Benefit Coverage of hospice services

For an individual to receive covered hospice services, a certification of the individual’s terminal illness must have been completed as set forth in §20.1, and a plan of care must be established before services are provided. Services must be consistent with the plan of care and reasonable and necessary for the palliation or management of the terminal illness and related conditions.

In establishing the initial plan of care the member of the interdisciplinary group (IDG) who assesses the patient’s needs must meet or call at least one other group member (nurse, physician, medical social worker or counselor) before writing the initial plan of care. At least one of the persons involved in developing the initial plan must be a nurse or physician. The plan must be established on the same day as the individual’s assessment if the day of assessment is to be a covered day of hospice care. Date the plan of care on the day it is first established. The other two members of the interdisciplinary group (the attending physician, who may be a nurse practitioner, and the medical director or physician designee) must review the initial plan of care within 2 calendar days following the day of assessment. A meeting of the group members is not required within this 2-day period; input may be provided by telephone.
A nurse practitioner serving as an attending physician should participate as a member of the interdisciplinary group that establishes and/or or updates the individual’s plan of care. The nurse practitioner may not serve as or replace the medical director or physician designee.
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);
Continuous home care (refer to §40.2.1);
Inpatient respite care (refer to §40.2.2); and
General inpatient care (refer to §40.2.2).

Hospices are expected to furnish the following services to the extent specified by the plan of care for the individual. The categories listed above are used in billing to describe the acuity of the services furnished. See Medicare Claims Processing Manual, Chapter 11,“Hospice,” for a description of billing procedures.

Covered Services

Appropriately qualified personnel must perform all services, but it is the nature of the service, rather than the qualification of the person who provides it, that determines the coverage category of the service. The following services are covered hospice services.