3.0 policy
3.1 Statutory
Background
Section 704 of the National Defense
Authorization Act (NDAA) for Fiscal Year (FY) 2018 authorizes the
Defense Health Agency (DHA) to provide concurrent curative Basic
Program benefits to beneficiaries under the age of 21 for the same
condition for which they are enrolled in the TRICARE hospice benefit.
This allows continued coverage of medically necessary curative treatment,
even after election of the hospice benefit by or on behalf of beneficiaries
under the age of 21. Medical necessity and appropriateness of care
shall remain the criteria for coverage of curative services while
elected hospice services shall provide the palliative services and
support to help children and their families live as normally as
possible, addressing physical, emotional, social, and spiritual
aspects of suffering. Overall, an organized system of holistic care
will improve the quality of life for children with terminal illnesses.
3.2 Scope
Of Coverage
3.2.1 Beneficiaries
under the age of 21 who have a diagnosis of a terminal illness with
a life expectancy of six months or less if the terminal illness
runs its normal course are eligible for medically necessary curative
treatment (i.e., treatment covered under the TRICARE Basic Program)
related to the illness in addition to palliative care provided under
the hospice benefit. Once a beneficiary turns age 21, they are no
longer eligible for concurrent care.
3.2.2 Coverage of curative treatment
related to the terminal illness extends to treatment provided by
individual health care professionals and other non-institutional/non-professional providers,
as well as institutional providers (both inpatient and outpatient
settings). Authorized providers include only the categories of providers
detailed in
Section 2 and providers who are authorized
providers of care under the TRICARE Basic Program.
3.2.3 All conditions for coverage
detailed in
Section 2 also apply.
3.3 Preauthorization
Requirement
Preauthorization is required
for the coverage and reimbursement of concurrent care provided to
beneficiaries under the age of 21 in order to ensure collaboration
between the hospice and referring outside providers. The preauthorization
of concurrent care is especially relevant given the enhanced case
management responsibilities of the contractor for ensuring collaboration
between the hospice and other providers and suppliers rendering
curative services. The preauthorization process shall also verify
the following beneficiary eligibility criteria for concurrent care:
3.3.1 Beneficiary Eligibility Criteria
3.3.1.1 The beneficiary
is under the age of 21 and has a diagnosis of a terminal illness
with a life expectancy of six months or less if the terminal illness
runs its normal course.
3.3.1.2 The referring
healthcare provider has identified the eligible beneficiary for
referral to the participating hospice.
3.3.1.3 A signed
and dated certification/attestation of the terminal illness has
been obtained from the referring provider and hospice medical director.
3.3.1.4 The beneficiary
has met the hospice eligibility and admission criteria.
3.3.1.5 The contractor
shall issue an authorization or denial letter to the referring healthcare provider,
hospice, and beneficiary once a determination has been made as a
result of the preauthorization review process.
3.3.1.6 The contractor
shall manage and resolve all inquiries related to the preauthorization
review process and the resulting final determination.
3.4 Conditions For Coverage
The pre-election process, election process,
and other conditions for coverage shall follow the same requirements
and procedures listed in
Section 3, with
the following exceptions:
3.4.1 TRICARE Basic Program services (i.e., those
services which are normally considered curative in nature) related
to the treatment of the terminal illness for which hospice care
was elected and provided during the hospice election shall be billed
to the contractor for non-hospice reimbursement. This reimbursement
is in addition to the non-hospice reimbursement currently available
for direct patient care services rendered by either an independent
attending physician or physician employed by or under contract with
a hospice and for treatment of non-related conditions.
3.4.2 Coverage of Basic Program
services for beneficiaries under the age of 21 shall no longer require
election revocation. Reimbursement of these Basic Program services
shall not be subject to the hospice payment limits as prescribed
in
Section 4, paragraph 3.1.6 and
3.1.7.
3.4.3 If the curative care is successful
and a physician determines the beneficiary no longer has a life
expectancy of six months or less if the terminal illness runs its
normal course, and the beneficiary revokes the hospice election,
but the beneficiary’s disease later returns or the beneficiary is
diagnosed with a new condition that reduces the beneficiary’s life
expectancy to six months or less, then the beneficiary is exempt
from the limitation on episodes of care detailed in
Section 3, and
is eligible for two additional 90-day episodes of care, followed
by an unlimited number of 60-day periods.
3.5 Treatment Plan
3.5.1 A consolidated treatment plan
shall be required for beneficiaries under the age of 21 who are
also receiving concurrent care, requiring coordination and case
management services both within the hospice and between the hospice
and other providers and suppliers rendering curative services with
the goal of achieving better patient-centered outcomes and supporting
shared decision-making. The treatment plan for beneficiaries receiving
concurrent hospice services and curative care shall include the
requirements in
Section 3, paragraph 3.4.
3.5.2 The hospice is expected to
conduct ongoing communication and education with the patient and
their family regarding coordination of treatment plans and treatment
options as prescribed by those providers and suppliers rendering
curative services.
3.5.3 The hospice care coordinator
shall be responsible for performing care coordination and case management
with the referring providers outside the hospice. The contractor
shall require the beneficiary’s care to be tracked using a monthly
service and activity log which includes, at a minimum, the following:
• Primary
diagnosis and co-morbidities;
• Services provided,
both palliative and curative;
• Staff categories
providing the services; and
• Number and length
of visits pertaining to both palliative and curative services.
3.6 Medical Review Process
3.6.1 Concurrent care for beneficiaries
under the age of 21 shall require enhanced case management and medical
review by the contractor to ensure collaboration between the hospice
and other providers and suppliers rendering the curative treatment
(i.e., Basic Program services provided in addition to the palliative
services rendered during the hospice election). This shall involve
monitoring and evaluation of the following key functional elements
used in carrying out care coordination and shared decision-making
between the hospice and other providers and suppliers:
• Letters
of engagement from those providers/suppliers with whom the hospice
has an established relationship (either a formal legal relationship,
or an established informal relationship).
• Designated staff members
responsible for interactions and communication between the hospice
and outside providers/suppliers;
• Policies, procedures,
or other mechanisms used to coordinate services and to collaborate with
physicians and other healthcare providers;
• Mechanisms in place
to resolve conflicts in care coordination and case management between
providers (e.g., in situations when there are inconsistencies or
overlapping of hospice and Basic Program services);
• Mechanisms in place
which ensure that clinically appropriate services are available, regardless
of the location where the hospice care is provided during the hospice
election period; and
• Internal controls
to ensure that duplicate claims are rejected.
3.6.2 The contractor shall have
overall responsibility of case management under concurrent care requiring
medical review and evaluation of a consolidated treatment plan along
with a monthly service and activity log to ensure consistency and
appropriateness of hospice and Basic Program services. Medical necessity
and appropriateness of care shall remain the criteria for coverage
of Basic Program services while elected hospice services shall provide
the palliative services/support to help children and their families
live as normally as possible, addressing physical, emotional, social,
and spiritual aspects of suffering. The contractor shall identify
and deny claims for any duplicative services during the post-payment
medical review process (i.e., where there is a duplication or overlapping
of services between the hospice and curative providers).
3.6.3 Contractor case management
shall also facilitate identification of duplicative services (i.e., where
the same services are provided by both the hospice and referring
healthcare provider or other TRICARE-authorized providers) through
the review of consolidated Plans of Care (POCs), monthly service
and activity logs, and claims data. Contractors shall ensure that
duplicate claims are rejected.
3.6.4 The contractor’s case management
process shall also facilitate how the treatment of relative services
are categorized and billed under the TRICARE program (i.e., whether
they are considered curative or palliative in nature). The process
for this evaluation shall reflect an understanding that each beneficiary’s
circumstance is unique and that decisions about what is curative reflects
each beneficiary’s individual needs. As a result, determinations
of what constitutes curative services for a beneficiary shall be
made on a case-by-case basis.
Example: If
a blood transfusion was performed as a curative treatment for the
condition, then the Basic Program would be responsible for the expense.
If, on the other hand, it was for pain and symptom control, then
the hospice provider would absorb the expense. A review of either
the physician’s orders or the consolidated POC may assist the hospice provider
and contractor in determining the purpose of the service or treatment.
The contractor would reimburse the authorizing provider for the
curative services, but would continue to reimburse hospice providers
for hospice services.
3.6.5 The contractor shall be responsible for the
establishment of procedural protocols with the hospice and providers/suppliers
rendering concurrent care for submission and review of consolidated treatment
plans and monthly service and activity logs in order to assess and
manage the beneficiary’s ongoing care.
3.6.6 The contractor shall conduct
random audits of the beneficiary’s medical records to compare the
consolidated POC to the monthly service and activity log to ensure
that the services provided reasonably match the POC.
3.7 Referring Provider And Hospice
Requirements
3.7.1 The referring
healthcare provider shall identify the eligible beneficiary for
referral to the participating hospice and attest that the beneficiary
meets the eligibility criteria.
3.7.2 Once a beneficiary’s eligibility
is established, the hospice shall conduct a comprehensive assessment
that follows the hospice conditions of participation (CoPs).
3.7.3 A consolidated POC requiring
coordination and case management, both within the hospice and between
the hospice and other providers and suppliers rendering the curative
treatment, shall be completed within three days of referral by the
referring provider. The consolidated POC shall be reviewed, revised,
and documented at least every 15 calendar days as required by the
hospice CoPs. The consolidated POC shall provide a detailed breakdown
of hospice and curative services.
3.7.4 The hospice shall have formal
policies and procedures in place for care coordination, case management,
and shared decision-making with referring physicians and other healthcare
providers having admitting and/or ordering privileges.
3.7.5 The participating hospice
shall have designated staff members responsible for interaction and
communication between the hospice and outside providers and suppliers.
3.7.6 The hospice shall perform
ongoing communication and education with the beneficiaries and their
families regarding coordination of treatment plans and treatment
options as prescribed by those providers and suppliers rendering
the curative treatment.
3.7.7 The hospice care coordinator shall have overall
responsibility for ensuring and monitoring care coordination and
case management with outside providers/suppliers. The hospice care coordinator,
along with appropriate interdisciplinary team members, shall meet
on a weekly basis (either telephonically or in person) with their
curative provider counterparts to review and revise, if necessary,
the beneficiary’s consolidated POC. The beneficiary’s care shall
be tracked using a monthly service and activity log as discussed
in
paragraph 3.5.3.
3.7.8 The hospice shall submit consolidated
treatment plans and service/activity logs to the contractor on a
monthly basis, along with any additionally requested medical documentation.
This shall ensure that the actual services performed reasonably
match the consolidated POC.
4.0 Reimbursement
Reimbursement for services under this section
shall follow the same methodology, requirements, and procedures
detailed in
Section 4, with the following exceptions:
4.1 Continued coverage and reimbursement
of medically necessary curative treatment is available to beneficiaries
under the age of 21 who have elected coverage under the TRICARE
Hospice Benefit (THB). This reimbursement shall be extended for
medically necessary curative treatment provided by individual health
care professionals and other non-institutional/non-professional
providers, as well as institutional providers (both inpatient and
outpatient settings).
4.2 Payment for the curative treatment shall be
subject to the standard Basic Program reimbursement methodologies
in place for the specific provider category and setting rendering
the care (e.g., CHAMPUS Maximum Allowable Charges (CMACs) for professional
services and Diagnostic Related Groups (DRGs) for institutional
care).
4.3 All payments
for curative treatment shall be subject to established cost-sharing
and deductible provisions.
4.4 Reimbursement of these Basic Program services
shall not be subject to the hospice payment and inpatient limits
as prescribed in
Section 4, paragraph 3.1.6 and
3.1.7.
4.5 The hospice shall notify the
contractor of all outside providers rendering curative treatment
as part of the consolidated treatment plan and monthly service and
activity log. This shall allow for the appropriate reimbursement
of curative treatment for beneficiaries under the age of 21 electing
hospice care. The contractors’ enhanced case management and review
process shall ensure the proper integration of curative and palliative
services, thus improving the quality of life for children with complex
life-threatening conditions. It shall also prevent the reimbursement
of duplicative services.