Community-Based Services Manual (CBSM)

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Community-Based Services Manual (CBSM)

CBSM Other Aging/DSD programs Hospice

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Hospice

Page posted: 1/1/04		Page reviewed:	Page updated: 8/30/16
Legal authority	CFR 42, section 418, Minn. Stat. § 256B.0651 , Minn. Stat. §144A.48, Minn. Stat. §144A.75, Minn. Stat. §144A.751, Minn. Stat. §144A.752, Minn. Stat. §144A.753, Minn. Stat. §256B.0625, Minn. Stat §256B.0652, Minn. R. 9505.0297
Definition	Hospice: Palliative and supportive care for people who are terminally ill and their families to meet the physical, nutritional, emotional, social, spiritual and special needs experienced during the final stages of illness, dying and bereavement.
Eligibility	Eligibility for the hospice benefit is established when a person meets all of the following criteria: · Agrees to receive only palliative care for the terminal illness or condition · Has a life expectancy of six months or less · Is certified terminally ill by a physician · Voluntarily enrolls in the benefit. The hospice benefit is available through Medicare and Medical Assistance (MA). If a dually eligible person elects the Medicare hospice benefit, he or she must also elect the MA hospice benefit. The person may revoke his or her election of the benefit at any time.
Covered services	A comprehensive package of services for the person's terminal illness and conditions related to his or her terminal illness are provided directly though the hospice program or through a service contract or other arrangement. Services include: · Counseling services · Dietary services · Home health aide · Homemaking · Medical social services · Medical supplies and equipment · Nursing · Outpatient medications for pain and symptom control related to the terminal illness · Pastoral care · Physician services · Respite care · Short-term inpatient care · Speech, physical and occupational therapy · Volunteers. Hospice services provided must: · Be available on a 24-hour basis to offer support and care · Offer support and comfort to the person and his or her family Continuous care is provided in the home only during brief periods of intense need attributed to the terminal diagnosis as determined by the hospice coordinator and stated in the care plan. A planned program of supportive services for the families during the bereavement period is also included in hospice services. A centrally coordinated program provides services to ensure continuity and consistency of home and inpatient care.
Non-covered services	Services that duplicate a health service that is provided for another disability, diagnosis or condition, or services where there would be a duplicate payment.
Secondary information	Hospice services may be used in the person’s home or a Medicare-certified facility, such as an Intermediate Care Facility for Persons with Developmental Disabilities (IFC/DD), nursing facility or hospital for short-term stay. Hospice and MA State Plan services A person enrolled in the hospice benefit may have a complex set of health care needs involving the terminal condition and other medical conditions and/or disabilities. MA State Plan services may need to be adjusted during the period the person receives the hospice benefit. There may be a need for increased MA State Plan services when the terminal diagnosis creates an increased need for assistance for the pre-existing condition. A person may need a new MA State Plan service in response to medical needs that arise during hospice benefit period, but are unrelated to the terminal illness. For more information, see Hospice and MA State Plan services process and procedure. Hospice and BI, CAC, CADI and DD waivers The waiver services are usually in place before the hospice benefit begins. A referral for waiver services may take place to access available services and supports not related to the terminal condition. The case manager/service coordinator must justify the enrollment onto a waiver for service, confirm coordination with the hospice program and confirm there is no duplication of services. For more information, see hospice and waiver services policy and procedure Hospice and long-term care facilities MA-eligible residents of ICFs/DD and NFs who also meet hospice service eligibility may elect to receive hospice services where they live. The hospice provider becomes the primary provider of the service, authorizes and funds the hospice benefits. Medicare and Medicaid payments are made to the hospice provider for both the hospice services it provides and for the residential services provided by the facility. Current law requires a payment of at least 95 percent of the rate that would have been paid for facility services for the person.
Required care coordination	The hospice provider is responsible for leading the hospice service and care coordination with the person, family and other providers. For more information, see hospice provider responsibilities. Care coordination must address each of the following: · Person’s unique situation, as decisions applicable to one person may not be applicable to another · Potential areas of, and plans to eliminate or avoid, duplication of service and /or payment · Purpose of the service · Type of service a person needs. Care coordination requires complete and timely communication and collaboration among all team members. The interdisciplinary team is a group of qualified persons with expertise in meeting the special needs of hospice patients and their families in a manner that enhances the quality of life but is not directed at curing the illness. This team meets regularly to develop, implement and evaluate the plan of care for each hospice patient and the family. Team members may include: · Person and his or her legal representative · Family · Hospice provider · Waiver case manager/service coordinator and/or county public health nurse (PHN) · Medicaid home care agency representative · Medicaid financial worker · Others as decided by the team. Care coordination must occur when home and community-based services: · Meet a need for ongoing continuous care that is not covered under the hospice benefit, such as foster care or supported living service · Provide a service that is not duplicative and/or not offered under the hospice benefit · Support a non-terminal, pre-existing, acute or other health care condition or need. For more information, see: · Care coordination with MA State Plan services · Care coordination with waiver services.
Provider standards and qualifications	The Minnesota Department of Health (MDH) and Minnesota Department of Human Services (DHS) provide licensing and certification for hospice programs. Each hospice program must be: · Enrolled as an MHCP hospice provider · Licensed as a hospice and · Medicare-certified as a hospice. The medical components of the hospice program are under the direction of a licensed physician who services as medical director.
Hospice provider responsibilities	The hospice provider is required to lead care coordination. The provider has the following responsibilities: · Develop an individualized plan of care to identify a person’s needs related to the terminal illness and how those needs will be addressed · Develop a care coordination document · Authorize and pay for all services covered under the hospice benefit related to the terminal illness · Notify the waiver case manager/service coordinator or Medicaid home care provider of a person’s election of the hospice benefit and anticipated start date within two business days of hospice benefit election · Share the care coordination document with the waiver case manager/service coordinator or the Medicaid home care contact within eight calendar days of hospice benefit election.
Process and procedure	Access Assessment Authorization of hospice and MA State Plan services Authorization of hospice and waiver services
Additional resources	Centers for Medicare and Medicaid Services (CMS) – Hospice MHCP Provider Manual – Hospice

Process and procedure

Access	The person voluntarily selects the hospice benefit by selecting and informing the hospice provider. The suggestion may come from a physician, discharge planner, family member or others who provide assistance.
Assessment	There may be more than one assessment of need depending on the services required and the type of services and program the person currently uses. The following lists who is responsible for the assessment under each program: · BI, CAC, CADI and DD waivers - County case manager/ service coordinator · Hospice benefit - Designated person from the hospice provider organization · MA State Plan services - County PHN for PCA services and agency nurse for skilled nurse, home health aide and home care nursing services.
Authorization of hospice and MA State Plan services	The determination process for use of the hospice benefit and MA State Plan services needs to focus on the purpose of the service. To determine the purpose of a service, consider what need of the person the service addresses. For example: · Pre-existing condition or need · Health care problem that would have existed even without the terminal diagnosis · Facilitate the person’s ability to live in the community setting rather than an institution and would that need have been present with or without the terminal diagnosis. The hospice provider is responsible for care coordination and to determine if a MA State Plan service duplicates a hospice service. For more information, see hospice provider responsibilities. County PHNs and home care providers are responsible to: · Assure that there is no duplication as per the care coordination document · Coordinate service and support with the hospice provider · Maintain a copy of the care coordination document developed by the hospice provider · Participate in team meetings whenever necessary · Communicate responsively and timely and collaborate with the person, his or her family and the hospice provider Required documentation The hospice provider must fax or mail the Hospice Transaction Form, DHS-2868 (PDF) or the hospice’s own election statement form to the Medicaid home care agency within two business days of the hospice benefit election. This is the written notification about the person’s election of the hospice benefit and the anticipated start date. Cooperative agreement The hospice provider develops a care coordination document and shares it with the Medicaid home care provider within eight calendar days of the hospice benefit election. This document must be maintained in the person’s hospice and waiver files. MMIS service agreements – PCA services County PHNs are responsible for timely MMIS service agreement updates to reflect the increase or reduction in PCA services. A comment must be added to the MMIS service agreement indicating there has been coordination of PCA services with the hospice provider. MMIS service agreements – SNV, HHA and HCN Home care providers are responsible for timely MMIS service agreement authorization updates to reflect the increase or reduction in other MA State Plan services such as home care nursing, skilled nurse visits and home health aide visits. A comment must be added to the MMIS service agreement indicating there has been coordination of MA State Plan services with the hospice provider.
Authorization of hospice and waiver services	The determination process for use of hospice benefit and waiver services needs to focus on the purpose of the service. To determine the purpose of a service consider what need of the person the service addresses. For example: · Facilitate the person’s ability to live in the community setting rather than an institution and would that need have been present with or without the terminal diagnosis · Health care problem that would have existed even without the terminal diagnosis · Pre-existing condition or need. The hospice provider is responsible for care coordination and assurance that there is no duplication of services. For more information, see hospice provider responsibilities. Case manager/service coordinators are responsible to: · Assure there is no duplication of service · Complete the Notice of Action Long-Term Services and Supports, DHS-2828 (PDF) to provide information on right to appeal following reduction, termination or denial of service · Coordinate service and support with the hospice provider · Inform waiver recipients of the hospice benefit option · Maintain a copy of the care coordination document · Participate in team meetings whenever necessary · Communicate responsively and timely, and collaborate with the person, his or her family and the hospice provider. Required documentation The hospice provider must fax or mail the Hospice Transaction Form, DHS-2868 (PDF) or the hospice’s own election statement form to the waiver case manager/service coordinator within two business days of the hospice benefit election. This is written notification about the person’s election of the hospice benefit and the anticipated start date. Cooperative agreement The hospice provider develops a care coordination document and shares it with the waiver case manager/service coordinator within eight calendar days of hospice benefit election. This document must be maintained in the person’s hospice and waiver files. MMIS A new screening document may be needed if there are changes in the person’s health status. A new or revised Service Agreement DHS-3070 (PDF) may be needed with the addition of the hospice benefit to reflect an increase or decrease of waiver and MA State Plan services. An MMIS informational edit will appear on the service agreement to alert lead agencies that the person has elected the hospice benefit. Comments are required on the MMIS service agreement comment section indicating that coordination of services has occurred. The notes must indicate why continuing care services are necessary (e.g., treating a need not related to the terminal illness). When waiver or Alternative Care provider claims are received by DHS, a claim edit suspends the claim when the date of service overlaps with the hospice benefit period. Because the hospice provider becomes the primary payer of services, DHS will manually review home and community-based services provider claims to determine if payment is appropriate. Case management notes in MMIS will be reviewed at that time to ensure hospice provider coordination with the county case manager has occurred. The claim will remain in suspense until the coordination has occurred. When payment appears appropriate, the claim will be paid as requested. The informational edit and manual review of claims will remain in place temporarily to encourage consistent coordination between the provider areas.

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