The Hospice benefit is an optional state plan service that includes an array of services furnished to terminally ill individuals. These services include: nursing, medical social services, physician services, counseling services to the terminally ill individual and the family members or others caring for the individual at home, short-term inpatient care, medical appliances and supplies, home health aide and homemaker services, physical therapy, occupational therapy and speech-language pathology services.
Individuals must elect the hospice benefit by filing an election statement with a particular hospice. They must acknowledge that they understand that other Medicaid services for the cure or treatment of the terminal condition are waived. Individuals may, however, revoke the election of hospice at any time and resume receipt of the Medicaid-covered benefits waived when hospice was elected.
A hospice provider must obtain a physician certification that an individual is terminally ill and hospice services must be reasonable and necessary for the palliation or management of the terminal illness and related conditions. A hospice plan of care must be established before services are provided.
Payment for hospice services is made to a designated hospice provider using the CMS annually published Medicaid hospice rates that are effective from October 1 of each year through Sept 30 of the following year. With the exception of payment for physician services Medicaid reimbursement for hospice care will be made at predetermined rates for each day the individual receives care under one of the following categories or levels of hospice care:
- Routine Home Care, (RHC), Hospice Providers are paid one of two levels of (RHC), effective for dates of service on or after January 1, 2016. This two-rate payment methodology will result in a higher RHC rate based on payment for days one (1) through sixty (60) of hospice care and a lower RHC rate for days sixty one (61) or later. A minimum of sixty (60) day’s gap in hospice services is required to reset the counter that determines which payment category a participant is qualified for.;
- Continuous Home Care, (CHC), which is furnished during a period of crisis and primarily consists of nursing care;
- Inpatient Respite Care, (IRC), which is short-term care and intended to relieve family members or others caring for the individual; and
- General Inpatient Care, (GIC), which is short term and intended for pain control or acute or chronic symptom management which cannot be provided in other settings.
- Effective January 1, 2016, Service Intensity Add-On which provides that hospice services are eligible for an end-of life service intensity add on payment when the following criteria are met:
- The day on which the services are provided is an RHC level of care;
- The day on which the service is provided occurs during the last seven days of life, and the client is discharged deceased;
- The service is provided by a registered nurse or social worker that day for at least fifteen minutes and up to four hours total and
- The service is not provided by the social worker via telephone.
The national hospice reimbursement rates for these four levels of care change annually. Medicaid Hospice Rates for federal Fiscal Year (FY) 2018 are based on the annual Medicare changes and are typically a little higher due to offsets attributable to Medicare coinsurance amounts.
Beginning March 23, 2010, with the enactment of the Affordable Care Act, Medicaid and CHIP-eligible individuals under age 21 who elect the hospice benefit no longer have to waive services for the cure or treatment of the terminal condition and can receive both curative care and hospice care for the terminal condition.