43.05-1
Covered Services
Covered hospice services must be reasonable and necessary
for the palliation or management of the terminal illness and related
conditions. To be covered, all services must be in accordance with the plan of
care and approved by the Interdisciplinary Team. Services unrelated to the
terminal illness which affect the plan of care must be reflected in the plan in
order to assure coordination and non-duplication of services.
The following are considered covered hospice services.
Unless noted otherwise, reimbursement shall be based on a per diem or hourly
rate, and in accordance with the provisions described in Section 43.07.
A. Physician Services (see Section 43.07-3
for further details).
B. Nursing
Services provided by or under the supervision of a registered nurse.
C. Medical Social Services provided by a
medical social worker working under the supervision of a physician.
D. Counseling Services must be available to
the member and family members or others caring for the member at home,
including dietary, spiritual and other counseling. Counseling may be given both
for the purpose of training caregivers to provide care, and for the purpose of
helping the member and those caring for him or her to adjust to the member's
approaching death.
E. Home Health
Aide Services furnished by certified home health aides and certified nursing
assistants. Home health aides may provide personal care and household services
essential to the comfort and cleanliness of the member and maintaining a safe
and healthy environment to allow implementation of the plan of care. Aide
services must be provided under the general supervision of a registered nurse.
Home health aide services can include the provision of
homemaker services. Homemaker services include maintenance of a safe and
healthy environment and services that enable the member to carry out the plan
of care.
F. Medical
Supplies, Drugs and Biologicals are covered only when used primarily for the
relief of pain and symptom control related to the member's terminal illness.
Appliances may include covered durable medical equipment as well as other
self-help and personal comfort items related to relief or management of the
terminal illness. Equipment is provided by the hospice for use in the member's
home while under hospice care. Medical supplies include those that are part of
the written plan of care.
G.
Short-Term Inpatient Care provided in a participating hospice inpatient unit or
a participating hospital or nursing facility which meets the special hospice
standards regarding staffing and patient areas. Participating facilities are
defined as those with which the hospice has a contract that provides for all
requirements contained within the Medicare Hospice conditions of participation.
Inpatient services must conform to the written plan of care. General inpatient
care may be required for procedures necessary for pain control or acute or
chronic symptom management that cannot be provided in other settings. Inpatient
care may also be furnished to provide respite for individuals caring for the
member at home.
H. Physical,
Occupational and Speech/Language Therapy provided for symptom control or to
allow the member to perform daily living activities and basic functional
skills.
I. Special Modalities,
including chemotherapy, radiation therapy, and other modalities that may be
used for palliative purposes if it is determined that these services are needed
for palliation. This determination is based on the member's condition and
philosophy of care giving of the hospice. No additional MaineCare reimbursement
shall be provided, regardless of the cost of the services.
J. Ambulance Services, when the medical
condition requiring ambulance transport is a result of the member's terminal
illness.
K. Other Items and
Services specified in the plan of care for which payment may otherwise be made.
This item reflects the hospice's responsibility for providing any and all
services in the plan of care necessary for the relief and management of the
terminal illness and related conditions.
43.05 -2
Special Coverage
Requirements
Bereavement counseling consists of counseling services
provided to the member's family for up to one (1) year after the member's
death. It is a required hospice service but is not separately billable.
43.05-3
Room and Board
Services for Nursing Facility Residents
The following services shall be included as room and
board services and shall be provided by the nursing facility for those
MaineCare members who elect to receive hospice while residing in the nursing
facility:
A. Performance of personal
care services;
B. Assistance in
activities of daily living
C.
Administration of medication;
D.
Maintaining cleanliness of resident's room; and
E. Supervising and assisting with the use of
durable medical equipment and prescribed therapies.
43.05-4
Coverage Restrictions During
Hospice Election
A.
Medically
Necessary/Non-Duplicative Services
A Member receiving hospice services may obtain other
medically necessary services (as defined by the Department) that are not
duplicative of hospice services or unrelated to a member's terminal illness.
The provider must appropriately document services rendered in the member
record, in accordance with Department specifications. These services are
subject to the same coverage provisions, limitations, prior authorization
requirements and conditions applied to services available to non-hospice
MaineCare members. (All services, related to and unrelated to the terminal
illness, must be consistent with the plan of care.) These services are
reimbursable by MaineCare outside of the hospice rate.
The services include:
1. Ambulance Services - Chapter II, Section
5, when the medical condition requiring ambulance transport is unrelated to the
terminal illness for which the member is receiving services under this
Section.
2. Speech and Hearing
Services - Chapter II, Section
109
3. Consumer Directed Attendant Services -
Chapter II, Section
12, subject to additional
restrictions that may be outlined in that Section
4. Chiropractic Services - Chapter II,
Section 15
5. Family Planning Agency Services - Chapter
II, Section
30
6. Home Health Services - Chapter II, Section
40 subject to additional
restrictions that may be outlined in that Section
7. Early and Periodic Screening, Diagnosis
and Treatment Services (EPSDT) Chapter II, Section 94.
8. Transportation Services - Chapter II,
Section 113
9. Podiatric Services - Chapter
II, Section
95
10. Private Duty Nursing and Personal Care
Services - Chapter II, Section
96, subject to additional
restrictions that may be outlined in that Section
11. Behavioral Health Services - Chapter II,
Section 65
12. Medical Supplies and Durable Medical
Equipment - Chapter II, Section
60
13. Medical Imaging Services - Chapter II,
Section 101
14. Occupational Therapy Services
- Chapter II, Section
68
15. Physical Therapy Services - Chapter II,
Section 85
B.
Continuation of
Services
In order to maintain activities of normal life for as
long as possible, certain MaineCare services may be continued after the hospice
election for those members who have been receiving these services for a
substantial period of time prior to the hospice election.
These services include:
1. Targeted Case Management Services -
Chapter II, Section
13
2. Community Support Services - Chapter II,
Section 17
3. Developmental & Behavioral Clinic
Services - Chapter II, Section
23
4. Rehabilitative and Community Support
Services for Children with Cognitive Impairments and Functional Limitations -
Chapter II, Section
28
5. Day Health Services - Chapter II, Section
26
6. Rehabilitative Services - Chapter II,
Section 102
7. Behavioral Health Homes
Services - Chapter II, Section
92
8. Behavioral Health Services - Chapter II,
Section 65
9. Psychiatric Hospital Services - Outpatient
services only, Chapter II, Section
46
10. Opioid Health Home Services - Chapter II,
Section 93
11. Private Non-Medical Institution Services
- Chapter II, Section
97
There may be instances where it is appropriate to allow
individual hospice members to receive these services even if they did not
receive them prior to electing the hospice benefit. However, the provider must
show that services are medically necessary given the member's terminal
condition, and are coordinated with the hospice plan of care. These services
are reimbursable by MaineCare outside of the hospice rate.
C.
Home and
Community Benefits
Eligibility for and limits on home and community benefits
for members of hospice care are delineated in the relevant section of Chapter
II of the MaineCare Benefits Manual (MBM).