(Medicare Benefit Policy Manual)

The hospice must notify the Medicare contractor and State Survey Agency of the circumstances surrounding the impending discharge.  The hospice may also need to make referrals to other relevant state/community agencies (i.e., Adult Protective Services) as appropriate.   Discharge order :  Prior to discharging a patient for any reason other than a patient revocation, transfer, or death, the hospice must obtain a written physician's discharge order from the hospice medical director.  If a patient has an attending physician involved in his or her care, this physician should be consulted before discharge and his or her review and decision included in the discharge note.  Effect of discharge:  An individual, upon discharge from the hospice during a particular election period for reasons other than immediate transfer to another hospice    Is no longer covered under Medicare for hospice care;   Resumes Medicare coverage of the benefits waived; and   May at any time elect to receive hospice care if he or she is again eligible to receive the benefit.   Discharge planning:  The hospice must have in place a discharge planning process that takes into account the prospect that a patient's condition might stabilize or otherwise change such that the patient cannot continue to be certified as terminally ill.  The discharge planning process must include planning for any necessary family counseling, patient education, or other services before the patient is discharged because he or she is no longer terminally ill.   Once a patient is no longer considered terminally ill with a life expectancy of 6 months or less if the disease runs its normal course, Medicare coverage and payment for hospice care should cease.  Medicare does not expect that a discharge would be the res ult of a single moment that does not allow time for some post -discharge planning.  Rather, it would be expected that the hospices interdisciplinary group is following the patient, and if there are indications of improvement in the individuals condition s uch that hospice may soon no longer be appropriate, then planning should begin.  If the patient seems to be stabilizing, and the disease progression has halted, then it could be the time to begin preparing the patient for alternative care.  Discharge planning should be a process, and planning should begin before the date of discharge.   In some cases, the hospice must provide Advanced Beneficiary Notification (ABN) or a Notice of Medicare Non -Coverage (NOMNC) to patients who are being discharged.  See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 30 Financial Liability Protecti ons, Section 50.15.3.1, for information on these requirements.   20.2.4 - Hospice Notice of Termination or Revocation  (Rev. 209, Issued: 05- 08-15, Effective: 10 -01-14, Implementation: 05- 04-15)  Upon discharge or revocation of hospice care, the beneficiary immediately resumes the Medicare coverage that had previously been waived by the hospice election.  As such, hospices should record the beneficiarys discharge or revocation in the claims proces sing system promptly.   If a hospice beneficiary is discharged alive or if a hospice beneficiary revokes the election of hospice care, the hospice shall submit a timely -filed Notice of Termination/Revocation (NOTR) unless the hospice has already filed a final claim.  A timely -filed NOTR is a NOTR that is submitted to and accepted by the Medicare contractor within 5 calendar days after the effective date of discharge or revocation. Hospices continue to have 12 months from the date of service in which to file their claims.   See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 11, Processing Hospice Claims for requirements for NOTR submission.  20.3 - Election by Skilled Nursing Facility (SNF) and Nursing Facilities (NFs) Residents and Dually Eligible Beneficiaries  (Rev. 1, 10- 01-03) HO- 204.2  A Medicare beneficiary who resides in an SNF or NF may elect the hospice benefit if:    The residential care is paid for by the beneficiary; or    The beneficiary is eligible for Medicaid and the facility is being reimbursed for the beneficiarys care by Medicaid, and    The hospice and the facility have a written agreement under which the hospice takes full responsibility for the professional management of the individuals hospice care and the facility agrees to provide room and board to the individual.  A beneficiary could be in a SNF under the SNF benefit for a condition unrelated to the terminal condition and simultaneously be receiving hospice for the terminal condition.  The State Medicaid Agency pays the hospice the daily amount allowed by the State for room and board while the patient is receiving hospice care, and the hospice pays the facility.  Room and board services include the performance of personal care services, assistance in activities of daily living, socializing activities, administration of medication, maintaining the cleanliness of a residents room, and supervising and assisting in the use of durable medical equipment and prescribed therapies.  Whenever Medicaid is involved, the hospice sends a copy of the election form to the State Medicaid Agency at the time of election, and also notifies this agency when the patient is no longer receiving hospice care.   In States that offer the hospice benefit under the Medicaid program, dually eligible beneficiaries must elect the benefit under both programs at once.   20.4 - Election by Managed Care Enrollees  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  A managed care enrollee may elect the hospice benefit.  After the hospice election, Medicare pays the hospice for hospice services and pays for services of the managed care attending physician, who may be a nurse practitioner, (as defined in section 20.1 of this chapter) and services not related to the patients terminal illness, through the fee -for-service system.  (See 42 CFR 417.531 and 417.585.)  Once under a hospice election, a managed care patient may also choose to use a provider outside of his or he r managed care organization for care unrelated to the terminal illness or related conditions, or as the attending physician.  See Pub. 100- 04, Medicare Claims Processing Manual, chapter 11, section 40 for requirements for physician billing.  Once a managed care enrollee has elected hospice, all his or her Medicare benefits revert to fee- for-service, though the enrollee still remains on managed care for any additional benefits provided by his or her managed care plan, such as dental or vision c overage.  The Medicare hospice benefit, through fee -for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.  During the election, fee- for-service Medicare also covers attending physician ser vices and all care unrelated  to the terminal illness.  Upon discharge or revocation, fee -for-service Medicare continues to cover the beneficiary through the end of the month when the beneficiary revokes or is discharged from hospice alive.  At the start of the month following revocat ion or discharge, all billing and coverage revert back to the managed care plan (see Pub 100- 04, Medicare Claims Processing Manual, chapter 11, 30.4).   30 - Coinsurance  (Rev. 1, 10- 01-03) A3-3142   Hospices may charge individuals for the applicable coinsurance amounts.  An individual who has elected hospice care is liable for the following coinsurance payments.  30.1 - Drugs and Biologicals Coinsurance  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  Hospices are to provide all drugs and biologicals for the palliation and management of pain and symptoms of a patients terminal illness and related conditions.  An individual is liable for a coinsurance payment for each palliative drug and biological pres cription furnished by the hospice while the individual is receiving routine home care or continuous home care.  The individual is not liable for any coinsurance for hospice -related drugs or biologicals provided while he or she is receiving general inpatient care or respite care.   The amount of coinsurance for each prescription approximates 5 percent of the cost of the drug or biological to the hospice, determined in accordance with the drug copayment schedule established by the hospice, except that the amount of coinsurance for eac h prescription may not exceed $5.00.  The cost of the drug or biological may not exceed what a prudent buyer would pay in similar circumstances.  The drug copayment schedule must be periodically reviewed for reasonableness and approved by the A/B MAC (HHH)  before it is used.   30.2 - Respite Care Coinsurance  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  The amount of coinsurance for each respite care day is equal to 5 percent of the payment made by Medicare for a respite care day.  The amount of the individuals coinsurance liability for respite care during a hospice coinsurance period may not exceed the inpatient hospital deductible applicable for the year in which the hospice coinsurance period began.   The individual hospice coinsurance period begins on the first day an election is in effect for the beneficiary and ends with the close of the first period of 14 consecutive days on each of which an election is not in effect for the beneficiary.   Thus, if a beneficiary receives hospice care for three election periods consecutively (without a 2- week break), he or she is subject to a maximum coinsurance for respite care equal to the hospital inpatient deductible.  Similarly, if a break between election periods exceeds 14 days, the maximum coinsurance for respite care doubles, triples, or quadruples (depending on the number of election periods used and the timing of subsequent elections).   EXAMPLE:  Mr. Brown elected an initial 90- day period of hospice care.  Five days after the initial period of hospice care ended, he began another period of hospice care under a subsequent election.  Immediately after the period ended, he began a third period of hospice care.  Mr. Brown received inpatient respite care during all three periods of hospice care.  Since these election periods were not separated by 14 consecutive days, they constitute a single hospice coinsurance period.  Therefore, a maximum coi nsurance for respite care during all three periods of hospice care may not exceed the amount of the inpatient hospital deductible for the year in which the first period began.   40 - Benefit Coverage  (Rev. 188, Issued: 05- 01-14; Effective: 08 -04-14; Implementation: 08 -04-14)  To be covered, hospice services must meet all of the following requirements:    They must be reasonable and necessary for the palliation and management of the terminal illness as well as related conditions; and    The individual must elect hospice care in accordance with sections 20.2  20.4 of this chapter; and    A plan of care must be established and periodically reviewed by the attending physician, the medical director, and the interdisciplinary group of the hospice program; and    That plan of care must be established before hospice care is provided; and    The services provided must be consistent with the plan of care; and    A certification that the individual is terminally ill must be completed as set forth in section 20.1 of this chapter.   A nurse practitioner serving as an attending physician should participate as a member of the IDG that establishes and/or or updates the individuals plan of care.  The nurse practitioner may not serve as or replace the medical director or physician designe e.  All services provided by the hospice must be in accordance with a patients individualized plan of care that is established and updated by the hospice interdisciplinary group, in consultation with the patients attending physician (if any).  The individualized plan of care is a continually evolving document.  As such, Medicare exp ects the plan of care to be initiated based upon the information gathered in the patients initial assessment, and the plan of care will be expanded upon, as appropriate, based on the information that is gathered during the comprehensive assessment.   Provided the above coverage criteria are met, hospices are paid a per diem rate based on the number of days and level of care provided during the election period.  Levels of care are defined as:    Routine home care (refer to 40.2.1); A routine home care day is a day on which an individual who has elected to receive hospice care is at home and is not receiving continuous home care.    Continuous home care (refer to 40.2.1);  A continuous home care day is a day on which an individual who has elected to receive hospice care is not in an inpatient facility (hospital, SNF, or hospice inpatient unit) and receives hospice care consisting predominantly of nursing care on a continuous  basis at home.  Hospice aide or homemaker services or both may also be provided on a continuous basis.  Continuous home care is only furnished during brief periods of crisis and only as necessary to maintain the te rminally ill patient at home.