Virginia Administrative Code
Title 12 - HEALTH
Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE
Section 12VAC30-60-130 - Hospice services
Universal Citation: 2 VA Admin Code 30-60-130
Current through Register Vol. 41, No. 3, September 23, 2024
A. Admission criteria.
1. Service election. To be eligible
for hospice coverage under Medicare or Medicaid, the recipient shall be
"terminally ill," defined as having a life expectancy of six months or less,
and, except for individuals younger than 21 years of age, elect to receive
hospice services rather than active treatment for the illness. Both the
attending physician (if the individual has an attending physician) and the
hospice medical director, or the attending physician and the physician member
of the interdisciplinary team, must initially certify the life expectancy. The
election statement shall include (i) identification of the hospice that will
provide care to the individual; (ii) the individual's or representative's
acknowledgment that the individual or representative has been given a full
understanding of the palliative rather than curative nature of hospice care as
it relates to the individual's terminal illness; (iii) with the exception of
children, defined as persons younger than 21 years of age, acknowledgment that
certain Medicaid services are waived by the election; (iv) the effective date
of the election; and (v) the signature of the individual or
representative.
2. Service
revocation. The recipient shall have the right to revoke election of hospice
services at any time during the covered hospice periods. DMAS shall be
contacted if the recipient revokes hospice services. If the recipient reelects
the hospice services, the hospice periods will begin as an initial timeframe.
Therefore, the certification and time requirements in this subsection will
apply. The recipient cannot retroactively receive hospice benefits from
previously unused hospice periods. The recipient's written revocation statement
shall be maintained in the recipient's medical record.
B. General conditions. The general conditions provided in this subsection apply to nursing care, medical social services, physician services, counseling services, short-term inpatient care, durable medical equipment and supplies, drugs and biologicals, home health aide and homemaker services, and rehabilitation services.
The recipient shall be under the care of a physician who is legally authorized to practice and who is acting within the scope of the physician's license. The hospice medical director or the physician member of the interdisciplinary team shall be a licensed doctor of medicine or osteopathy. Hospice services may be provided in the recipient's home or in a freestanding hospice, hospital, or nursing facility.
The hospice shall obtain the written certification that an individual is terminally ill in accordance with the following procedures:
1. For the initial 90-day
benefit period of hospice coverage, a Medicaid written certification (DMAS 420)
shall be signed and dated by the medical director of the hospice and the
attending physician, or the physician member of the hospice interdisciplinary
team and the attending physician, at the beginning of the certification period.
This initial certification shall be submitted for preauthorization within 14
days from the physician's signature date. This certification shall be
maintained in the recipient's medical record.
2. For the subsequent 90-day hospice period,
a Medicaid written certification (DMAS 420) shall be signed and dated before or
on the begin date of the 90-day hospice period by the medical director of the
hospice or the physician member of the hospice's interdisciplinary team. The
certification shall include the statement that the recipient's medical
prognosis is that the recipient's life expectancy is six months or less. This
certification of continued need for hospice services shall be maintained in the
recipient's medical record.
3.
After the second 90-day hospice period and until the recipient is no longer in
the Medicaid hospice program, a Medicaid written certification shall be signed
and dated every 60 days on or before the begin date of the 60-day period. This
certification statement shall be signed and dated by the medical director of
the hospice or the physician member of the hospice's interdisciplinary team.
The certification shall include the statement that the recipient's medical
prognosis is that the recipient's life expectancy is six months or less. This
certification shall be maintained in the recipient's medical record.
C. Utilization review. Authorization for hospice services requires an initial preauthorization by DMAS and physician certification of life expectancy. Utilization review will be conducted to determine if services were provided by the appropriate provider and to ensure that the services provided to Medicaid recipients are medically necessary and appropriate. Services not specifically documented in the recipients' medical records as having been rendered shall be deemed not to have been rendered and no coverage shall be provided.
D. Hospice services are a medically directed, interdisciplinary program of palliative services for terminally ill people and their families emphasizing pain and symptom control. The rules pertaining to hospice services are:
1. Interdisciplinary
team. An interdisciplinary team shall include at least the following
individuals: a physician (either a hospice employee or a contract physician), a
registered nurse, a social worker, and a pastoral or other counselor. Other
professionals may also be members of the interdisciplinary team depending on
the terminally ill recipient's medical needs.
2. Nursing care. Nursing care shall be
provided by a registered nurse or by a licensed practical nurse under the
supervision of a graduate of an approved school of professional nursing and who
is licensed as a registered nurse.
3. Medical social services. Medical social
services shall be provided by a social worker who has at least a bachelor's
degree from a school accredited or approved by the Council on Social Work
Education, and who is working under the direction of a physician.
4. Physician services. Physician services
shall be performed by a professional who is licensed to practice, who is acting
within the scope of the professional's license, and who is a doctor of medicine
or osteopathy, a doctor of dental surgery or dental medicine, a doctor of
podiatric medicine, a doctor of optometry, or a chiropractor. The hospice
medical director or the physician member of the interdisciplinary team shall be
a licensed doctor of medicine or osteopathy.
5. Counseling services. Counseling services
shall be provided to the terminally ill individual and the family members or
other persons caring for the individual at home. Counseling, including dietary
counseling, may be provided both for the purpose of training the individual's
family or other caregiver to provide care and for the purpose of helping the
individual and those caring for the individual to adjust to the individual's
approaching death. Bereavement counseling consists of counseling services
provided to the individual's family up to one year after the individual's
death. Bereavement counseling is a required hospice service, but it is not
reimbursable.
6. Short-term
inpatient care. Short-term inpatient care may be provided in a participating
hospice inpatient unit or a participating hospital or nursing facility. 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 the individual's
family or other persons caring for the individual at home.
7. Durable medical equipment and supplies.
Durable medical equipment as well as other self-help and personal comfort items
related to the palliation or management of the patient's terminal illness is
covered. Medical supplies include those that are part of the written plan of
care.
8. Drugs and biologicals.
Only drugs that are used primarily for the relief of pain and symptom control
related to the individual's terminal illness are covered.
9. Home health aide and homemaker services.
Home health aides providing services to hospice recipients shall meet the
qualifications specified for home health aides by
42 CFR
484.80. Home health aides may provide
personal care services. Aides may also perform household services to maintain a
safe and sanitary environment in areas of the home used by the patient, such as
changing the bed or light cleaning and laundering essential to the comfort and
cleanliness of the patient. Homemaker services may include assistance in
personal care, maintenance of a safe and healthy environment, and services to
enable the individual to carry out the plan of care. Home health aide and
homemaker services shall be provided under the general supervision of a
registered nurse.
10.
Rehabilitation services. Rehabilitation services include physical and
occupational therapies and speech-language pathology services that are used for
purposes of symptom control or to enable the individual to maintain activities
of daily living and basic functional skills.
a. Occupational therapy services shall be
those services furnished a patient that meet all of the following conditions:
(1) The services shall be directly and
specifically related to an active written treatment plan designed by the
physician after any needed consultation with an occupational therapist
registered and certified by the American Occupational Therapy Certification
Board;
(2) The services shall be of
a level of complexity and sophistication, or the condition of the patient shall
be of a nature, that the services can only be performed by an occupational
therapist registered and certified by the American Occupational Therapy
Certification Board or an occupational therapy assistant certified by the
American Occupational Therapy Certification Board under the direct supervision
of an occupational therapist; and
(3) The services shall be specific and
provide effective treatment for the patient's condition in accordance with
accepted standards of medical practice, including the requirement that the
amount, frequency, and duration of the services shall be reasonable.
b. Physical therapy services shall
be those furnished a patient that meet all of the following conditions:
(1) The services shall be directly and
specifically related to an active written treatment plan designed by a
physician after any needed consultation with a physical therapist licensed by
the Board of Medicine;
(2) The
services shall be of a level of complexity and sophistication, or the condition
of the patient shall be of a nature, that the services can only be performed by
a physical therapist licensed by the Board of Medicine, or a physical therapy
assistant who is licensed by the Board of Medicine and under the direct
supervision of a physical therapist licensed by the Board of Medicine;
and
(3) The services shall be
specific and provide effective treatment for the patient's condition in
accordance with accepted standards of medical practice, including the
requirement that the amount, frequency, and duration of the services shall be
reasonable.
c.
Speech-language pathology services shall be those services furnished a patient
that meet all of the following conditions:
(1)
The services shall be directly and specifically related to an active written
treatment plan designed by a physician after any needed consultation with a
speech-language pathologist licensed by the Board of Audiology and
Speech-Language Pathology;
(2) The
services shall be of a level of complexity and sophistication, or the condition
of the patient shall be of a nature, that the services can only be performed by
a speech-language pathologist licensed by the Board of Audiology and
Speech-Language Pathology; and
(3)
The services shall be specific and provide effective treatment for the
patient's condition in accordance with accepted standards of medical practice,
including the requirement that the amount, frequency, and duration of the
services shall be reasonable.
11. Documentation of hospice services shall
be maintained in the recipient's medical record. Coordination of patient care
between all health care professionals should be maintained in the recipient's
medical record.
Statutory Authority: §§ 32.1-324 and 32.1-325 of the Code of Virginia.
Disclaimer: These regulations may not be the most recent version. Virginia 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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
