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.