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.