Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 437.000 - Hospice Services
Section 437.412 - Electing Hospice Services
Universal Citation: 130 MA Code of Regs 130.437
Current through Register 1531, September 27, 2024
(A) Eligibility for Hospice Services.
(1) MassHealth members, including
dual-eligible members, but not including those identified in
130
CMR 437.412(A)(2), are
eligible for hospice services if
(a) their
coverage type as set forth in
130
CMR 450.105: Coverage Types
covers hospice services; and
(b)
they fulfill the following requirements:
1.
are certified as terminally ill in accordance with
130
CMR 437.411;
2. agree to waive certain MassHealth benefits
in accordance with
130
CMR 437.412(B);
and
3. elect to receive hospice
services in accordance with
130
CMR 437.412(C).
(2) MassHealth members
younger than 21 years old who have elected the hospice benefit will have
coverage for curative treatment and all medically necessary services for which
they are eligible. For such members, the hospice provider remains responsible
for all hospice services as described in
130
CMR 437.423.
(3) For members enrolled in a
MassHealth-contracted managed care organization (MCO) or accountable care
organization (ACO) who elect hospice services, the hospice provider must be
contracted with the member's ACO/MCO plan, as applicable, and the hospice
provider must comply with the ACO/MCO's requirements for the delivery of
hospice services.
(B) Waiver of Other Benefits. With the exception of members described in 130 CMR 437.412(A)(2), upon electing to receive hospice services, a member waives all rights to MassHealth coverage for the following services for the duration of the election of hospice services:
(1) hospice services provided by a
hospice provider other than the one designated by the member on the hospice
election form submitted to the MassHealth agency;
(2) any MassHealth services that are related
to the treatment of the terminal illness for which hospice services were
elected, not including room and board in a nursing facility or ICF/IID when
nursing facility or ICF/IID is otherwise a covered benefit for a member's
coverage type (see 130 CMR 437.424(B)
and
130
CMR 450.105: Coverage
Types'); and
(3) any
MassHealth services that are equivalent to or duplicative of hospice services,
except for
(a) MassHealth state plan personal
care services, including MassHealth Personal Care Attendant (PCA) Program
services (130 CMR 422.000) and MassHealth Adult Foster Care/Group Adult Foster
care Program services (130 CMR 408.000: Adult Foster Care), as
well as MassHealth Home and Community-based Services (HCBS) waiver services
that provide assistance with personal care, when used to the extent that the
hospice provider would routinely use the services of a member's family in
implementing the plan of care. As provided under
130
CMR 437.423(B), PCA,
AFC/GAFC, and HCBS waiver services that provide personal care must be
coordinated with the provision of hospice services, as well as with any in-home
support services that the member is receiving or is eligible to receive, from a
home and community-based services network; and
(b) physician services provided by the
member's attending physician if that physician is not an employee of the
designated hospice or receiving compensation from the hospice for those
services.
(C) Hospice Election and Change in Hospice Election. Each time a MassHealth member who meets the requirements of 130 CMR 437.412(A) seeks to elect hospice services, revoke hospice services, or change hospice providers in accordance with 42 CFR 418.24 and 130 CMR 437.412, the hospice provider must notify the MassHealth agency of the member's hospice election or change in hospice election.
(1)
Hospice Election
Statement. When a member meets the requirements of
130
CMR 437.412(A) and chooses
to elect hospice, the hospice provider must have the member or member's
representative sign a hospice election statement that meets all requirements of
42 CFR
418.24(b) and (c). The
hospice election statement must be specific to MassHealth and the member must
be aware that in signing the election statement they are waiving their rights
to MassHealth coverage for certain services for the duration of their hospice
election. See
130
CMR 437.412(B).
(2)
Hospice
Revocation. The member or the member's representative may revoke
the election of hospice services at any time during the hospice election
period. The hospice provider must document the revocation in the member's
medical record and notify the MassHealth agency according to
130
CMR 437.412(C). Upon
revocation of the election of hospice services for a particular election
period, the member:
(a) is no longer covered
under MassHealth for hospice services;
(b) resumes MassHealth coverage for the
services waived upon election of hospice services; and
(c) may at any time elect to receive hospice
services for any remaining hospice election periods for which the member is
eligible.
(3)
Change in MassHealth Hospice Providers. A member may
change hospice providers once in each hospice election period. To change from
one hospice provider to another, the new hospice provider must notify the
MassHealth agency according to
130
CMR 437.412(C) indicating a
change in hospice providers. A member does not revoke election of hospice
services by changing their MassHealth hospice provider.
(4)
Hospice
Disenrollment. The hospice provider must document hospice
disenrollment in the member's medical record and include the reason for
disenrollment and the effective date of disenrollment.
(5)
MassHealth Application
Pending. Once an individual's eligibility is approved for a
MassHealth coverage type that includes hospice care, MassHealth coverage for
hospice services for an individual who meets the requirements of
130
CMR 437.412(A) may be
effective only on or after the date the individual signs a hospice election
statement that meets the requirements of
130
CMR 437.412(C)(1),
regardless of any previous hospice election by the individual for an insurer
other than MassHealth, and no earlier than the date the individual's MassHealth
eligibility is approved.
(6)
Dual-eligible Members. Hospice providers must ensure
that dual-eligible members elect and revoke their MassHealth hospice benefit
simultaneously with their Medicare hospice benefit.
(7)
Notifying the MassHealth
Agency of Hospice Election and Change in Hospice Election. A
hospice provider must notify the MassHealth agency of a member's hospice
election or change in hospice election through the provider portal, or as
otherwise instructed by the MassHealth agency within 14 calendar days after the
effective date of election.
(8)
Exceptions. If a Hospice provider is unable to timely
notify the MassHealth agency of a Hospice Election and/or Change in Hospice
Election, the hospice provider must fully document and furnish any requested
documentation to the MassHealth agency for a determination of exception as soon
as possible and no later than 90 days from the date of election. The
permissible exceptions are as follows:
(a)
fires, floods, earthquakes, or other unusual events that inflict extensive
damage to the hospice provider's ability to operate;
(b) an event that produces a data filing
problem due to a MassHealth contractor systems issue that is beyond the control
of the hospice provider;
(c) a
newly enrolled MassHealth hospice provider that is notified of enrollment after
the MassHealth enrollment date, or is awaiting its MassHealth provider ID from
MassHealth;
(d) the member's
MassHealth eligibility is approved and retroactively applied after the member
signs the hospice election form; and
(e) other situations determined by the
MassHealth agency to be beyond the control of the hospice.
(D) Effective Date for Hospice Services.
(1) The
effective date for hospice election, hospice revocation, or changing hospice
providers is the effective date entered by the hospice provider on the hospice
election form submitted to the MassHealth agency.
(2) The effective date for hospice services
may not be earlier than the date the member or the member's representative
signed the hospice election statement.
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