Criteria
Initial and Continued Hospice Admission
Coverage Criteria (Note: these are not Medical Necessity criteria, as the Hospice admitting Physician should already have determined medical necessity for Hospice prior to the preauthorization request)
Initial Hospice services may be covered when ALL of the following Points one (1) through three (3) are met.
- There is written certification from a physician that the medical prognosis is for a life expectancy of six (6) months or less, AND;
- The primary focus of care is palliative and supportive, AND;
- The Hospice provider is licensed and Medicare-certified, AND;
Continued Hospice services may be covered beyond the initial approval period when the following Points are met:
- One (1) through three (3) continue to be met, AND
- For continuation of Hospice beyond a period of 6 months, the Hospice physician documents that the member continues to be appropriate for Hospice.
If an individual improves and/or stabilizes sufficiently over time while in hospice such that he/she no longer has a prognosis of six (6) months or less from the most recent recertification evaluation or definitive interim evaluation, that individual should be considered for discharge from the hospice benefit. Such individuals can be re-enrolled when a decline in their clinical status is such that their life expectancy is again six (6) months or less. On the other hand, individuals in the terminal stage of their illness who originally qualify for the hospice benefit but stabilize or improve while receiving hospice care, yet have a reasonable expectation of continued decline for a life expectancy of less than six (6) months, remain eligible for hospice care benefits.
Levels of Hospice Care
1. Routine Home Care (HRH)
The primary type of Hospice care. Typically, provided in the home setting and is not receiving continuous home care.
2. Continuous Home Care (HCH)
- Short-term care provided during periods of crisis to maintain the member at home to achieve palliation or management of acute medical symptoms.
- HCH cannot be provided in a skilled nursing facility, inpatient hospice, inpatient hospice facility, long term care hospital, or an inpatient psychiatric facility.
- Requires at least eight (8) hours-per-day of direct individual care, including nursing and/or homemaker or aide services, in a 24-hour day, beginning at midnight.
- Nursing care includes skilled observation and monitoring when necessary, and skilled care is needed to control pain and other symptoms, such as onset of uncontrollable pain, active bleeding, seizures, respiratory distress, uncontrollable anxiety or agitation, new or worsening delirium, uncontrolled nausea or vomiting
- Care must be predominantly nursing (RN, LPN or LVN), and is billed daily. At least 50 percent of the total care provided must be provided by nursing, with the remaining hours supplemented by homemaker or aide services. When aide hours exceed the nursing hours, routine home care must be billed. When fewer than eight (8) hours of care are required, the services are covered as routine home care rather than continuous home care.
3. General Inpatient Care (HGI)
- Inpatient care when the individual is unable to be managed at home such as:
- Imminent death or condition rapidly deteriorating- periods of unresponsiveness or coma, weak thready pulse and low blood pressure, chest congestion, agonal breathing, apnea, peripheral shutdown
- Uncontrollable pain, active bleeding, frequent seizures, respiratory distress, uncontrollable anxiety or agitation, new or worsening delirium, open wounds requiring frequent skilled care, pathological fractures, uncontrolled nausea or vomiting.
- Documentation should include both:
- A precipitating event (onset of uncontrolled symptoms or pain), AND
- The interventions tried in the home that have been unsuccessful at controlling the symptoms (frequent evaluation by a doctor or nurse, frequent medication adjustment, IV’s that cannot be administered at home, aggressive pain management, complicated technical delivery of medication.
- Equipment needs exceed what can be managed in the home setting, such as wall-mount suction, high-flow oxygen exceeding the capacity of an oxygen generator.
- Family or caregiver inability or refusal to provide non-skilled care at home, or lack of availability of a caregiver does not necessarily constitute a skilled need for general inpatient hospice care. Frequent administration of pain medication by any route does not in-and-of itself constitute a skilled need for general inpatient hospice care.
- HGI is not intended to be custodial or residential. Once the individual’s symptoms are stabilized, or pain is managed, he/she must return to a routine level of care. The individual may remain in a facility due to safety, but benefits are not available for HGI unless the individual is in need of this level of care, and it is clearly documented in the medical records.
Not Covered
Hospice services are not a covered benefit when:
- There is treatment being provided with curative intent
- The treatment is “aggressive”.
- The member’s condition is not terminal and/or they do not have a life expectancy of six (6) months or less
- All other times when coverage criteria above are not met
- NOTE: There may be special circumstances dictated by law where children must be provided hospice benefits even when the condition is not terminal, the life expectancy is not six (6) months or less, the treatment has curative intent, or the treatment is aggressive. Benefits will follow applicable laws in these circumstances.
Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information.
