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.