Benefit Coverage

40 - Benefit Coverage (Rev. 188, Issued: 05-01-14; Effective: 08-04-14; Implementation: 08-04-14) To be covered, hospice services must meet all of the following requirements: • They must be reasonable and necessary for the palliation and management of the terminal illness as well as related conditions; and • The individual must elect hospice care in accordance with sections 20.2 – 20.4 of this chapter; and • A plan of care must be established and periodically reviewed by the attending physician, the medical director, and the interdisciplinary group of the hospice program; and • That plan of care must be established before hospice care is provided; and • The services provided must be consistent with the plan of care; and • A certification that the individual is terminally ill must be completed as set forth in section 20.1 of this chapter. A nurse practitioner serving as an attending physician should participate as a member of the IDG that establishes and/or or updates the individual’s plan of care. The nurse practitioner may not serve as or replace the medical director or physician designee. All services provided by the hospice must be in accordance with a patient’s individualized plan of care that is established and updated by the hospice interdisciplinary group, in consultation with the patient’s attending physician (if any). The individualized plan of care is a continually evolving document. As such, Medicare expects the plan of care to be initiated based upon the information gathered in the patient’s initial assessment, and the plan of care will be expanded upon, as appropriate, based on the information that is gathered during the comprehensive assessment. Provided the above coverage criteria are met, hospices are paid a per diem rate based on the number of days and level of care provided during the election period. Levels of care are defined as: • Routine home care (refer to §40.2.1); A routine home care day is a day on which an individual who has elected to receive hospice care is at home and is not receiving continuous home care. • Continuous home care (refer to §40.2.1); A continuous home care day is a day on which an individual who has elected to receive hospice care is not in an inpatient facility (hospital, SNF, or hospice inpatient unit) and receives hospice care consisting predominantly of nursing care on a continuous basis at home. Hospice aide or homemaker services or both may also be provided on a continuous basis. Continuous home care is only furnished during brief periods of crisis and only as necessary to maintain the terminally ill patient at home. • Inpatient respite care (refer to §40.1.5 and §40.2.2); An inpatient respite care day is a day on which the individual who has elected hospice care receives care in an approved facility on a short-term basis for respite. • General inpatient care (refer to §40.1.5); A general inpatient care day is a day on which an individual who has elected hospice care receives general inpatient care in an inpatient facility for pain control or acute or chronic symptom management which cannot be managed in other settings. Hospices are expected to furnish the following services to the extent specified by the plan of care for the individual. The categories listed above are used in billing to describe the acuity of the services furnished. See Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, “Processing Hospice Claims,” for a description of billing procedures.