Covered Services

Covered Services The Division of Medicaid covers hospice services in accordance with the hospice plan of care (POC), when prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or designated entity and provided in a manner that is consistent with accepted standards of practice and complies with all federal and state laws in addition to Medicare's Conditions of Participation and includes the following: A. Core services, with the exception of physician services, must be provided directly by hospice employees on a routine basis. The following are hospice core services: 1. Physician services, 2. Nursing services by a registered nurse (RN), 3. Medical social services by a licensed 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, 4. Counseling services which includes, but not limited to: a) Bereavement counseling services provided to the beneficiary’s family before and up to one (1) year after the beneficiary’s death and the hospice provider must: 1) Have an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief or loss counseling. 2) Counsel residents of a skilled nursing facility/nursing facility (SNF/NF) or an intermediate care facility for individuals with intellectual disabilities (ICF/IID) when appropriate and identified in the bereavement plan of care (POC). 3) Ensure that bereavement services reflect the needs of the bereaved. 4) Develop a bereavement POC that notes the kind of bereavement services to be offered and the frequency of service delivery. b) Spiritual counseling, and c) Dietary counseling by a registered dietician, RN, or other qualified professionals. B. Non-core services which include: 1. Physical therapy, occupational therapy, and speech-language pathology services, 2. Hospice aide and homemaker services furnished by qualified personnel, and 3. Volunteer services used in defined roles and under the supervision of a designated hospice employee. C. Routine Home Care (RHC) which is a day when a beneficiary who has elected to receive hospice care is at home and is not receiving Continuous Home Care. D. Continuous Home Care which is a day when a beneficiary who has elected to receive hospice care is not in an inpatient facility and receives hospice care consisting predominantly of nursing care on a continuous basis at home. 1. The hospice must provide a minimum of eight (8) aggregate hours of care by an RN, hospice aide and/or homemaker during a twenty-four (24) hour day that begins and ends at midnight. Homemaker or hospice aide services or both may supplement the nursing care during periods of crisis but care during these periods must be predominantly nursing care provided by an RN, which means more than half of the hours of care are provided by an RN. 2. Continuous Home Care may not be provided when the hospice beneficiary is a long-term care facility resident or an inpatient of a free-standing hospice. E. Inpatient Respite Care which is a day when a beneficiary who has elected hospice care receives care in an approved facility on a short-term basis for respite when necessary to relieve the family members or other persons who normally care for the beneficiary at home and must not be: 1. Greater than five (5) consecutive days at a time. 2. Long-term care facility resident, assisted living (AL) waiver participant, or an inpatient of a free-standing hospice, or 3. Provided when services are duplicated or any other like services are being delivered to the beneficiary. F. General Inpatient Care which is a day when a beneficiary 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 and provided in a participating hospice inpatient unit, hospital, or a participating skilled nursing facility (SNF) or nursing facility (NF) that additionally meets the special hospice standards regarding patient and staffing areas. G. Medical supplies and appliances, drugs and biologicals related to the palliation and management of the beneficiary’s terminal illness and related conditions as identified in the hospice POC. H. Concurrent hospice and home and community based-services (HCBS) waiver services only if: 1. Hospice benefits which address the person’s terminal illness are fully utilized prior to waiver service utilization in instances of potential duplication including, but not limited to: a) Hospice aide/homemaker and HCBS waiver personal care attendant services, b) Hospice in-patient respite and HCBS waiver institutional respite, c) Hospice medical appliances/supplies and HCBS waiver specialized medical equipment/supplies, d) Hospice physical therapy, speech-language pathology, occupational therapy and HCBS waiver physical therapy, speech therapy, occupational therapy, and e) Hospice nursing care and HCBS waiver home health skilled nurse visits. 2. A face-to-face person centered planning (PCP) conference with both providers is held within five (5) business days of a person receiving concurrent services. If the face-to- face conference cannot be held within five (5) business days due to justifiable logistical reasons, a conference call must be held: a) Within five (5) business days of a person receiving concurrent services, and b) A face-to-face conference with both providers must be held within thirty (30) days of the person receiving concurrent services. 3. A face-to-face PCP conference is conducted within five (5) business days of a significant change in the person’s condition that warrants changes to the person’s services on the hospice POC and/or HCBS plan of services and supports (PSS). 4. The following persons are in attendance at the face-to-face PCP conference: a) The person and/or the person's designated representative, b) The hospice provider, and c) The HCBS waiver case manager/support coordinator. 5. The hospice POC and an HCBS PSS: a) Are maintained by both providers in the medical record, b) Identify the services the person receives, c) Designate which provider is responsible for delivering each service, d) Indicate the frequency of each service, e) State a reason each service performed by a waiver is not covered by hospice, f) Meet the standard requirements of the hospice POC and the applicable requirements of the HCBS waiver program's PSS, g) Are signed by both the hospice provider and HCBS waiver case manager/support coordinator, and h) Are approved by the Division of Medicaid.