Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
KRS
205.520,
42
C.F.R. 418.3, 418.20-418.30,
42 U.S.C.
1395d,
1395x(dd)(2),
1396d(o)
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services has responsibility to administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the terms and
conditions under which the Medicaid Program shall provide hospice care to both
the categorically and medically needy.
Section
1. Definitions.
(1) "Department
approved system" means a technology system in which:
(a) Providers electronically submit and track
level of care (LOC) requests through a self-service portal;
(b) The system triggers LOC tasks as
reminders to providers and allows them to submit reassessments electronically;
and
(c) Information is exchanged
electronically with Kentucky's:
1. Medicaid
Enterprise Management System (MEMS); and
2. Integrated eligibility
system.
(2)
"Hospice care" means a package of palliative and supportive services:
(a) Provided by a hospice program to a
terminally ill Medicaid recipient and the recipient's family to:
1. Alleviate the recipient's pain and
suffering; and
2. Assist the
recipient and the recipient's family to cope with dying and the circumstances
surrounding terminal illness; and
(b) Provided in lieu of the benefits
established in
42 U.S.C.
1395d(d)(2)(A) and services
provided by an intermediate care facility for individuals with an intellectual
disability.
(3)
"Representative" means an individual who:
(a)
Has the authority under state law (whether by statute or pursuant to an
appointment by a court of law) to authorize or terminate medical care or to
elect or revoke the election of hospice care on behalf of a terminally ill
recipient who is mentally or physically incapacitated; and
(b) May be the recipient's legal
guardian.
(4) "Terminally
ill" is defined by
42
C.F.R. 418.3.
Section 2. General Provisions.
(1) The recipient or the recipient's
representative shall voluntarily elect hospice care if hospice care is to be
provided.
(2) Institutionalized
hospice care shall be provided to an individual in a skilled nursing or
intermediate care facility.
(3)
Non-institutionalized hospice care shall be provided to an individual in a home
or hospice facility.
(4) Hospice
care shall only be provided by an appropriately licensed, accredited, and
certified hospice program, as defined by
42
U.S.C. 1395x(dd)(2),
participating in both Medicare and Medicaid.
(5) Agency staff and participating providers
of hospice services may review the federal Medicaid hospice regulations located
in 42 C.F.R. part 418 for additional benefit descriptions and operating
instructions relating to hospice services care.
Section 3. Voluntary Election.
(1) Any terminally ill Medicaid recipient or
recipient's representative may elect hospice coverage if hospice care is
provided by a participating hospice program in that county service
area.
(2) Each recipient shall have
the following items completed in the department approved system:
(a) MAP-374, Election of Medicaid Hospice
Benefits, to authenticate voluntary selection; and
(b) MAP-377, Physician's Statement for
Medicaid Hospice Service, which is a statement from a physician to show that
the recipient's illness is terminal and that death is expected to occur within
six (6) months.
Section
4. Covered Services.
(1) To be
covered, hospice services shall be reasonable and medically necessary for the
palliation or management of the terminal illness as well as related
conditions.
(2) Covered services
shall include:
(a) Nursing care and services
by or under the supervision of a registered nurse;
(b) Mental health, nutritional, dietary, and
bereavement counseling services for the recipient and the family;
(c) Physical therapy;
(d) Occupational therapy;
(e) Speech language pathology;
(f) Home health aide that performs simple
procedures as an extension of:
1. Therapy
services;
2. Personal
care;
3. Ambulation and
exercise;
4. Household services
essential to health care at home;
5. Assistance with medications that are
ordinarily self-administered;
6.
Reporting changes in the patient's condition and needs; and
7. Completing appropriate records;
(g) Medical supplies and
appliances;
(h) Short term
inpatient care for pain control and symptom management;
(i) Medical social services;
(j) Respite care;
(k) Physician services;
(l) Pharmacy services for drugs related to
the recipient's terminal illness;
(m) Room and board if the recipient is
residing in a long term care facility; and
(n) Bed reservation days if in a long term
care facility.
Section
5. Duration of Benefits.
(1)
There shall not be a limit on the number of days an individual may participate
in the hospice program if the days fall within a covered benefit period as
established in subsection (2) of this section.
(2) Hospice benefits shall consist of these
benefit periods:
(a) Two (2) ninety (90) day
periods; and
(b) Additional sixty
(60) day periods that last until revocation or termination for other reasons
such as ineligibility or death.
Section 6. Concurrent Medicare Coverage. If a
Medicaid eligible individual with concurrent eligibility for hospice services
under Medicare wishes to enroll in a hospice program under Medicaid, the
individual shall, as a prerequisite for Medicaid hospice enrollment, enroll in
the Medicare hospice program.
Section
7. Disenrollment, Reenrollment, and Transfers.
(1)
(a) A
recipient may disenroll from a hospice program at any time.
(b) In accordance with
42 C.F.R.
418.28, a recipient who disenrolls during any
benefit period shall lose the unused portion of that benefit
period.
(2) If an
enrolled individual revokes his or her Medicare enrollment, the Medicaid
enrollment shall be revoked simultaneously.
(3) If a county is served by two (2) or more
hospice programs, or if the recipient moves county of residence to a county
serviced by a different hospice, the recipient may transfer between hospice
programs.
Section 8.
Admission, Reassessment, and Discharge.
(1)
Prior to or on admission, a hospice provider shall submit on the department
approved system the information required by the following forms, either by
using the forms listed in paragraphs (a) and (b) of this subsection or by using
a document developed by the hospice provider that includes the same
information:
(a) MAP-374; and
(b) MAP-377.
(2) For reassessment, a hospice provider
shall complete on a department approved system a MAP-377 prior to or on the
date of expiration of the current authorization period.
(3) The discharge date shall be entered into
a department approved system on or before the date of discharge.
Section 9. Incorporation by
Reference.
(1) The following material is
incorporated by reference:
(a) MAP-374,
"Election of Medicaid Hospice Benefits", 1/18; and
(b) MAP-377, "Physician's Statement for
Medicaid Hospice Service", 1/18.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law:
(a) At the Department for Medicaid Services,
275 East Main Street, Frankfort, Kentucky, Monday through Friday, 8:00 a.m. to
4:30 p.m.; or
13 Ky.R. 1016;
eff. 12-2-1986; Am. 15 Ky.R. 1983; eff. 3-15-1989; 17 Ky.R. 150; eff.
9-13-1990; 45 Ky.R. 2790; eff. 8-2-2019.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3)