Hospice services are available to persons receiving MA LTC who are dying. The person must get services from a hospice that is certified by Medicare and enrolled in the MA LTC Program. A list of certified, enrolled hospice providers is available on PROMISe.
The goal of hospice services is to make the dying individual as physically and emotionally comfortable as possible. The individual may receive hospice services at any of the following locations:
At home.
The home of a friend.
The home of a relative.
A hotel.
A personal care home.
A domiciliary care facility.
An intermediate care facility.
A skilled Long Term Care (LTC) facility.
A hospital.
Hospice centers
NOTE: A hospital, domiciliary care, or intermediate or an LTC facility must be approved by the Office of Medical Assistance Programs to provide hospice services.
If the individual who is requesting hospice services does not have MA LTC, the CAO applies MA LTC rules as it would for any other MA LTC applicant. This includes deciding a person’s payment toward cost of care if the individual is receiving hospice service in an LTC facility. 42 USC 1396d(a) 55 Pa. Code § 1130.21
The hospice provider must let the CAO know within 7 days if the individual :
Chooses hospice care.
Cancels hospice care.
Moves to another hospice facility; or
Dies.
55 Pa. Code § 1130.51 55 Pa. Code § 1130.52
The hospice provider will complete the following hospice service forms:
Certification of Terminal Illness (MA 372) - The hospice provider has the form signed by the attending physician and hospice medical director every 60 days. An illness is considered terminal if the individual is expected to live six months or less. The CAO does not need a copy of this form.
Election of Hospice Care (MA 373) - This form is signed by the individual to confirm that he or she wants to get hospice care. The hospice provider gives the CAO a copy of the form when a individual is applying for MA LTC or when a person moves to another hospice facility.
Change of Hospice Provider (MA 374) - If a individual chooses a new hospice provider, the new provider must get this form. The CAO must get a copy.
Revocation of Hospice Care (MA 375) - This form shows that the individual decided to cancel hospice services. The CAO must get a copy.
NOTE: If the individual cancels and then restarts hospice care with the same provider during the same certification period, a new certification of terminal illness (MA 372) is not needed until the beginning of the next certification period.
When the CAO gets the MA 373, the CAO will:
1. Make sure all needed information is on the form:
Check line 13 for a change of address. If there is an address change, take the right action.
Line 6 for the signature of the patient. If there is no patient signature, review line 9 for the name of the appointed legal representative. If no legal representative is listed, return the MA 373 to the provider and point out that the information is missing.
2. Check to see if the individual is getting hospice care in an intermediate or LTC facility.
If the individual is getting care in a place other than an intermediate or LTC care facility, see Section 438.71.
If the individual is getting hospice care in an intermediate or LTC facility, see Section 438.72.
If the individual is getting hospice services at a place other than an LTC facility, the CAO will decide if the individual is already qualified for MA LTC.
If the individual qualifies for MA LTC, the CAO will:
Change the address, if needed.
File the MA 373 in the record.
If the individual is not getting MA LTC, the CAO will:
1. Decide if the individual can get MA LTC. Consider categories PAN, PJN, PVN, TAN, TJN, PAW, PMW, PJW, or PCW.
2. File the MA 373 in the record.
Hospice services may be given by a hospice provider to an individual living in an intermediate or LTC facility. Services are provided under a special room and board plan.
The CAO determines cost of hospice service as follows:
1. Determine the amount the individual must pay toward the cost of care using these guidelines:
Determine the category of MA LTC as if he or she were applying for LTC services.
Do not allow for deductions of medical expenses for items or services that are related to the terminal illness and that are given by the hospice provider.
Allow a deduction for paid medical expenses that are not related to the terminal illness. Subtract the expenses only in the month they are paid.
2. Contact the hospice provider to get the MA LTC rate for hospice services. Include the amount charged to the hospice provider by the facility for room and board. Ask the provider to send a written statement of the costs to the CAO.
3. Figure the number of days in the calendar month that the person got hospice service in the institution.
4. Multiply the MA rate by the number of days to determine the cost of hospice care for the calendar month.
5. Compare the cost of hospice care with the person’s payment toward cost of care.
If the individual ’s share is equal to or more than the cost of hospice care, DPW will not pay toward the cost of care.
If the individual ’s share is less than the cost of hospice care, subtract the individual ’s payment toward cost of care from the hospice cost to determine what DPW will pay toward the cost of hospice care.
6. Send a notice telling the individual whether they can get MA LTC payment. If the individual is not eligible for a MA LTC payment, tell the person that the hospice may not charge a rate which is more than the MA LTC rate.
7. Send copies of the notice to both the provider and the LTC facility.
An individual may change hospice providers once during the 60 day period set by the MA 372
EXAMPLE: Mr. W received MA LTC hospice services from Hospice of PA for 40 days beginning on December 1. On January 9, the Hometown Hospice sent a copy of an MA 374 to the CAO to let the CAO know that Mr. W changed his hospice to Hometown. After Hometown Hospice gave services to Mr. W for 21 days, the CAO received an MA 374 on January 30 that says Mr. W decided to return to Hospice of PA.
Mr. W was able to make both changes, because each occurred in a separate 60 day certification period. If Mr. W wants to make another change, he must wait until April 1 (60 days from the last change).
When a provider change is made, the CAO must get a completed MA 374 from the new provider. The CAO will review the information to see whether any changes are needed and will keep the form in the record.
If the individual moves from one hospice location to another, the new hospice provider will give the CAO an MA 373 within 7 calendar days.
When a change in the hospice address is received, the CAO will:
1. Change the address.
2. If the individual has moved out of an LTC hospice facility, decide MA eligibility using the same rules for an individual who is not in an LTC facility.
3. If the individual has moved into a hospice located in an LTC facility, decide the individual’s payment toward the cost of care. See Section 438.72, Eligibility for Hospice in an Intermediate or LTC facility.
An individual may stop hospice service at any time for any reason. If the individual stops hospice care while in an LTC facility, the CAO will determine MA LTC eligibility for the required level of care.
If the individual decides to stop hospice care, the hospice provider will fill out and send the MA 375 to the CAO within 7 calendar days.
If the individual wants hospice care again, the hospice provider must complete an MA 373 and send a copy to the CAO.
Issued March 12, 2012