1. 2015 National Training Program
Medicare’s Coverage of Hospice Services
This session presents an overview of hospice services and supplies covered by Medicare.
This session should help you
Explain face-to-face requirements
Determine core vs. non-core services
Discuss hospice election, discharge, and revocation
Identify coordination between Part D sponsors, hospices, and prescribers
Explain differences for hospice coverage for people in a Medicare Advantage Plan
This training module was developed and approved by the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Federally-facilitated Health Insurance Marketplace. The information in this module was correct as of June 2015.
The CMS National Training Program provides this as an informational resource for our partners. It’s not a legal document or intended for press purposes. The press can contact the CMS Press Office at Official Medicare program legal guidance is contained in the relevant statutes, regulations, and rulings.
For Those Who Counsel People With Medicare
July 2015

2. History of Modern Hospice
English physician Dame Cicely Saunders works with terminally ill
Saunders brings the concept to U.S. at Yale University
First modern hospice—St. Christopher’s Hospice in UK
1948
1963
1967
Dr. Elisabeth Kübler-Ross published her book
“On Death and Dying”
Hospice, Inc. was founded in the U.S.
Connecticut Hospice was founded
1969
The following is a detailed timeline to show that hospice was a philosophical concept first in the United Kingdom and later adopted by the United States. For the purpose of a live presentation, we will highlight and 1974.
The term hospice was first applied to specialized care for dying patients by English nurse, social worker, and then physician Dame Cicely Saunders. She started her work with the terminally ill in 1948 and eventually went on to create the first modern hospice—St. Christopher’s Hospice—in a residential suburb of London in 1967.
1963: Saunders introduced the idea of specialized care for the dying to the United States during a visit with Yale University.
1969: Dr. Elisabeth Kübler-Ross, a psychiatrist who taught at U.S. medical schools, was troubled that nothing in the medical school curriculum addressed death and dying. She later went on to publish her book, “On Death and Dying”.
Kübler-Ross identified the 5 stages of dying (denial, anger, bargaining, depression, and acceptance), which many patients experience at the end of life. She argued for the provision of care in the patient's home rather than in the institutional setting and for allowing patients to participate in making decisions for themselves with respect to choices at the end of life. The book became a world-wide best seller.
1971: Hospice, Inc. was founded, first bringing the principles of modern hospice care to the United States. Florence Wald RN, MSN, FAAN, was an internationally recognized pioneer in improving the care of dying patients across the world. Wald organized an interdisciplinary team and opened the first hospice in 1971.
1972: Kübler-Ross testified at the first national hearings on the subject of death with dignity, which were conducted by the U.S. Senate Special Committee on Aging. In her testimony, Kübler-Ross stated, “We live in a very particular death-denying society. We isolate both the dying and the old, and it serves a purpose. They are reminders of our own mortality. We shouldn’t institutionalize people. We can give families more help with home care and visiting nurses, giving the families and the patients the spiritual, emotional, and financial help in order to facilitate the final care at home.”
1974: Florence Wald, along with 2 pediatricians and a chaplain, founded the Connecticut Hospice in Branford, Connecticut.
1971
1974
06/01/2015
Medicare’s Coverage of Hospice Services

3. Hospice Legislative History
1986
Medicare hospice benefit is made permanent
States are given the option of including hospice in their Medicaid programs
2008
Medicare Hospice Conditions of Participation (regulations) are significantly revised
The following is a timeline to show that hospice was not always a benefit, but for the purpose of a live presentation, we will highlight 1986 and 2008.
1986: The Medicare hospice benefit is made permanent by Congress and hospices are given a 10% increase in reimbursement rates. States are given the option of including hospice in their Medicaid programs. Hospice care is now available to terminally ill nursing home residents. (Congress had included a provision to create a Medicare hospice benefit in the Tax Equity and Fiscal Responsibility Act of 1982, with a sunset provision.)
2003: The burgundy hospice awareness ribbon is unveiled prior to November’s National Hospice Month (see cover).
2008: The regulations (Conditions of Participation) for Medicare certified hospice providers issued by CMS were significantly revised for the first time since the original publication.
NOTE: CMS develops Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries. CMS also ensures that the standards of accrediting organizations recognized by CMS (through a process called "deeming") meet or exceed the Medicare standards set forth in the CoPs / CfCs.
Source: NHPCO.org/history-hospice-care.
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Medicare’s Coverage of Hospice Services

4. Hospice as a Philosophy
Most services take place in the patient’s place of residence (67%)
An interdisciplinary team approach to treatment and care planning
Attends to the physical, emotional, psychosocial, and spiritual aspects of dying and caregiving
Focuses on quality of life and death, and views death as a natural process of living
Affirms life and neither hastens nor postpones death
Determines specific things that bring quality of life to you, including the right to die pain-free and with dignity
You’re encouraged to complete advance directives
Your choices regarding resuscitation measures and curative treatments are respected and honored
Medicare Part A covers hospice care, which is a special way of caring for terminally ill people and their families. Hospice care is meant to help you make the most of the last months of life by giving you comfort and relief from pain. It involves a team of providers that addresses your medical, physical, social, emotional, and spiritual needs. The goal of hospice is to care for you and your family, not to cure your illness. You must sign a statement choosing hospice care instead of routine Medicare-covered benefits to treat your terminal illness. However, medical services not related to your hospice condition would still be covered by Medicare. You can get hospice care as long as your doctor certifies that you are terminally ill.
Hospice as a philosophy
Most services take place in the patient’s place of residence (67% in 2013, of which 42% is a private residence[home])
Interdisciplinary approach
Attends to the emotional, psychosocial, and spiritual aspects of dying and caregiving.
The hospice team develops a care plan that meets each patient’s individual needs for pain management and symptom control. This interdisciplinary team usually consists of the patient’s personal physician, hospice physician or medical director, nurses, hospice aides, social workers, bereavement counselors, clergy or other spiritual counselors, trained volunteers, and speech, physical, and occupational therapists, if needed.
Focuses on quality of life and death, and views death as a natural process of living.
Affirms life and neither hastens nor postpones death.
Hospice care involves acknowledging that most diseases in their advanced form can’t be cured. It doesn’t mean giving up hope. The focus of hope shifts towards helping the patient achieve maximum physical comfort and peace of mind.
Helps determine specific things that bring quality of life to each patient, including the right to die pain-free and with dignity.
Patients are encouraged to complete advance directives. Patients’ choices regarding resuscitation measures and curative treatments are respected and honored by hospice. Advance directives are legal documents that allow you to spell out your decisions about end-of-life care ahead of time. They give you a way to tell your wishes to family, friends, and health care professionals and to avoid confusion later on.
A living will tells which treatments you want if you are dying or permanently unconscious. You can accept or refuse medical care. You might want to include instructions on the use of dialysis and breathing machines, if you want to be resuscitated if your breathing or heartbeat stops, hydration and/or tube feeding, organ or tissue donation.
A durable power of attorney for health care is a document that names your health care proxy. Your proxy is someone you trust to make health decisions for you if you are unable to do so.
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Medicare’s Coverage of Hospice Services

5. "All Hospice Care is Palliative but Not All Palliative Care is Hospice"
Palliative Care Programs
May include curative care and treatments
Can be received by patients at any time, at any stage of illness whether it be terminal or not
Often in an inpatient facility
No life expectancy of 6 months or less requirement
Don’t have to provide the same range of core services as required by the hospice benefit
Hospice Care Benefit
A Medicare benefit for the terminal phase of life when a cure is no longer probable
6 months or less life expectancy
Addresses physical comfort symptoms and the emotional and spiritual concerns about dying for the patient and family, often at home
All hospice care is palliative, but not all palliative care is hospice.
It’s important to understand the subtle differences between Palliative Care programs vs. the Medicare hospice benefit. Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. Hospice services and palliative care programs share similar goals of providing symptom relief and pain management. Both programs enhance comfort and promote the quality of life for individuals and their families.
Palliative Care is a program and a relatively new specialty. Starting in 2006 in the United States, palliative medicine became a board certified sub-specialty of internal medicine with specialized fellowships for physicians who are interested in the field. In the United States today, 55% of hospitals with more than 100 beds offer a palliative-care program, and nearly one-fifth of community hospitals have palliative-care programs. Since there are no time limits based on life expectancy of 6 months or less related to when you can receive palliative care, it acts to fill the gap for patients who want and need comfort at any stage of any disease, whether terminal or chronic. In a palliative care program, there is no expectation that life-prolonging therapies such as chemotherapy will be avoided. It is most common to receive palliative care in an institution such as a hospital, extended care facility, or nursing home that is associated with a palliative care team. Palliative care programs don’t have to provide the same range of core services that are associated with hospice care – Interdisciplinary Team (IDT), bereavement, spiritual, social work, patient/family, etc.
Hospice is a type of palliative care but it concentrates on comfort rather than curative disease treatment. For this presentation, we will refer to hospice as the Medicare benefit. Hospice is often administered in the home. Hospice relies upon the family caregiver, as well as a visiting hospice nurse. By electing to forego extensive life- prolonging treatment, hospice patients can concentrate on getting the most out of the time they have left, without some of the negative side-effects that life prolonging treatments can have. Most hospice patients can achieve a level of comfort that allows them to concentrate on the emotional and practical issues of dying.
*Both provide “palliative care” which enhances comfort and
promotes the quality of life for individuals and their families.
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Medicare’s Coverage of Hospice Services

6. Who is Electing Hospice? Top Hospice Claims Diagnoses 2004-2013
Non-Alzheimer’s dementia
Congestive Heart Failure
CVA/stroke
Other Respiratory and Heart Disease
Alzheimer's disease
Parkinson’s disease
Chronic liver and kidney disease
Debility and Adult Failure to Thrive
ALS
HIV/Aids
Cancer (37%)
Breast, lung, colorectal, prostate, liver, pancreatic and bladder
Blood and lymph cancers such as leukemia, lymphomas and multiple myeloma
More Medicare beneficiaries are taking advantage of the quality and compassionate care provided through the hospice benefit. As greater numbers of beneficiaries have availed themselves of the benefit, the mix of hospice patients has changed over time, with relatively fewer cancer patients as a percentage of total patients (37%). 
Top Hospice Terminal Claims Diagnoses (2004 to 2013 Calendar Year Data)
Non-Alzheimer’s dementia
Congestive Heart Failure
CVA/stroke
Other Respiratory and Heart Disease
Alzheimer's disease
Parkinson’s disease
Chronic liver and kidney disease
Debility and Adult Failure to Thrive
ALS
HIV/AID
Cancer—breast, lung, colorectal, prostate, liver, pancreatic, bladder
Blood and lymph cancers—leukemia, lymphomas, and multiple myeloma
NOTE: Lung cancer has been recognized as the most common diagnosis among Medicare hospice patients every year since 1998.
Expenditures for the Medicare hospice benefit have increased approximately $1 billion per year. In calendar year (CY) 1998, expenditures for the Medicare hospice benefit were $2.2 billion, while in CY 2009, expenditures for the Medicare hospice benefit were $12.1 billion. There were more than twice as many Medicare hospice patients in 2009 than in 1998.
SOURCE: CMS.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Medicare_Hospice_Data.html and nhpco.org/sites/default/files/public/Statistics_Research/2014_Facts_Figures.pdf
Lung cancer has been recognized as the most common diagnosis among Medicare hospice patients every year since 1998
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Medicare’s Coverage of Hospice Services

7. Hospice Utilization Data
According to claims data at the time of death, only 47% of people with Medicare were enrolled in hospice care
Only 25% of deaths occur at home
More than 70% of Americans would prefer to die at home (Robert Wood Johnson Foundation)
The determination and/or decision to elect hospice is made extremely close to the end of life
The median (50th percentile) length of service in 2013 was 18.5 days
Most people are enrolled into hospice within one week of death
Half of hospice patients were enrolled for less than one month at the time of their death
According to claims data, at the time of death, only forty-seven percent of people with Medicare are enrolled in hospice.
This means over half of people with Medicare aren’t enrolled in hospice at the time of their death.
Twenty-five percent of deaths occur at home, but more than 70% of Americans would prefer to die at home (Robert Wood Johnson Foundation).
It seems that the determination and/or decision to elect hospice is made extremely close to the end of life.
The median (50th percentile) length of service in 2013 was 18.5 days
Data shows that most people are enrolled into hospice within one week of death.
And 50% of hospice patients are enrolled for less than one month at the time of their death.
The total number of days that a hospice patient receives care is referred to as the length of service (or length of stay). Length of service can be influenced by a number of factors including disease course, timing of referral, and access to care. The average length of stay for hospice ranges often depends on the diagnosis. In 2009, the average length of stay for kidney disease was 27 days while it was 106 days for Alzheimer’s disease and other degenerative conditions.
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Medicare’s Coverage of Hospice Services

8. When Should I Elect Hospice Services?
According to external research, to allow you to get the full benefit of hospice services, it is preferred that hospice be on board for at least 2-3 months prior to death, in order to
Maximize comfort and decrease pain
Receive counseling
Attend to closure tasks which may include putting affairs in order, saying goodbye, letting go, finding meaning and value in life and death, and mending relationships
Have a straightforward conversation with your doctor about end of life issues
The determination and/or decision to elect hospice is often made extremely close to the end of life. According to external research, having hospice on board for at least 2-3 months prior to death is preferable to allow patients to get the full benefit of hospice services.*
In order to maximize comfort and decrease pain.
As you can imagine, there’s a lot to attend to after receiving a terminal prognosis. You can receive counseling which may include, assisting with closure tasks such as putting affairs in order, saying goodbye, letting go, finding meaning and value in life and death, and mending relationships. Bereavement counseling is a required hospice service but it isn’t reimbursable. It must be made available from admission through 12 months after the patient’s death.
Have a straightforward conversation with your doctor about end of life issues
*(2007) What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Soc Sci Med 65:1466–1478.
(2003) Barriers to physicians' decisions to discuss hospice: Insights gained from the United States hospice model. J Eval Clin Pract 9:363–372.
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Medicare’s Coverage of Hospice Services

9. Medicare’s Coverage of Hospice Services
Eligibility
If you have Medicare Part A (Hospital Insurance) AND meet these conditions, you can get hospice care
Your doctor must certify that you’re terminally ill (with a life expectancy of 6 months or less)
You accept palliative care (for comfort) instead of care to cure your illness (except children in Medicaid)
You sign a statement electing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions
Hospice care is a benefit under the Medicare hospital insurance program. To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered to be terminally ill if their medical prognosis determines that the individual’s life expectancy is 6 months or less assuming the illness runs its normal course.
If you have Medicare Part A (Hospital Insurance) AND meet these conditions, you can get hospice care:
Your hospice doctor and your attending physician (regular doctor, if you have one) certify that you’re terminally ill with a life expectancy of 6 months or less.
You accept palliative care for comfort instead of care to cure your illness. Currently, Medicare beneficiaries are required to forgo curative care in order to receive access to hospice care services. In 2010, a provision in The Patient Protection and Affordable Care Act required state Medicaid programs to allow children with a life-limiting illness to receive both hospice care and curative treatment.
You sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions.
NOTE: “Attending physician" means the individual doctor who has the most significant role in the determination and delivery of your medical care. This could be an oncologist, cardiologist, primary care practitioner, etc.
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Medicare’s Coverage of Hospice Services

10. Election of Hospice Care
A valid hospice election statement signed by you or your representative is required
You should be seen within 48 hours of the election
Know what you are “electing” and that you are eligible
The election statement must include the following information
Identification of the particular hospice and attending physician or nurse practitioner (if they have one) that will provide care to the individual
Acknowledgment that the individual understands hospice care particularly the palliative rather than curative nature of treatment
Acknowledgement that certain Medicare services are waived by the election
The effective date of the election
The signature of the individual or authorized representative
A person with Medicare choosing to elect the hospice benefit for end-of-life care must do so in writing, by signing a valid hospice election statement, with a specific hospice provider of their choice. You should be seen by the hospice within 48 hours of the election. Know what you are “electing” and that you are eligible. A hospice election should be one of informed consent so you recognize that you are choosing a specific type of care delivery. And by electing this benefit, if you seek and receive care that is related to their terminal prognosis outside of hospice, you may be liable for the entire cost of that care if the hospice didn’t arrange it. This should not be a benefit that is “lightly” elected as it is a very personal choice.
 The election statement must include the following information:
Identification of the particular hospice and attending physician or nurse practitioner (if they have one) that will provide care to the individual
Acknowledgment that the individual understands hospice care, particularly the palliative rather than curative nature of treatment (forgo curative treatment)
Acknowledgement that certain Medicare services are waived by the election
The effective date of the election
The individual’s designated attending physician of their choice
The signature of the individual or his or her authorized representative
For the duration of a hospice care election, an individual waives all rights to Medicare Part A payments for any Medicare services related to the treatment of the terminal condition, or a related condition, for which hospice care was elected.
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
1. Remains in the care of a hospice
2. Doesn’t revoke the election; and
3. Isn’t discharged from the hospice
Hospice providers will have a maximum of 5 days to have the Notice of Election (NOE) submitted and accepted by their Medicare contractor for claims processing. This is different than the “election statement“ signed by the beneficiary.
NOTE: See Electronic Code of Federal Regulations § Election of hospice care. See also Chapter 9 of the Medicare Benefit Policy Manual for Hospice eligibility requirements and election of hospice care available at CMS.gov/Regulations-and-Guidance/ Guidance/Manuals/downloads/bp102c09.pdf.
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Medicare’s Coverage of Hospice Services

11. How Long Does Hospice Care Last?
Care is given in “election periods”
Doctor must certify each “election period”
Two 90-day periods (to equal 6 months)
Face-to-face encounter required prior to the third election period and each subsequent 60-day recertification
Then unlimited 60-day periods
Care is given in “election periods”—two 90-day periods (6 months) followed by unlimited 60-day periods. At the start of each period, the hospice medical director or other hospice doctor must recertify that you’re terminally ill (with a life expectancy of 6 months or less), so you can continue to get hospice care.
We will discuss the face-to face requirement on the next slide.
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Medicare’s Coverage of Hospice Services

12. Face-to-Face Encounter
A face-to-face (FTF) encounter must
Occur within 30 calendar days prior to the start of the third election period (during your 5th month of care and each subsequent 60 day recertification)
Verify clinical findings supporting life expectancy of 6 months or less
Be documented with attestation
Be performed by a hospice physician or a hospice nurse practitioner (NP) 
If the FTF encounter requirements aren’t met, the patient will no longer be eligible for the Medicare hospice benefit
The hospice should continue to care for the patient at its own expense and have them sign a new election when the FTF occurs
With passage of the Affordable Care Act in March 2010, hospice physicians or hospice nurse practitioners (NPs) are required to have a Face-to-Face (FTF) encounter with Medicare hospice patients prior to the 180th-day recertification, and every recertification thereafter, and to attest that the encounter occurred. CMS implemented the policies related to this new requirement (which became effective on January 1, 2011).
A face-to-face (FTF) encounter must
Occur within 30 calendar days prior to the start of the third election period (during your 5th month of care and each subsequent 60 day recertification).
The documentation must include who provided the FTF and the clinical findings must verify the life expectancy. A hospice physician (employed, volunteer, or contracted) or a hospice NP (full-time, part-time, or per diem) must have a face-to-face encounter with the patient.
If a hospice NP or non-certifying physician performs the FTF, they must share the clinical findings with the certifying physician. The NP can’t sign the recertification, even though she/he provided the FTF. The FTF encounter must document clinical findings supporting a life expectancy of 6 months or less.
If the FTF requirements aren’t met, the patient is no longer eligible for the Medicare Hospice benefit.
When a discharge from the Medicare hospice benefit occurs due to failure to perform a required FTF encounter timely, the claim should include the most appropriate patient discharge status code. The hospice can re-admit the patient to the Medicare hospice benefit once the required encounter occurs, provided the patient continues to meet all of the eligibility requirements and the patient (or representative) files an election statement in accordance with CMS regulations. If the only reason the patient ceases to be eligible for the Medicare hospice benefit is because of the hospice’s failure to meet the FTF requirement, CMS would expect the hospice to continue to care for the patient at its own expense until the required FTF occurs, enabling the hospice to re- establish Medicare eligibility.
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Medicare’s Coverage of Hospice Services

13. Hospice Team As Your Primary Provider Of Services
Hospice should provide comprehensive and coordinated care
Once you choose hospice care, your hospice benefit should cover most everything you need
You shouldn’t have to go outside of hospice to get care
Except in very rare situations unrelated to the terminal illness and related conditions
A hospice nurse and doctor are on-call 24 hours a day, 7 days a week
To give you and your family support and care when you need it
If unavailable, contact your state survey agency to file a complaint
If the hospice team determines that you need inpatient care, they will make arrangements for your stay
Contact the hospice and document the direction they have provided
Ask them to communicate directly with non-hospice providers
Hospice should provide comprehensive and coordinated care.
Once you choose hospice care, your hospice benefit should cover most everything you need.
You shouldn’t have to go outside of hospice to get care
Except in very rare situations unrelated to the terminal prognosis and related conditions
A hospice nurse and doctor are on-call 24 hours a day, 7 days a week
To give you and your family support and care when you need it
If they are unavailable, you may file a complaint with your state survey agency and quality improvement organization
If the hospice team determines that you need inpatient care, the hospice team will make the arrangements for your stay.
Contact the hospice and document the direction they have provided
Ask them to communicate directly with non-hospice providers
The majority of services should be covered under the hospice benefit. Once you elect hospice, there would be very little that would be outside of hospice coverage as there are many conditions that contribute to a terminal prognosis.
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Medicare’s Coverage of Hospice Services

14. Medicare Hospice Coverage
Consulting hospice physician 100% covered
Attending non-hospice affiliated physician
Is covered at 80% under Part B
You must pay the deductible and coinsurance amounts for all Medicare-covered services to treat health problems that aren’t part of your terminal illness and related conditions*
You must continue to pay Medicare premiums
You must continue to pay Medicare Supplement Insurance (Medigap) premiums, if applicable
The consulting hospice physician is covered at 100%. This is often the medical director who may not see you directly until your 5th month of care.
Your attending non-hospice affiliated physician is covered at 80% under Part B and is encouraged to be part of the interdisciplinary team since they know you best.
You must pay the deductible and coinsurance amounts for all Medicare-covered services to treat health problems that aren’t part of your terminal illness and related conditions.*
You also must continue to pay Medicare premiums, and
Medigap (Medicare Supplement Insurance) policy premiums, if applicable.
NOTE: Medicare covers a certain portion of hospice related costs. The other portion is the responsibility of the patient. If the patient has a Medigap policy, it will cover some portion or all of the coinsurance. Coverage of hospice coinsurance depends on the type of Medigap policy that is purchased. If you have a Medigap (Medicare Supplement Insurance) policy, some plans may cover your hospice costs for drugs and respite care and most plans cover copayments and coinsurance. All Medigap plans cover Part A hospice care coinsurance or copayments at 100% except for Plan K (50%) and Plan L (75%). Your Medigap policy may also help cover health care costs for problems that aren’t part of your terminal illness and related conditions. Call your Medigap policy for more information. To get more information about Medigap policies, visit Medicare.gov or call MEDICARE.
Visit CMS.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/ Training- Library-Items/CMS html to view Module 3 on Medigap (Medicare Supplement Insurance) policies.
*Unrelated is determined on a case-by-case basis and all care must be comprehensive and coordinated
*Unrelated is determined case-by-case and must be coordinated by the hospice.
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Medicare’s Coverage of Hospice Services

15. Medicare Covered Hospice Services
Includes physical care, counseling, equipment, and supplies for the terminal illness and related conditions
Drugs for symptom control and pain relief
No more than $5 out-of-pocket cost per Rx to manage pain and symptoms while the patient is at home
Short-term inpatient care in a Medicare/Medicaid participating facility for pain and symptom management that can’t be managed in the home
Respite care (caregiver relief) in a Medicare-certified facility, up to 5 days each time, no limit to how often
The patient is responsible for 5% inpatient respite care cost
On a case-by-case basis, home respite may be available
Part A services typically include physical care, counseling, drugs, equipment, and supplies* for the terminal illness and related conditions.
Drugs for symptom control and pain relief
For hospice care in Original Medicare, you pay a copayment of no more than $5 for each prescription drug and other similar products for pain relief and symptom control while receiving routine or continuous care at home.
Short-term care in the hospital, hospice inpatient facility, or skilled nursing facility in a Medicare/ Medicaid participating facility, when needed crisis care is needed for pain and symptom management that can’t be managed at home.
Inpatient respite care, which is care given to you by another caregiver, so your usual caregiver can rest. You’ll be cared for in a Medicare-approved facility, such as a hospice inpatient facility, hospital, or nursing home. You can stay up to 5 days each time you get respite care, and there’s no limit to the number of times you can get respite care. Hospice care is usually given in your home (or a facility you live in). However, Medicare also covers short-term hospital care when needed. You pay 5% of the Medicare-approved payment amount for inpatient respite care. For example, if Medicare has approved a charge of $150 per day for inpatient respite care, you’ll pay $7.50 per day. The amount you pay for respite care can change each year.
On a case-by-case basis, home respite may be available, if the hospice can make supplemental staffing arrangements.
*Equipment and medical supplies: The physician and nurse will work with the family to determine which medical supplies and equipment the patient needs. Generally most hospice providers will order the equipment and have it delivered to the home. Examples include hospital beds and infusion pumps.
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Medicare’s Coverage of Hospice Services

16. Service Details That Must Be Provided by the Hospice
The hospice agency must provide directly*
Directly, contracted or under arrangements
Core Services
Physician services
Nursing care
Social work and counseling services including pastoral care
Bereavement services for up to one year
(*W2 employees of the hospice)
Non-Core Services
Therapy services
Hospice aide services
Home health aide/homemaker services
Volunteer services
Other services may be provided under arrangement
Short-term inpatient or respite care
Medical equipment/ supplies
Medications for symptom management and pain relief
The hospice agency provides “Core and Non-Core Services.” Core hospice services (42 CFR § ) must routinely be provided directly by hospice employees. They include: physician services, nursing services, [(routinely available and/or on call on a 24-hour basis, 7 days a week) provided by or under the supervision of a registered nurse (RN) functioning within a plan of care developed by the hospice’s interdisciplinary group (IDG) in consultation with the patient’s attending physician, if the patient has one], medical social services by a qualified social worker under the direction of a physician, and counseling (including, but not limited to, bereavement, dietary, and spiritual counseling). The hospice must make bereavement services available to the family and other individuals identified in the bereavement plan of care up to one year following the death of the patient.
In addition to the hospice core services (physician services, nursing services, medical social services, and counseling), a hospice must also provide the following non-core services (42 CFR §418.70), either directly or under arrangements, to meet their patients’ and their families’ needs.
Supplemental services may be contracted in order to meet unusual staffing needs that cannot be anticipated and that occur so infrequently it would not be practical to hire additional staff to fill these needs such as physical and occupational therapy and speech-language pathology services; hospice aide services; homemaker services; and volunteers.
Other services may be provided under arrangement (42 CFR § ) such as medical supplies (including drugs and biologicals on a 24-hour basis) and the use of medical appliances related to the terminal diagnosis and related conditions; short-term inpatient care (including respite care and interventions necessary for pain control and acute and chronic symptom management) in a Medicare/ Medicaid participating facility.
NOTE: In the event you encounter issues with any of your non-core services, the hospice must maintain professional, financial and administrative responsibility for the services even if not their own staff and assure that all staff meet the regulatory qualification requirements.
06/01/2015
Medicare’s Coverage of Hospice Services

17. Medicare Reimburses 4 Levels of Hospice Care
Routine Home Care―is most common; patient is at home under care of the hospice and not receiving any other category of care
Continuous Home Care―patient is at home and in a period of crisis requiring a high level of care to maintain them in the home setting. (A minimum of 8 total hours a day must be provided, of which, more than half must be provided by an RN or LPN in addition to aide or homemaker care)
Inpatient Respite Care―patient is in an approved inpatient facility* and receiving respite care (caregiver relief); 5 days maximum in a single period at a *Medicare or Medicaid certified hospital, SNF, hospice facility, or NF
General Inpatient Care―patient is inpatient at a Medicare certified hospice facility, hospital or skilled nursing facility
With the exception of payment for physician services, Medicare payment for hospice care is made at 1 of 4 predetermined rates for each day that a Medicare patient is under the care of the hospice. The rate paid for any particular day varies depending on the level of care furnished to the patient.
Routine Home Care―The hospice is paid the routine home care rate for each day the patient is under the care of the hospice and not receiving one of the other categories of hospice care. This rate is currently paid without regard to the volume or intensity of routine home care services provided on any given day, and is also paid when the patient is receiving outpatient hospital care for a condition unrelated to the terminal condition.
Continuous Home Care (CHC)―The hospice is paid the continuous home care rate when continuous home care is provided in the patient’s home. Continuous home care is not paid during a hospital, skilled nursing facility, or inpatient hospice facility stay. This rate is paid only during a period of crisis and only as necessary to maintain the terminally ill individual at home. The continuous home care rate is divided by 24 hours in order to arrive at an hourly rate. A minimum of 8 hours must be provided. Nursing care must be provided for more than half of the period of care and must be provided by either a registered nurse or licensed practical nurse. The hospice must provide a minimum of 8 hours of nursing, hospice aide, and/or homemaker care during a 24-hour day, which begins and ends at midnight. Continuous home care is not intended to be used as respite care. For more detailed information on Continuous Home Care, see Pub , Chapter 9, §
Inpatient Respite Care―The hospice is paid at the inpatient respite care rate for each day on which the person with Medicare is in an approved inpatient facility and is receiving respite care. Payment for respite care may be made for a maximum of 5 continuous days at a time including the date of admission but not counting the date of discharge. Payment for the sixth and any subsequent days is to be made at the routine home care rate. More than one respite period (of no more than 5 days each) is allowable in a single billing period. Payment at the respite rate is made when respite care is provided at a Medicare or Medicaid certified hospital, SNF, hospice facility, or NF.
General Inpatient Care―Payment at the inpatient rate is made when general inpatient care is provided at a Medicare certified hospice facility, hospital, or skilled nursing facility.
Source- Medicare Claims Processing Manual- CMS Publication , Chapter 11-Processing Hospice Claims.
The needs of the patient determine the level of care.
06/01/2015
Medicare’s Coverage of Hospice Services

18. Services Covered―Limited Room and Board
Room and board are covered in some instances
During short-term respite care
During short-term inpatient stays for pain/symptom management
Room and board aren’t covered by Medicare if
You receive routine home care hospice services while a resident of a nursing home, or at a freestanding hospice residential facility
But if you have Medicaid and live in nursing facility
Room and board are covered by Medicaid
Room and board are only payable by Medicare in certain cases. Room and board are covered during short-term inpatient stays for pain and symptom management, and for respite care.
Room and board could be covered at a hospice's residential facility if the patient is admitted under General Inpatient (GIP) or Inpatient Respite (IRC) level of care.
Room and board aren’t covered if you receive general hospice services while a resident of a nursing home or a hospice’s residential facility. However, if you have Medicaid as well as Medicare, and reside in a nursing facility, room and board are covered by Medicaid.
Medicare may cover short term inpatient stays in a skilled nursing facility (SNF) only if the SNF has a contract with Medicare.
06/01/2015
Medicare’s Coverage of Hospice Services

19. Hospice and Nursing Home/Facility
Medicare covers hospice at a skilled nursing facility (SNF) for general inpatient care and inpatient respite care
Only if the SNF has a contract with the hospice to provide you care
Short term inpatient care
To manage crisis symptoms and control pain
In a hospice freestanding facility, hospital or nursing facility
Provide caregiver relief (respite care)
Inpatient hospital or nursing facility care
Medicare covers hospice at a skilled nursing facility (SNF)
Only if the SNF has a contract with the hospice to provide you care
The hospice benefit won’t pay for room and board at the SNF for your hospice care.
Short term inpatient care
Medicare will cover short-term in-patient care in a hospice, hospital or nursing facility if your pain and symptoms can’t be managed in any other place.
Medicare pays for inpatient hospital or nursing facility care to provide relief to your caregivers. This is called respite care.
If you are already a resident in a facility and are approached to sign an election, ask for details so that your consent is informed.
NOTE: For more information visit the Medicare Benefit Policy Manual, Chapter 9, Section 20.3 at CMS.gov/Regulations-and-Guidance/Guidance/Manuals/ downloads/bp102c09.pdf.
*If already a resident in a SNF and approached to “elect” this benefit, ask for details so that your consent is informed.
06/01/2015
Advanced Hospice

20. Hospice and Medicare Advantage (MA)
MA Plans must inform enrollees about all of the hospice options that are available in the area they live
MA enrollees may elect hospice
With any Medicare certified hospice provider and your hospice services are covered by Original Medicare
From the effective date of election to the date of discharge or revocation through the end of the month when you revoke or are discharged from hospice alive
If you need health care services that are not covered by your hospice you can receive those services through Original Medicare
With 20% cost sharing or through your MA plan at the plan cost sharing rate
Those enrolled in MA Plans, like all people with Medicare, are eligible to elect the hospice benefit. MA organizations must inform enrollees who are eligible for hospice care about the available Medicare hospice programs in their community. The patient can select any Medicare-certified hospice provider. After the hospice election, Medicare pays the hospice for hospice services and pays for services of the MA attending physician, who may be a nurse practitioner, and services not related to the patient’s terminal illness, through the fee- for-service (FFS) system. The hospice benefit is always covered under Original Medicare.
MA enrollees who decide to elect hospice can receive the hospice benefit but it is paid for by Original Medicare not the MA plan (see CFR ). The MA regulations, at below, also require MAOs to inform enrollees about all of the hospice options that are available in the area they live. If an MA enrollee elects hospice then they can stay enrolled in their MA plan but all of their hospice services would be covered by Original Medicare. The MA Plan can’t disenroll someone for electing hospice.
The Medicare hospice benefit, through Original Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the hospice election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness. Upon discharge or revocation, fee-for-service Medicare continues to cover the patient through the end of the month when the patient revokes or is discharged from hospice (while alive). At the start of the month following revocation or discharge, all billing and coverage revert back to the managed care plan (see Pub , Medicare Claims Processing Manual, Chapter 11, §30.4 at CMS.gov/Regulations-and-Guidance/Guidance/Manuals/ Downloads/clm104c11.pdf).
Once a managed care enrollee has elected hospice, all Medicare benefits revert to fee-for-service, though the enrollee still remains on managed care for any additional benefits provided by the managed care plan, such as dental or vision coverage. While all Medicare services, both hospice and non-hospice, revert to FFS while under a hospice election, the patient can still go to MA-participating providers.
To the extent there are non-hospice health care services that the MA enrollee requires the MA enrollee in hospice has the option of getting those services either through Original Medicare (and paying the 20% copay) or going through their MA plan and paying applicable plan cost sharing. More information on MA plans and hospice coverage is located in Chapter 4 section 10.4 at the web link CMS.gov/Medicare/Health-Plans/HealthPlansGenInfo/index.html.
NOTE: § Special rules for hospice care.
(a) Information. An MA organization that has a contract under subpart K of this part must inform each Medicare enrollee eligible to select hospice care under § of this chapter about the availability of hospice care (in a manner that objectively presents all available hospice providers, including a statement of any ownership interest in a hospice held by the MA organization or a related entity) if—
(1) A Medicare hospice program is located within the plan's service area; or
(2) It is common practice to refer patients to hospice programs outside that area.
06/01/2015
Medicare’s Coverage of Hospice Services

21. Coordination Between Part D Sponsors, Hospices, and Prescribers
The Code of Federal Regulations § and § (f) require hospice programs to provide individuals under hospice care with drugs and biologicals
Related to the palliation and management of the terminal illness and related conditions as defined in the hospice plan of care
For prescription drugs to be covered under Part D when the enrollee has elected hospice
The drug must be for treatment of a condition that’s unrelated to the terminal condition which will be determined by the hospice interdisciplinary group
The Code of Federal Regulations Title 42, § and § (f) require hospice programs to provide individuals under hospice care with drugs and biologicals related to the palliation and management of the terminal illness and related conditions as defined in the hospice plan of care.
In addition to routine medications to treat the terminal illness and the related conditions, the hospice provides a “comfort kit.” The hospice comfort kit, also known as the emergency kit, e- kit, or hospice kit, is a prescribed set of medications that are kept in a patient's home in the event of an emergency. Having the medications already in the home will help the hospice team treat any distressing symptoms as quickly as possible. The most basic of comfort kits contain medications for pain, anxiety, nausea, insomnia, constipation, and breathing problems. A more extensive list of medications, based on anticipated symptoms and treatments, may be found in a hospice comfort kit.
For prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is unrelated to the terminal condition of the individual which is determined by the hospice interdisciplinary group in the plan of care.
Ask your hospice provider to send information to your Part D Plan to indicate instances where a prescription you need is unrelated to your terminal condition. On the next slide, we will discuss a CMS-approved form for them to do so.
If you choose to end hospice care, provide your Part D plan written proof of the change, so it can update your status in its systems. If you don’t give your plan this information, you may get medication denials.
06/01/2015
Medicare’s Coverage of Hospice Services

22. Communication Between Medicare Part D Plans and Hospice Providers
Optional standardized form “Hospice Information for Medicare Part D Plans CMS-10538” and its instructions are available on CMS' website
CMS.gov/Medicare/Prescription-Drug- Coverage/PrescriptionDrugCovContra/index.html
Part D sponsors and hospice organizations are strongly encouraged to begin using the optional form as soon as possible
Prior authorization is recommended for the following drugs frequently used in hospice settings
Analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics)
An optional standard prior authorization form to facilitate coordination between Part D sponsors, hospices, and prescribers has been finalized. It’s called the “Hospice Information For Medicare Part D Plans CMS-10538” (formerly, Prior Authorization Form for Beneficiaries Enrolled in Hospice); for more information on the public comment process and development of this form, visit CMS.gov/Regulations-and-Guidance/ Legislation/ PaperworkReductionActof1995/ PRA-Listing.html.
Part D sponsors and hospice organizations are strongly encouraged to begin using the optional form as soon as possible. To access the form and its instructions directly, visit CMS.gov/Medicare/Prescription-Drug-Coverage/ PrescriptionDrugCovContra/ Downloads/Instruction-and-Form-for-Hospice-and-Medicare-Part-D.pdf.
The CMS July 18, 2014, guidance strongly encouraged Part D sponsors to place beneficiary-level Prior Authorization (PA) requirements on the 4 categories of prescription drugs [frequently used in hospice and identified by the DHHS Office of Inspector General (OIG)] for analgesics(pain), antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics).
Another helpful CMS webpage for Hospice updates is the Hospice Center at CMS.gov/Center/Provider-Type/Hospice-Center.html.
NOTE: View the Appendix in notes view for a full size view of the CMS form.
06/01/2015
Medicare’s Coverage of Hospice Services

23. Medicare’s Coverage of Hospice Services
Revocation of Hospice
You or your representative may revoke (end) the election of hospice care in writing at any time for any reason
If an election has been revoked by you or a representative, you may at any time
Resume Medicare coverage of the benefits waived while under hospice
May then seek medical care outside the parameters of the defined hospice benefit
If you have a Medicare Advantage Plan, the plan starts covering you the first day of the next month
Elect to receive hospice coverage for any other future hospice election periods for which you’re eligible
Revocation is the right of the patient. CMS allows an individual or representative to revoke the election of hospice care at any time, but it must be done in writing. You may no longer need hospice care if your health improves or your illness goes into remission. You always have the right to stop hospice care at any time for any reason. 
If you stop your hospice care, you’ll get the type of Medicare coverage you had before you chose a hospice program, like Original Medicare, a Medicare Advantage Plan, or another type of Medicare health plan.
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 and may seek medical care outside of the defined hospice benefit.
Managed care enrollees who have elected hospice may revoke hospice election at any time, but claims will continue to be paid by fee-for-service contractors as if the beneficiary were a fee-for-service beneficiary until the first day of the month following the month in which hospice was revoked.
If you’re eligible, you may at any time elect to receive hospice coverage again.
To revoke the election of hospice care, the individual must file a document with the hospice that includes a signed statement that the individual revokes the election for Medicare coverage of hospice care for the remainder of that election period and the effective date of that revocation (as discussed on the next slide). The hospice must file a timely Notice of Election Termination/Revocation (NOTR).
A hospice may discharge the patient, per guidelines for discharge found in Code of Federal Regulations (CFR) § but may not revoke the patient’s election of hospice care.
See also Electronic Code of Federal Regulations § “Revoking the election of hospice care.”
06/01/2015
Medicare’s Coverage of Hospice Services

24. Signed Written Statement of Revocation
The written statement must contain the effective date of the revocation
A verbal revocation of hospice election is NOT acceptable
You forfeit hospice coverage for any remaining days in that election period
You may not designate a revocation effective date earlier than the date the revocation is made – do not sign this form in advance of actual revocation
The day of revocation is a billable day
The hospice can’t revoke the beneficiary’s election, nor can the hospice demand the beneficiary revoke his/her election
There is not a standardized hospice revocation form
To revoke the election of hospice care, the beneficiary/representative must give a signed written statement of revocation to the hospice.
The statement must contain the effective date of the revocation.
A verbal revocation of hospice election is NOT acceptable.
The individual forfeits hospice coverage for any remaining days in that election period.
An individual may not designate a revocation effective date earlier than the date the revocation is made.
The day of revocation is a billable day.
The hospice can’t revoke the beneficiary’s election, nor can the hospice demand the beneficiary revoke his/her election.
There is no standardized hospice revocation form.
06/01/2015
Medicare’s Coverage of Hospice Services

25. Acceptable Reasons for Discharge from Hospice Care
Medicare regulations Title 42 Code of Federal Regulations define 3 reasons for discharge from hospice care.
The patient moves out of the hospice’s service area or transfers to another hospice.
The hospice determines that the patient is no longer terminally ill.
The hospice determines the patient meets its internal policy regarding discharge for cause.
Medicare regulations Title 42 Code of Federal Regulations(CFR) define 3 reasons for discharge from hospice care:
The patient moves out of the hospice’s service area or transfers to another hospice.
The hospice determines that the patient is no longer terminally ill.
The hospice determines the patient meets their internal policy regarding discharge for cause such as in extraordinary circumstances in which a hospice would be unable to continue to provide hospice care to a patient. These situations would include issues where patient safety or hospice staff safety is compromised. When a hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired, the hospice can consider discharge for cause. The hospice must: advise the patient that a discharge for cause is being considered; make a serious effort to resolve the problem(s) presented by the patient's behavior or situation; ascertain that the patient's proposed discharge is not due to the patient's use of necessary hospice services; and document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into the patient’s medical records. The hospice must notify the Medicare contractor and State Survey Agency of the circumstances surrounding the impending discharge. The hospice may also need to make referrals to other relevant state/community agencies (i.e., Adult Protective Services) as appropriate.
Hospice patients have the right to an expedited appeal when their provider decides to discontinue hospice care entirely because they believe the patient no longer has a life expectancy of 6 months or less. The hospice provider must give the patient a standardized "valid written notice" at least 2 days prior to the cessation of care. Among other pieces of information, the standardized notice must outline the date that coverage of services ends; the date that the patient’s financial liability for continued services begins; and a description of the patient’s right to an expedited determination. This Notice of Medicare Non-Coverage (NOMNC) must be given to people with Medicare when their Medicare covered service(s) are ending. The notice is valid when the patient (or authorized representative) has signed and dated the notice to indicate that he or she has received the notice and can comprehend its contents. The standardized notice contains the telephone number for the Quality Improvement Organization (QIO) serving the beneficiary's state. Visit “Beneficiary Notices” at CMS.gov/Medicare/Medicare- General-Information/BNI/ FFSEDNotices.html.
06/01/2015
Medicare’s Coverage of Hospice Services

26. Hospice Scenario―Anton
Anton has Original Medicare with Part D. He has had insulin-dependent diabetes for 10 years.
He has taken Ativan (lorazepam) for anxiety since his diagnosis 10 years ago.
He now has terminal pancreatic cancer and elects the hospice benefit.
Is the hospice or Part D responsible for his insulin and/or Ativan?
NOTE: This section provides 3 possible scenarios for discussion as time allows. Select 1 or 2 based on your audience needs for interactive review. Hide slides accordingly.
Anton: Medications with Hospice vs. Part D
Jermaine: Continuous home care
Betty: Medicare Advantage and hospital care
Anton has Original Medicare with Part D.
He had been an insulin-dependent diabetic for 10 years.
He also has taken Ativan (lorazepam) for anxiety since his diagnosis 10 years ago.
He now has terminal pancreatic cancer and elects the hospice benefit.
Is the hospice or Part D responsible for these medications? Discussion with the next slide.
06/01/2015
Medicare’s Coverage of Hospice Services

27. Hospice Scenario 1 Review―Anton Hospice vs. Part D Medication
Is his need for insulin related to his terminal diagnosis (pancreatic cancer)? Who makes the determination? Is his need for antianxiety medication related to his terminal diagnosis ? What should be done if the hospice believes either of these drugs should be covered by Anton’s Part D plan?
Is his need for insulin related to his terminal diagnosis (pancreatic cancer)? Hospices are required to provide services for the palliation and management of the terminal illness and related conditions. However, Medicare hasn’t defined the term "related conditions." Additionally, the hospice determines through the interdisciplinary group treatment planning, what is related versus unrelated to the terminal prognosis. Body systems are interrelated and decisions regarding what is related versus unrelated must be reviewed on a case by case basis.
Diagnoses alone don’t necessarily indicate relatedness or unrelatedness in a terminally ill patient. Hospices are required to care for those who are dying, not just a single or even multiple diagnoses, rather the total condition of the patient that renders him/her terminally ill. This is a very important concept in the "holistic" nature of hospice. Holistic means integrated whole and data suggests that there is widely varying interpretation as to what it means to be "related" versus "unrelated.” Title 42 of the Code of Federal Regulations § and § (f) require hospice programs to provide individuals under hospice care with drugs and biologicals related to the palliation and management of the terminal illness as defined in the hospice plan of care.
Who makes the determination?
Anton’s diabetes/insulin may or may not be related to his terminal diagnosis since the pancreas effects insulin production. For purposes of preauthorization, this is a class of drugs that doesn’t require a preauthorization through Part D. The hospice must address these issues through the interdisciplinary group/team treatment planning.
Is his need for antianxiety medication related to his terminal diagnosis ?
The antianxiety medication may or may NOT be related to the terminal diagnosis, however, it falls in the recommended prior authorization category
What should be done if the hospice believes either of these drugs should be covered by Anton’s Part D plan?
For prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is unrelated to the terminal condition of the individual.
Recommend
“Hospice Information For Medicare Part D Plan” be filled out for the antianxiety medication and possibly both to avoid any issues.
Prior authorization is suggested for analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics). CMS.gov/Medicare/Prescription-Drug-Coverage/ PrescriptionDrugCovContra/Downloads/Instruction-and-Form-for-Hospice-and- Medicare-Part-D.pdf.
06/01/2015
Medicare’s Coverage of Hospice Services

28. Hospice Scenario 2—Jermaine
Jermaine experienced new onset seizures, his wife Mabel called the hospice and a hospice nurse arrived at 10 AM. The nurse provided skilled care and remained with him until 2 PM (4 total hours) when his symptoms were better controlled. She also provided training to Mabel. Mabel is exhausted and says she can’t provide any more care for her husband. A hospice aide is assigned to monitor him for 24 hours, beginning at 2 PM, with a total of 8 hours of direct care the first day. The nurse returned intermittently to administer medications to control his symptoms, assess Jermaine, and relieve the aide for breaks for an additional 5 hours the same day. The hospice’s social worker spent 3 hours counselling Mabel and identifying alternative methods to care for Jermaine.
NOTE: This section provides 3 scenarios for discussion as time allows. Select 1 or 2 based on your audience needs for interactive review. Hide slides accordingly.
Scenario
Jermaine elected hospice care. His wife Mabel is his caregiver. When he experienced new onset seizures, Mabel called the hospice and a hospice nurse arrived at 10 AM. He continues to have episodes of vomiting. The nurse remains with the patient for 4 hours (10 AM – 2 PM) until the seizures cease. During that time she provides skilled care and family teaching. The patient’s wife states she is unable to provide any more care for her husband. A hospice aide is assigned to the patient for monitoring for 24 hours, beginning at 2:00 PM, with a total of 8 hours of direct care in the first day. The nurse returns intermittently for a total of an additional 5 hours to administer medications, assess the patient and to relieve the aide for breaks. The social worker provides 3 hours of services to work with the patient’s wife in identifying alternative methods to care for the patient.
Does the scenario appear to qualify as continuous home care (CHC)? See discussion questions on the next slide.
Determination will be guided through questions on the next slide. This qualifies as a continuous home care day. This constitutes a medical crisis, including collapse of family structure. The caregiver has been providing skilled care and the change in the patient’s condition requires the nurse’s interventions. Since there is no overlap in nursing care, 17 hours of care (i.e., 9 hours of nursing care and 8 hours of aide care) would be computed as CHC. The social worker hours wouldn’t be incorporated. If the caregiver had been providing custodial care and his medical crisis resolved within a short time frame, this situation wouldn’t have qualified as CHC.
For additional examples of what may or may not qualify as CHC, visit Section Continuous Home Care (CHC) of the Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services under Hospital Insurance.
06/01/2015
Medicare’s Coverage of Hospice Services

29. Hospice Scenario 2— Continuous Home Care Review
Let’s look at parts of this scenario that could guide if it qualifies for Continuous Home Care (CHC). Was this a medical crisis? What happened to his family support system? Did he need frequent medication adjustments to control his symptoms? What is the minimum number of hours of services provided to be considered CHC? How many hours of nursing care (LPN or RN) was provided? How many hours of aide services were provided? Do all the hours of services have to be continuous? Does this scenario qualify for CHC?
Let’s look at parts of this scenario that could guide if it qualifies for Continuous Home Care (CHC).
Was this a crisis? Yes, this constitutes a medical crisis, which means the patient has uncontrolled symptoms and requires continuous care, which is predominantly nursing care, to achieve palliation or management of acute medical symptoms.
What happened to his family support system? Collapse of family structure. The caregiver has been providing skilled care and the change in the patient’s condition now requires the nurse’s interventions.
Did he need frequent medication adjustments to control his symptoms? Yes, the nurse came intermittently for a total of 9 hours to adjust medications to keep him at home.
What is the minimum number of hours of services provided to be considered CHC? The hospice must provide a minimum of 8 hours of nursing, hospice aide, and/or homemaker care during a 24-hour day. The nurse (LPN or RN) must provide must than ½ the total hours. 17 hours of care (i.e., 9 hours of nursing care and 8 hours of aide care) would be computed as CHC.
Do all the hours of services have to be continuous? The 8 hour minimum can be divided into segments, which begins and ends at midnight.
Does this scenario qualify for CHC? This qualifies as a continuous home care day. It is considered CHC within the hospice benefit, if the patient is being managed in the home setting and it is typically provided during a period of crisis. The social worker hours wouldn’t be incorporated.
There may be circumstances where the patient’s needs require direct interventions by more than one covered discipline resulting in an overlapping of hours between the nurse and hospice aide. The total hours paid cannot exceed 24 hours per day. This means that all nursing and aide hours should be included in the computation for CHC and when the aide hours exceed the nursing hours, CHC would be denied and routine payment will be made. The statutory definition of continuous home care is meant to include the full range of services needed to achieve palliation and management of acute medical situations. Deconstructing what is provided in order to meet payment rules is not allowed. In other words, hospices cannot discount any portion of the hours provided in order to qualify for a continuous home care day. For additional examples of what may or may not qualify as CHC, visit Section Continuous Home Care (CHC) of the Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services under Hospital Insurance.
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Medicare’s Coverage of Hospice Services

30. Medicare’s Coverage of Hospice Services
Special Quote
English nurse, social worker, and then physician Dame Cicely Saunders.
"You matter because you are you. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but also to live until you die." ~ Dame Cicely Saunders
Resources and the Part D form are found at the end of the session materials.
06/01/2015
Medicare’s Coverage of Hospice Services

31. CMS National Training Program (NTP)
To view all available NTP training materials, or to subscribe to our list, visit
CMS.gov/Outreach-and-Education/Training/ CMSNationalTrainingProgram/index.html
For questions about training products
This training module is provided by the CMS National Training Program (NTP).
To view all available CMS NTP materials, including additional training modules, job aids, educational activities, and webinar and workshop schedules, or to subscribe to our list, visit CMS.gov/Outreach-and- Education/Training/CMSNationalTrainingProgram/index.html
For questions about these training products,

32. Medicare’s Coverage of Hospice Services
Hospice Resources
Electronic Code of Federal Regulations
§ 418—Hospice Care
Medicare Benefit Policy Manual
Chapter 9 - Coverage of Hospice Services Under Hospital Insurance
Medicare Claims Processing Manual
Chapter 11 - Processing Hospice Claims
Section 30.4 addresses Managed Care
Medicare.gov Publication
“Medicare Hospice Benefits”
Hospice Center
CMS.gov/Center/Provider-Type/Hospice-Center.html
Electronic Code of Federal Regulations § 418—Hospice Care. Visit ecfr.gov/cgi-bin/text- idx?rgn=div5;node=42:
Medicare Benefit Policy Manual
Chapter 9—Coverage of Hospice Services Under Hospital Insurance. Visit CMS.gov/Regulations- and-Guidance/Guidance/ Manuals/ downloads/ bp102c09.pdf
Medicare Claims Processing Manual
Chapter 11—Processing Hospice Claims. Visit CMS.gov/Regulations-and-Guidance/ Guidance/Manuals/Downloads/clm104c11.pdf
Section 30.4 addresses Managed Care
Federal regulations require that Medicare fee-for-service contractors maintain payment responsibility for managed care enrollees who elect hospice. These regulations are found at Title 42 Code of Federal Regulations (CFR), Part 417, Subpart P: 42 CFR Special Rules: Hospice Care (b); and 42 CFR Hospice Care Services (b). Medicare Fee for Service retains payment responsibility for all hospice and non-hospice related claims beginning on the date of the hospice election.
Medicare.gov Publication
“Medicare Hospice Benefits” at Medicare.gov/Pubs/pdf/02154.pdf.
Hospice Center at CMS.gov/Center/Provider-Type/Hospice-Center.html
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Medicare’s Coverage of Hospice Services

33. Finding Your State Hospice Organization
Medicare.gov/contacts/
Finding a hospice program
The hospice program you choose must be Medicare-approved to get Medicare payment. To find out if a certain hospice program is Medicare-approved, ask your doctor, the hospice program, your state hospice organization, or your state health department. State hospice organizations are membership associations for hospice and palliative care programs, services, and facilities available in each state. Generally, they offer training, support, resources. They provide information on where hospice services are available in their state.
Medicare.gov has the state hospice organizations listed.
Consider these questions when choosing hospice care providers:
Is the hospice program certified and licensed by the state or federal government?
Does the hospice provider train caregivers to care for you at home?
How will your doctor work with the doctor in the hospice program?
How many other patients are assigned to each member of the hospice care staff?
Will the hospice staff meet regularly with you and your family to discuss care?
How does the hospice staff respond to after-hour emergencies?
What measures are in place to ensure hospice care quality?
What services do hospice volunteers offer? Are they trained?
06/01/2015
Medicare’s Coverage of Hospice Services

34. Appendix–Page 1 Hospice/Part D Form
CMS.gov/Medicare/Prescription-Drug-Coverage/ PrescriptionDrugCovContra/Downloads/Instruction-and-Form-for-Hospice-and-Medicare-Part-D.pdf
Appendix–Page 1 Hospice/Part D Form
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06/01/2015
Medicare’s Coverage of Hospice Services

35. Appendix–Page 2 Hospice/Part D Form
CMS.gov/Medicare/Prescription-Drug-Coverage/ PrescriptionDrugCovContra/Downloads/Instruction-and-Form-for-Hospice-and-Medicare-Part-D.pdf.
View this page in Notes View
06/01/2015
Medicare’s Coverage of Hospice Services