New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 325 - SPECIALTY SERVICES
Part 4 - HOSPICE CARE SERVICES
Section 8.325.4.13 - COVERED SERVICES AND SERVICE LIMITATIONS
Universal Citation: 8 NM Admin Code 8.325.4.13
Current through Register Vol. 35, No. 18, September 24, 2024
For recipients electing hospice care, medicaid covers hospice core services furnished to eligible recipients that are reasonable and necessary for the palliation or symptom management of a recipient's terminal illness and related conditions. Hospice core services include the medications, durable medical equipment and medical supplies needed to deliver palliative care. Hospice providers are reimbursed for the delivery of core services based on daily rate.
A. The hospice services necessary for a specific recipient must be documented in an individualized treatment plan. The plan must be developed by attending physicians, medical directors and interdisciplinary groups and must meet certain requirements: See 42 CFR 418.50 et. seq.
(1) Hospices must
designate a registered nurse to coordinate the implementation of each
recipient's plan of care.
(2) The
interdisciplinary group, including nursing services, medical social services,
physician services and counseling services practitioners are responsible for
the following:
(a) developing the plan of
care;
(b) providing or supervising
hospice care and services;
(c)
reviewing and updating the plan of care;
(d) establishing policies for daily provision
of hospice care and services; and
(e) coordinating with other medicaid support
service providers such that the plan of care is not duplicative of hospice
services.
(3) All
hospice services must be available 24 hours per day to the extent necessary to
meet the needs of the terminally ill recipients.
B. Core services: Medicaid covers the following nursing, medical social service, physician and counseling services as core hospice services:
(1) nursing services
furnished by or under the supervision of registered nurses and based on the
treatment plan and recognized standards of practice;
(2) medical social services furnished by a
qualified social worker under the direction of a physician;
(3) physician services performed by a doctor
of medicine or osteopathy, including palliation and management of terminal
illness and related conditions and the recipient's general medical needs not
met by the recipient's attending physician;
(4) counseling services available to
recipients and family members; counseling can be furnished for training
families to provide care and preparing recipients and families to adjust to the
recipient's approaching death; counseling includes dietary, spiritual and other
counseling for recipients and families and bereavement counseling furnished
after a recipient's death; the following counseling services must be furnished
by hospices:
(a) organized program of
bereavement services under the supervision of qualified professionals; the plan
of care for these services must reflect family needs and provide a clear
outline of the type, frequency and duration of counseling; bereavement
counseling is a required but nonreimbursed service;
(b) dietary counseling, when applicable,
furnished by qualified professionals;
(c) spiritual counseling, including notice to
recipients of the availability of clergy; and
(d) other counseling, furnished by members of
the interdisciplinary group or other qualified professionals.
(5) home health aide and homemaker
services at frequencies sufficient to meet the needs of recipients; home health
aides must meet training and qualification requirements; see 42 CFR 484.36 ;
registered nurses must visit a recipient's residence every two weeks to assess
the performance of the aide or homemaker services;
(6) physical therapy, occupational therapy
and speech-language therapy must be available if needed to control symptoms or
maintain activities of daily living;
(7) durable medical equipment, medical
supplies, and pharmacy services related to the palliation and management of the
terminal illness and related conditions:
(a)
See 8.324.5 NMAC, Durable Medical Equipment and Medical
Supplies.
(b) Medicaid
covers only drugs and biologicals defined in Section 1861 (t) of the Social
Security Act and used primarily for pain relief and symptom control related to
terminal illness. All drugs and biologicals must be administered in accordance
with accepted standards of practice.
(c) Every hospice must have a policy for the
disposal of controlled drugs kept in the recipient's home when those drugs are
no longer needed.
(d) Drugs and
biologicals are to be administered only by the following individuals:
(i) a licensed nurse or physician;
(ii) the recipient with the approval of the
attending physician; and
(iii) any
other individual in accordance with applicable state and local laws; the
individual and each drug and biological they are authorized to administer must
be specified in the recipient's plan of care.
(8) short-term inpatient services for pain
control and symptom management delivered in a facility which is a medicaid
provider; and
(9) short-term
inpatient respite services furnished in a facility which is a medicaid
provider; medicaid covers five consecutive days of inpatient respite care which
can be needed on an infrequent basis to provide respite for the recipient's
family or primary caregivers.
(a) The need for
and duration of inpatient respite services must be specified in the treatment
plan.
(b) Inpatient respite must be
furnished by a hospice facility, hospital, or nursing facility that meets the
requirements in 42 CFR
Section 418.100.
C. Continuous nursing care services: Medicaid covers continuous nursing care required to achieve pain control and symptom management. Continuous care can be covered during a period of crisis if the recipient needs such care to achieve palliation and manage acute medical symptoms at home.
(1) To be
considered continuous care, nursing care must be furnished for eight
consecutive hours in a 24 hour period. Medicaid covers the homemaker or aide
services furnished during the other 16 hours as routine home care.
(2) Medicaid covers continuous nursing
services for a maximum of 72 consecutive hours.
Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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