General Provisions and Definitions

General Provisions and Definitions A. Admission to hospice and subsequent election periods must be prior authorized through a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or designated entity. B. The hospice provider must provide all required services to meet the needs of the beneficiary related to the terminal illness and related conditions. C. The Division of Medicaid covers medically necessary hospice services for beneficiaries when the following criteria are met: 1. A written certification specifying the beneficiary's medical prognosis is for a life expectancy of six (6) months or less if the terminal illness runs its normal course and the written certification is in accordance with 42 C.F.R. § 418.22 and the Mississippi State Department of Health (MSDH) Minimum Standards of Operation for Hospice, 2. A beneficiary or a beneficiary's guardian/legal representative has elected hospice care services for the palliation and management of a beneficiary's terminal illness and related conditions, 3. Services are reasonable and necessary for the palliation and management of a beneficiary's terminal illness and related conditions, 4. A plan of care (POC) is established, prior to hospice care services beginning, which requires periodic review by the attending physician, if any, the medical director, and the interdisciplinary group of the hospice program, and 5. The hospice care services are consistent with the beneficiary's established plan of care. D. Hospice services are only covered for palliative management of a terminal illness except for Early and Periodic Screening, Diagnosis and Treatment (EPSDT)-eligible beneficiaries. E. The hospice provider must develop and maintain a system of communication and integration. Therefore, the hospice’s own policies and procedures must: 1. Ensure that the interdisciplinary team/interdisciplinary group (IDT/IDG) maintains responsibility for directing, coordinating, and supervising the care and services provided. 2. Ensure that the care and services are provided in accordance with the POC. 3. Ensure that the care and services provided are based on all assessments of the beneficiary and family needs. 4. Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. 5. Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. F. Persons enrolled in Home and Community-Based Services (HCBS) waivers who elect to receive hospice care may not receive HCBS waiver services which are duplicative of any services rendered through hospice. Persons may receive non-duplicative HCBS waiver services in coordination with hospice services. G. The Division of Medicaid holds the hospice provider liable for the following circumstances including, but not limited to: 1. Duplicative hospice and/or HCBS waiver services, and/or 2. Failure to fully utilize hospice benefits and palliative services related to the person’s terminal illness and related conditions prior to utilizing HCBS waiver services. H. The Division of Medicaid defines: 1. Terminal illness as an illness/condition with a prognosis of life expectancy of six (6) months or less, if the illness/condition follows its normal course. 2. Hospice as a public agency or private organization or subdivision of either of these that is primarily engaged in providing hospice care to terminally ill beneficiaries and meets Medicare Conditions of Participation for hospices and has a valid Medicaid provider agreement. 3. Hospice care as a comprehensive set of services, described in section 1861(dd)(1) of the Social Security Act, identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill beneficiary and/or family members as delineated in a specific plan of care for the beneficiary. 4. Palliative care as beneficiary and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate beneficiary autonomy, access to information, and choice. 5. Hospice physician as a doctor of medicine or osteopathy who is legally authorized to practice medicine in the state of Mississippi and designated by the hospice to provide care to hospice beneficiaries in coordination with the beneficiary' s attending physician, if the beneficiary has an attending physician. 6. Attending physician as a doctor of medicine or osteopathy who is legally authorized to practice medicine in the state of Mississippi or a nurse practitioner who meets training, education, and experience requirements as described in 42 C.F.R. § 410.75 and in accordance with the Mississippi Nurse Practice Act. The attending physician is identified by the beneficiary, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the beneficiary's medical care. 7. False claims as a term used when a person knowingly makes an untrue statement or claim to gain a benefit or reward. 8. Election statement as a written statement electing hospice care filed by a beneficiary or the beneficiary's guardian/legal representative with a hospice provider. 9. Prior authorization as the process of reviewing a request for services and determining beneficiary eligibility, coverage, medical necessity, and appropriateness of services. Refer to Miss. Admin. Code Part 205, Rule 1.11 for required documentation. 10. Election period as a predetermined timeframe for which a beneficiary may elect to receive Medicaid coverage of hospice care during the beneficiary's lifetime. Election periods consist of: a) An initial ninety (90)-day period once in a lifetime, b) A subsequent ninety (90)-day period once in a lifetime, and c) Subsequent sixty (60)-day periods with unlimited increments which require face-to- face encounters with a hospice physician or hospice nurse practitioner. 11. Reasonable and necessary as safe and effective services which are not experimental or investigational and are appropriate, including the duration and frequency in terms of whether the item or service is: a) Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the beneficiary's condition or to improve the function of a malformed body member, b) Ordered and furnished in a setting appropriate to the beneficiary's medical needs and condition, and c) One that meets, but does not exceed, the beneficiary's medical need. 12. Period of crisis as a period in which a beneficiary requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms. 13. Bereavement counseling as emotional, psychosocial, and spiritual support and services provided before and after the death of the patient to assist with issues related to grief, loss, and adjustment.