plan of care for
these services should reflect family needs, as well as a clear delineation
of services to be provided and the frequency of service delivery
up to one year following the death of the patient.
Note: Although bereavement therapy is an integral part
of the hospice concept (i.e., a family-centered, model emphasizing
supportive services) and must be made available to the family as
a condition for participation it is not reimbursable.
3.2.5 Short-term
inpatient care, both respite and general, may be provided in Medicare participating
hospice inpatient units, hospitals, or skilled nursing facilities.
3.2.5.1 Inpatient
Respite Care.
3.2.5.1.1 Inpatient respite care is provided when necessary
to relieve family members or other persons caring for the individual
at home.
3.2.5.1.2 Respite care may be provided only on an occasional
basis and is limited to no more than five consecutive days at a
time.
3.2.5.1.3 The necessity and frequency of respite care
will be determined by the hospice interdisciplinary group with input
from the patient’s attending physician and the hospice’s medical director.
3.2.5.1.4 Respite
care is also subject to post-payment medical review by the contractor.
3.2.5.1.5 Inpatient
respite care is the only type of hospice care that can be provided
in the Medicaid (Title XIX) certified nursing facility.
3.2.5.2 General
Inpatient Care.
3.2.5.2.1 Services must conform to the written plan of
care.
3.2.5.2.2 Care is required for procedures necessary for
pain control or acute or chronic symptom management which cannot
be provided in a home setting.
3.2.6 Medical
supplies, including drugs and biologicals.
3.2.6.1 Drugs must
be used primarily for the relief of pain and symptom control related
to the individual’s terminal illness in order to be covered under
the hospice program.
3.2.6.2 Medical
supplies include those that are part of the written plan of care.
3.2.7 Durable
Equipment (DE) and Durable Medical Equipment (DME), as well as other
self-help and personal comfort items related to the palliation or
management of the patient’s terminal illness and provided for use
in the patient’s home.
3.2.8 Home
health aide services furnished by qualified aides, and homemaker
services.
3.2.8.1 Coverage.
3.2.8.1.1 Personal
care services.
3.2.8.1.2 Household
services to maintain a safe and sanitary environment in areas of
the home used by the patient; e.g., changing of beds, light house
cleaning and/or laundering.
3.2.8.2 Supervision.
3.2.8.2.1 The aide
services must be provided under the general supervision of the RN.
However, the RN does not have to be physically present while aide
services are being rendered.
3.2.8.2.2 Home health
aide services must be documented in the nursing notes as well as
the treatment plan.
3.2.8.2.3 A RN must
visit the home site at least every two weeks when aide services
are being provided, and the visit must include an assessment of
the aide services.
3.2.8.2.4 The contractor
shall assess/evaluate overall RN supervision through the post-payment medical
review process.
Note: The contractors shall be looking
for utilization trends on random samples of claims. A pattern of
failure to adequately meet the supervisory requirements for home
health aide services (refer to
paragraph 3.2.8) will result in denial or
reclassification of the particular rate category.
3.2.9 Physical
therapy, occupational therapy and speech-language pathology services
for the purposes of symptom control or to enable the individual
to maintain activities of daily living and basic functional skills.
3.3 The hospice
must ensure that substantially all the following core services are
routinely provided directly by hospice employees or provided under
an “Authorized use of Arrangements”. “Authorized use of Arrangements”
are when the primary hospice enters into a contract arrangement with
another hospice to provide core services under extraordinary, exigent
or other non-routine (i.e., high patient load, staffing shortages
due to illness) circumstances. The primary hospice may bill the TRICARE
program. However, TRICARE payments for core services remain limited
to and reimbursed at one of the four nationally predetermined Medicare
rates. Core services consist of:
• Physician services;
• Nursing care;
• Medical social
services; and
• Counseling service
for individuals and care givers.
Note: Counseling services may be provided by a member
of the interdisciplinary group (doctor of medicine or osteopathy,
RN, social worker, and pastoral or other counselor) as well as by
other qualified professionals as determined by the hospice.
3.4 Although
the following non-core services may be provided under arrangement
with other agencies or organizations, the hospice must maintain
professional management of the patient at all times and in all settings:
• Home
health aide services;
• Medical appliances
and supplies;
• Physical and occupational
therapy;
• Speech-language
pathology;
• Short-term
inpatient care; and
• Ambulance services.
Note: If contracting is used, the hospice must maintain
professional financial, and administrative responsibility for the
services and must assure that the qualifications of staff and services
provided meet the requirements specified in this policy. The requirements
that a hospice make physical therapy, occupational therapy, speech
language pathology services, and dietary counseling available on
a 24-hour basis may be waived if granted by the Centers for Medicare
and Medicaid Services (CMS). These waivers are available only to
an agency or organization that is located in an area which is not
an urbanized area and can demonstrate that it has been unable, despite
diligent efforts, to recruit appropriate personnel.
Note: Physical therapy, occupational therapy and speech-language
pathology services are included as part of the treatment plan of
the interdisciplinary group (a member of which is a doctor of medicine
or osteopathy). Medical review of these services will occur as part
of the post-payment medical review process.
3.5 The hospice
must make nursing services, physician services, and drugs and biologicals routinely
available on a 24-hour basis. All other covered services must be
available on a 24-hour basis to the extent necessary to meet the
needs of individuals that are reasonable and necessary for the palliation
and management of the terminal illness and related condition.
3.6 Hospice
services must be provided in a manner consistent with accepted standards
of practice.
3.7 Twenty-four (24) hour nursing and home health
aide services may be provided only during periods of crisis and
then only as necessary to maintain the terminally ill individual
at home.
Note: A period of crisis is defined as
the time a patient requires continuous care to achieve palliation
or management of acute medical symptoms.
3.8 The hospice
benefit is exempt from those limitations on custodial care and personal
comfort items applicable to the Basic Program.
3.9 All services,
medical appliances, and supplies associated with the palliative
care of the terminal patient are included within the hospice rate
with the exception of hands-on physician services (both hospice
based and independent attending physicians).
3.9.1 The hospice will be responsible
for providing medical appliances -- which includes covered DE (e.g.,
DME, hospital bed, wheelchair, etc.) as well as other self-help
and personal comfort items related to the palliation or management
of the patient’s terminal illness -- for use in the patient’s home while
he or she is under hospice care. The use of this equipment is included
in the daily hospice rate.
3.9.2 Parental and enteral nutrition
therapies would be covered under the daily hospice rate if determined
to be essential for the palliative care of the terminal
patient; however, these types of therapies will be relatively rare
in a hospice setting since they are considered life sustaining treatment modalities.
3.10 Any other
item or service which is specified in the treatment plan and for
which payment may otherwise be made is a covered service under the
hospice benefit.
Example: A hospice determines that
a patient’s condition has worsened and has become medically unstable.
An inpatient stay will be necessary for proper palliation and management
of the condition. The hospice adds this inpatient stay to the treatment plan
of care and decides that, due to the patient’s fragile condition,
the patient will need to be transported to the hospital by ambulance.
In this case, the ambulance service becomes a covered hospice service.
3.11 If a hospice
furnishes, at the request of a beneficiary, items or services in
addition to those that are covered under the hospice benefit, the
hospice may charge the beneficiary for these items or services.