Current through Bulletin 2024-06, March 15, 2024
(1) Hospice service
coverage includes medically necessary services as outlined in Subsection
R414-1-2(18).
(2) Continuous home care is limited to
alleviate or manage acute medical symptoms.
(a) Extended stay residents of nursing
facilities are not eligible for continuous home care days.
(b) Continuous home care is covered only as
required to maintain the terminally ill member at the member's place of
residence.
(c) The hospice agency
shall maintain documentation to support the requirement that the service was
medically necessary and complied with an established plan of care.
(3) Medicaid covers hospice room
and board in a nursing facility, ICF/ID, or a freestanding hospice inpatient
facility and includes:
(a) medication
administration;
(b) personal
care;
(c) social
activities;
(d) routine and
therapeutic dietary services, including direct feeding assistance;
(e) maintaining the cleanliness of the
member's room;
(f) assistance with
activities of daily living (ADLs);
(g) durable medical equipment;
(h) medical supplies; and
(i) prescribed therapies.
(4) Other services unrelated to
care associated with the terminal illness are covered under the Utah Medicaid
State Plan nursing facility benefit.
(5) If a member who resides in a nursing
facility revokes one's hospice benefits, the hospice agency shall notify the
facility of the revocation. The following notification requirements apply:
(a) the notice must be in writing;
and
(b) the hospice agency must
provide the notification to the facility on or before the revocation
date.
(6) A member may
receive general inpatient care provided in a hospice inpatient unit, a
hospital, or a nursing facility. General inpatient care days may not be used
due to the breakdown of the primary caregiving living arrangements or the
collapse of other sources of support for the member.
(7) Any change in hospice agencies must
adhere to the requirements of
42 CFR
418.30. The member or the member's legal
representative shall file the change with both the hospice agency from which
care has been received and with the newly designated hospice agency on or
before the effective date.
(8) A
member or legal representative may voluntarily revoke the member's election of
hospice benefits. The member or the member's representative must sign an
acknowledgement that the member will forfeit hospice service coverage for any
remaining days in the election period.
(9) Medicaid does not separately cover
modalities for palliative purposes as this is the responsibility of the hospice
agency. For the duration of an election for hospice care services, an
individual waives rights to Medicaid payments for the following services.
(a) Hospice care provided by a hospice agency
other than the hospice agency designated by the individual, unless provided
under arrangements made by the designated hospice agency.
(b) Services for illnesses or conditions
unrelated to the member's terminal illness, as these services are covered
ancillary to hospice benefits when provided by an appropriate provider or
facility.
(c) Any Medicaid services
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 provided by:
(i) the designated
hospice agency;
(ii) another
hospice agency under arrangements made by the designated hospice agency;
and
(iii) the individual's
attending physician if that physician is not an employee of the designated
hospice agency or receiving compensation from the hospice agency for those
services.
(10) The following applies for concurrent
care for members under 21 years of age.
(a)
For the duration of the election of hospice care, pediatric members may only
receive hospice care that is:
(i) provided by
the designated hospice agency; or
(ii) provided under arrangements made by the
designated hospice agency.
(b) Pediatric members who elect to receive
hospice care services may also receive concurrent Medicaid State Plan services
for the terminal illness and other related conditions.
(c) Medicaid does not separately cover any
modalities for palliative purposes as this is the responsibility of the hospice
agency.
(i) Hospice agencies that provide
services outside of the hospice benefit shall report directly to Medicaid for
coverage.
(ii) Hospice agencies are
not responsible for reimbursing other providers or facilities for
life-prolonging services given to pediatric members.
(d) Hospice agencies that perform pediatric
care shall develop a training curriculum to ensure that the hospice's
interdisciplinary team members, including volunteers, are adequately trained to
provide hospice care services. Staff members and volunteers who provide
pediatric hospice care services must receive training before providing hospice
services and at least annually thereafter.
(11) The training shall include the following
pediatric-specific elements:
(a) growth and
development;
(b) pediatric pain and
symptom management;
(c) loss,
grief, and bereavement for pediatric families and the child;
(d) communication with family, community, and
interdisciplinary team;
(e)
psychosocial and spiritual care of children; and
(f) coordination of care with the child's
community.
(g) Medicaid
incorporates by reference standards for pediatric hospice care services set
forth by the National Hospice and Palliative Care Organization, 2022.
(12) The hospice agency is
responsible for notifying Medicaid when a member is enrolled in hospice care,
when a member is discharged from hospice care, when a member moves into a
long-term care facility, ICF/ID, or freestanding inpatient hospice facility, or
when there has been a change in hospice agencies.
(13) If Medicare determines that a member is
no longer eligible for Medicare coverage of hospice care services, then the
member no longer qualifies for Medicaid coverage of hospice services.
Subsequently, hospice agencies shall immediately notify Medicaid of the members
change in eligibility upon learning of Medicare's determination. Medicaid
coverage for hospice care services ends the day after Medicare notifies the
hospice agency that the member is no longer eligible for hospice
care.
(14) Hospice agencies may not
initiate the discharge of a member from hospice unless the member meets the
circumstances outlined in
42 CFR
418.26.
(15) Inpatient respite care follows special
coverage requirements, which are outlined in
42 CFR
418.204(b)(2).
(a) Medicaid does not cover inpatient respite
care for members who reside in nursing facilities, ICF/IDs, or freestanding
hospice inpatient units.
(b)
Medicaid may not provide consecutive coverage for inpatient respite care for
more than five days at a time.
