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 .
The attending physician will bill in his or her own right and be subject
to the appropriate allowable charge methodology (refer to
Section 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.
3.2.8.2.5 The contractor 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 (PT), occupational
therapy (OT), and speech-language pathology (SLP) services for the purposes
of symptom control or to enable the individual to maintain activities
of daily living (ADL) 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 (e.g., 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;
• PT and OT;
• SLP;
• 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 TP, OT, SLP 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: PT, OT,
and SLP 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) 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.