Section 441.78.36. Hospice services.

       78.36(1) General characteristics. A hospice is a public agency or private organization or a subdivision of either that is primarily engaged in providing care to terminally ill individuals. A hospice provides palliative and supportive services to meet the physical, psychosocial, social and spiritual needs of a terminally ill individual and the individual’s family or other persons caring for the individual regardless of where the individual resides. Hospice services are those services to control pain and provide support to individuals to continue life with as little disruption as possible.

        a.           Covered services. Covered services shall include, in accordance with Medicare guidelines, the following:

       (1)             Nursing care.

       (2)             Medical social services.

       (3)             Physician services.

       (4)             Counseling services provided to the terminally ill individual and the individual’s family members or other persons caring for the individual at the individual’s place of residence, including bereavement, dietary, and spiritual counseling.

       (5)             Short-term inpatient care provided in a participating hospice inpatient unit or a participating hospital or nursing facility that additionally meets the special hospice standards regarding staffing and patient areas for pain control, symptom management and respite purposes.

       (6)             Medical appliances and supplies, including drugs and biologicals, as needed for the palliation and management of the individual’s terminal illness and related conditions, except for “covered Part D drugs” as defined by 42 U.S.C. Section 1395w-102(e)(1)-(2) for a “Part D eligible individual” as defined in 42 U.S.C. Section 1395w-101(a)(3)(A), including an individual who is not enrolled in a Part D plan.

       (7)             Homemaker and home health aide services.

       (8)             Physical therapy, occupational therapy and speech-language pathology unless this provision has been waived under the Medicare program for a specific provider.

       (9)             Other items or services specified in the resident’s plan that would otherwise be paid under the Medicaid program.

Nursing care, medical social services, and counseling are core hospice services and must routinely be provided directly by hospice employees. The hospice may contract with other providers to provide the remaining services. Bereavement counseling, consisting of counseling services provided after the individual’s death to the individual’s family or other persons caring for the individual, is a required hospice service but is not reimbursable.

        b.           Noncovered services.

       (1)             Covered services not related to the terminal illness. In accordance with Medicare guidelines, all medical services related to the terminal illness are the responsibility of the hospice. Services unrelated to the terminal illness are to be billed separately by the respective provider.

       (2)             Administrative duties performed by the medical director, any hospice-employed physician, or any consulting physician are included in the normal hospice rates. Patient care provided by the medical director, hospice-employed physician, attending physician, or consulting physician is separately reimbursable. Payment to the attending or consulting physician includes other partners in practice.

       (3)             Hospice care provided by a hospice other than the hospice designated by the individual unless provided under arrangements made by the designated hospice.

       (4)             AZT (Retrovir) and other curative antiviral drugs targeted at the human immunodeficiency virus for the treatment of AIDS.

       78.36(2) Categories of care. Hospice care entails the following four categories of daily care. Guidelines for core and other services must be adhered to for all categories of care.

        a.           Routine home care is care provided in the place of residence that is not continuous.

        b.           Continuous home care is provided only during a period of crisis when an individual requires continuous care which is 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 and a nurse must be providing care for more than half of the period of care. A minimum of eight hours of care per day must be provided during a 24-hour day to qualify as continuous care. Homemaker and aide services may also be provided to supplement the nursing care.

        c.           Inpatient respite care is 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. Respite care may not be provided when the individual is a resident of a nursing facility.

        d.           General inpatient care is provided in periods of acute medical crisis when the individual is hospitalized or in a participating hospice inpatient unit or nursing facility for pain control or acute or chronic symptom management.

       78.36(3) Residence in a nursing facility. For purposes of the Medicaid hospice benefit, a nursing facility can be considered the residence of a beneficiary. When the person does reside in a nursing facility, the requirement that the care of a resident of a nursing facility must be provided under the immediate direction of either the facility or the resident’s personal physician does not apply if all of the following conditions are met:

        a.           The resident is terminally ill.

        b.           The resident has elected to receive hospice services under the Medicaid program from a Medicaid-enrolled hospice program.

        c.           The nursing facility and the Medicaid-enrolled hospice program have entered into a written agreement under which the hospice program takes full responsibility for the professional management of the resident’s hospice care and the facility agrees to provide room and board to the resident.

       78.36(4) Approval for hospice benefits. Payment will be approved for hospice services to individuals who are certified as terminally ill, that is, the individuals have a medical prognosis that their life expectancy is six months or less if the illness runs its normal course, and who elect hospice care rather than active treatment for the illness.

        a.           Physician certification process. The hospice must obtain certification that an individual is terminally ill in accordance with the following procedures:

       (1)             The hospice may obtain verbal orders to initiate hospice service from the medical director of the hospice or the physician member of the hospice interdisciplinary group and by the individual’s attending physician (if the individual has an attending physician). The verbal order shall be noted in the patient’s record. The verbal order must be given within two days of the start of care and be followed up in writing no later than eight calendar days after hospice care is initiated. The certification must include the statement that the individual’s medical prognosis is that the individual’s life expectancy is six months or less if the illness runs its normal course.

       (2)             When verbal orders are not secured, the hospice must obtain, no later than two calendar days after hospice care is initiated, written certification signed by the medical director of the hospice or the physician member of the hospice interdisciplinary group and by the individual’s attending physician (if the individual has an attending physician). The certification must include the statement that the individual’s medical prognosis is that the individual’s life expectancy is six months or less, if the illness runs its normal course.

       (3)             Hospice care benefit periods consist of up to two periods of 90 days each and an unlimited number of subsequent 60-day periods as elected by the individual. The medical director or a physician must recertify at the beginning of each benefit period that the individual is terminally ill.

        b.           Election procedures. Individuals who are dually eligible for Medicare and Medicaid must receive hospice coverage under Medicare.

       (1)             Election statement. An individual, or individual’s representative, elects to receive the hospice benefit by filing an election statement, Form 470-2618, Election of Medicaid Hospice Benefit, with a particular hospice. The hospice may provide the individual with another election form to use provided the form includes the following information:

        1.            Identification of the hospice that will provide the care.

        2.            Acknowledgment that the recipient has been given a full understanding of hospice care.

        3.            Acknowledgment that the recipient waives the right to regular Medicaid benefits, except for payment to the regular physician and treatment for medical conditions unrelated to the terminal illness.

        4.            Acknowledgment that recipients are not responsible for copayment or other deductibles.

        5.            The recipient’s Medicaid number.

        6.            The effective date of election.

        7.            The recipient’s signature.

       (2)             Change of designation. An individual may change the designation of the particular hospice from which the individual elects to receive hospice care one time only.

       (3)             Effective date. An individual may designate an effective date for the hospice benefit that begins with the first day of the hospice care or any subsequent day of hospice care, but an individual may not designate an effective date that is earlier than the date that the election is made.

       (4)             Duration of election. The election to receive hospice care will be considered to continue until one of the following occurs:

        1.            The individual dies.

        2.            The individual or the individual’s representative revokes the election.

        3.            The individual’s situation changes so that the individual no longer qualifies for the hospice benefit.

        4.            The hospice elects to terminate the recipient’s enrollment in accordance with the hospice’s established discharge policy.

       (5)             Revocation. Form 470-2619, Revocation of Medicaid Hospice Benefit, is completed when an individual or the individual’s representative revokes the hospice benefit allowed under Medicaid. When an individual revokes the election of Medicaid coverage of hospice care, the individual resumes Medicaid coverage of the benefits waived when hospice care was elected.

This rule is intended to implement Iowa Code section 249A.4.