Opinion ID: 4512608
Heading Depth: 3
Heading Rank: 1

Heading: Medicare Hospice Benefit

Text: In 1983, Congress established the Medicare Hospice Benefit (“MHB”). See 48 Fed. Reg. 56,008 (Dec. 16, 1983) (codified at 42 C.F.R. pts. 400, 405, 408, 409, 418, 420, 421, 489). This regulation expanded the Health and Human Services Secretary’s statutory authority to reimburse contractors that provide hospice care to eligible persons. 42 U.S.C. §§ 1395h (2006), 1395kk-1 (2015). Hospice care is considered palliative care, meaning it is “patient and familycentered care that optimizes quality of life by anticipating, preventing, and treating suffering.” 42 C.F.R. § 418.3 (2019). It aims to “mak[e a terminally ill] individual as physically and emotionally comfortable as possible.” 48 Fed. Reg. at 56,008. A patient who has been certified as eligible for hospice care and elects to receive the MHB waives the right to Medicare payment for “curative” care that is designed to help improve the individual’s condition. See 42 U.S.C. § 1395d(d)(2)(A) (2005); 42 C.F.R. § 418.24(e) (2019); 72 Fed. Reg. 50,452, 50,452 (Aug. 22, 2014). 5 The Medicare provisions that set forth the conditions for payment of the MHB require that an individual be certified within a ninety-day period by one or more physicians as terminally ill. 42 U.S.C. § 1395f(a)(7)(A)(i). The patient must also be recertified in a similar manner for each additional sixtyor ninety-day period during which he or she remains in hospice care. 1 Id. § 1395f(a)(7)(A)(ii). An individual is considered “terminally ill” when the individual has a medical prognosis 1 In relevant part, the statute states that: payment for services furnished an individual may be made . . . only if . . . in the case of hospice care provided an individual— (A)(i) in the first 90-day period— (I) the individual’s attending physician . . . , and (II) the medical director . . . of the hospice care program providing (or arranging for) the care, each certify in writing at the beginning of the period, that the individual is terminally ill . . . based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness, and (ii) in a subsequent 90- or 60-day period, the medical director or physician described in clause (i)(II) recertifies at the beginning of the period that the individual is terminally ill based on such clinical judgment . . . § 1395f(a)(7)(A); see also § 1395f(a)(7)(B)–(E) (providing the other statutory prerequisites). 6 that the individual’s life expectancy is six months or less, if the illness runs its normal course. Id. § 1395x(dd)(3)(A) (2018); 42 C.F.R. § 418.3. Regulations promulgated by the Secretary add another requirement. See 42 C.F.R. § 418.20. The regulations provide that, “[i]n order to be eligible to elect hospice care under Medicare, an individual must be . . . (b) Certified as being terminally ill in accordance with § 418.22.” Id. Section 418.22, in turn, imposes certain obligations on hospices regarding the timing, content, and source of a certification, in addition to a maintenance-of-records requirement. Among these is the requirement that [c]linical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification as set forth in paragraph (d)(2) of this section. Initially, the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice’s eligibility assessment. § 418.22(b)(2) (2011). Therefore, in order for a patient to be eligible to receive the MHB and for a hospice provider to be entitled to bill for such benefits, an individual’s certification of terminal illness must be signed by at least one physician, and be accompanied by “[c]linical information and other documentation that support the medical prognosis” of terminal illness in the medical record. Id. Indeed, while the Center for Medicare & Medicaid Services, the agency responsible for administering health benefits, has recognized that “making a prognosis is not 7 an exact science,” it has explained that this inexactitude “does not negate the fact that there must be a clinical basis for a certification[:] [a] hospice is required to make certain that the physician’s clinical judgment can be supported by clinical information and other documentation that provide a basis for the certification of 6 months or less if the illness runs its normal course.” 79 Fed. Reg. at 50,470 (emphasis added); see also 70 Fed. Reg. 70,532, 70,534–35 (Nov. 22, 2005) (“A hospice needs to be certain that the physician’s clinical judgment can be supported by clinical information and other documentation that provide a basis for the certification of 6 months or less if the illness runs its normal course. A signed certification, absent a medically sound basis that supports the clinical judgment, is not sufficient for application of the hospice benefit under Medicare.”).