Hospice Services

[Pages:112]INDIANA HEALTH COVERAGE PROGRAMS

PROVIDER REFERENCE MODULE

Hospice Services

LIBRARY REFERENCE NUMBER: PROMOD00033 PUBLISHED: SEPTEMBER 28, 2021 POLICIES AND PROCEDURES AS OF APRIL 1, 2021 VERSION: 5.0

? Copyright 2021 Gainwell Technologies. All rights reserved.

Revision History

Version 1.0

Date

Policies and procedures as of October 1, 2015 Published: February 25, 2016

1.1 Policies and procedures as of April 1, 2016

Published: November 1, 2016

1.2 Policies and procedures as of April 1, 2016

(CoreMMIS updates as of February 13, 2017)

Published: April 13, 2017

2.0 Policies and procedures as of May 1, 2017

Published: November 7, 2017

3.0 Policies and procedures as of January 1, 2019

Published: September 5, 2019

4.0 Policies and procedures as of March 1, 2020

Published: July 28, 2020

5.0 Policies and procedures as of April 1, 2021

Published: September 28, 2021

Reason for Revisions New document

Scheduled update

CoreMMIS update

Completed By FSSA and HPE

FSSA and HPE

FSSA and HPE

Scheduled update

FSSA and DXC

Scheduled update

FSSA and DXC

Scheduled update

FSSA and DXC

Scheduled update:

? Edited text as needed for clarity

? Changed ISDH references with IDOH

? Replaced DXC references with Gainwell

? Removed ICES references; replaced with IEDSS if needed

? Changed surveillance and utilization (SUR) review references to Program Integrity

? Updated the Basic Hospice Provider Enrollment Requirements section

? Updated the Medicare Hospice Certification and State Hospice Licensure section

? Updated IC and IAC references in the Regulatory Process section

? Updated the Non-MedicareCertified Hospice Providers section

FSSA and Gainwell

Library Reference Number: PROMOD00033

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Published: September 28, 2021

Policies and procedures as of April 1, 2021

Version: 5.0

Hospice Services Version

Date

iv

Reason for Revisions

? Added HIP Maternity reference in the Healthy Indiana Plan section

? Removed hospital from the Right Choices Program (Lock-In) Members section

? Added PE Family Planning Services Only in the Programs and Aid Categories Ineligible for the IHCP Hospice Benefit section

? Updated the introductory text for Section 4: Hospice Election, Revocation and Discharge to better reflect the information in that section and to add information about dually eligible members not residing in an NF

? Updated the Election by Member section and the Nursing Facility Residents subsection, and removed the Medicaid-Only and Dually Eligible Members subsection

? Updated information in the Revocation by Member section regarding documentation requirements for reelecting IHCP hospice after revocation

? Updated the Documentation Requirements for Hospice Members Residing in a Nursing Facility section

? In the Clarification Regarding When the IHCP Can Mirror a Hospice Agency's Benefit Periods section:

? Updated the FSSA Response to Example 1

? Updated the FSSA Response to Example 2

? In the Hospice Authorization Process section:

? Updated requirements for the hospice agency election form for dually eligible members residing in an NF

? Changed the time frame for hospice providers to submit documentation to the Gainwell PA Unit from 10 days to 10

Completed By

Library Reference Number: PROMOD00033 Published: September 28, 2021

Policies and procedures as of April 1, 2021 Version: 5.0

Version

Date

Hospice Services

Reason for Revisions

business days of the member's hospice election effective date

? Updated the policies for facilitating paperwork

? Added note on Table 5 ? Indiana Health Coverage Programs Prior Authorization Request Form Fields for Hospice Requests that electronic signatures are not accepted

? Updated the Exceptions Related to Untimely Submissions section

? Updated and reorganized the Certification for Medicaid-Only Hospice Members section

? Added UnitedHealthcare to list of MCEs in the Hospice Services for Hoosier Care Connect Members section

? Updated reference to ICD diagnosis code in the Amyotrophic Lateral Sclerosis (ALS) section

? Updated Table 10 ? Documentation Requirements for Hospice Providers

Completed By

Library Reference Number: PROMOD00033

v

Published: September 28, 2021

Policies and procedures as of April 1, 2021

Version: 5.0

Table of Contents

Section 1: Introduction ......................................................................................................................1

Medicare Conditions of Participation for Hospice Care.................................................................1 Medicaid Hospice in Conjunction With Other Funding Sources ...................................................1 Covered Services in the IHCP Hospice Per Diem..........................................................................2

Hospice Core and Noncore Services ........................................................................................3 Comparison of IHCP Hospice Covered Services and Medicare Hospice Covered Services ....4 Dialysis for End-Stage Renal Disease during Hospice Stays ...................................................4 Hospice Providers' Contractual Responsibilities as the Professional Manager of a Member's

Hospice Care ....................................................................................................................5 Hospice Levels of Care ..................................................................................................................5

Routine Home Hospice Care ....................................................................................................6 Continuous Home Hospice Care ..............................................................................................6 Inpatient Respite Hospice Care ................................................................................................6 General Inpatient Hospice Care................................................................................................6 Location of Routine or Continuous Home Hospice Care ...............................................................7 Hospice Residence....................................................................................................................7 Assisted Living Facility............................................................................................................7 Residential Care Facility Providing Residential Care Assistance Program Services ...............7 Intermediate Care Facility for Individuals With Intellectual Disabilities .................................8 Location of Inpatient Hospice Care................................................................................................8

Section 2: Hospice Provider Enrollment ..........................................................................................9

Basic Hospice Provider Enrollment Requirements ........................................................................9 Affordable Care Act Risk Category Requirements ........................................................................9 Medicare Hospice Certification and State Hospice Licensure .....................................................10

Application Process for a Hospice License or Approval ........................................................10 Regulatory Process .................................................................................................................11 Non-Medicare-Certified Hospice Providers.................................................................................11 Hospice Providers Located Outside Indiana ................................................................................12 Medicare-Certified Hospice Providers .........................................................................................12 Institutional Requirements ...........................................................................................................12 Interdisciplinary Group...........................................................................................................13 Rights of IHCP Hospice Members .........................................................................................13

Section 3: Member Eligibility for Hospice Services ......................................................................15

General Requirements for IHCP Hospice Benefits ......................................................................15 Eligibility by Population Category...............................................................................................15

Managed Care Members.........................................................................................................16 Traditional Medicaid Members ..............................................................................................17 Dually Eligible (Medicare and Medicaid) Members ..............................................................17 Members Receiving Home- and Community-Based Services................................................18 Right Choices Program (Lock-In) Members ..........................................................................19 Members Residing in Group Homes ......................................................................................19 IHCP-Pending Individuals......................................................................................................19 IHCP Members Without IHCP Nursing Facility Level of Care .............................................20 Individuals in the Residential Care Assistance Program ........................................................21 Programs and Aid Categories Ineligible for the IHCP Hospice Benefit ......................................22

Section 4: Hospice Election, Revocation and Discharge ...............................................................23

Admission Procedures..................................................................................................................23 Election by Member .....................................................................................................................24

Concurrent Care for Children Exception ................................................................................24 Nursing Facility Residents......................................................................................................25

Library Reference Number: PROMOD00033

vii

Published: September 28, 2021

Policies and procedures as of April 1, 2021

Version: 5.0

Hospice Services

Table of Contents

Revocation by Member ................................................................................................................25 Discharge by Hospice Provider ....................................................................................................26

Nursing Facility Hospice Discharge .......................................................................................29 Patients Admitted to a Noncontracted Nursing Facility .........................................................30 Patients Admitted to Noncontracted Hospital.........................................................................30 Change in Hospice Provider.........................................................................................................30 Short Absences for Hospice Patients............................................................................................31 Medical Records Standards ..........................................................................................................32

Section 5: Hospice Authorization ...................................................................................................33

Submitting Hospice Authorization Requests................................................................................33 Election, Plan of Care and Benefit Period Process.......................................................................34

Benefit Periods .......................................................................................................................35 Criteria for Adequate Medical Documentation.......................................................................36 Documentation Requirements for Hospice Members Residing in a Nursing Facility ............37 Dually Eligible Members in Nursing Facilities ......................................................................38 Clarification Regarding When the IHCP Can Mirror a Hospice Agency's Benefit Periods...38 Hospice Authorization Process.....................................................................................................40 Certification for Dually Eligible Hospice Members Residing in Nursing Facilities ....................44 Certification for Medicaid-Only Hospice Members.....................................................................44 Hospice Plan of Care Documentation Requirements ...................................................................46 Plan of Care for Concurrent Hospice and Curative Care Services for Children .....................47 Additional Hospice Authorization Forms.....................................................................................47 Timely Submission of Hospice Authorization Paperwork ...........................................................48 Exceptions Related to Untimely Submissions ........................................................................48 Administration Reconsideration and Appeals Process for Hospice Authorization ......................49 Hospice Coverage and Authorization for Managed Care Members .............................................49 Hospice Services for HIP Members........................................................................................49 Hospice Services for Hoosier Care Connect Members...........................................................50 Hospice Services for Hoosier Healthwise Members ..............................................................50 Program of All-Inclusive Care for the Elderly .......................................................................51 Prior Authorization for Treatment of Nonterminal Conditions ....................................................52 Request for Home Health Service Reimbursement in Addition to the Hospice Per Diem ...........52 Submission of the Medicaid Hospice Discharge Form and Gainwell Authorization Procedures 53 Hospice Authorization Guidelines for Medical Necessity Review ..............................................54 Amyotrophic Lateral Sclerosis (ALS) ....................................................................................54 Alzheimer's Disease and Related Disorders...........................................................................55 Cardiopulmonary Disease.......................................................................................................56 Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) ....59 Liver Disease ..........................................................................................................................59 Renal Disease .........................................................................................................................60 Stroke and Coma ....................................................................................................................61 Adult Failure to Thrive Syndrome..........................................................................................62

Section 6: Billing and Reimbursement ...........................................................................................63

Billing and Reimbursement for Concurrent Hospice and Curative Care for Children .................63 Method of Calculation..................................................................................................................64

Routine Home Hospice Care ..................................................................................................64 Continuous Home Hospice Care ............................................................................................65 Inpatient Respite Hospice Care ..............................................................................................66 General Inpatient Hospice Care..............................................................................................66 Billing Services Associated With the SIA Payment.....................................................................66 Payment for Nursing Facility Residents .......................................................................................67 Room and Board.....................................................................................................................67 Decertification of a Nursing Facility and Payment of Room and Board ................................68 Payment for Date of Discharge...............................................................................................69 Patient Liability for a Hospice Member Residing in a Nursing Facility.................................70

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Library Reference Number: PROMOD00033

Published: September 28, 2021

Policies and procedures as of April 1, 2021

Version: 5.0

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