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.