HI 00601.295 Hospice Care - Requirements for Coverage
A. Certification requirements
In order to be entitled to hospice benefits under Medicare, an individual must be entitled to Part A, be certified as terminally ill, and elect to receive hospice benefits.
An individual is considered terminally ill if the medical prognosis is a life expectancy of six months or less. To be covered, a certification that the individual is terminally ill must have been completed and hospice services must be reasonable and necessary for the palliation or management of the terminal illness and related conditions. A plan of care must be established before services are provided, and services must be consistent with the plan. The Medicare hospice benefit is provided in periods of care. The periods consist of two 90-day periods and an unlimited number of 60-day periods.
The hospice must obtain the certification that an individual is terminally ill in accordance with the following procedures:
For the first 90-day period of hospice coverage, the hospice must obtain, no later than two calendar days after hospice care is initiated, 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 the individual has an attending physician). The attending physician is a physician who is a doctor of medicine or osteopathy and is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care.
For the subsequent periods, the hospice must obtain, no later than two 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 that his or her life expectancy is six months or less and the signature(s) of the physician(s).
B. Election requirements
If an individual elects to receive hospice care, he or she must file an election statement with a particular hospice. 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 patient, State law determines the extent to which the individual may act on the patient's behalf.
The two 90-day election periods must be used before the 60-day periods. An election to receive hospice care will be considered to continue through the initial election period and through the 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. An individual may designate an effective date for the election period that begins with the first day of hospice care or any subsequent day of hospice care, but not earlier than the date the election is made.
An individual must waive all rights to Medicare payments for the duration of the election of hospice care for the following services:
Hospice care provided by a hospice other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice).
Any Medicare 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—
provided (either directly or under arrangement) by the designated hospice;
provided by another hospice under arrangements made by the designated hospice; and
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.
An individual or representative may revoke the election of hospice care at any time. To revoke the election of hospice care, the individual must file a signed statement with the hospice that revokes the election for Medicare coverage of hospice care for the remainder of that election period and the date that the revocation is to be effective. The effective date cannot be earlier than the date that the revocation is made. The individual forfeits coverage for any remaining days in that election period.
Upon revoking the election of Medicare coverage of hospice care for a particular election period, an individual resumes Medicare coverage of the benefits waived when hospice care was elected. An individual may at any time elect to receive hospice coverage for any other hospice election periods for which he or she is eligible.
An individual may change, once in each election period, the designation of the particular hospice from which he or she 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 programs, the individual must file, with the hospice from which he or she 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 he or she plans to receive care and the date the change is to be effective. A change of ownership of a hospice is not considered a change in the patient's designation of a hospice and requires no action on the patient's part.
C. Special coverage requirements
1. Continuous home care
Continuous home care is covered only during a period of medical crisis to maintain an individual at home. A period of crisis is when a patient requires continuous, primarily nursing care to achieve palliation or management of acute medical symptoms. Nursing care must be provided by either a registered nurse or a licensed practical nurse. A nurse must be providing care for more than half of the period of care. A minimum of 8 hours of care must be provided during a 24-hour day which begins and ends at midnight. There can be intervening periods between periods when services are provided, e.g., 4 hours could be provided in the morning and another 4 hours in the evening. Homemaker and aide services may also be provided to supplement the nursing care. If less skilled care is needed on a continuous basis to enable the person to remain at home, this is covered as routine home care.
2. Respite care
Respite care is short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual at home. Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time.
3. Bereavement counseling
Bereavement counseling consists of counseling services provided to the individual's family after the individual's death. Bereavement counseling is a required hospice service, but it is not reimbursable.