Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This proposed amendment updates the
publication information of the MO HealthNet Hospice Manual, and increases the
document retention period to six (6) years.
PURPOSE: This rule establishes the MO HealthNet
payment policy for the Hospice Program. The goal of the Hospice Program is to
meet the needs of participants with life-limiting illnesses and to help their
families cope with related problems. Hospice care is an approach to treatment
that recognizes that the impending death of an individual warrants a change in
focus from curative care to palliative care.
(1) Administration. The Hospice Program shall
be administered by the Department of Social Services, MO HealthNet Division.
The medical services covered and not covered, the program limitations under
which services are covered, and the maximum allowable fees for all covered
services shall be determined by the MO HealthNet Division and shall be included
in the MO HealthNet Hospice Provider Manual, which is incorporated by reference
and made part of this rule as published by the Department of Social Services,
MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its
website at
http://manu-als.momed.com/collections/collection_hos/print.pdf,
November 25, 2020. This rule does not incorporate any subsequent amendments or
additions. Hospice services covered by the MO HealthNet program shall include
only those that are clearly shown to be medically necessary. The division
reserves the right to affect changes in services, limitations, and fees with
proper notification to MO HealthNet hospice providers.
(2) Persons Eligible. Participants eligible
for medical assistance benefits from the Department of Social Services are
certified by a physician to be terminally ill with a medical prognosis of life
expectancy of six (6) months or less if the illness runs its normal course and
who elects hospice benefits is eligible. The individual must agree to seek only
palliative care for the duration of the hospice enrollment with the following
exception:
(A) Hospice services for a child
under twenty-one (21) years of age may be concurrent with the care related to
curative treatment of the condition for which a diagnosis of a terminal illness
has been made.
(3)
Enrollment of Participant. The components involved in hospice enrollment are-
physician certification; election procedures, including election statement,
revocation, and change; the assignment of an attending physician; and the
development of the plan of care.
(A)
Physician Certification. The hospice must obtain the certification that an
individual is terminally ill in accordance with the following procedures:
1. Prior to billing for the first period of
hospice coverage (ninety (90) days), the hospice must obtain, written
certification statements signed by the medical director of the hospice or the
physician member of the hospice interdisciplinary group and the individual's
attending physician (if that attending physician is other than a hospice staff
member). The certification must include the statement that the individual's
medical prognosis is a life expectancy of six (6) months or less if the illness
runs its normal course and the signature(s) of the physician(s). If the hospice
does not obtain written physician certification within two (2) days of the
initiation of hospice care, a verbal physician certification must be obtained
within the two (2) days. Payment will not be made for days prior to the written
certification if the verbal certification requirement is not met.
2. For any subsequent period of hospice
coverage, the hospice must obtain, no later than two (2) calendar days after
the beginning of that period, a written certification statement prepared by the
medical director of the hospice or the physician member of the hospice's
interdisciplinary group. The certification must include the statement that the
individual's medical prognosis is a life expectancy of six (6) months or less
if the illness runs its normal course and the signature of the physician. The
hospice must maintain the certification statements.
(B) Election Procedures. To elect hospice
services, an individual must file a Hospice Election Statement with a MO
HealthNet participating hospice provider. An election may also be filed by a
representative acting pursuant to state law. With respect to an individual
granted the power of attorney for the participant, state law determines the
extent to which the individual may act on the patient's behalf.
1. Election period. An election to receive
hospice care will be considered to continue through the initial election period
and through any subsequent election periods without a break in care as long as
the individual remains in the care of the hospice and does not revoke the
election.
2. Waiver of MO HealthNet
fee-for-service payments related to the terminal illness. In order to elect
hospice services, the individual must waive all rights to MO HealthNet payments
for services that would be covered under the Medicare program for the duration
of the election of hospice care for the following services:
A. Hospice care provided by a hospice other
than the hospice designated by the individual (unless provided under
arrangements made by the designated hospice); and
B. Any MO HealthNet services that are related
to the treatment of the terminal condition for which hospice care was elected
or a related condition, or that are equivalent to hospice care except for
services-
(I) Provided (either directly or
under arrangement) by the designated hospice;
(II) Provided by another hospice under
arrangements made by the designated hospice;
(III) Provided by the individual's attending
physician if that physician is not an employee of the designated hospice or
receiving compensation from the hospice for those services; or
(IV) Provided to a child under twenty-one
(21) and such services are curative treatment services for the condition for
which a diagnosis of terminal illness has been made, as required by the federal
Patient Protection and Affordable Care Act (PPACA),
P.L.
111-148,
section
2302.
3. Election, revocation, and change of
hospice.
A. Election periods. An individual
may elect to receive hospice care during one (1) or more of the following
election periods:
(I) An initial ninety-
(90-) day period;
(II) A subsequent
ninety- (90-) day period; and
(III)
Unlimited subsequent sixty-(60-) day periods.
B. Election statement. The election statement
must include the following items of information:
(I) Identification of the particular hospice
that will provide care to the individual;
(II) The individual's or representative's
acknowledgment that s/he has been given a full understanding of hospice
care;
(III) The individual's or
representative's acknowledgment that s/he understands that certain MO HealthNet
services are waived by the election;
(IV) The effective date of the
election;
(V) The name of the
attending physician;
(VI) The
signature of the individual or representative; and
(VII) The signature of the witness when the
participant's representative signs the form.
C. Revocation. An individual or
representative may revoke the election of hospice care at any time. To revoke
the election of hospice care, the individual, or representative, must file a
revocation of hospice benefit statement with the hospice. This statement must
include a signed statement that the individual revokes the election for MO
HealthNet coverage of hospice care for the remainder of that election period.
The date that the revocation is to be effective is the date of the signature or
may be a later date subsequent to the date of signature. The individual
forfeits coverage for any remaining days in that election period. The
individual or representative may not designate an effective date earlier than
the date that the revocation statement is signed. Upon revoking the election of
MO HealthNet coverage of hospice care for a particular election period, an
individual resumes MO HealthNet coverage of the benefits waived when hospice
care was elected. An individual may elect at any time to receive hospice
coverage for any other hospice election periods for which s/he is
eligible.
D. Change of Hospice. An
individual may change, once in each election period, the designation of the
particular hospice from which s/he elects to receive hospice care. The change
of the designated hospice is not considered a revocation of the election. To
change the designation of hospice providers, the individual must file with the
hospice from which s/he has received care and with the newly designated hospice
a signed statement that includes the following information: the name of the
hospice from which the individual has received care, the name of the hospice
from which s/he plans to receive care, and the date the change is to be
effective.
(C) Attending Physician. The attending
physician is a doctor of medicine or osteopathy and is identified by the
individual, at the time s/he elects to receive hospice care, as having the most
significant role in the determination and delivery of the individual's medical
care. The attending physician is the participant's physician of choice who
participates in the establishment of the plan of care and works with the
hospice team in caring for the patient. The physician continues to give the
medical orders and may have privileges in the hospice inpatient care. MO
HealthNet will make payments directly to a hospice participant's attending
physician if the physician is not employed by the hospice provider.
(D) Plan of Care. The hospice must conduct
and document in writing a patient-specific comprehensive assessment that
identifies the patient's need for hospice care and services and the patient's
need for physical, psychosocial, emotional, and spiritual care. This assessment
includes all areas of hospice care related to the palliation and management of
the terminal illness and related conditions. The hospice registered nurse must
complete an initial assessment within forty-eight (48) hours after the election
of hospice care. The hospice interdisciplinary group, in consultation with the
individual's attending physician (if any), must complete the comprehensive
assessment no later than five (5) calendar days after the election of hospice
care. The hospice must designate an interdisciplinary group or groups which, in
consultation with the patient's attending physician, must prepare a written
plan of care for each patient. The plan of care must specify the hospice care
and services necessary to meet the patient and family-specific needs identified
in the comprehensive assessment as such needs relate to the terminal illness
and related conditions. The hospice interdisciplinary group (in collaboration
with the individual's attending physician, if any) must review, revise, and
document the individualized plan as frequently as the patient's condition
requires, but no less than every fifteen (15) calendar days. The plan of care
must be maintained in the patient's record and made available to the MO
HealthNet Division or its agent upon request.
(4) Provider Participation. To be eligible
for participation in the MO HealthNet Hospice Program, a provider must meet the
following criteria:
(A) Be certified as a
Medicare hospice provider;
(B) Be
licensed by the Missouri State Department of Health and Senior Services as a
hospice provider; and
(C) Be
enrolled as a MO HealthNet hospice provider.
(5) Benefits and Limitations. All services
must be performed by appropriately qualified personnel. Nursing care, medical
social services, and counseling are core hospice services and must routinely be
provided directly by hospice employees. A hospice must ensure that
substantially all the core services are routinely provided directly by hospice
employees. A hospice may use contracted staff, if necessary, to supplement
hospice employees in order to meet the needs of patients during periods of peak
patient loads or under extraordinary circumstances. If contracting is used, the
hospice must maintain professional, financial, and administrative
responsibility for the services and must assure that the qualifications of
staff and services provided meet all requirements. Hospice covered services are
identified in section 13 of the MO HealthNet Hospice Provider Manual which may
be referenced at www.dss.mo.gov/mhd. The individual's
plan of care must specify what hospice services are needed.
(6) Non-covered services are identified in
section 13 of the MO HealthNet Hospice Provider Manual which may be referenced
at www.dss.mo.gov/mhd.
(7) Reimbursement. Hospice services, as
defined in this rule and provided by qualified providers, shall be reimbursed
for dates of service beginning on or after May 15, 1989. The reimbursement rate
for hospice services includes all covered services related to the treatment of
the terminal illness, including the administrative and general supervisory
activities performed by physicians who are employees of or working under
arrangements made with the hospice. These activities would generally be
performed by the physician serving as the medical director and the physician
member of the hospice interdisciplinary group. Group activities would include
participation in the establishment of plans of care, supervision of care and
services, periodic review and updating of plans of care, and establishment of
governing policies. The costs for these services are included in the
reimbursement rates for routine home care, continuous home care, and inpatient
respite care.
(A) A per-diem rate for each
day on which hospice services are provided will be established based on the
Title XVIII Medicare rate for the specific hospice based on the level of care
provided-
1. Routine home care;
2. Continuous home care. A minimum of eight
(8) hours of continuous care must be provided during a twenty-four (24)-hour
period;
3. General inpatient care;
and
4. Inpatient respite care.
Reimbursement is limited to five (5) days per calendar month and to the
mandatory inpatient day limit.
(B) Nursing Home Room and Board. MO
HealthNet-eligible individuals residing in MO HealthNet-certified NFs who meet
the hospice eligibility criteria may elect MO HealthNet hospice care services.
In addition to the routine home care or continuous home care per diem rates, an
amount may be paid to the hospice to cover the nursing home room and board
costs. The hospice will reimburse the nursing home.
1. There must be a written agreement between
the hospice and the nursing home under which the hospice takes full
responsibility for the professional management of the individual's hospice care
and the nursing home agrees to provide room and board to the individual. The
hospice and the nursing home will retain a copy of the agreement.
2. For purposes of the MO HealthNet hospice
benefit, a NF can be considered the individual's residence.
3. Payment for nursing facility (NF) room and
board will be determined in accordance with rates established under section
1902(a)(13) of the Social Security Act. It is the responsibility of the hospice
provider to be aware of the NF reimbursement rate and whether it is a final
rate or if it is subject to change. The MO HealthNet Division may recoup
payments made to hospice providers for NF room and board if the nursing
facility reimbursement rate changes retroactively.
(C) Physician Services. MO HealthNet will
reimburse the hospice provider for certain physician services, such as direct
patient care services, furnished to individual patients by hospice employees
and for physician services furnished under arrangements made by the hospice
unless the patient care services were furnished on a volunteer basis. MO
HealthNet will reimburse the hospice for attending physician services when the
physician is employed by the hospice. These physician services will be
reimbursed in accordance with MO HealthNet reimbursement policy for physician
services based on the lower of the actual charge or the MO Health-Net maximum
allowable amount for the specific service.
(D) Limitation on Payments for Inpatient
Care. Payments to hospice providers for inpatient care must be limited
according to the number of days of inpatient care furnished to MO HealthNet
patients. During the twelve-(12-) month period beginning November 1 of each
year and ending October 31, the aggregate number of inpatient days (both for
general inpatient care and inpatient respite care) may not exceed twenty
percent (20%) of the aggregate total number of days of hospice care provided to
all MO HealthNet participants during that same period. This limitation is
applied once each year, at the end of the hospice's cap period (11/1-10/31).
For purposes of this computation, if it is determined that the inpatient rate
should not be paid, any days for which the hospice receives payment at a home
care rate will not be counted as inpatient days. Any excess reimbursement will
be refunded by the hospice.
(8) Cost Sharing. Hospice services shall be
exempt from these Medicaid cost-sharing requirements as may be otherwise
applicable to a comparable service when provided other than as a hospice
service.
(9) General Regulations.
General regulations of the MO HealthNet program apply to the hospice
program.
(10) Records Retention.
Sanctions may be imposed by the MO HealthNet agency against a provider for
failing to make available, and disclosing to the MO HealthNet agency or its
authorized agents, all records relating to services provided to MO HealthNet
participants or records relating to MO HealthNet payments, whether or not the
records are comingled with non-Title XIX (Medicaid) records in compliance with
13 CSR
70-3.030. These records must be retained for six (6)
years from the date of service. Fiscal and medical records coincide with and
fully document services billed to the MO HealthNet agency. Providers must
furnish or make the records available for inspection or audit by the Department
of Social Services or its representative upon request. Failure to furnish,
reveal, or retain adequate documentation for services billed to the MO
HealthNet program, as specified above, is a violation of this
regulation.
*Original authority: 208.152, RSMo 1967, amended 1969,
1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993;
208.153, RSMo 1967, amended 1973, 1989, 1990, 1991; and 208.201, RSMo
1987.
