(Medicare Benefit Policy Manual)

Waiver requests and any extensions with supporting documentation must be sent to the regional office for review.  Regional offices have the authority to review, and approve, or deny the waiver application.  40.5 - Non-core Services  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  In addition to the hospice core services (physician services, nursing services, medical social services, and counseling), the following services must be provided by the hospice, either directly or under arrangements, to meet the needs of the patient and fa mily:   Physical and occupational therapy and speech- language pathology services.   Hospice aide services.  A hospice aide employed by a hospice, either directly or under contract, must meet the qualifications required by 1891(a)(3)  of the Act and implemented at 42CFR418.76.   Homemaker services.    Volunteers.    Medical supplies (including drugs and biologicals on a 24- hour basis) and the use of medical appliances related to the terminal illness 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.   Section 1861(dd)(5)  of the Act  allows CMS to permit certain waivers of the requirements that the hospice make physical therapy, occupational therapy, speech language pathology services, and dietary counseling available (as needed) on a 24- hour basis.  CMS is also allowed to waive the r equirement that hospices provide dietary counseling directly.  These waivers are available only to an agency or organization that is located in an area which is not an urbanized area (as defined by the Bureau of Census) and that can demonstrate to CMS that  it has been unable, despite diligent efforts, to recruit appropriate personnel.   50 - Limitation on Liability for Certain Hospice Coverage Denials  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  Section 1879 of the Act provides beneficiaries with liability protections from unexpected charges for certain denied claims when items or services are furnished by Medicare Part A hospice providers.  Hospice providers may also be protected from liability under 1879 of the Act when certain conditions apply to a claim denial. The limitation on liability protections applies when a hospice claim denial is expected because:    the beneficiary is determined to be not terminally ill as defined in 1879(g)(2) of the Act;    specific items or services billed separately from the hospice per diem, such as physician services, are not reasonable and necessary as defined in either 1862(a)(1)(A) or 1862(a)(1)(C); or    the level of hospice care is determined to be not reasonable or medically necessary as defined in 1862(a)(1)(A) or 1862(a)(1)(C), specifically for the management of the terminal illness and/or related conditions.  A/B MACs (HHH)  will apply the usual procedures of the limitation on liability provision when a claim denial is based upon one of these reasons.  When limitation on liability protections applies, the hospice provider must issue the Advance Beneficiary Notice of Noncoverage (ABN), Form CMS -R-131, per CMS guidelines in order to transfer liabilit y to the beneficiary .  See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 30,  Financial Liability Protections," particularly Section 50, Advance Beneficiary Notice of Noncoverage.   60 - Provision of Hospice Services to Medicare/Veterans Eligible Beneficiaries  (Rev. 1, 10- 01-03)  Medicare beneficiaries that are dually eligible veterans, and reside at home in their community may elect the Medicare Hospice Benefit and have hospice services paid for under the Medicare Hospice Benefit.  See 1853(c)  and 1814(d)  of the Act.   If a duly eligible veteran, who had been receiving Medicare hospice services in his/her home, is admitted to a VA owned and operated inpatient facility, the beneficiary must revoke the Medicare hospice benefit.  Medicare is not allowed to pay for those ser vices for which another federal entity is primary payer (1853(c) and 1814(d)).   Dually eligible veterans may elect to receive Medicare hospice services while residing in community nursing homes and state homes and have those services paid for under the Medicare hospice benefit.  (This is similar to paying for hospice care if a beneficiary lives in a nursing facility.  See 20.3.)   70  Hospice Contracts with An Entity for Services not Considered Hospice Services  (Rev. 1, 10- 01-03) A-02-102  The law governing the provision of Medicare hospice services is found at 1861(dd)  of the Act.  This law specifies the services covered as hospice care and the conditions a hospice program must meet in order to participate in the Medicare program.  One of the conditions a hospice program must meet is that it be primarily engaged in pr oviding hospice care and services to terminally ill individuals.  The law further clarifies that terminally ill individuals are individuals having a medical prognosis that their life expectancy is six months or less if the illness runs its normal course .  Although the law does not explicitly define its expectations for primarily engaged, CMS has interpreted it to mean exactly what it says, that a hospice provider must be primarily engaged in providing hospice care and services (1861(dd)(2)(A)(i)).  Primarily does not mean exclusively.  This requirement does not preclude provision of non- hospice services to terminally ill individuals who are not hospice patients or services to individuals, who are not terminally ill, so long as the primary activity of the hospice is the provision of hospice services to terminally ill individuals.   The CMS recognizes that there may be circumstances in which another health care entity may wish to purchase some of the highly specialized staff time or services of a hospice to better meet the needs of its specific patient population.  In these cases, t he services are not hospice services in terms of Medicare payment but become part of the service package of the provider under whose care the patient is.  Examples of such circumstances are provided below.   EXAMPLE 1:   A dually eligible Medicare/Medicaid beneficiary enrolled in the Program of All -Inclusive Care for the Elderly (PACE) program for approximately 2 years has been diagnosed with a life limiting terminal illness with a prognosis of six months or less.  In the course of routine assessments, the PACE provider recognizes that the beneficiary would benefit from the specialized services of a pain management specialist or a grief counselor.  The PACE provider would then enter into a contractual arrangement with a Medicare certified hospice to purchase these specialized services.  The hospice provider would bill the PACE provider for the services, and the PACE provider would in turn pay the hospice provider directly.  Neither provider type would be allowed to bill Medi care separately for the contracted services (which in this example are PACE services and included in the PACE providers capitated rate).  In this example, the PACE provider would maintain a medical record on the patient and the hospice provider would subm it any documentation related to the care of the PACE patient to the PACE provider.   EXAMPLE 2:   A Medicare beneficiary is receiving skilled services from a Medicare certified home health agency (HHA).  The beneficiary has been diagnosed with a life limiting terminal illness, but chooses to continue curative treatments, thereby rendering him ineligibl e for the Medicare hospice benefit.  The beneficiary is experiencing a period of intractable pain, and the HHA wishes to purchase specialized pain control services from the hospice provider.  The HHA would then enter into a contractual arrangement with a M edicare certified hospice to purchase specialized nursing services.  The hospice would bill the HHA and the HHA would pay the hospice provider directly.  Neither provider type would be allowed to bill Medicare separately for the contracted services (which,  in this example, are home health services and therefore included in the HHAs episode payment).  In this example, the HHA would maintain a medical record on the patient, and the hospice submits any documentation related to the pain management to the HHA.   EXAMPLE 3:   A Medicare beneficiary (non -dual eligible) resides in a skilled nursing facility (SNF) and has a diagnosis of Alzheimers disease.  The beneficiarys disease process has progressed to a stage in which he/she can no longer ingest food or fluids.  The benefi ciarys family has been approached by the SNF regarding the placement of a feeding tube and has been told, their loved one may not live much longer.  The family is struggling with this concept and has requested assistance from the SNF regarding hospice care and grief counseling.  The SNF has provided information about the Medicare hospice benefit to the family, but the patients legal representative has made a decision not to elect hospice care at this time.  The SNF does not have a trained grief counselor or full -time social worker on staff, but has a business relationship with a local hospice and has requested the services of a pastoral or grief counselor.  The SNF and hospice enter into a contractual arrangement for the provision of grief counseling to this beneficiarys family by a pastoral care counselor.  The hospice provider would bill the SNF, and the SNF would pay the hospice provider directly.  Neither provider type would be allowed to bill Medicare Part A or B separately for the pastoral care ser vices (which in this example are included in the Medicares Resource Utilization Group or RUG payments to the SNF).  The SNF maintains the medical record on this patient and the hospice provider would submit any documentation related to the pastoral care s ervices provided to the SNF.   In all of the examples provided above, the billing and payment for the services are between each of the providers.  Medicare must not be billed separately for any of the contracted services referred to in the examples provided above.   70.1 - Instructions for the Contractual Arrangement  (Rev. 1, 10- 01-03)  A contractual agreement between both parties must be on file and available for review by the state survey agency responsible for conducting surveys on behalf of CMS to assess compliance with the relevant conditions of participation for the provider contrac ting for the hospice services.  Where a PACE organization contracts with a hospice organization, the contract, which is reviewed by CMS, must meet the requirements specified in 42 CFR  460.70.  The agreement must specify each of the services to be provided, the credentials required for any of the professionals providing the services, the billing method and payment amounts, and any required documentation.  80 - Hospice  Pre-Election Evaluation and Counseling Services (Rev. 28, Issued: 12- 03-04, Effective: 01 -01-05, Implementation: 01- 03-05)  Effective January 1, 2005, section 512 of the MMA amends section 1812(a)(1)(5) of the Act which, provides for a one -time payment to be made to a hospice for evaluation and counseling services furnished by a physician who is either the medical director of or employee of a hospice agency.  In order to be eligible to receive this service, a beneficiary must:    be determined to have a terminal illness (which is defined as having a prognosis of 6 months or less if the disease or illness runs its normal course;    not have made a hospice election, and    not previously received the pre -election hospice services    Services under this benefit are comprised of:    evaluating the individuals need for pain and symptom management;    counseling the individual regarding hospice and other care options, and may include;    advising the individual regarding advanced care planning.  The services that comprise this benefit are currently available through other Medicare benefits. For example, evaluation and counseling are often provided by an individuals physician as well as by other sources such as discharge planners, case managers, s ocial workers and nonphysician providers.  Therefore, this service may not be reasonable and necessary for all individuals.  To the extent that beneficiaries have already received Medicare- covered evaluation and counseling with respect to end -of-life care,  the hospice pre-election benefit would seem duplicative.  However, if a beneficiary or the beneficiarys physician deem it necessary to seek the expertise of a hospice medical director or physician employee, this benefit is available to assure that a bene ficiarys end -of-life options for care and pain management are addressed.   Since the decision to utilize this benefit is determined by the beneficiary or the beneficiarys physician, the evaluation and counseling service may not be initiated by the hospice, that is, the entity receiving payment for the service.  Payments by hospi ce agencies to physicians or others in a position to refer patients for services furnished under this provision may implicate the Federal anti- kickback statute.   If the beneficiarys physician is also the medical director or physician employed by a hospice or possesses expertise in the provision of palliative or hospice care, that physician already possesses the expertise necessary to furnish end- of-life services and will have received payment for these services through the use of evaluation and management codes.   For example: