Medicaid hospice, respite benefit - CSHCS

What Is Hospice Care?

Medicaid participants can receive hospice care when they are terminally ill. “Terminally ill” means the patient has been diagnosed with a medical condition that reduces their life expectancy and is near the end of life. Each State can decide the length of the life expectancy a patient must have to receive hospice care under Medicaid. Some States, including Kentucky[1] and Texas,[2] use the Medicare definition of “terminally ill” as a medical prognosis with a life expectancy of 6 months or less if the illness runs its normal course.[3] Other States, like New York, define “terminally ill” as a medical prognosis with a life expectancy of 12 months or less for hospice eligibility.[4] Your State may allow the election of the hospice benefit sooner. Check with your SMA if you have questions.

The goal of hospice care is to:

• Improve quality of life; and
• Help manage a terminal illness and related conditions



WHAT IS THE HOSPICE MEDICARE/MEDICAID BENEFIT?


Under Medicare/Medicaid, hospice is a comprehensive program of care delivered in a person’s home. The Hospice Medicare and/or Medicaid Benefit provides all the reasonable and necessary medical and support services for the management of a terminal illness.


THE HOSPICE MEDICARE/MEDICAID BENEFIT COVERS:

• physician services provided by LifeCare Hospice Medical Director
• nursing care from LifeCare Hospice nurses
• medical equipment and supplies
• medicines for symptom management and pain relief
• short-term (hospitalization) inpatient care for symptom management
• home health aide services
• specialized therapies such as physical therapy, speech therapy, etc.
• medical social services
• counseling, including dietary and bereavement counseling
• respite care: up to 5 days stay in a contract facility
• continuous care is utilized on a short-term basis to maintain a person’s comfort in the home.


WHO IS ELIGIBLE?

 Hospice care is available under this Benefit only if:
• the patient is eligible for Medicare Hospital Insurance (Part A), or Medicaid.
• the patient’s doctor and the hospice medical director certify that the patient is terminally ill, with a life expectancy of six months or less.
• the patient signs a statement choosing The Hospice Medicare and/or Medicaid Benefit.
• the patient receives care from a Medicare-approved hospice program.


HOW LONG CAN HOSPICE CARE CONTINUE?


Medicare/Medicaid Benefit Periods: Special benefit periods apply to hospice care. These periods are as follows:

First Benefit Period -- 90-days

Second Period -- 90-days

Unlimited number of subsequent 60-day periods


The benefit periods may be used consecutively or at intervals. Regardless of whether they are used one right after the other or at different times, the patient must be recertified with a life expectancy of six months or less, before the beginning of each benefit period.



HOW DOES RECERTIFICATION HAPPEN?

To assure compliance with Medicare/Medicaid rules and regulations, all patients receiving the Hospice Medicare/Medicaid Benefit must be evaluated near the end of each benefit period. Recertification is a decision process which is completed by the Medical Director with physician, patient/family, and Hospice Team input. The outcome determines a patient’s eligibility for continued hospice services into the next benefit period. The same rules apply during recertification that were followed at the time of admission.

As a part of the recertification process, your attending physician may request that certain diagnostic tests be completed or repeated. This will assist the Medical Director and your physician in making their decision about your case.



If, at recertification, the patient has improved – Medicare/Medicaid rules state that the Hospice is required to suspend hospice care. If hospice care is suspended and in the future the patient declines, hospice care may be started again.

Should you have questions or concerns about the recertification process, please feel free to contact your Nurse Case Manager, or the Patient Care Coordinator. Should you disagree with the Medical Director’s decision, you may appeal to Medicare by filing a Demand Bill. Please call the Patient Care Coordinator for information, should you wish to appeal.



What Does the Medicaid Hospice Program Cover?

Hospice services are covered as part of your Medicaid benefits.[22] Services are provided by a team to meet your needs. The hospice team may include you, your family, and others who can help meet your physical, psychosocial, spiritual, and emotional needs. Your needs are written in a plan of care (POC), also called a plan.

The benefits listed below are examples of hospice services you may receive:

• Physician services provided by the hospice agency;
• Nursing care;
• Medical equipment;
• Medical supplies;
• Drugs for symptom control and pain relief;
• Hospice aide and homemaker services;
• Physical therapy;
• Occupational therapy;
• Speech-language pathology services;
• Social worker services;
• Dietary counseling; and
• Short-term inpatient care for pain control, symptom management, and respite care.

Hospice benefits may also include anything needed to manage your terminal illness and related conditions that is normally covered by Medicaid. The following hospice services must be provided directly by hospice employees:

• Nursing care;
• Physician services;
• Medical social services; and
• Counseling.

Other hospice services may be provided, such as visits by a physician who specializes in your illness.Hospice benefits may be different in each State. Check with your SMA about hospice benefits in the area.


HOSPICE BENEFIT

The CSHCS hospice benefit provides assistance to a family/beneficiary when end of life care related to the beneficiary’s CSHCS qualifying diagnosis is appropriate. Hospice is intended to address the medical needs of the beneficiary with a terminal illness whose life expectancy is limited to six months or less.

Hospice services must be prior authorized. Prior authorization requests require medical documentation from the beneficiary’s enrolled CSHCS subspecialist who is authorized (i.e., listed on the beneficiary’s CSHCS authorized provider file) to treat the terminal illness. The medical documentation must include all of the following:

* A statement of the terminal diagnosis.

* A statement that the beneficiary has reached the terminal phase of illness where the CSHCS subspecialist deems end of life care necessary and appropriate.

* Documentation of the need to pursue end of life care.

* A statement of limited life expectancy of six months or less.

* A proposed plan of care to address the service needs of the beneficiary that is:

* less than 30 days old;

* consistent with the philosophy/intent of the CSHCS hospice benefit as described above;

* clinically and developmentally appropriate to the beneficiary’s needs and abilities;

* representative of the pattern of care for a beneficiary who has reached the terminal phase of illness; and

* signed by the CSHCS subspecialist authorized to treat the terminal illness.

The prior authorization time period does not exceed six months. To continue hospice services beyond six months, a new prior authorization request with medical documentation must be submitted as described above.

Hospice may not be authorized and/or continued for a beneficiary when one or more of the following is true:

* The medical documentation no longer supports the above criteria (e.g., change in condition, change in the plan of care, etc.).

* The family chooses to discontinue hospice.

* The medical services being rendered by the hospice provider are available through another benefit.

Requests for hospice must be made in writing to CSHCS. (Refer to the Directory Appendix for contact information.) CSHCS responds to all prior authorization requests for hospice services in writing.



RESPITE BENEFIT

Respite services provide limited and temporary relief for families caring for beneficiaries with complex health care needs when the care needs require nursing services in lieu of the trained caregivers. Services are provided in the family home by hourly skilled and licensed nursing services as appropriate. To be eligible and authorized for respite, MDHHS must determine the beneficiary to have:

* Health care needs that meet the following criteria:

* That skilled nursing judgments and interventions be provided by licensed nurses in the absence of trained and/or experienced parents/caregivers responsible for the beneficiary’s care;

* That the family situation requires respite; and

* That no other community resources are available for this service.

* No other publicly or privately funded hourly skilled nursing services in the home that would be duplicated by the CSHCS respite benefit.

* Service needs which can reasonably be met only by the CSHCS Respite benefit, not by another service benefit.

Respite is reimbursed when provided by a Medicaid enrolled home health agency, a Medicaid enrolled registered nurse (RN) who is licensed to practice in the state of Michigan, or a Medicaid enrolled licensed practical nurse (LPN) who is licensed to practice in the state of Michigan and working under supervision according to the Michigan Public Health Code. It is the responsibility of the LPN to secure the appropriate supervision and maintain documentation that identifies the supervising professional.

A maximum of 180 hours of CSHCS Respite services may be authorized per family during the 12-montheligibility period. When there is more than one respite-eligible beneficiary in a single home, the respite  service is provided by one nurse at an enhanced reimbursement rate for the services provided to multiple beneficiaries. Allotted respite hours may be used at the discretion of the family within the eligibility period. Unused hours from a particular eligibility period are forfeited at the end of that period and cannot be carried forward into the next eligibility period.

Beneficiaries receiving services through any of the following publicly funded programs and benefits are not eligible for the CSHCS Respite benefit:

* Private Duty Nursing Benefit

* Children’s Waiver

* Habilitation Supports Waiver

* MI Choice Waiver

Requests for respite must be made in writing to MDHHS (refer to the Directory Appendix for contact information) and include
the following information:

* The health care needs of the beneficiary;

* The family situation that influences the need for respite; and

* Other community resources or support systems that are available to the family (e.g., CMH services, MDHHS services, adoption subsidy, SSI, trust funds, etc.).

MDHHS responds to all requests for respite in writing.