Long Term Care Division

Long Term Care Division

Alabama Medicaid Agency

Long Term Care Division

Revised: December 2010

P R E S E N T P R E S E N T SS

An Overview of An Overview of

HOSPICE HOSPICE CARECARE

HOSPICE CAREHOSPICE CARE

• Hospice care is Hospice care is defined as defined as services which services which are necessary for are necessary for the palliation or the palliation or management of management of the terminal the terminal illness and illness and related related conditions.conditions.

LEVEL OF CARE LEVEL OF CARE DETERMINATIONDETERMINATION

• The attending physician or hospice The attending physician or hospice medical director certifies the recipient medical director certifies the recipient has a terminal illness and requires has a terminal illness and requires services that are medically necessary for services that are medically necessary for palliative care.palliative care.

• Certification of the terminal illness of an Certification of the terminal illness of an individual who elects the hospice benefit individual who elects the hospice benefit shall be based on the physician’s clinical shall be based on the physician’s clinical judgment regarding the normal course of judgment regarding the normal course of the individual’s illness.the individual’s illness.

LEVEL OF CARE LEVEL OF CARE DETERMINATIONDETERMINATION

• Certification of Certification of terminal illness must terminal illness must include specific include specific findings and medical findings and medical documentation documentation including, but not including, but not limited to, medical limited to, medical records, lab, x-rays, records, lab, x-rays, pathology reports, pathology reports, etc.etc.

HOSPICE ELECTION AND HOSPICE ELECTION AND CERTIFICATIONCERTIFICATION

• If the recipient is dually If the recipient is dually eligible for Medicare and eligible for Medicare and Medicaid, the hospice Medicaid, the hospice benefit must be elected benefit must be elected simultaneously.simultaneously.

• The Medicaid Hospice The Medicaid Hospice Election Form 165 must Election Form 165 must be completed.be completed.

FORM 165FORM 165


• The form should indicate if The form should indicate if the individual is a Medicare the individual is a Medicare recipient and if the recipient and if the recipient is in a nursing recipient is in a nursing facility.facility.

• The Hospice Election Form The Hospice Election Form should be signed and should be signed and dated by the patient or the dated by the patient or the patient’s representative. patient’s representative.


• The signature or mark of The signature or mark of the patient or the the patient or the patient’s representative patient’s representative signature should be signature should be witnessed and dated by witnessed and dated by the hospice provider agent the hospice provider agent obtaining the signatures.obtaining the signatures.

• The physician must sign The physician must sign and date the form with the and date the form with the date the signature is date the signature is obtained.obtained.


• The physician’s signature The physician’s signature must be an original (white-must be an original (white-out or CRNP signatures are out or CRNP signatures are not acceptable).not acceptable).

• The date of the physician’s The date of the physician’s signature must be within 2 signature must be within 2 calendar days of the calendar days of the election date unless there election date unless there is a verbal order received is a verbal order received for initiation of care. for initiation of care.


• If there is a verbal order the If there is a verbal order the physician’s signature and date must be physician’s signature and date must be within within 8 days8 days of the election date. of the election date.

• All subsequent benefit periods must be All subsequent benefit periods must be certified in writing within certified in writing within 2 calendar 2 calendar daysdays..

• If the recipient has Medicare Part A, If the recipient has Medicare Part A, Medicare would be the payor for Medicare would be the payor for hospice benefits in the community. hospice benefits in the community.

TRANSFERSTRANSFERS

• An individual or An individual or representative may representative may change, once in change, once in each election each election period, the period, the designation of the designation of the particular hospice particular hospice from which care will from which care will be received.be received.

TRANSFERSTRANSFERS

• To change the designation of the To change the designation of the hospice provider, the individual or hospice provider, the individual or representative must file a signed representative must file a signed statement that includes the following:statement that includes the following:

1. The name of the hospice from which 1. The name of the hospice from which care hascare has

been received.been received.

2. The name of the hospice from 2. The name of the hospice from which the which the individual plans to individual plans to receive care.receive care.

3. The effective date of the transfer.3. The effective date of the transfer.

TRANSFERSTRANSFERS

• The previous hospice The previous hospice provider would submit provider would submit a Form 165B to the a Form 165B to the contractor indicating contractor indicating the date of revocation the date of revocation or discharge. or discharge.

• The new hospice The new hospice provider would provider would complete the complete the Medicaid Hospice Medicaid Hospice Election Form 165.Election Form 165.

REVOCATIONREVOCATION

• Notices of revocation or death Notices of revocation or death should be submitted on the should be submitted on the Form 165B to the AMA or its Form 165B to the AMA or its designee within 48 hours. designee within 48 hours.

• If the recipient is certified by If the recipient is certified by the Medicaid District Office the Medicaid District Office (DO), the DO must be notified (DO), the DO must be notified of permanent changes such as of permanent changes such as revokes with no intent to revokes with no intent to return, or the death of the return, or the death of the individual.individual.

HOSPICE IN A NURSING HOSPICE IN A NURSING FACILITYFACILITY

• Hospice providers may Hospice providers may send the Medicaid send the Medicaid Hospice Election Form Hospice Election Form (Form 165) to the DO, (Form 165) to the DO, when applying for when applying for financial eligibility.financial eligibility.

• This form indicates to the This form indicates to the DO that the client meets DO that the client meets the level of care criteria.the level of care criteria.

SSI Recipients Transitioning SSI Recipients Transitioning from Home to Institutionfrom Home to Institution

• SSA must be SSA must be notified by the notified by the provider or provider or sponsor of the sponsor of the individual’s individual’s change of change of residence. The residence. The individual’s individual’s income must be income must be adjusted adjusted accordingly by accordingly by SSA.SSA.

Hospice Review Hospice Review ProcessProcess

PROSPECTIVE REVIEW POLICY PROSPECTIVE REVIEW POLICY OF HOSPICE ADMISSIONSOF HOSPICE ADMISSIONS

• To ensure that state and federal rules To ensure that state and federal rules and guidelines are adhered to by and guidelines are adhered to by hospice providers, the Alabama hospice providers, the Alabama Medicaid Agency (AMA) implemented Medicaid Agency (AMA) implemented a 100 percent review of medical a 100 percent review of medical records for hospice admissions and records for hospice admissions and recertifications, effective 2/1/2006. recertifications, effective 2/1/2006.

PROSPECTIVE REVIEW PROSPECTIVE REVIEW PROCESSPROCESS• The AMA professional nursing and medical The AMA professional nursing and medical

staff or its designee, will conduct staff or its designee, will conduct prospective reviews of hospice providers. prospective reviews of hospice providers.

• Each provider will mail or fax to AMA or its Each provider will mail or fax to AMA or its designee, the medical record for every designee, the medical record for every hospice admission or recertification for hospice admission or recertification for Medicaid only recipients. Medicaid only recipients.

• The AMA or its designee will not be The AMA or its designee will not be responsible for any cost associated with the responsible for any cost associated with the copying or mailing of requested documents. copying or mailing of requested documents.

PROSPECTIVE REVIEW PROSPECTIVE REVIEW PROCESS...CONTINUEDPROCESS...CONTINUED

• The AMA professional staff or its designee, The AMA professional staff or its designee, will review requested documents to will review requested documents to ensure compliance with federal and state ensure compliance with federal and state guidelines governing the Hospice program guidelines governing the Hospice program and to ensure the medical necessity of the and to ensure the medical necessity of the services rendered.services rendered.

• The review must be completed by the AMA The review must be completed by the AMA or its designee, within 30 days from or its designee, within 30 days from receipt of the requested information from receipt of the requested information from the hospice provider.the hospice provider.


• Upon review of the requested Upon review of the requested documents, the provider will be notified documents, the provider will be notified in writing within 30 days as to whether in writing within 30 days as to whether the admission or recertification has the admission or recertification has been approved or denied. been approved or denied.

• AMA or its designee, will submit the AMA or its designee, will submit the dates to the LTC file for approved dates to the LTC file for approved admissions or recertifications. admissions or recertifications.


• Providers will be notified of their Providers will be notified of their appeal rights including the informal appeal rights including the informal reconsideration, as well as a fair reconsideration, as well as a fair hearing process.hearing process.

Hospice in the Hospice in the Nursing HomeNursing Home

HOSPICE IN THE NURSING HOSPICE IN THE NURSING HOMEHOME

• Medicaid will not restrict hospice Medicaid will not restrict hospice services based on a patient’s place of services based on a patient’s place of residence.residence.

• A nursing facility resident may elect A nursing facility resident may elect to receive hospice benefits if he or to receive hospice benefits if he or she meets the requirements for she meets the requirements for hospice care under the Medicaid hospice care under the Medicaid Program.Program.

HOSPICE IN NURSING HOMESHOSPICE IN NURSING HOMES• If the resident elects to receive hospice If the resident elects to receive hospice

benefits, the nursing home should submit benefits, the nursing home should submit the application to discharge the resident the application to discharge the resident from the nursing home and admit to hospice.from the nursing home and admit to hospice.

• The hospice provider is responsible for The hospice provider is responsible for completion of Form 165 (Hospice Election completion of Form 165 (Hospice Election Form) and submission of medical record if Form) and submission of medical record if the resident does not have Medicare Part A. the resident does not have Medicare Part A. If the resident has Medicare Part A, the If the resident has Medicare Part A, the hospice provider must send Form 165B hospice provider must send Form 165B (Hospice Recipient Status Change) to AMA or (Hospice Recipient Status Change) to AMA or its designee.its designee.

HOSPICE TRANSFERSHOSPICE TRANSFERS

• If the individual transfers from If the individual transfers from hospice to a nursing home or hospice to a nursing home or nursing home to hospice, nursing home to hospice, federal guidelines indicate that federal guidelines indicate that hospice should be paid for hospice should be paid for each day of service. each day of service.

• These applications should be These applications should be processed as a transfer to processed as a transfer to allow for an overlap of dates. allow for an overlap of dates. NOTE: Same date of discharge from NOTE: Same date of discharge from

nursing home = admit nursing home = admit date to date to hospice. hospice.


• The level of care The level of care determination and determination and admissions process admissions process would be the same would be the same as in the as in the community.community.

• If the recipient received hospice in If the recipient received hospice in the home and transitioned to a the home and transitioned to a nursing home, SSA should be notified nursing home, SSA should be notified by the provider or sponsor of the by the provider or sponsor of the admission. The individual’s income admission. The individual’s income must be adjusted accordingly by SSA.must be adjusted accordingly by SSA.


CONTACT INFORMATIONCONTACT INFORMATION

Policy QuestionsPolicy Questions Felicha Fisher, LTC Provider/Recipient Services Felicha Fisher, LTC Provider/Recipient Services

Unit, Unit, 334-353-5153 [email protected] [email protected]

Billing QuestionsBilling Questions HPHP 334-215-0111334-215-0111

Admission QuestionsAdmission QuestionsLTC Medical & Quality Review Unit LTC Medical & Quality Review Unit 334-242-5578334-242-5578

Documents

Long Term Care Division