Hospice Care Services

Scope:

Louisiana Healthcare Connections (the Plan) Medical Management Department

Purpose:

To ensure that terminally ill members, with a prognosis of six (6) months or less, have access to appropriate hospice care. This policy is:

  1. To be used as a guideline to determine the appropriateness of Hospice, as well as the level of Hospice, for members needing end-of-life care, and
  2. To ensure that hospice service requests are accompanied by required certification and that utilization review decisions are based on relevant clinical information and appropriately documented and secure.

Overview:

Hospice is a coordinated, integrated program developed by a multidisciplinary team of professionals to provide end-of-life care, which is primarily focused on relieving pain and symptoms specifically related to the terminally ill diagnosis of members with a life expectancy of six (6) months or less. Most hospice services are provided at home, by a licensed certified hospice provider, under the direction of an attending physician, who may be the member’s primary care physician or the hospice medical director. Hospice services are provided under a plan of care designed by the multidisciplinary team to meet the needs of members who are terminally ill, as well as their families.

Hospice services include skilled nursing, homemaker and hospice aide services, physician services, physical, occupational and speech therapy, medical social services, volunteer services, nutritional, spiritual, psychosocial/supportive and bereavement counseling related to the management of the terminal illness. Hospice includes drugs and biologics related to the management of the terminal illness, to relieve pain, provide hydration and deliver enterals as a primary source of nutrition. Durable medical equipment and medical supplies are also included in hospice, when related to the management of a terminal illness. Only individuals younger than the age of 21 who are under the care of a hospice are eligible for curative treatment related to the terminal illness as specified in the Patient Protection and Affordable Care Act, section 2302.

Procedure:

In accordance with policies and procedures of The Department of Health and Hospitals Louisiana Medicaid Program, to be eligible to elect hospice care under Medicaid, a written certification statement of terminal illness must accompany the request. The certification must include the statement that the beneficiary’s medical prognosis is six (6) months or less at the time of referral to hospice and that therapeutic strategies directed toward cure and control of the disease are no longer appropriate. If 21 years of age or over, the member must acknowledge the terminal illness and elect to receive the palliative care of the hospice service rather than active treatment of the terminal condition.

Hospice Service is only available if all of the following conditions are met:

  • The patient’s physician and/or the hospice medical director certify that the patient is terminally ill (for hospice purposes terminal illness is defined as a life expectancy of six (6) months or less if the terminal illness runs its normal course); and
  • The patient or legal representative, in the event the patient is physically or mentally unable to sign, signs an election statement indicating an informed choice of hospice benefits for the terminal illness; and
  • The services are provided in accordance with a plan of care established by the patient’s attending physician, the medical director or physician designee and the interdisciplinary group. The plan must include an assessment of the individual’s needs and identification of the services including the management of discomfort and symptom relief. It must state in detail the scope and frequency of services needed to meet the patient’s and family’s needs. Detailed plan of care and interdisciplinary group requirements are identified in 42 CFR Part 418.

The rules governing hospice care are outlined in the State Provider Manual at http://www.lamedicaid.com/provweb1/Providermanuals/manuals/Hospice/Hospice.pdf.

  • The clinical decision process begins when a request for authorization of services is received at the Plan.
  • Upon intake of a request for hospice service, a Plan Referral Specialist (RS) reviews the request to ensure receipt of the written certification statement.
  • On verification of receipt of required documentation, the standard authorization process is followed. To support the utilization review decision making process, clinical information relevant to the case, as well as the rationale used to make the clinical decision, is documented consistently and accurately. This process is outlined in the associated policies (LA.UM.02.01, LA.UM.06, LA.UM.06.01)
  • Authorization timeframes shall follow the hospice benefit which is divided into distinct election periods. The maximum number of days in each election period reflects an authorization timeframe:
    • 1st – 90 days
    • 2nd – 90 days
    • 3rd – 60 days – unlimited increments

The member must be certified/re-certified for each benefit period.

Classification of Care:

Each day of hospice care is classified into one of four levels of care see Coding
Implications below for revenue codes:

  • Routine home care – Routine home care is received at the patient’s home; it is not continuous home care. Routine home care is reimbursable to Hospice providers for each day the recipient is under the care of the hospice and not receiving another level of care, whether or not the recipient is visited in the home by the Hospice provider on the days being billed.
  • Continuous home care – Continuous home care consists of continuous, predominately skilled nursing care provided on an hourly basis, for a minimum of eight hours during brief crisis periods. Home health aide and/or homemaker services may also be provided.
  • Respite care – Respite care occurs when the patient receives care in an approved inpatient facility on a short-term basis to provide relief for family members or others caring for the individual. Each episode is limited to no more than five (5) days.
  • General inpatient care – General inpatient care occurs when the patient receives general care in an inpatient facility for pain control, or acute/chronic symptom management that cannot be managed in other settings.

Level of Care Core Services:

Core services within each level of care include:

  • Nursing services
  • Physical and occupational therapy
  • Speech-language pathology
  • Medical social services, hospice aide and homemaker/ attendant services
  • Medical supplies and appliances
  • Prescription drugs and biologicals that are necessary for the palliation and management of the terminal illness and related conditions
  • Physician services
  • Short-term inpatient care
  • Counseling

Patient Revocation of Hospice Service:

If the patient revokes hospice care, the patient, as well as the Hospice provider, must inform the Plan in writing by submitting the hospice revocation form signed by the patient or legal representative. A notice of revocation is due within 3 calendar days of revocation. Subsequently, if the patient re-elects hospice care, the Hospice provider must submit a new patient hospice election and Physician Certification to the Plan. The Hospice Provider retains the initial certification of terminal illness from the hospice physician in the terminally ill patient’s medical record and new Notice of Election and Certification of Terminal Illness forms are required upon the re-election of hospice. Upon revocation, the recipient loses any remaining days in the election period but may, at a future time, elect to receive hospice coverage for any other hospice periods for which he/she is eligible.

Patient Discharge from Hospice:

If the patient is discharged from hospice care due to the patient’s death or due to a decision made by the hospice care team, the Hospice provider must inform the Plan in writing and this notice is due within 2 calendar days of discharge.